Serious Mental Illness in the Older Adult: Care and Treatment

 

OVERVIEW

A. Severe mental illnesses can include diagnoses such as schizophrenia spectrum disorders, bipolar disorder, major depression, and post-traumatic stress disorder.

B. Severe mental illness in older adults is an underrepresented and overlooked area of nursing practice, and it is imperative for all nurses to be well-versed in background and nursing strategies.

C. Anxiety and psychosis are common syndromes associated with SMI.

 

BACKGROUND AND STATEMENT OF PROBLEM

SMI is due to the complex interaction between a wide range of biological, psychological, social, and environmental factors.

A. Psychosis

  1. There is a need for nurses to be knowledgeable and competent to care for the older adult population, especially when they experience psychosis.
  2. Psychosis is a collection of symptoms that affect the brain, in which an individual loses touch with reality. A person’s thinking and perceptions are disrupted to the extent that they cannot recognize what is real and what is not.
  3. Essential elements of psychosis include the following:
    • Psychosis among older adults is a debilitating form of SMI that is associated with significant morbidity and mortality. Further, it can have a significant impact on one’s ADLs and ability to function independently.
    • The DSM-5 and the World Health Organization require the presence of hallucinations, delusions, or both for a diagnosis of psychosis.

B. Anxiety

  1. Anxiety can affect approximately 17% of the older adult population, with severe anxiety affecting approximately 4% of older adults.
  2. Risk factors can include widow status, poor self-rated health, poor resiliency, cognitive impairment, low socioeconomic status, and lower level of education.
  3. Presentation can include worry, ruminations, obsessions, flashbacks, or specific anxieties to older adults, such as FOF.
  4. The impact on older adults is significant, and can reduce quality of life, level of functioning, and daily comfort, and increase caregiver burden and burnout in loved ones.

PARAMETERS OF ASSESSMENT

A. Psychosis

  1. Psychoses among older adults are generally attributable to primary conditions (psychiatric disorders) or secondary conditions (medical or neurological disorders).
  2. Initial assessment of psychotic disorders includes a cognitive assessment (including evaluating for the presence of delirium), physical exam, bulk complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, vitamin B12, folate, rapid plasma regain, urinalysis, toxicology, and erythrocyte sedimentation rate.
  3. MRI or CT scan and an EEG may be indicated.
  4. A thorough assessment, medical history, and information from caregivers and healthcare professionals can help distinguish between primary and secondary factors.

B. Anxiety

  1. Determine if it is acute or chronic.
  2. Investigate possible causes, including medications, disorders, or lifestyle changes.
  3. Use validated tools such as:
    • Geriatric Anxiety Index
    • Geriatric Anxiety Scale
    • Adult Manifest Anxiety Scale
    • Beck Anxiety Inventory

NURSING CARE STRATEGIES

A. Communication can be tailored to the adult with a severe mental illness, including speaking slowly in a neutral tone. Do not ask multiple questions. Give instructions one at a time.

B. Use appropriate nursing interventions, including:

  1. Nursing process
  2. Active listening
  3. Guided imagery
  4. Therapeutic communication
    • Summary
    • Silence
    • Open-ended questions
    • Body language

C. When pharmacological solutions are being considered, so should the use of nonpharmacological solutions, including, but not limited to:

  1. Lifestyle changes
  2. Exercise
  3. Mindfulness
  4. Music/pet therapy
  5. Psychotherapy

D. When pharmacological approaches are used for psychosis:

  1. If psychosis is due to a secondary condition, treat the underlying cause first.
  2. If psychosis remains after treatment, antipsychotics may be necessary, especially when there exists a risk of harm to oneself or others.
  3. Antipsychotics should be used cautiously, in low doses and on a short-term basis due to potential for adverse effects.
  4. Second-generation antipsychotics are considered a better choice than conventional antipsychotics due to the adverse effects of conventional antipsychotic agents.

RELEVANT PRACTICE GUIDELINES

A. Bartels, S. J., DiMilia, P. R., Fortuna, K. L., & Naslund, J. A. (2018). Integrated care for older adults with serious mental illness and medical comorbidity: Evidence-based models and future research directions. Psychiatric Clinics of North America, 41(1), 153–164. https://doi.org/10.1016/j.psc.2017.10.012

B. Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Ameringen, M. V., Canadian Anxiety Guidelines Initiative Group on behalf of the Anxiety Disorders Association of Canada/Association Canadienne des troubles anxieux and McGill University, Antony, M. M., Bouchard, S., Brunet, A., Flament, M., Grigoriadis, S., Mendlowitz, S., O’Connor, K., Rabheru, K., Richter, P. M., Robichaud, M., & Walker, J. R. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry, 14(Suppl 1), S1. https://doi.org/10.1186/1471-244X-14-S1-S1

C. Lehman, A. F., Lieberman, J. A., Dixon, L. B., McGlashan, T. H., Miller, A. L., Perkins, D. O., & Kreyenbuhl, J. (2004). Practice guideline for the treatment of patients with schizophrenia (2nd ed.). American Journal of Psychiatry, 161 (2 Suppl), 1–56.

D. Subramanyam, A. A., Kedare, J., Singh, O. P., & Pinto, C. (2018). Clinical practice guidelines for geriatric anxiety disorders. Indian Journal of Psychiatry, 60(Suppl 3), S371–S382. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5840911/?report=reader

ABBREVIATIONS

ADL          activities of daily living

SMI           serious mental illness

DSM-5      Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

FOF           fear of falling

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Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 33, Riley, K. & Mariolis, T. (2025) Serious Mental Illness in the Older Adult: Care and Treatment

 

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