Never more so perhaps than in 2020, have we asked ourselves the question, “How can we help?” The Royal Commission into Aged Care has effectively directed the spotlight onto the multitude of systemic flaws within aged care. COVID-19 has sadly provided the conclusive evidence that our most revered and vulnerable are in peril. So how can we help? The following article is written with the intention of demystifying geropsychology and aged care; and with the sincere hope that more psychologists will consider expanding their scope of practice to aged care.
While this year has placed varying burdens, hardships and heartbreaks on diverse groups and individuals, it has proved to be an unusually cruel testing ground to evaluate how, as a society, we look after ourselves as we age. Not only in relation to our physical health, but our mental, social and spiritual health. How are we, or aren’t we, meeting our own expectations, wants, needs, desires and our intrinsic human rights?
A few facts we can agree upon:
- We will grow and shrink as we get older, rarely do we know how long for.
- Some of us will be blessed with continuing good health and/or a loving social network and/or values and beliefs that comfort us.
- Ageing increases the risk of more health problems, chronic health conditions and complex concomitant conditions.
- Older adults benefit from many of the same mental health assessment and treatment approaches used for adults of all ages (e.g., for depression).
- Of all of the diseases related to ageing, dementia can present with some of the most debilitating symptoms. It is not unique to older people with younger-onset dementia diagnoses increasing. Dementia is the leading cause of death in women and the second leading cause of death in men.
Now sit for a moment with these facts. Consider that it was intentional when I asked, as a society, how we look after ourselves? Notice I did not ask, how we look after ‘them’, or how we look after ‘the elderly’ or ‘older persons’?
Psychologists have a remarkably thorough education and training encompassing foundational principles including person-centred care – a term coined by psychologist Carl Rogers. Coupled with our in-depth understanding of cognitive, mental and behavioural health, we are uniquely placed to make a very valuable contribution working in aged care and with people living with dementia and their caregivers.
By the numbers
So why on earth don’t the numbers add up? Here in Australia, where in 20 years’ time almost a quarter of the population will be aged 65 and over, only a very small percentage of psychologists identify as working predominantly with older adults. Despite those older Australians living in a residential aged care facility (RACF) having higher rates of mental health disorders than those living in the community (APS Submission to the Royal Commission into Aged Care Quality and Safety, 2019; bit.ly/2VIBLtl) there is very little chance of access to a psychologist.
Associate Professor Sunil Bhar also asked the question, “Why is psychology so absent in aged-care settings?” in this magazine back in 2016 (bit.ly/2UY2li3). Numerous barriers were proposed including a lack of foundational training in geropsychology to accompany appropriately supervised placements in aged care.
Stargatt et al. (2017) conducted the first Australian study to investigate the accessibility of psychological services for older adults living in RACFs. What they found confirmed that residents were rarely referred to psychologists. The reasons included lack of staff skill in identifying mental health problems, staff attitudes (e.g., nothing can be done for late-life depression), resident attitudes and stigma attached to mental health, and lack of availability and funding to access psychologists. Residents with depression and anxiety were much more likely to be treated with medication and activities; referrals much more likely to be made to occupational therapists and diversional therapists.
The story overseas is no better. In the most recent figures from the USA, and the first large scale survey to include both members and non-members of the American Psychological Association, Moye et al. (2018) found that only 1.2 per cent of psychologists stated their primary specialty as geropsychology.
In Australia, psychologists have not been funded to provide Medicare services to RACF residents as it was considered ‘double-dipping’. It has taken a Royal Commission and a pandemic to finally wave the red flag on the unethical plight of RACF residents. Some headway has now been made, with the Federal Government a) providing block funding via Primary Health Networks to deliver psychological services into RACFs, and b) allowing residents of RACFs to access up to 20 individual psychological services where their general practitioner or psychiatrist determines they would clinically benefit from additional mental health support. This expansion of MBS Better Access Scheme is valid from 10 December 2020 until 30 June 2022. This is obviously great news for RACF residents, staff and psychologists alike.
A versatile group
It is worth taking a look at the diversity of roles psychologists working in aged care and dementia can undertake. Many psychological therapies are equally applicable for older adults (e.g., CBT and ACT) for depression and anxiety. Morante et al. (2020) and Winefield (2020) researched the experience of a small number of clinical psychologists providing therapy to older adults. Reflections included: the need for adaptive and flexible therapeutic interventions depending on the ‘psychological-mindedness’ of the adult; and the need for modifications when working with someone with cognitive impairment. Their research reinforced the value of mentoring initiatives in geropsychology.
It is not just in the treatment of major mental health disorders that psychologists can be of great assistance. Older adults experience a diverse range of clinical and subclinical symptoms that can negatively impact on their daily functioning and quality of life. Some of these issues include:
- late-life adjustment such as retirement, health issues, moving to a RACF, grief and loss
- health-related anxiety
- pain and sleep management
- alcohol and other drug dependence
- concomitant mood disturbance and emotional dysregulation that accompanies some medical diagnoses (e.g., depression in Parkinson’s disease)
- the need for cognitive screening and assessment
- the need for assessment of decision-making capacity
- behavioural/non-pharmacological interventions to manage behavioural and psychological symptoms of dementia (BPSD)
- interrelated family and caregiver needs (both informal and formal caregivers) including psychoeducation on prevention of carer burnout
- the under-researched area of elder abuse and human rights violations in RACFs.
Recently, Ibrahim et al. (2020) completed an excellent piece of research that could not be more timely; coinciding with the Royal Commission into Aged Care, and right on the cusp of the COVID-19 hijacking our finely but precariously balanced aged-care applecart.
Ibrahim's Five Needs Model
They conceptualised the essential factors to meet the needs of older people living in RACFs in Australia into a clear multifaceted model. Then they widely consulted with 382 diverse and representative stakeholders over a 16-month period. The draft model was then theoretically tested using common scenarios that may cause organisation failure. The final product is a model that encompasses the aged care resident at its heart.
The concept map encompasses five main areas of need. Addressing every individual resident’s needs based on Ibrahim’s Five Needs Model can best be accomplished by a genuine multidisciplinary team comprising a general practitioner, specialist in/outreach doctors (geriatrician, psychiatrist etc.), RACF nursing and personal carer staff, and allied health staff including psychology in concert with the person themselves, and their family and caregivers.
For example, while an occupational therapist can conduct a cognitive screen and apply this to developing activities, behavioural therapies and reablement, they are not trained to assess psychological and emotional aspects. Social workers have understanding of emotional and social needs and rights advocacy but lack training in cognition and its application across every aspect of the person’s needs. Medical professionals are typically less familiar with psychological and cognitive functioning. They also cost the most, are a limited resource and are already time-poor.
Despite many nursing staff embracing patient-centred care and dementia-specific training, their inadequate ratio to residents typically sees them having little time to attend to anything but physical health and medication needs. Inadequate staff to resident ratios also severely impair personal carers from delivering person-centred care as they are typically rushing just to assist residents with basic activities such as showering and meals.
These staffing and time constraints leading to deficits in care are not lost to the aged care workforce. Quite the contrary, they suffer an enormous daily burden of awareness that whatever they do is not enough. The moral and ethical dilemma of working within an ineffective model of care, standing witness to that which is broken, is in return breaking them.
So you begin to see the enormous need, and therefore enormous potential for psychology to take a key role as part of a multidisciplinary team to provide a model of care that meets the needs of individual residents. Additionally psychologists are also well-suited to providing psychoeducation to residents and staff across several topics including emotional and social wellbeing and self-care. They can also support staff specifically – enhancing effective communication and interpersonal relationships, clinical case conferencing and team building, psychoeducation on various topics such as person-centred care, prevention of carer burnout, self-reflection and supervision, and facilitating family and team meetings (Davison et al., 2016).
To further highlight the role a psychologist can play within a RACF, let’s examine two particular needs from Ibrahim’s Five Needs model – dementia management and rights – and the interplay between the two.
Living with dementia
People living with dementia are the most likely to be disadvantaged by the current medically focused model of care. Ibrahim’s Five Needs Model was consciously designed to emphasise and support the fact that the needs of the person living with dementia, and the extent that behavioural and psychological symptoms of dementia impact on all other aspects of the resident and broader facility, warrants its very own component within the model.
Most RACFs are staffed predominantly by personal carers; many who have undertaken Certificate III in Aged Care. While there is a dementia component to this course that used to comprise of up to 20 hours of learning, unconfirmed reports are that the dementia-specific component has been eroded to a great extent and is now grossly inadequate. Lack of dementia-specific training within RACFs leads to a vicious cycle of struggle and hardship for residents and staff alike.
Understanding cognitive functioning is an essential skill-set when working with people living in RACFs given that approximately half of the population of RACFs has dementia. The importance of being aware of any emerging cognitive impairment is critical to every facet of person-centred care. For example, psychological therapeutic interventions may not be effective, if cognitive deficits have not been considered. Therapy techniques can be adjusted for short-term memory loss via the use of memory aids; or by shifting to a greater emphasis on behavioural rather than cognitive techniques. Adjustments to therapeutic interventions can be made for speed of processing deficits; expressive and/or receptive language deficits; as well as complex executive dysfunctions such as disinhibition, compromised insight, disorganisation and attentional deficits.
Typically, the higher degree of cognitive impairment identified, the greater the need to include caregivers (RACF staff, and family and informal caregivers) in the psychological or behavioural intervention. Therapeutic interventions are directed more so towards the caregivers as the cognitive impairment advances.
These considerations and adjustments are also equally important for addressing every other need of the resident such as activities of daily living, recreational and social activities, participation in the management of their health, goal-setting, participating in all manner of decisions about themselves… the list goes on. Therefore, if cognitive screening and assessment is not available, or poorly understood, then all other treatments and care provided cannot be informed and tailored to that individual’s needs. This can result in person-centred care not being achieved.
Dementia-specific knowledge is critical for anyone working directly or indirectly in an environment with people living with dementia, and their family and carers. Person-centred care is never more important to enact than with these vulnerable people as their symptoms may impair their comprehension, their recall, their insight, their ability to express their needs, to make decisions, or the ability to defend their rights. Everyone that they interact with has a responsibility to appreciate who they are as a person, and to assist and enable them by whatever means, to do all of the above.
Facilitation of consistency and compassion are essential, along with non-verbal communication and an appreciation of some of the more complex symptoms of dementia such as confabulation (which is often misinterpreted as deceit or denial), delusions and hallucinations. Many other symptoms are misunderstood and mostly represent unmet need and are therefore referred to as ‘response behaviours’ as the person is responding to not having their needs met.
Dementia, decisions and rights
When a person is diagnosed with dementia, the symptoms themselves create various risks – physical, emotional, functional – in relation to self-determination and preservation of autonomy and independence. Essentially managing dementia symptoms becomes a tightrope walk of balancing autonomy versus risk mitigation, with the important distinction here that we all have a right to adherence to dignity of risk as detailed in Ibrahim et al’s model. Within that courageous walk across a teetering tightrope, triggering scenarios, events and situations requiring decisions crop-up (imagine these as that point at which a tightrope walker gets a little wobble up).
In my clinical experience, about 90 per cent of these trigger points can be addressed via good quality communication, compassion and compromise (aka healthy interpersonal social skills). But sometimes dementia symptoms themselves create triggers where the level of risk to the person with dementia, or someone else may be deemed to be of concern.
It is easy to imagine some of the larger decisions that may arise. For example: Can a person decide for themselves to stay living at home? Can they decide to vacate the RACF if they no longer feel safe there? But it is actually in many other little ways that the concept of establishing decision-making capacity is overlooked, avoided or mismanaged for people who are developing cognitive impairment. The medical model is steadfast (as it should be) maintaining its adherence and respect for a person’s right to privacy and confidentiality. So what happens when it becomes clinically sensible or necessary to include caregivers in the care plan?
The reality is that many people living with emerging cognitive impairment or a diagnosis of dementia visit their doctor alone. How does the doctor determine decision-making capacity in each instance? Whether or not their patient shares information and seeks support from loved ones or carers is often left up to them. Sometimes there is no consequence, but at other times lack of inclusion may mean diagnoses and prognoses are not disclosed, caregivers may be unaware of implications to daily functioning, or areas of increased risk (e.g., unaware of instructions not to drive).
This can hinder proactive, preparative, protective and enablement strategies from being activated. Without consideration of decision-making capacity, numerous other examples see the tightrope walker teeter too far the other way. The RACF resident is not consulted about matters that directly impact their care, their environment or their rights.
Historically, capacity assessments are conducted by medical doctors, lawyers and psychologists. Given that they often take time, skill and experience, they are often also avoided altogether, which is a large problem when trying to respect someone’s rights. Psychologists’ capacity assessments hold weight due to their ability to apply cognitive, psychological, behavioural and interpersonal analyses to determine the presence or absence of evidence of compromised capacity. Importantly, for anyone conducting a capacity assessment in this population, dementia-specific knowledge and experience is essential.
How can psychologists help?
It is worth noting, that while this article focuses on psychologists working in RACFs, there is scope for psychologists to be working in the primary-care setting. Multidisciplinary models of care incorporating general practitioners, nursing and allied health services in the community, while not yet widely adopted, are bound to prove to be the most effective care and wellbeing model for aged care.
Not only for the ability to provide person-centred holistic care, but also because multidisciplinary teams can provide a rich and effective in situ ‘training and education-based focus’ that can contribute to futureproofing the aged-care workforce. This is a high priority due to the current and future deficit of aged-care and dementia-specific trained workforce.
Engage with resources and support
The aged-care applecart may have taken a tumble, but there are a few apples that you can pick up:
- Appreciate that, as a psychologist, your comprehensive education and training affords you a unique and versatile set of foundational skills that can be applied to working with older people including those with mental illness and dementia. Caregivers to people living in aged care, formal and informal, would also benefit from psychological therapies enabling them to not only offset carer burnout, but to thrive in the carer role.
- Self-reflect on what schemas, beliefs and values may be influencing your decision-making regarding your clientele. Consider what steps you can take, regardless of whether you work in the public, private or academic sectors, to ensure you are reaching your entire village.
- Review the various guidelines and articles on the APS website and consider joining the APS Psychology and Ageing Interest Group which currently has 326 members. Some useful resources include:
- APS ethical guidelines for working with older adults, and noting Section 5 – Competence which details the importance of seeking additional training and supervision and flags the ethical responsibilities associated with abuse, neglect and criminal activities (bit.ly/2VgSILz)
- APS Applied Mental Health in Residential Aged Care training (bit.ly/39NsqJh)
- APS Submission to the Royal Commission into Aged Care Quality and Safety (September, 2019; bit.ly/2VIBLtl)
- Enhancing quality of life in older people (bit.ly/3m9cIeO)
- Facts on ageing: Demographic data is key for psychology to support wellbeing of older Australians (bit.ly/2JdJDAq)
- Understanding and treating comorbid anxiety and depression in older adults (bit.ly/3mazKSp)
- The American Psychological Association Guidelines for Psychological Practice With Older Adults (bit.ly/3ghNZml)
- Look into building knowledge and skills via:
- geropsychology courses – University of Queensland (UQ) has the only accredited doctoral course in clinical geropsychology in Australia at present (and is the first university in the Southern Hemisphere to join the Age Friendly Universities Global Network) (bit.ly/3q6agrY).
- interdisciplinary courses specific to aged care and dementia – many are free:
- Explore your local access to placements, mentoring and supervision from colleagues with experience and/or qualifications in the field of geropsychology or gerontology such as:
- Swinburne University of Technology psychology placements within nursing home and community settings
- Lifespan Health, Sunshine Coast, offer supervision for psychologists who are delivering psychological services to older adults residing in RACFs (www.lifespanhealth.com.au).
After all, an apple a day…
Make aged care your priority and help look after all of us big kids, old kids, older kids and the oldest kids – those very special few with the crinkly eyes full of wisdom and kindness and grace, stories and silences, warmth and patience.
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