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  • Will further discuss in later slides.
  • Preventable and treatable however (under recognition of the syndrome & poor understanding of the underlying pathophysiology, have hampered the development of successful therapies) (Ramaswamy, et al., 2010)
    Not always transient and reversible,( can result in long term cognitive changes (Ramaswamy, et al., 2010)
  • Must identify through assessment of clients that are at risk of developing delirium, recognize early signs of delirium, determine etiology, and rapidly institute measures to correct underlying causes
    Observation with a brief history can determine however use of tool assessment can bring clarification of the condition.
    CAM-nine-item standardized instrument to assist clinicians with no psychiatric training in the recognition and detection of delirium; used primarily in inpatient settings; most commonly used. ( Tusaie Used when patient exhibits acute change in mental status or fluctuating changes in mental status; can only be used if patient is arousal in response to a voice without need for physical stimulation.
    & Fitzpatrick,p303)
    Most widely used is the CAM; nine item standarized instrument to assist clinicians with no psychiatric training in the recognition and detection of delirium, included is a four item diagnositc algorithm. This can be found in page 304 & 305 in Tusaie & Fitzpatrick.
  • MMSE- most common and familiar measurement worldwide; excellent reliability and validity; widely used in primary care practice for detecting and tracking cognitive impairment
  • Safety assessments-Environmental hazards ( gas appliance, firearms, staircases)
    May be unable to live on their own ( related to assistance with activities daily living, wandering, incontinence, & severe behavioral disturbances occur
    Driving should be considered to decreased/discontinued even with mild dementia
    Caregiviers-Zarit Burden Interview(ZBI) 22 item self -rate scale use to measure the caregivers burden
    Respite Care, educational programs and family counseling (McCarron, Xiong, & Bourgeois, 2009)
    Cognitive rehabiliation-( crossword or jigsaw puzzles, playing chess or a muscial instrument. painting, writing)
    Sensory stimulation(sunlight)
    ABC behavioral model(use for maladaptive behavior)
  • Side effects: Cholinesterase Inhibitors gastrointestinal ( nausea, vomiting, & diarrhea); anorexia & weight loss; bradycardia, confusion, agtiation; increase monitoring of heart rate, should be 60 beats and over while taking and special care is needed if patient taking beta blockers, calcium channel inhibitors, or digoxin. Also increase awareness for patient with severe asthma or COPD ChEIs provoke bronchospasm.
  • Common conditions associated with depression:
    Heart Disease
  • Screen and prevention are key
  • Risk Factors for Suicide Among Older Adults
    Antidepressants have an increased risk of suicidal idealization
    Older age, male gender, white race, unmarried
    Depression, comorbid anxiety, substance abuce, isolation, loneliness, lack of social supports, and declining physical health
  • Cognitive bibliotherapy involves a book and or reading material for patient
    Problem solving therapy
    Brief Psychodynamic therapy focuses on unconscious processes as they are manifested in the clients behavior
    Reminiscence therapy uses life experiences of the individual to improve mental well-being
  • Major categories of grief
    anticipatory grief ( unconscious process, and not conscious, deliberative process) (ex)
    uncomplicated grief( normal emotional state experiences a loss that causes a reaction an emotional low)
    complicated grief ( deny, repress, or avoid aspects of the loss, its pain, and its implication > 1 year of loss
    disenfranchised grief ( grief that persons experience when they incur a loss tha is not or cannot be open acknowledged, publicly mourned, or socially supported
    Unresolved grief
  • Physical_ Headaches, dizziness, exhausation, insomnia, loss of appetite, muscular aches,
    Cognitive_ sense of depersonalization, inability to concentrate, sense of debelief and confusion; fleeting visual, tactile, olfactory, auditory hallucinatory experiences
    Emotional_ anger, guilty, anxiety, sense of helplessness, numbness
    Behavioral_crying,withdrawal, imparied work performance
  • Mediations cannot cure grief but help the client feel well enough to participate in other forms of therapy.
    Support groups reported by Carol Steiner suggests that it provides emotional support, validation, education about grief and themselves, and coping techniques((Rainer, 2013, p.56)
    Counseling _ to help the client expressive themselves through journal writing, venting anger(banging a pillow on the bed, screaming at home, crying); actively listening to the bereaved share their story.
  • Older adults whom experience anxiety are associated with reduced quality of life and lower life satisfaction
  • Over 80% of older adults have at least one chronic medical condition
  • Medical Conditions
    Symptoms can be difficult to separate
    Older adults often express anxiety symptoms as somatic
    Medication side effects make diagnosing difficult
    Older adults attribute symptoms to medical problems
    Also difficult to separate
    Impaired memory may relate to anxiety or dementia
    Older adult are more likely to include depressive symptoms in anxiety
  • The assessment tool is attached
  • Pharmacological Treatment
    Use with caution in older adults:
    metabolism changes
    risk of interactions with other medications
    effects of medication on co morbid medical problems
    Monitor for non-compliance
    Benzodiazepines-most common
    “Start low and go slow”
    Short-term use is recommended
    Can increase risks for falls
    May lead to memory problems
    Older adults more likely to develop disabilities effecting ADLs
    May require 7 to 30 days to reach desired effect
    Can cause unpleasant symptoms
    Nausea, diarrhea, nervousness and insomnia frequently reported
    Headache, tremor, anxiety, somnolence, and sexual dysfunction also reported
    —with lower doses side effects can be more mild
    MAOIs and TCAs used less frequent than SSRIs
  • Relaxation training includes deep breathing, progressive muscle relaxation and imagery
    CBT involves cognitive restructuring and problem solving techniques
    Supportive therapy reinforces healthy and adaptive thought behaviors
  • Insomnia is a prevalent condition the effects the lives of many in older adulthood. 30-60 percent of all older adults have some form of sleep disturbance. These sleep issues can range from difficulty falling asleep to extreme day time fatigue.
  • Family presentation

    1. 1. Interventions for Geriatrics in Mental Health By: Amber Knight, Sibyl Kirkland, and Heather Zimmerman
    2. 2. Geriatrics • Population in United States 2012 – US residents age 65 and over: 41.4 million • Life expectancy – Men at 65 years: 17.7 years/Women at 65 years:20.3 years • Heath Status – Non-institutionalized persons age 65 and over in fair or poor health: 24.7% – Non-institutionalized s age 65 who needs help with personal care from others: 7.3% (CDC, 2012)
    3. 3. Geriatrics • Aging is not associated with significant cognitive decline, but minor memory problems can occur a normal part of aging. (Sadock & Sadock, 2008).
    4. 4. Neurocognitive Disorders • DSM – 5 defines the cognitive domains which identifies the criteria of the disorders , their levels and the subtypes to diagnosis. • Five domains includes: – – – – – – Complex attention Executive function Learning and memory Language Perceptual –motor Social cognition (American Psychiatric Association, 2013)
    5. 5. Neurocognitive Disorders • Delirium • Major & Mild Neurocognitive disorders – – – – – – – – – – Alzheimer’s disease Frontotemporal lobar degeneration Lewy body disease Vascular disease Traumatic brain injury Substance/medication use HIV Infection Prion disease Parkinson’s disease Huntington’s disease (American Psychiatric Association, 2013)
    6. 6. Dementia • Not a specific disorder but an universal term to describe the vast range of symptoms • Defined as an acquired, persistent , and progressive impairment in multiple cognition leading to significant functional decline. • 1 of 3 US residents 55 years of age and older & 1 of 5 at least 65 years of age by the year 2030. • Dementia prevalence increases with age – 5 % in 71 to 79 years of age – 37.4 % in 90 years of age and greater • “Elderly patients with dementia and other psychiatric disorders are most often cared for by their primary care.” (McCarron, Xiong, & Bourgeois, 2009)
    7. 7. Treatment • Early diagnosis and treatment of dementia is important to slow cognitive and functional decline. (McCarron, Xiong, & Bourgeois, 2009)
    8. 8. Delirium • Defined as an acute decline in attention and cognition , is a common, life-threatening and potentially preventable clinical syndrome in older adults. (Ramaswamy et al, 2010)
    9. 9. Characteristics • Rapid onset • Most common psychiatric syndrome in general medical setting and associated with significant mortality and morbidity both during and post hospitalization Results from urinary and upper respiratory infections, dehydration, and medicationrelated mishaps • Preventable and treatable • Not always transient and reversible (Tusaie & Fitzpatrick, 2013) (Ramaswamy, et al., 2010)
    10. 10. Additional Characteristics • Up to 2/3 of all cases of delirium in the elderly increases the risk for dementia. • More than 20% of hospitalized patients aged 65 years and older each year increases hospital costs by $2,500 per hospital stays. • Admission ranges 14% to 24% whereas incidence during hospitalization can be as high 56%. (Ramaswany et al, 2010)
    11. 11. Assessment Tool • Delirium Observation Screening Scale • CAM- Confusion Assessment Tool • CAM - ICU • Other tools: MDAS, ICDSC, Cognitive Test for delirium; DSI (Tusaie & Fitzpatrick, 2013)
    12. 12. Treatment • Non pharmacological strategies first line of treatment • Reorientation and behavioral intervention • Clear instructions with frequent eye contact with patients • Minimized sensory impairments in vision and hearing loss by providing the assist tools. • Avoid physical restraint ( decreases mobility, increased agitation, prolongs delirium • Limited room and staff changes provide a quiet setting with low level lightning at night. (Ramaswamy, et al., 2010) • Pharmacological • Haloperidol, Risperidone, Olanzapine, Quetiapine – widely used drugs for the treatment of delirium-related agitation • Lorazepam – Reserved for treatment of drug withdrawal, diffuse Lewy body disease • Use of drugs for hypoactive delirium must be warranted – Increase sedative effects (Ramaswamy, et al., 2010)
    13. 13. Alzheimer’s Disease • Defined as an degenerative progressive neuropsychiatric disorder resulting in global impairment of cognition, emotions, and behavior leading to physical and functional decline and death. (Tusaie & Fitzpatrick, 2012)
    14. 14. Characteristic • Insidious and progressive onset • Current estimates suggest that 1 in 8 persons over 65 have Alzheimer’s disease and a total of 5.3 million Americans have Alzheimer’s disease. (Alzheimer's, 2009) • 6th leading cause of death in the United States overall and 5th leading cause of death for those age 65 and older. (Alzheimer's Association, 2013)
    15. 15. Impact on Caregivers. • An estimated 11 million caregivers provide 12.5 billion hours of care each year to an estimated 5 million persons with dementia • 15.4 million caregivers provided more than 17.5 billion hours of unpaid care valued at $216 billion. • 40% to 70% of caregivers exhibit significant symptoms of depression, with 25% to 50% meet the criteria of major depressive disorder. (Alzheimer’s Association, 2011; Hoch, 2009; Nichols, Martindale-Adams, Burns, Graney, & Zuber, 2011 as cited in Easom, Alston, & Coleman, 2013) (Alzheimer's Association, 2013)
    16. 16. Screening Tools • • • • • • Folstein’s Mini Mental State Examination Short, Portable Mental Status Questionnaire Clock Draw Test Minicog MoCA Functional Assessment Screening Tool Tusaie&Fitzpatrick, 2013
    17. 17. Interventions • Safety Assessments • Care for Caregivers • Psychosocial – Cognitive rehabilitation, memory training, and engagement in pleasurable activities – Sensory stimulation – Recreational activities and social interaction – ABC behavioral model (McCarron, Xiong, & Bourgeois, 2009)
    18. 18. Treatment Cholinesterase Inhibitor (ChEIs) N-methyl-D-aspartate (NMDA) Donzepril(Aricept) Rivastigimine ( Exelon) Galantamine ( Razadyne) • Memantine ( Namenda) (McCarron, Xiong, & Bourgeois, 2009) (McCarron, Xiong, & Bourgeois, 2009)
    19. 19. Depression • 25% of patients with AD may experience major depression. • May contribute to cognitive impairments. • Dementia, delirium and depression are not mutually exclusive conditions all three conditions can be present in the same individual and any given time. • Increased risk for suicide if depression is not detected in older adults with chronic illness and those with new dx of dementia. (Sadock & Sadock, 2008) (McCarron, Xiong, & Bourgeois, 2009)& (Tusaie & Fitzpatrick, 2013)
    20. 20. Depression and the Older Adult • 15% of older adults have depressive symptoms • Age itself is not a risk factor • Being widowed or having a chronic illness increase risk for depressive disorder • Presenting symptoms in older adults may differ from those of younger adults • Increased emphasis on somatic complaints in older adults
    21. 21. Co morbidity of Depression • Co morbidity of depression with physical disorders is common • Negatively influences the course of the depression • Increases functional impairment, health costs, and use of health services • Common conditions associated with depression
    22. 22. Depression and Suicide • 20% is the suicide rate among older adults • White males over 85 have the highest suicide completion rates • Males over 80 take their lives at twice the rate of women • Over 70% of older suicide victims had had contact with PCP in the 3 months prior to the suicide
    23. 23. Risk Factors for Suicide Among Older Adults • Medication • Demographics • Clinical
    24. 24. Suicide Management in Older Adults • Promote connection with personal, family, and community to prevent suicide • Treatment doesn't differ from treatment in younger adults
    25. 25. Geriatric Depression Scale • Scales specific for adults 60+ • Available in long and short form • Can be downloaded at:
    26. 26. Treatment • Same medications are used just in lower dosages, emphasis upon self-efficacy, activities and social involvement in psychotherapy in the geriatric population. (Tusaie & Fitzpatrick, 2013)
    27. 27. Pharmacological Treatments • Treatment basically the same as in younger adults • Antidepressants • SSRIs and TCAs most common in older adults • Older adults are at increased risk for drug interaction • Lower doses of medication are needed
    28. 28. Non-Pharmacological • • • • • Cognitive Behavioral Therapy Cognitive Bibliotherapy Problem-Solving Therapy Brief Psychodynamic Therapy Reminiscence Therapy
    29. 29. Loss • Loss is an "absence of an object, position, ability, or attribute. –Loss of someone or something that is significant to that individual. –Independence (precious commodity, feel value less or useless) –Deprivation (fewer opportunities, physical frailty, shrinking of individual's feeling of competence and self-esteem (Ferrell & Coyle, 2006)(Harris, 2011)
    30. 30. Grief • Grief is a "person's emotional response to the event of loss"; " state of mental and physical pain that is experienced when the loss of significant object, person, or part of the self is realized". (Ferrell & Coyle, 2006)
    31. 31. Grief • Major categories of grief – anticipatory grief – uncomplicated grief – complicated grief – disenfranchised grief – Unresolved grief (Ferrell & Coyle, 2006)
    32. 32. Characteristics • Symptoms of grief • • • • Physical Cognitive Emotional Behavioral
    33. 33. Assessment • The bereaved are often exhausted and fatigue from caring for the love one who died and forgo their own needs. NP’s should – Inquire of routine physical exams, social networks, family roles, and major changes within self. – Be aware of clinical depression, prolonged deep grief, self destructive behavior, increased use of alcohol and/or drugs, preoccupation with the deceased to the exclusion of others. (Ferrell & Coyle, 2006)
    34. 34. Interventions • No medications exist to treat symptoms of grief because grief is not consider an illness. • Use of antidepressant and sleep medications may help with severe and complicated grief • Support Groups • Counseling (Rainer, 2013, p.56)
    35. 35. Anxiety and the Older Adult • Anxiety is a common and a major problem in older adults • Receives less attention then depressive disorders • 15.3% of adults over the age of 60 are diagnosed with anxiety disorders • In older adults anxiety is a risk factor for greater disability
    36. 36. DSM Anxiety Disorders in Older Adult • Most common – GAD – Phobias • Less common – OCD – Panic Disorders
    37. 37. Medical Co morbidities • Studies have shown an association between anxiety and medical illnesses including but not limited to: • • • • • • • Diabetes Dementia Coronary heart disease Cancer COPD gastrointestinal disorders Parkinson's disease
    38. 38. Anxiety and Depression • Anxiety in older adults often co-occurs with depression • 50% of older adults with depression had co morbid anxiety • An increased risk for poor outcomes in cases of co morbid anxiety and depression • Older adults with anxious depression report increased suicidality • Anxiety more commonly precedes depression
    39. 39. Diagnostic Difficulties • Medical Conditions • Dementia • Depression
    40. 40. Geriatric Anxiety Inventory • Specific scale for older Adults • Sound psychometric properties specific for older adults • 20 item self report • Greater then 10 “agrees” may indicate an anxiety disorder
    41. 41. Pharmacological Treatment • Use with caution in older adults • Benzodiazepines – Most common • Antidepressants – SSRIs – MAOIs – TCAs
    42. 42. Non-Pharmacological • Evidenced-based psychological treatments in older adults • Relaxation Training • Cognitive Behavioral Therapy (CBT) • Supportive Therapy
    43. 43. Behavioral Health and the Older Adult • Insomnia • Insomnia is one of the most dominant behavioral health issue that older adults face. • 30-60% of all older persons have one or more sleep complaint (McCurry, 2007) • Sleep complaints for most older adults include: – Difficulty falling and staying asleep – Early morning awakenings – Excessive day time sleepiness • – Day time fatigue (APA, 2005)
    44. 44. Behavioral Health cont….. DSM-5 Insomnia Disorders o Is defined as, “A predominant complaint of dissatisfaction with sleep quantity or quality” and is associated with one or more of the following features:  Difficulty initiating sleep  Difficulty maintaining sleep  Early morning awakenings
    45. 45. Diagnostic Considerations for the FNP – The sleep dysfunction causes distress and interruptions in ADLs – Sleep difficulty occurs for at least 3 times per week – Sleep difficulty occurs for at least 3 months – The insomnia can/cannot be attributed to substance abuse – The insomnia can/cannot be attributed to another illness or sleep disorder
    46. 46. Things to Remember…….. • Older adults tend to go to bed earlier and wake up earlier. • Life style changes can impact sleep • Sleep disturbances in older person in most cases is related to medical or psychiatric disorder (Tusaie & Fitzpatrick, 2013) • Comprehensive health history should be obtained, including but not limited to: physical health history and medication history
    47. 47. Non-Pharmalogical Treatments for Insomnia • Cognitive behavior therapy • Sleep hygiene instruction • Avoidance of stimulating substances (alcohol and caffeine) • Reduction of environmental and stimuli (Janicak, 2011) • These treatments may work better than pharmacological options due decreased metabolic processes of the older adult (APA, 2005)
    48. 48. Pharmacological Treatments for Insomnia • Benzodiazepines: doses should be low and length of treatment should be short. This is due to decreased drug clearance in older patients, Example: Triazolam • Zolpidem, zaleplon, eszopiclone, ramelteon (prescribe in low doses) • Older patients should be weaned from medication slowly
    49. 49. Substance Abuse in Older Adults • -Alcohol abuse is a significant problem for older Americans • -17% of older adults misuse an abuse drugs and alcohol • Alcohol abuse can cause: – – – – Cirrhosis Malnutrition Osteomalacia Cognitive decline • -4.4 million older adults are foreseen to need substance abuse treatment in 2020 (Gfroerer et al., 2003) • -“Polypharmacy” drug use • -Older adults may dependent on “pill taking” (Tusaie & Fitzpatrick, 2013)
    50. 50. DSM-5 Substance Related Disorders • Alcohol/Substance Abuse – Excessive use of alcohol leading to clinically significant impairment or distress for 12 months – Excessive use of substances such as opioids, hallucinogens, cannabis, tobacco, stimulants, etc., leading to clinically significant impairment or distress for 12 months
    51. 51. Symptoms and Diagnosing -Symptoms: Slurred speech -Diagnosing: • Severity: • Mild, Moderate, Severe • Remission: Incoordination • Early or sustained • Environment: Unsteady Gait • Controlled • Frequency of ingestion Nystagmus -Alcohol/Substance Withdrawal: • Signs and symptoms: Impairment in memory/attention • Nausea, vomiting insomnia, tachycardia, Stupor/Coma etc.
    52. 52. Diagnostic Considerations for the FNP – Comprehensive physical exam with medication history – Evaluate for underlying medical and psychological conditions – Situational sensitivity (Tusaie & Fitzpatrick, 2013)
    53. 53. Non-Pharmcalogical Treatments for Alcohol and Substance Abuse Cognitive Behavior Therapy • Health care professionals can help older adults boost their motivation to stop drinking, identify circumstances that trigger substance abuse, and learn new methods to cope with high risk drinking situations (APA, 2005)
    54. 54. Pharmacological Treatments for Alcohol and Substance Abuse – Precise history of drugs taken and pharmacies used by the older patient. This will help with identifying potential adverse drug reactions, and frequency of self-administration. – If any medications are prescribed the provider should be cognizant of decreased drug metabolism in older adults. – Antidepressants and anxiolytics are occasionally used in treatment • Dosing should be low • Treatment should be short (Tusaie & Fitzpatrick, 2013)
    55. 55. Chronic Illness, Mental Health, and the Older Adult • 85% of older adults have chronic illness • Chronic illness can be caused by alcohol and substance abuse, poor nutrition and inactivity (Speer, 2003) • Healthcare providers can help their patients cope effectively with: • Motivational interviewing • Cognitive behavior therapy
    56. 56. Pharmacological Treatments for Alcohol and Substance Abuse – Precise history of drugs taken and pharmacies used by the older patient. This will help with identifying potential adverse drug reactions, and frequency of self-administration. – If any medications are prescribed the provider should be cognizant of decreased drug metabolism in older adults. – Antidepressants and anxiolytics are occasionally used in treatment • Dosing should be low • Treatment should be short (Tusaie & Fitzpatrick, 2013)
    57. 57. Case Study • 73 year old woman who presents with 2 month history of tearfulness, loss of energy, apathy, inability to get out of bed in the morning, and insomnia with early morning awakenings. • She describes increasing anxiety, an inability to cope, forgetfulness, problems reading or even watching TV, a 30 lb weight loss and feels very constipated. • She expresses a concern that something is wrong with her stomach. Her lower back has also been bothering her more.
    58. 58. Case Study • She lost her husband 8 months ago and one of her children a little over 1 year ago. • She has a remote history of resected breast cancer and a more recent history of thyroid cancer which was resected 3 years ago. She also has a history of atrial fibrillation. • She has no past psychiatric history and has always been able to cope with difficulties until recently. • She is on Coumadin and a beta blocker.
    59. 59. Reference • • • • • • • • Alzheimer's Association. (2013, November 14). What is Dementia? Retrieved from Alzheimer's Association: American Psychiatric Association. (2013). American psychiatric association: desk reference to the diagnostic criteria from dsm-5. Arlington: American Psychiatric Association. Ayers, C. R., Sorrell, J. T., Thorp, S. R., &Wetherell, J L.. (2007). Evidence-based psychological treatments for late-life anxiety. Psychology And Aging, 22(1), 8-17. doi:10.1037/08827974.22.1.8 Cully, J. A., & Stanley, M. A. (2008). Assessment and treatment of anxiety in later life. In K. Laidlaw, B. Knight (Eds.) , Handbook of emotional disorders in later life: Assessment and treatment (pp. 233-256). New York, NY US: Oxford University Press. Ferrell, B. R., & Coyle, N. (2006). Textbook of Palliative Nursing. In I. B. Corless, Bereavement (pp. 531-544). New York: Oxford Univerity Press. Fong, T. G., Tulebaev, S. R., & Inouye, S. K. (2009). Delirium in elderly adults; diagnosis, prevention and treatment. Nature Reviews Neurology, 210-220. Gellis, Z.D. & McCracken, S.G. (2008). Anxiety disorders in older adults. In S. Diwan (Ed.), Mental Health and Older Adults Resource Review. CSWE Gero-Ed Center, Master's Advanced Curriculum Project. Gellis, Z.D. & McCracken, S.G. (2008). Depressive Disorders in Older Adults.. In S. Diwan (Ed.), Mental Health and Older Adults Resource Review. CSWE Gero-Ed Center, Master's Advanced Curriculum Project.
    60. 60. • • • • • • • • • • • • • Gfroerer, J., Penne, M., Pemberton, M., Folsom, R. (2003). Substance abuse treatment need among older adults in 2020: the impact of the aging baby-boom cohort, Drug and Alcohol Dependence, 69 (2), 127-135. Harris, D. L. (2011). Counting our losses. New York: Taylor & Francis Group. Janicak, P. G., Marder, S. R., & Pavuluri, M. N. (2011). Principles and practice of psychopharmacotherapy (5th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27 McCarron, R. M., Xiong, G. L., & Bourgeois, J. A. (2009). Lippincott's Primary Care:Psychiatry. Philadelphia: Lippincott Williams & Wilkins. McCurry, S. M., Logsdon, R. G., Teri, L., & Vitiello, M. V. (2007). Evidence-based Psychological Treatments for Insomnia in Older Adults. Psychology and Aging, 22(1), 18-27. Rainer, J. (2013). Life after loss. Eau Claire: PESI Publishing and Media. Ramaswamy, R., Dix, E. F., Drew, J. E., Diamond, J. J., Inouye, S. K., & Roehl, B. J. (2010). Beyond grand rounds: a comprehensive and sequential intervention to improve identification of delirium. The Gerontologist, 122131. Sadock, B. J., & Sadock, V. A. (2008). Concise Textbook of Clinical Psychiatry. Philadelphia: Lippincott Williams & Wilkins. Tusaie, K. R., & Fitzpatrick, J. J. (2013). Advance Practice Psychiatric Nursing. New York: Springer Publishing Company. Sadock, B. J. & Sadock, V. A. (2008). Kaplan & Sadock's concise textbook of clinical psychiatry (3rd ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins. Scogin, F., Welsh, D., Hanson, A., Stump, J., & Coates, A. (2005). Evidence-Based Psychotherapies for Depression in Older Adults. Clinical Psychology: Science And Practice, 12(3), 222-237. doi:10.1093/clipsy/bpi033 Wolitzky-Taylor, K. B., Castriotta, N., Lenze, E. J., Stanley, M. A., & Craske, M. G. (2010). Anxiety disorders in older adults: A comprehensive review.