Introduction
The needs of the elderly are now among the key concerns for the medical practitioners and counselors. Today, the life expectancy in developed countries for all genders and races is close to 80 years, and it is projected to grow further in the next years and decades. An increase in life expectancy in the second half of the 20th century is usually attributed to the improvement of health management in the older population (ONS, 2015). Today, people are expected to live longer and be healthier in the later stages of life; however, the older age is still associated with health and social issues that affect the quality of life in older adults.
Gerontological Counseling is now essential, as it can help the people to cope with the changes in their lives. However, many concerns are pertaining to the practice of any gerontological counselor. Among the key issues are the neurodegenerative conditions that lead to cognitive impairment. It is important for the counselor to understand the specifics of these conditions and to be aware of the ethical and operational issues that may be encountered in treating such patients.
Historical Perspective
Historical perspective on gerontology and aging in general, as well as on the neurodegenerative conditions that affect cognitive function is an interesting topic, particularly as the study of these areas has not been a major focus of researchers until the second half of the 20th century. Smith (2014) provides a useful overview of how the knowledge of the older age and the issues associated with aging developed over time in the United States.
The National Institute of Health was established in 1930; however, the gerontology branch has not become part of it until 1948. Smith (2014) explains that at that time, gerontology was viewed as a supplementary discipline rather than an independent one: even though some argued for the establishment of a separate Institute of Aging, these efforts turned out to be futile when a physician to the Senate insisted that there was no need to research aging and older adult health specifically. Further discussion has lasted over 25 years, and the National Institute on Aging (NIA) was only established in 1974. Active research on gerontology began when the Adult Development and Aging branches of the Gerontology Research Center became core parts of the newly established NIA in 1975 (Smith, 2014).
The study of neurodegenerative conditions affecting older adults developed gradually after the establishment of the NIA and its research center. For instance, in 1982, the NIA Laboratory of Neurosciences Clinical Program began admitting older adults for inpatient treatment, and in 1984, the first Alzheimer’s Disease Centers were introduced (Smith, 2014). The NIA’s program for Alzheimer’s Disease Education and Referral (ADEAR) was among the first significant steps in the development of our understanding of neurodegenerative conditions, as it was designed to spread knowledge regarding the Alzheimer’s disease to medical practitioners and the public.
Despite the numerous studies and the substantial body of research on these conditions, the guidelines for diagnostics and practice were not frequently updated. For example, Smith (2014) states that the first effort to update the diagnostic guidelines for Alzheimer’s disease were led in 2011, over 27 years after their initial publication. Massano and Bhatia (2012) note the same trend in Parkinson’s disease research: although it was published 300 years ago, “the original clinical description of the disease remains a landmark reference” (p. 1).
However, this is understandable, as the development of new research and ideas regarding diagnostics, prevention, and treatment correlates with the development of medical technology and education. Looking at Smith’s (2014) summary of the historical perspective on gerontology, it is clear that the majority of promising studies of neuroscience in gerontology began after the 2000s. For example, the National Alzheimer’s Project Act was initiated in 2011 as “a coordinated national effort to find ways to treat or prevent Alzheimer’s disease and related dementias and to improve care and services” (Smith, 2014, p. 24). Similarly, Massano and Bhatia (2012) explain that there are many prospective topics of research regarding Parkinson’s disease that have not been explored yet.
Overall, gerontology and aging research are relatively new topics that only emerged towards the end of the twentieth century as part of the struggle for human rights and equal treatment. Therefore, the body of knowledge regarding neurogenerative conditions affecting the older populations is likely to expand dramatically in the next few decades. Being conscious of the current developments is crucial for a gerontological counselor, as new research may indicate appropriate practices and provide guidelines for treatment and management of these conditions that will help to improve the quality of patients’ lives.
According to Mulley (2012), other notions can be observed while exploring the history of gerontology and aging research. For example, the author argues that the past studies indicated that the clinical presentation of diseases might vary between the people of the older age, which stresses the importance of an individual approach to each patient. Secondly, Mulley (2012) argues that political interference and social discrimination affects most older adults and may be especially harmful to those suffering from chronic conditions. This highlights the counselor’s role in helping the patient to mediate the negative effect of the socio-political environment on his or her life and the importance of advocating for the needs of elderly patients both on a personal and on a global level.
Lastly, Mulley (2012) explains that the observation of previous studies indicates that lifestyle plays an important part in the quality of life of the elderly. This trend is also relevant to those living with neurodegenerative conditions, as some studies suggest that healthy eating and exercise may have a mediating effect, halting the neurodegeneration and supporting healthy cognitive function (Farooqui & Farooqui, 2015), which is why gerontological counselors need to promote lifestyle changes among their patients.
Current Knowledge of Neurodegeneration and Cognitive Impairment
Cognitive impairment is characterized by “a progressive and devastating reduction in most cognitive abilities, functional independence, and social relationships” (Peracino & Pecorelli, 2016). The current knowledge on the topic suggests that chronic brain diseases, including Parkinson’s and Alzheimer’s diseases, as well as the natural aging of the brain, can lead to various degrees of cognitive impairment.
For example, a study by Draganski, Lutti, and Kherif (2013) shows that physiological aspects of brain structure have a differential effect on the development of cognitive impairment, which opens new opportunities for research on diagnostics and prevention of cognitive functioning difficulties. The changes to brain structure can be a result of both natural and pathological causes, although natural brain aging is usually associated with mild cognitive impairment, whereas pathological neurodegeneration may lead to a severe decline in cognition. Mild cognitive impairment (MCI) is evident in 10-20% of adults over 65 years of age (Langa & Levine, 2014).
It is characterized by the decline of one or more cognitive domains, such as memory, language, attention, visuospatial skills, or executive function (Langa & Levine, 2014). One of the crucial aspects of MCI is that the patients preserve the independence and can perform functional tasks without assistance; they can also perform their occupational duties and lead normal social lives (Langa & Levine, 2014).
These characteristics of the patient’s condition are especially important to gerontological counseling, as they determine the patient’s needs. Therefore, a gerontological counselor must be aware of the differences in cognitive function between the various stages of cognitive impairment to provide effective care and support. It is important to understand that the differences in cognitive impairment are individual and not condition-specific. For instance, patients with Parkinson’s disease may exhibit a variety of forms of cognitive impairment, affecting their functioning in different ways (Ding, Ding, Li, Han, & Mu, 2015).
The current knowledge on the issue of cognitive impairment also suggests that people who develop cognitive impairment in the older age share similar characteristics that can be designated as risk factors. For example, Zhuang et al. (2012) suggest that living alone and having more children may cause CI symptoms to appear earlier or be more severe. Similar trends are associated with diabetes and obesity (Zhuang et al., 2012). On the other hand, people with higher levels of education and stable marriage, as well as those who live a healthy lifestyle are less prone to develop CI (Zhuang et al., 2012). These findings are also important to the counselors as they indicate personal characteristics that may lead to the development of cognitive impairment or higher severity of the symptoms.
Gerontological Counseling
Key Needs
Patient and Family Needs
As indicated above, patients with various degrees of cognitive impairment can suffer from functional difficulties, memory loss, a decline of visuospatial abilities, and more. The reduction of cognitive function is traumatizing both for the patient and for their families, which leads to other difficulties that must be addressed by the counselor. For instance, patients with known cognitive impairment diagnosis may develop anxiety, depression, and fear of social isolation and abandonment (Borson et al., 2013). Patients’ families, on the other hand, may develop anxiety because of the need to care for the older adult or due to their inability to provide the required support and assistance. Both patient and family factors can severely affect the quality of the patient’s life. Gerontological counseling can help in mediating the social consequences of the diagnosis and in building a solid, supportive connection between patients and their families.
Social Needs
According to Kennedy and Arthur (2014), social justice is also among the key concerns of the counselors: “Counselling psychology, with its focus on domains such as health and wellness-promotion, psychoeducation, illness prevention, and remediation of client concerns, is in a strong position to lead psychology toward taking a stance on social justice” (p. 187). Older adults with cognitive impairment may become subject to social injustice, which will have an adverse effect on their mental health and quality of life and may increase the symptoms of anxiety and depression due to the diagnosis. By promoting social justice both in their practice and in a larger social setting, gerontological counselors can help people with cognitive impairment to live more fulfilling lives.
Multiculturalism
The process of globalization has led to the growing multiculturalism of Western and European societies. For many people of the minority ethnic and racial backgrounds, this may lead to issues such as discrimination and stigmatization. For older adults with cognitive impairment, this adds to the existing discrimination based on their condition. Patients from minority religious and ethnic backgrounds need a multicultural approach to counseling, which would take into account the issues they face daily, including negative societal labeling, lack of support from government and state entities, and social pressure (Aga Mohd Jaladin, 2013). Knowledge of the target culture and empathy, as well as further multicultural training and guidance, is required for the counselors to be effective in treating patients with a variety of backgrounds (Pedersen, Lonner, Dragnus, Trimble, & Scharron-del Rio, 2015).
Key Issues
Introduction of New Programs
The evaluation of every new program and model for counseling becomes more difficult due to the variation in the clients’ needs. For instance, different programs and approaches are required for people with varying degrees of cognitive impairment. Furthermore, a variety of supporting patient issues, such as depression, anxiety, and fear of social exclusion, need to be reflected in the new models and programs, which creates additional concerns. Mental health and psychosocial variables, including cultural backgrounds, also have to be addressed to avoid cultural bias or exclusion (McBride & Hays, 2012). The new programs and models have to be developed in accordance with the changing needs of the target population in order to be effective in supporting patients with cognitive impairment.
One of the possible ways to address some of the issues is by focusing on programs that provide additional training for counselors. For instance, multicultural counseling clearly requires a separate training course to ensure that the counselors are properly equipped to support people from a variety of backgrounds. Such programs would have to target the challenges related to counselor characteristics, such as “language barrier, lack of experience and exposure to diverse cultures, perceived multicultural incompetence and counselors’ value conflicts” (Aga Mohd Jaladin, 2013, p. 179). Knowledge related to culture-specific characteristics, on the other hand, could assist the counselors in responding to client challenges, including the lack of trust towards a counselor from a different culture, misconceptions or prejudice related to counseling in general, as well as the conflict between the client’s cultural values and personal needs (Aga Mohd Jaladin, 2013).
Ethical Issues
The American Counseling Association’s Code of ethics provides a useful overview and guidelines on the ethical issues associated with counseling. Nevertheless, when it comes to gerontological counseling and the treatment of people with cognitive impairment, some ethical issues remain to be solved. For instance, the ACA (2014) considers patient privacy and confidentiality to be among the key ethical values in counseling.
However, such an approach may harm the counselor’s effectiveness when dealing with patients with cognitive impairment. For example, to help the patient and his or her family to establish a supportive relationship in spite of the condition, the counselor may have to explain the patient’s concerns to the family members to avoid misunderstanding and provoke empathy. Privacy and confidentiality rules established by the ACA (2014), however, instruct to only share information with sound legal or ethical justification or with the patient’s consent. Depending on the severity of cognitive impairment, it may be impossible to obtain informed consent from the patient, which may lead to a decrease in counseling effectiveness.
Another ethical concern that affects today’s counseling practice is multiculturalism. As explained above, patients from different cultural backgrounds may have views that conflict with the counselors. The ACA (2014) emphasizes the value of multicultural competency and respect for different cultural values. However, there may be cases where the patient’s cultural values may affect his or her end of life decisions; for instance, in certain cultures, cognitive impairment is viewed as a dishonorable disease and the patient may be inclined to commit suicide before the condition worsens. On the one hand, by the ACA (2014), the counselor would have to report about harmful patient intentions; on the other hand, however, doing so would disrespect the client’s cultural beliefs.
Conclusion
Overall, both in the cognitive impairment counseling and in the general gerontologic counseling, it is crucial for the professionals to advocate for the needs of clients and to promote practices that support those needs on both personal and global levels. Due to the variety of challenges associated with this type of care, there are many ways in which such advocacy can be achieved. First, the counselor has to be aware of the current trends in care and diagnostics that relate to cognitive impairment and associated conditions. Secondly, the counselor should promote evidence-based practices to clients and other professionals, thus increasing their competency in responding to health challenges posed by cognitive impairment.
Moreover, the counselor should strive for continuous education on all the issues pertaining to the target client population. Finally, each mental health professional should understand the importance of an individual, patient-centered approach to care. Careful application of knowledge to each patient will ensure the effectiveness of therapy in responding to the client’s needs.
References
Aga Mohd Jaladin, R. (2013). Barriers and challenges in the practice of multicultural counselling in Malaysia: A qualitative interview study. Counselling Psychology Quarterly, 26(2), 174-189. Web.
American Counseling Association (ACA). (2014). 2014 ACA Code of Ethics. Web.
Borson, S., Frank, L., Bayley, P. J., Boustani, M., Dean, M., Lin, P. J.,… & Stefanacci, R. G. (2013). Improving dementia care: The role of screening and detection of cognitive impairment. Alzheimer’s & Dementia, 9(2), 151-159. Web.
Ding, W., Ding, L. J., Li, F. F., Han, Y., & Mu, L. (2015). Neurodegeneration and cognition in Parkinson’s disease: A review. European Review for Medical and Pharmacological Sciences, 19(12), 2275-2281. Web.
Draganski, B., Lutti, A., & Kherif, F. (2013). Impact of brain aging and neurodegeneration on cognition: Evidence from MRI. Current Opinion in Neurology, 26(6), 640-645. Web.
Farooqui, A. A., & Farooqui, T. (2015). Diet and exercise in cognitive function and neurological diseases. Hoboken, NJ: John Wiley & Sons. Web.
Kennedy, B. A., & Arthur, N. (2014). Social justice and counselling psychology: Recommitment through action. Canadian Journal of Counselling and Psychotherapy, 48(3), 186-205. Web.
Langa, K. M., & Levine, D. A. (2014). The diagnosis and management of mild cognitive impairment: A clinical review. JAMA, 312(23), 2551-2561. Web.
Massano, J., & Bhatia, K. P. (2012). Clinical approach to Parkinson’s disease: Features, diagnosis, and principles of management. Cold Spring Harbor Perspectives in Medicine, 2(6), 1-16. Web.
McBride, R. G., & Hays, D. G. (2012). Counselor demographics, ageist attitudes, and multicultural counseling competence among counselors and counselor trainees. Adultspan Journal, 11(2), 77-88. Web.
Mulley, G. (2012). A history of geriatrics and gerontology. European Geriatric Medicine, 3(4), 225-227. Web.
Office for National Statistics (ONS). (2015). How has life expectancy changed over time? . Web.
Pedersen, P. B., Lonner, W. J., Draguns, J. G., Trimble, J. E., & Scharron-del Rio, M. R. (Eds.). (2015). Counseling across cultures. Thousand Oaks, CA: SAGE. Web.
Peracino, A., & Pecorelli, S. (2016). The epidemiology of cognitive impairment in the aging population: Implications for hearing loss. Audiology and Neurotology, 21(1), 3-9. Web.
Smith, P. R. (2014). A historical perspective in aging and gerontology. In Vakalahi, H.F.O., et al. (Eds.), The Collective Spirit of Aging Across Cultures (pp. 7-27). Dordrecht, Netherlands: Springer. Web.
Zhuang, J. P., Wang, G., Cheng, Q., Wang, L. L., Fang, R., Liu, L. H.,… & Tang, H. D. (2012). Cognitive impairment and the associated risk factors among the elderly in the Shanghai urban area: A pilot study from China. Translational Neurodegeneration, 1(1), 22-26. Web.