9.3 Mental Health Disorders, Grief, and End-of-Life Care

Mental Health Disorders, Grief, and End-of-Life Care

Quick Answer: The CNA recognizes and reports changes in mood and behavior — they do not diagnose. Indiana CNA items test depression recognition, the four major mental health disorders (depression, anxiety, bipolar, schizophrenia), common defense mechanisms, the five Kubler-Ross grief stages, hospice philosophy, signs of impending death, and post-mortem care steps.

The Mental Health & Psychosocial domain (8% of the written exam) expects you to distinguish normal aging and grief from clinical disorders, to know when to report, and to deliver end-of-life care with dignity. The single rule that runs through every question: a CNA reports, never diagnoses.

Depression

Depression is the most common mental health disorder in older adults and the most-tested mental health topic on the Indiana CNA exam. In long-term care it is frequently underrecognized because the symptoms in older adults differ from the classic "sadness" picture.

The CNA role is to observe and report any of these signs — particularly a sudden change after a loss, move, illness, or medication change. Report to the nurse objectively ("Mr. Lee has not eaten more than half his tray for three days and stays in his room with the lights off"); do not add a diagnosis (do not say "Mr. Lee is depressed").

Trap to remember: A common exam bait offers a depressed resident and asks what the CNA should do. The answer is report to the nurse, not "tell the resident to cheer up," not "suggest the resident join an activity," and not "ask the resident about their childhood." Listening and reporting are the CNA role; treatment decisions belong to the nurse, physician, and care team.

Suicide Risk in Older Adults

Older men, particularly those with recent loss, chronic illness, or new disability, have the highest suicide rate of any age group. Report any talk of death, giving away possessions, sudden calm after a period of depression, or a statement like "I'm a burden." Stay with the resident and notify the nurse immediately. Never leave a suicidal resident alone.

Anxiety Disorders

Anxiety in older adults shows as restlessness, pacing, trembling, sweating, rapid heartbeat, or excessive worry about health or family. Panic attacks can mimic heart attack symptoms (chest pain, shortness of breath). The CNA response:

1. Stay with the resident and speak calmly
2. Reduce stimulation (dim lights, quiet the room)
3. Encourage slow breathing
4. Report to the nurse — anxiety can be a sign of hypoxia, pain, infection, or a medication effect, not just a primary anxiety disorder

Bipolar Disorder

Bipolar disorder involves swings between mania (elevated mood, little need for sleep, rapid speech, impulsive or risky behavior, grandiosity) and depression. A CNA caring for a resident in a manic phase may see:

• Talking rapidly and loudly, jumping between topics
• Refusing to sleep, pacing at night
• Overeating or not eating
• Intrusive behavior toward other residents
• Disinhibition — undressing, making inappropriate comments

Report changes in mood and behavior to the nurse. Protect other residents from intrusive behavior by redirecting the manic resident to a quieter space. Do not argue; mania is not a discipline problem.

Schizophrenia

Schizophrenia involves positive symptoms (hallucinations, delusions, disorganized speech) and negative symptoms (flat affect, withdrawal, lack of motivation, poor self-care). The CNA role:

• Do not argue with delusions or validate hallucinations as real — stay calm, redirect, and ensure safety
• Watch for medication side effects (stiffness, tremor, shuffling gait — signs of extrapyramidal effects; report to the nurse)
• Encourage self-care and ADL participation; negative symptoms can look like laziness but are not
• Report any new or worsening hallucination, especially command hallucinations (voices telling the resident to hurt themselves or others)

Defense Mechanisms

Defense mechanisms are unconscious ways the mind copes with stress. The exam tests the following by name:

Recognizing defense mechanisms helps the CNA understand behavior without taking it personally (the resident shouting at you is displacing anger — it is not about you) and guides the report to the nurse.

Grief — the Kubler-Ross Stages

Elisabeth Kubler-Ross described five stages of grief, originally for the dying person and later applied to any loss (a spouse, independence, a home, a diagnosis). The stages are not linear and a resident may revisit any stage at any time.

Trap to remember: The exam tests the order of the five stages (denial → anger → bargaining → depression → acceptance) and the fact that residents do not move through them in order and may revisit stages. A resident can be in anger one morning and acceptance that afternoon, or bounce between bargaining and depression for weeks. Both are normal.

Hospice Care

Hospice is comfort-focused (palliative) care for residents with a life expectancy of 6 months or less if the disease runs its usual course. Hospice may be provided in the facility, at home, or in a dedicated hospice unit. Care focuses on symptom relief, pain control, emotional and spiritual support, and dignity — not cure. Curative treatments are stopped; the care plan shifts to comfort.

The CNA role in hospice:

• Mouth care every 2 hours — dry mouth is a major comfort issue; use swabs and water or the facility's moistening product
• Turn and reposition every 2 hours to prevent pressure injuries and promote comfort
• Pain observation — watch for nonverbal cues (grimacing, restlessness, guarding) since a dying resident may not ask for pain medication; report to the nurse
• Family support — offer water, a chair, and presence; listen; do not counsel or preach
• Respect rituals — clergy, prayer, music, family at bedside per the resident's and family's wishes
• Do not call it "giving up" — hospice is active comfort care, not abandonment

Signs of Impending Death

As death approaches (hours to days), the body shows predictable changes. The CNA observes and reports these; they are expected, not emergencies to fix.

Trap to remember: Hearing is often the last sense to go. Continue to speak to the dying resident, identify yourself before touching, and never talk about the resident over them as if they are not there. Family should be encouraged to say what they need to say.

Post-Mortem Care

After the nurse has pronounced death and the family has had private time (per facility policy), the CNA performs post-mortem care. The goals are dignity, infection control, and preparation for the funeral home. Steps:

1. Confirm the nurse has pronounced death and the family has finished their visit before starting
2. Gather supplies — gown, gloves, wash basin, washcloths, towels, plastic bag for soiled items, clean gown or shroud
3. Perform hand hygiene and don gloves and gown — standard precautions apply even after death
4. Close the resident's eyes gently if still open; position the body flat and straight (arms at sides, legs straight) to prevent rigor mortis from fixing the body in a curled position
5. Remove jewelry and dentures per facility policy — dentures may be left in for viewing; follow the policy exactly
6. Wash the body — face, arms, chest, abdomen, legs, back, perineal area; remove any tubes or dressings per facility policy and order
7. Apply a clean gown or shroud; place a waterproof pad under the body
8. Tie a identification tag to the body (and a second to the shroud or wrist) per facility policy
9. Lower the head of the bed flat and raise the side rails; place a pillow under the head
10. Remove equipment and supplies; bag soiled linens per isolation precautions; perform hand hygiene
11. Document per facility policy — time of care, who performed it, any observations (such as jewelry removed and to whom it was given)
12. Provide privacy and support — keep the room respectful; offer family the chance to return if they wish

Post-mortem care is not "just cleaning." It is the last dignity a CNA can give. Treat the body with the same respect as a living resident — knock before entering, close the curtain, do not discuss the death within earshot of other residents, and never let other residents see the body being transported.

Trap to remember: A resident's right to dignity and privacy does not end at death. Rolling the body roughly, leaving the door open during care, or discussing the death in the hallway are violations of OBRA resident rights and can be cited by surveyors.