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GERIATRIC MENTAL HEALTH 101

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Depression and anxiety are major contributors to social isolation and high suicide rates ... Note: Suicide among Am Indian/AK Native population at 80 years and ... – PowerPoint PPT presentation

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Title: GERIATRIC MENTAL HEALTH 101


1
GERIATRIC MENTAL HEALTH 101
  • A Presentation
  • By
  • Michael B. Friedman, LMSW
  • Chairperson
  • The Geriatric Mental Health Alliance of
  • New York

2
Why Geriatric Mental Health Is Important
  • Mental Disorders Are a Major Impediment to Living
    Well in Old Age.
  • Losing ones mind or getting Alzheimers
    disease is a major fear about aging
  • Mental illness has a terrible impact on health
  • Depression and anxiety are major contributors to
    social isolation and high suicide rates

3
Importance of Geriatric Mental Health (Cont.)
  • Mental and behavioral disorders of older adults
    and/or family caregivers are major contributors
    to unnecessary placement in institutions.
  • Most mental disorders are treatable.

4
Why Geriatric Mental Health is Often Neglected in
Practice and in Policy
  • Ageism
  • Belief that mental illness especially
    depression is normal in old age
  • Stigma
  • Shame about being mentally ill
  • Ignorance
  • About mental illness
  • About effectiveness of treatment
  • About where to get help

5
The Population of People 65 In The US Will
Double from 35-70 Million Over the Next 25 Years
Source U.S. Bureau of the Census. (2000).
Population projections of the United States by
age, sex, race and hispanic origin 1995- 2050,
Current Population Reports, P25-1130.
6
Demographics
  • US
  • Increase from 13-20 of the population
  • 5 decline of working age adults
  • Adults age 85 and over will more than double
  • Majority of older adults will be ages 65-74
  • Minority population of elderly population will
    grow from 16 to 25
  • NYS
  • Disproportionate increase in ages 80

7
THE NUMBER OF OLDER ADULTS WITH MENTAL ILLNESS IN
THE UNITED STATES WILL DOUBLE FROM 2000 TO 2030.
Sources U.S. Department of Health and Human
Services, Mental Health A Report of the Surgeon
General (Rockville, MD 1999). U.S. Bureau of
the Census. (2000). Population projections of the
United States by age, sex, race and hispanic
origin 1995-2050, Current Population Reports,
P25-1130.
8
Prevalence Varies By Age
Adults 18-54
Older Adults 55
This does not include minor depression. 25-30
of older adults have symptoms of
depression. NOTE These figures represent the
prevalence of mental disorders in a 1-year
period. NOTE The percentages do not add up to
100 due to co-occurring disorders. Source U.S.
Department of Health and Human Services, Mental
Health A Report of the Surgeon General
(Rockville, MD 1999).
9
Heterogeneous Population
  • Long-term psychiatric disabilities
  • Late life psychotic conditions
  • Dementia
  • Severe anxiety, depressive, and paranoia
  • Less severe anxiety and mood disorders
  • Addictive disorders lifelong and late life
  • Emotional problems related to aging

10
Long-Term Psychiatric Disabilities
  • Usually develop prior to 30 some in late life
  • Diagnoses include
  • Schizophrenia
  • Treatment refractory mood disorders
  • Involve severe functional impairment
  • Some people experience recovery over time
  • High risk for obesity, hypertension, diabetes,
    heart and pulmonary conditions
  • High rates of suicide and accidents
  • Premature mortality 10 TO 25 YEARS

11
Treatment of Long-Term Psychiatric Disabilities
  • Service Needs
  • Atypical Anti-Psychotic Medications
  • Effective but
  • Side effects include obesity and diabetes
  • Stable housing
  • Rehabilitation
  • Wellness and Healthcare

12
Late Life Psychotic Conditions
  • Major thought and/or perceptual disorders such as
    hallucinations and/or delusions
  • Difficulty grasping reality
  • Functional impairment
  • Transient, recurrent, or long-term
  • SPMI Look-alikes

13
Treatment Of Psychotic Disorders
  • Inpatient and Outpatient Treatment
  • Medication
  • Supportive Psychotherapy
  • Day Programs
  • Social Supports in-home care, case management,
    housing/residential care, relationships, and
    activities

14
Dementia
  • Alzheimers disease most common form (70)
  • Memory loss reduced cognitive functioning
  • Progressive decline
  • Depression and/or anxiety are common during early
    and mid phases

15
Prevalence of Dementia Doubles Every 5 Years
Beginning at 60
Sources U.S. Department of Health and Human
Services, Mental Health A Report of the Surgeon
General (Rockville, MD 1999). Cummings, Jeffrey
L. and Jeste, Dilip V. (1999) Alzheimers Disease
and Its Management in the Year 2010. Psychiatric
Services. 509, 1173-1177
16
Treatment of Dementia
  • Early and differential diagnosis is critical.
  • New medications slow deterioration due to
    dementia.
  • Anxiety and/or depression are commonplace in
    early and mid stages.
  • Effective treatment of depression can improve
    cognitive functioning.
  • Support for family caregivers helps them and
    delays nursing home placement.

17
Major Depression
  • Not just sadness
  • Cardinal symptoms Deep sadness with sense of
    hopelessness or loss of interest and pleasure in
    life
  • Other symptoms
  • Changes in patterns of sleep, eating, or
    activity,
  • Difficulty concentrating
  • Frequent thoughts of death or suicide,
  • Low sense of self-worth
  • Need 5 in total

18
Prevalence of Depression
  • Major depression 5
  • Minor depression 10
  • Symptoms of depression 25-30
  • Higher rates of major depression among younger
    cohorts 7
  • DEPRESSION IS NOT NORMAL
  • IN OLD AGE

19
Treatment of Depression
  • Strong evidence-base for
  • Screening, such as PHQ-9
  • Anti-Depressant Medications
  • Psychotherapy
  • Cognitive-behavioral
  • Problem-solving
  • Interpersonal
  • Psychosocial Interventions, e.g. care management,
    exercise, activity, relationships, dealing with
    real life problems such as finding appropriate
    housing

20
Older Adults Complete Suicide Nearly 50 More
Than the General Population
Source Mortality Reports. National Center for
Injury Prevention and Control. Centers for
Disease Control and Prevention. http//www.cdc.go
v/ncipc/wisqars/
21
White Males 85 Complete Suicide Nearly 6x the
General Population
Note Suicide among Am Indian/AK Native
population at 80 years and above is virtually
non-existent.
Source Mortality Reports. National Center for
Injury Prevention and Control. Centers for
Disease Control and Prevention, http//www.cdc.go
v/ncipc/wisqars/
22
Suicide Prevention
  • Identification of risk by Gatekeepers
  • Primary care physicians
  • Home health providers
  • Social service workers
  • People in the neighborhood
  • Outreach to those at risk
  • Depression treatment and care management
  • Public education

23
Anxiety
  • Prevalence 11-12 (most common mental disorder)
  • Ranges from extreme worry-warts to extreme
    suspiciousness to those too frightened to leave
    home
  • Consensus regarding effectiveness of
  • Medications
  • Psychotherapy
  • Cognitive-behavioral therapy
  • Problem-solving therapy
  • Psychosocial Interventions

24
Addictive disorders
  • 17 have substance use problems
  • Lifelong vs. Late life
  • Very few heavy, lifelong alcohol or illegal drug
    abusers survive into old age
  • Methadone
  • MOSTLY ALCOHOL AND/OR MEDICATIONSESP. TO MANAGE
    PAIN
  • Gambling

25
Treatment of Addictive Disorders
  • Screening, esp. in primary care
  • Brief motivational or cognitive-behavioral
    therapies non-confrontational
  • Medications e.g. naltrexone, acamprosate,
    buprenorphine
  • Detoxification Outpatient/Inpatient
  • Rehabilitation Community-based or residential
  • Mutual aid/self-help e.g. AA

26
Emotional Challenges Adjusting to Old Age
  • Role changes e.g. retirement
  • Loss of status
  • Diminished (but not lost) physical and mental
    skills
  • Losses of family and friends
  • Confronting death

27
Coping With Transition
  • Planning for retirement
  • Meaningful activities (paid or volunteer work,
    physical or creative activities)
  • Relationships (family, friends,
    intimateincluding sexualrelationships)
  • Spiritual matters
  • Get help when needed
  • Homecare
  • Elder care
  • Assisted living and lifecare communities

28
Behavioral Problems Often Lead to
Institutionalization
  • Distrust/paranoia,
  • Rejection of help
  • Non-adherence to treatment
  • Belligerence/abusiveness,
  • Dangerous Behaviors e.g. Leaving stove on,
    smoking in bed
  • Hoarding
  • Wandering
  • Annoying behavior e.g. frequent complaints,
    repetitive questions

29
Treatment of Behavior Problems
  • Very careful use of psychotropic medications
  • Skilled, humane interaction
  • Respect for clients as human beings
  • Effort to understand clients motivation
  • Careful listening
  • Time and patience
  • Design of living settings to encourage
    alternatives to wandering or to doing nothing

30
Only 40-45 of older adults with a mental or
substance use disorder get treatment
  • More than 20 of older adults have a diagnosable
    mental or substance abuse disorder
  • 40-45 get treatment

31
  • Treatment of Mental Illness
  • Among Older Adults

Source U.S. Department of Health and Human
Services, Older Adults and Mental Health Issues
and Opportunities (Rockville, MD 2001).
32
Low Utilization of Mental Health Professionals
  • More than half of those who get treatment get it
    from primary care physicians 12.7 minimally
    adequate treatment
  • Fewer than 25 get treatment from mental health
    professionals 48.3 minimally adequate
    treatment

33
Vast shortage of geriatric mental health
professionals, now and in the future.
Sources Halpain, Maureen C.et al. (1999).
Training in Geriatric Mental Health Needs and
Strategies. Psychiatric Services. 509,
1205-1208. Jeste, Dilip V. et al. (1999).
Consensus Statement on the Upcoming Crisis in
Geriatric Mental Health. Archives of General
Psychiatry, 56, 848-853.
34
Thanks to Family Caregivers The Vast Majority of
Older Adults Live in the Community
  • 92 of geriatric patients/older adults live in
    the community
  • Most are not disabled
  • 80 of disabled older adults are cared for by
    family caregivers
  • High risk of stress, depression, anxiety and
    physical illness
  • The national economic value of informal
    caregiving was 196 billion in 1997. (360
    billion in current dollars)
  • Family as workforce

35
Support of Family Caregivers Reduces Their Mental
and Physical Problems and Delays Placement in
Nursing Homes
  • Mittelman Model
  • Counseling
  • Family Counseling
  • Support Groups
  • Responsiveness to CRISIS
  • Respite
  • Psycho-education for caregivers
  • Elder care managers
  • Financial support such as tax relief

36
Co-Morbidities Are Virtually Universal
  • Most older adults have chronic physical
    conditions, including those with mental
    disorders.
  • People with serious mental illness are
  • At high risk of obesity, hypertension, diabetes,
    cardiac, and respiratory problems
  • Have 10-25 years lower life expectancy.

37
Co-Morbidities are Virtually Universal (cont.)
  • People with serious chronic health conditions
    (such as diabetes, heart disease, and
    neuromuscular disorders) are at high risk of
    anxiety and/or depression which increase
    disability, mortality, and health care costs.

38
Integrating Mental Health into Primary Care
  • Well-trained primary care providers
  • Co-location
  • Integrated teams
  • Disease/care management (e.g. Impact, Prism-E,
    Prospect, and Respect-D.)
  • Telepsychiatry (using telephone or video
    conferencing for consultation, assessment, or
    treatment)

39
Integrating Health Into Mental Health
  • Health care in mental health clinics
  • Health satellites in mental health programs
  • Special health clinics for people with mental
    illness and/or substance abuse disorders
  • Formal or informal networks
  • Disease management
  • Wellness and self-management

40
Integrating Mental Health into Long-Term Care
  • Specialized home health care
  • Specialized adult medical day care
  • Improved mental health services in adult homes
    and nursing homes

41
Integrating Mental Health And Aging Services
  • Community Gatekeepers
  • Screening in senior centers, NORCs, social adult
    day programs, and case management
  • Neighborhood-based networks (formal or informal)
  • On-site treatment services in community settings
  • Activity and socialization promote mental health

42
How YOU Can Help Direct Service
  • Get trained
  • Provide outreach and public education
  • Use screening, assessment, and treatment model
  • Provide home and community-based services
  • Develop working relationships across
    systemsespecially informally
  • Learn how to get the most out of current funding
    streams (especially Medicare)

43
How YOU Can Help Local Systems
  • Develop cross-system coalitions or alliances
  • Local planning
  • Collaborative program development
  • ADVOCACY FOR POLICY CHANGE
  • Establish cross-systems networks to handle tough
    cases, especially with APS
  • Develop initiative to optimize funding

44
JOIN THE GERIATRIC MENTAL HEALTH
ALLIANCE center_at_mhaofnyc.org (212)
614-5751 www.mhawestchester.org/advocates/geriatr
ichome.asp
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