GERIATRIC MENTAL HEALTH 101

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GERIATRIC MENTAL HEALTH 101

• A Presentation
• By
• Michael B. Friedman, LMSW
• Chairperson
• The Geriatric Mental Health Alliance of
• New York

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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

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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.

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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

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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.
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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

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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.
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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).
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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

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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

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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

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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

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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

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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

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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
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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.

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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

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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

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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

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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/
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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/
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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

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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

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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

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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

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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

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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

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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

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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

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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

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• 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).
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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

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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.
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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

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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

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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.

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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.

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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)

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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

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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

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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

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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)

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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

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