RECOGNIZING MENTAL HEALTH ISSUES IN OLDER ADULTS

1
RECOGNIZING MENTAL HEALTH ISSUES IN OLDER ADULTS

• Fuqua Center for Late-Life DepressionEmory
  University
• Jocelyn Chen Wise, LCSW, MPH

2
What is the Fuqua Center for Late-Life
Depression?
Mr. JB Fuqua
Emory University School of Medicine
3
Purpose

• Describe three conditions commonly seen among
  older adults.

4
Goal

• Audience learns to recognize signs and symptoms
  of these conditions.
• Audience feels better equipped to take first
  steps toward treatment for these conditions.

5
Case study

• Ms. Smith is a 74 year old, African American,
  retired teacher who lives independently.
  Recently, shes been looking tired and is less
  talkative than usual. Ms. Smith denies feeling
  sad but reports that she has bad nerves. She
  explains that she has trouble sleeping due to
  getting up frequently to use the bathroom at
  night. Her adult daughter reports that Ms. Smith
  has had difficulty remembering things lately like
  appointments and names.

6
What could be going on?

• The Three Ds
• Dementia
• Depression
• Delirium
• Under-recognized, under-treated
• Often occur simultaneously with overlapping
  symptoms

7
DEPRESSION
8
What is Depression?

• A physical disorder of the brain
• Impacts more than 6.5 million people age 65
• Not a normal part of aging
• High rates of depression among people who have
  had heart attack, cardiovascular disease, stroke,
  cancer, diabetes
• 20 of persons with Alzheimers
• The most common treatable risk factor for
  Alzheimers

Blazer DG. Depression in late life review and
commentary. J Gerontol A Biol Sci Med Sci 2003.
Andreescu et al, American Journal of Geriatric
Psychiatry, 2007.Lenze et al, Depression and
Anxiety, 2001.
9
Symptoms of Major Depression

• Core symptoms 1) Depressed mood and/or
  2) Lack of interest
• Other symptoms
• Feelings of worthlessness or guilt
• Poor concentration or ability to make decisions
• Fatigue
• Agitation or retardation
• Problems with sleep
• Change in weight or appetite
• Recurrent thoughts of death or suicidal ideation

10
Suicide Rate by Age, Sex, and Raceusing National
1999-2010 data
National Center for Health Statistics, CDC Wonder
11
Risk Factors for Suicide

• Mental health diagnosis, particularly depression
  and substance abuse
• Age
• Chronic illness or pain
• Previous attempts or family history of suicide
• Recent loss of loved one
• History of impulsive behavior (alcohol, drugs,
  lack of responsibility)

12
Myths and Facts About Suicide

• MYTH

• FACT

• Asking about suicide may give someone the idea to
  kill themselves.

• The opposite is true. Asking someone directly
  about their suicidal feelings will often lower
  their anxiety level and act as a deterrent to
  suicide.

13
Myths and Facts About Suicide

• FACT

• MYTH

• Most people who kill themselves give definite
  warning signs of their suicidal intentions.

• Talking about suicide is usually a cry for help.

• 8 out of 10 give signs. All threats and attempts
  should be taken seriously.

14
Is Late-Life Depression Different?

• May not endorse sadness, rather irritability or
  nerves
• Hard to explain feelings
• Stigma
• Cultural beliefs
• Somatic or physical complaints more common
• More problems with cognition

Gallo JJ et al. Depression without sadness
functional outcomes of nondysphoric depression in
later life. J Am Geriatr Soc. 1997
May45(5)570-8.
15
Screening for Depression

• Patient Health Questionnaire 9 (PHQ-9)
• Geriatric Depression Scale (GDS)
• Cornell Depression Scale for Depression in
  Dementia
• Relies on input from family or caregivers

16
Depression Screening PHQ-9
17
Depression Screening PHQ-9
18
PHQ-9 Scoring
19
PHQ-9

• Patient Health Questionnaire 9 (PHQ-9)
• http//phqscreeners.com
• or
• http//www.integration.samhsa.gov/images/res/PHQ2
  0-20Questions.pdf
• Free and available to public

20
DEMENTIA
21
Definition of Dementia

• A chronic and progressive loss of intellectual
  functions severe enough to interfere with
  everyday life.

Dementia
Alzheimers Disease 60-80
Vascular dementia
Parkinsons dementia
Lewy Body dementia
Frontotemporal dementia
Bonifas, R. Depression, Dementia, and Delirium
Teaching Module. CSWE Gero Education Center.
Arizona State University.
22
Types of Dementia
23
What is Alzheimers Disease?

• Begins gradually
• Progression different for everyone
• Symptoms
• Forget recent events
• Have difficulty performing familiar tasks
• Confusion
• Personality and behavioral changes
• Impaired judgment
• Communication difficulties

24
Changes that can come with dementia

• Memory
• Language voice and written
• Sensory perception vision, hearing, touch,
  taste, smell
• Organization sequencing
• Abstraction
• Attention / concentration
• Judgment
• Changes in personality
• Loss of initiative

25
Screening Tools

• Montreal Cognitive Assessment (MoCA)
• http//www.mocatest.org
• Mini-Mental Status Exam (MMSE)
• Mini-Cog clock draw, orientation
• http//www.alz.org/documents_custom/minicog.pdf

26
DELIRIUM
27
What is Delirium?

• A mental disturbance characterized by sudden
  changes in mental functioning or acute confusion
  and fluctuating levels of consciousness.
• Delirium is the most acute condition of the three
  Ds and is a true medical emergency.

Bonifas, R. Depression, Dementia, and Delirium
Teaching Module. CSWE Gero Education Center.
Arizona State University.
28
Symptoms of Delirium

• Disorganized thinking
• Disorientation to time and place
• Reduced level of attention (drowsiness)
• Person may fall asleep during an interview
• Increased or decreased psychomotor activity
• Apathy - sometimes mistaken for depression
• Increased agitation
• Disturbances in sleep cycle

Bonifas, R. Depression, Dementia, and Delirium
Teaching Module. CSWE Gero Education Center.
Arizona State University.
29
Types of Delirium

• Hyperactive psychomotor agitation, increased
  arousal and delusions, may see some cognitive
  impairment
• Hypoactive withdrawal, lethargy and reduced
  arousal
• Mixed Characteristics of both

Bonifas, R. Depression, Dementia, and Delirium
Teaching Module. CSWE Gero Education Center.
Arizona State University.
30
Criteria for Delirium Diagnosis

• Four criteria are assessed in diagnosing
  delirium. Delirium diagnosis includes
• Acute onset and fluctuating course and
• Inattention, then either
• Disorganized thinking or
• Altered level of consciousness

Bonifas, R. Depression, Dementia, and Delirium
Teaching Module. CSWE Gero Education Center.
Arizona State University.
31
Causes of Delirium

• The primary causes are underlying medical
  conditions, medications, or drug withdrawal
• Infections urinary tract infections, pneumonia
• Reaction to prescribed medications or illicit
  drugs
• Low blood pressure
• Head injuries or falls
• Dehydration
• Alcohol withdrawal
• Sensory deprivation (often experienced by
  hospitalized seniors, those having hearing
  impairments, or other sensory input limitations)

Bonifas, R. Depression, Dementia, and Delirium
Teaching Module. CSWE Gero Education Center.
Arizona State University.
32
Why is delirium an emergency?

• 1 year mortality rate is 35-40
• Often there is an underlying medical issue
  causing delirium
• Check for adequate treatment

Bonifas, R. Depression, Dementia, and Delirium
Teaching Module. CSWE Gero Education Center.
Arizona State University.
33
Seeking Treatment
34
Red Flags

• Sudden change in cognitive status
• Feeling suicidal
• Violent
• Recent hospitalization
• Medicine changes

35
Emergency Treatment

• 911
• Hospital or Emergency Room
• Primary care physician
• Georgia Crisis Access Line
• http//www.mygcal.com
• 1-800-715-4225
• 24 hour hotline of mental health professionals
  available to discuss situation, find clinics or
  hospitals based on insurance and geography, or
  send mobile assessment team

36
Non-emergency Treatment

• Medical doctor
• Primary care
• Neurologist
• Psychiatrist
• Talk therapist (does not prescribe medicine)
• Psychologist
• Marriage and family therapist (MFT)
• Licensed clinical social worker (LCSW)
• Licensed professional counselor (LPC)

37
Evaluation

• Psychosocial history
• Medical evaluation
• Lab tests
• Medical history
• Substance use assessment
• Collateral information!

38
Laboratory Tests
TESTS Rule out
Urinalysis Kidney dysfunction, toxic encephalopathy
CBC, sedimentation rate, electrolytes Anemia, electrolyte imbalance
Blood Urea Nitrogen (BUN)/creatinine, liver function test Liver dysfunction
Thyroid function Thyroid dysfunction
Serum B 12 Vitamin deficiency
Syphilis serology Syphilis
HIV test AIDS dementia
Neuroimaging studies CT or MRI Tumor, subdural hematomas, abscess, stroke, or hydrocephalus
Common tests
Less common
39
Summary
Dementia Delirium Depression
Onset Gradual Acute Recent
Reversibility Usually irreversible (95) Usually reversible (90) Reversible with treatment
Alertness Usually constant Inattention is more common Often c/o memory loss
Other info Collateral information Patients with dementia are at higher risk for delirium Evaluate for family history of depression
40
Tips

• Accompanied to medical appointment
• Bring current medications
• Let the clinician know what you are concerned
  about
• Call the medical office if dont see improvement
  or if gets worse
• Request an order for a home health nurse or
  social worker
• Make sure medical office understands the level of
  care the person has (or doesnt have) at home

41
Starting the Conversation

• Listen nonjudgmentally
• Give reassurance and information
• Encourage professional help
• Encourage self-help
• Assess for risk of suicide or harm

42
Encouraging Professional Help

• Have you felt this way before?
• Was there something or someone that helped you
  in the past?
• Would you be ok speaking to someone about whats
  going on?

43
Mental Health Services in Georgia
www.fuquacenter.org
44

• Questions?

45
Thanks!

• Fuqua Center for Late-Life Depression
• Jocelyn Chen WiseOffice 404-712-6943
• jchen86_at_emory.edu
• www.fuquacenter.org