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GERIATRIC MENTAL HEALTH 101

GERIATRIC MENTAL HEALTH 101 A Presentation By Michael B. Friedman, LMSW Chairperson The Geriatric Mental Health Alliance of New York Why Geriatric Mental Health Is Important Mental Disorders Are a Major Impediment to Living Well in Old Age.

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GERIATRIC MENTAL HEALTH 101

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  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 one’s mind” or getting Alzheimer’s 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 • Alzheimer’s 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) Alzheimer’s Disease and Its Management in the Year 2010. Psychiatric Services. 50:9, 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.gov/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.gov/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 MEDICATIONS—ESP. 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, intimate—including sexual—relationships) • 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 client’s 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. 50:9, 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 systems—especially 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@mhaofnyc.org (212) 614-5751 www.mhawestchester.org/advocates/geriatrichome.asp

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