Physical Illness and Co-occurring Mental Disorders

1. Physical Illness and Co-occurring Mental Disorders Developed by DATA of Rhode Island through a special grant from the RI Department of Human Services

2. Training Goals • Discuss and identify behavioral health issues for adults with persisting health conditions • Identify implications of the co-occurrence of physical and mental illness • Identify the most common co-morbid health and mental health conditions

3. Mental disorders and physical illness Relationships are varied & include: (1) Mental disorder biologically due to physical illness (2) Psychological reaction to physical illness/disability (3) Mental disorder due to medications (4) Mental disorder causes physical disorder (5) The conditions are coincidental

4. Stress and Physical illness • Major health problems are stressful • Response to this stress dependent upon individual • Perception / Beliefs of illness • Vulnerability • Coping ability • Response of others

5. Individual Vulnerability • Personality traits make a difference (e.g. tendency to worry about illness) • Prior experience of illness within a family • An individual’s psychological state at the time of the illness • Previous experience of trauma, or a neglected or abusive childhood

6. Selected Medical Conditions associated with Mental Disorders

7. Depression is most common in medical illness • All depressive disorders 15-36% • Each problem alone may have major implications for how an individual functions • Issues together often are interactive and can have overwhelming effects when they coexist. • Managing co-occurring mental health problems not only improves mental status health status is improved

8. Mental Health Issues and our Aging Population • Significant continuous growth in near future • By 2030, U.S. population >65 years old = 70 million • 2030, >65 years old = 20% of U.S. population • Age bracket w/ most growth: >100 years old • Current healthcare system not able to support growth • Increased need for specialized healthcare professionals and housing www.research.aarp.org

9. The Myths of Aging • Adults over 70 do not have sex. • Older persons can’t really learn or change. • To be old is to be sick. • Older people are unproductive in society • Older people are rigid and cranky

10. Mental Health Issues and EldersRelocation Stress Syndrome • Anxiety, restlessness, apprehension • Insecurity, vigilance • Confusion • Depression, withdrawal, loneliness • Sleep disturbance • Change in eating habits, weight change • Unfavorable comparison of pre-transfer and post-transfer staff

11. Geriatric Depression • Depression is not a normal part of aging • Approx. 6 million people 65+ women>men1 • 15% community; up to 25% in residents • Can be triggered by medical condition, drugs, losses, nothing at all • “I think I’m going crazy!” • Reoccurrence rate is a concern • Can exacerbate other medical conditions 1 The Brown University Long-Term Care Quality Advisor, vol 9, no 13, p.5. July 14, 1997.

12. Mid-Life depressed mood  diminished pleasure  weight,  appetite  insomnia negative attitude  guilt, worthlessness   concentration  suicidal ideation  Late-Life irritable, critical of others isolation, withdrawal  weight,  taste, swallow early A.M. awakening hypersomatic “the end”, burden, anxiety confusion, crazy not overtly expressed Geriatric DepressionSigns & Symptoms

13. Suicide in the Older Adult • Greatest Risk: older white male • More lethal attempts, successful often • 1:4 success rate • May not discuss the desire to die • > 50% visited physician within 1 week of death • Be direct when questioning • Fear of moving to supervised housing, pain, loss, incapacity, finances

14. Dementia • Approximately 4 million Americans have AD • In 2050 ~ 14 million Americans will have AD • Greatest risk: Advancing age • 10% >65 years old 50% >85 years old • Family history: ? Genetics • Duration range 3 - 20 years, avg. 8 years • Family disease: patient & family are = victims www.alz.org/AboutAD/Statistics.htm

15. Dementia • Neuropathological syndrome with progressive deterioration of intellectual functioning, problem solving, and learning new skills • Irreversible and progressive • Secondary: A result of other processes • 65% - Alzheimer’s • Higher occurrence in women, Down’s and head injuries

16. Dementiawith Reversible Causes • Depression • Medications • Thyroid disease • Tumor • B-12 deficiency • Malnutrition • Infection • Hypo/hyperglycemia • Dehydration

17. DementiaSigns & Symptoms • Memory Impairment • impaired ability to learn new info • Functional Impairments (acts) • ADL’s,  social • significant decline from previous LOF (gradual onset) • Cognitive Impairment (thinks) • aphasia - comprehension & speech • apraxia - motor activities (eating, brush teeth, comb hair) • agnosia - inability to recognize familiar objects • disturbance in executive functioning (organizing, planning, sequencing, abstracting)

18. Progression of Dementia • Decline in everyday life activities • Failure of memory and intellect • Disorganization of the person • Psychotic changes

19. Causes Infections Degenerative neurological disorders Vascular disorders Structural disorders of brain tissue Behavior(gradual/insidious) Multiple cognitive deficits Memory impairment Aphasia Apraxia Agnosia Disturbed executive functioning Catastrophic reactions Perceptual alterations Wandering Disinhibition Dementia: Process and Characteristics

20. Progression of Alzheimer’s Early Stage: • Difficulty remembering names, appointments, where things are. • Emotionally unstable, new onset depression

21. Progression of Alzheimer’s Second Stage (2 ½ years): • Recent memory deficit • Decrease in orientation • Restless nights, wandering • Beginning of catastrophic reactions • Misperceptions cause paranoia • May blame family/staff for stealing lost objects

22. Progression of Alzheimer’s Final Stage(months to 5 years) • Severe disorientation • Psychotic symptoms • Severe emotional disregulation • Blunted emotions • Inability for self-care • Does not recognize family/staff

23. BEHAVIORAL SUPPORTS IN DEMENTIA • Calm consistent environment • Cuing and reminding or validation • Emphasize cognitive strengths • Music, familiarity • Watch for changes in functioning • Provide safe environment • Daytime exercise, minimize naps

24. Delirium • Acute, reversible etiologies • Most of the time secondary to underlying medical condition, medication reactions or intoxication • Most often seen in children and adults over age 65 • If untreated may progress to dementia, coma or death

25. DeliriumTriad of Symptoms • Onset • Acute, hours - days • Lasting hours - weeks • Disturbance in Consciousness • ↓ awareness of environment • Lethargic or hypervigilant (agitated) • Changes in Cognition/Perceptual Disturbance • Memory impairment • Sensory changes

26. Cognitively impaired Medically ill Acute/sudden onset Disorientation Hallucinations Delusions Visuospatial deficits Apraxias Lethargy Comprehension deficits Altered level of consciousness Agitation, irritability CLINICAL FEATURES OF DELIRIUM vs Dementia

27. Etiology & Risk Factors for Dementia • General medical condition • Substance use/abuse • Drug intoxication, polypharmacy • Systemic infections • Dehydration, fluid & electrolyte imbalance • Hepatic or renal disease • Hypoxia • Metabolic Disorders • Nutrition deficiencies • Limited mobility

28. MANAGEMENT OF DELIRIUM • Schedule appt w/ MD or 911 • Re-orient patient • Quiet, less stimulating environment • Maintain resident and staff safety • 1:1 observation if possible until managed by medical personnel

29. Geriatric Substance Abuse • ~2-3% women, ~10% men >60yo • Early Onset (<60yo) • About 2/3 of geriatric alcohol use disorders have been abusing throughout adult life • Greater financial, legal and social problems than later onset • Heavier drinkers than later onset patients • Late Onset (>60yo) • About 1/3 of geriatric alcohol use disorders begin after 60 • Aging social drinkers more intoxicated with same dose • Cognitive disorder in heavy drinkers • Social drinkers who increase drinking after losses

30. Medical Complications of Substance Use • Worsening dementia • Anxiety • Psychosis • Alcohol-induced mood disorder • Dementia-like symptoms from mood disorder • Suicide • Exacerbation or worsening of existing medical conditions, ie, diabetes, blood pressure

31. Possible Warning Signs • Cognitive decline or self care neglect • Family estrangement • Unexpected delirium after hospitalization (withdrawal) • GI problems • Frequent injuries, falls, “accidents” • Does not attend medical appointments • Socially Withdrawn • Poor appetite • Depression • Difficulty sleeping

32. Contributing Factors • Loss of spouse/pet/loved one • Financial problems • Retirement • Sale of home, move to supervised housing • Loss on independence/control • Depression

33. Conclusions • Adults with certain medical conditions are at greater risk of co-occurring mental illness problems • The mental illness is frequently under diagnosed • Identification and intervention with these problems can help both the patients mental status and health status

34. Questions