Assessment

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Assessment Response to Mental Health Problems
of Older Adults How Can We Help?

• Margaret E. Adamek, MSW, PhD
• madamek_at_iupui.edu
• Indiana University
• School of Social Work
• Senior Service America, Inc.
• SCSEP Conference
• September 10, 2008

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Session Objectives

• To share key facts about common mental health
  issues of older adults (depression anxiety,
  suicide, substance abuse, and dementia)
• To consider barriers to identifying mental health
  concerns among older adults
• To present recommendations for responding to
  mental health needs
• To identify resources for meeting mental health
  needs of older adults

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KEY FACTS DEPRESSION AND ANXIETY
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Prevalence

• Depression
• 8-20 of community older adults
• 37 of geriatric primary care patients
• 50 of LTC residents
• doubles after age 70-85
• affects twice as many older women than men

• Anxiety
• 10-25 of older adults
• affects more women than men

As many as 1 in 5 older adults experience mental
health problems that are NOT associated with
normal aging.
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Severe Depressive Symptoms
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Late Life Depression and AnxietyCommon
Characteristics

• most common psychiatric condition in late life
• major public health problem
• often undetected
• can be pervasive and chronic in nature
• often viewed as a normal part of aging
• tendency to discount the disorder
• negative impact on quality of daily life
• commonly co-occurs with physical illness

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Common Characteristics (contd)

• More likely to be presented in primary care than
  mental health settings
• An understanding of the impact of depression
  anxiety on older adults is lacking (e.g., older
  adults emphasize somatic complaints)
• Most studies are based on younger adults
• Most often treated with medication
• Counseling approaches are underutilized and
  under-studied

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Symptoms

• Depression
• Depressed mood
• Loss of interest
• Weight or appetite changes
• Sleep disturbances
• Psychomotor agitation or slowing
• Low energy
• Feeling worthless
• Difficulty concentrating

• Anxiety
• Excessive anxiety worry
• Restlessness or feeling on edge
• Sleep disturbance
• Easily fatigued
• Irritability
• Muscle tension
• Difficulty concentrating

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Consequences

• Decreased quality of life
• Increased morbidity
• Shorter life span
• Greater use of health services
• Greater functional impairment
• More expense
• Becoming suicidal

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KEY FACTS ELDER SUICIDE
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Elder Suicide

• 12 of the population 18 of suicides
• 15 older adults, on average, kill themselves each
  day
• over 5,000 older adults per year
• White males 85 have the highest rates
• Firearms most common method73 of older adult
  suicides

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Elder Suicide Risk Factors

• Gender
• Substance abuse history
• Mood disorders mental illness
• Age
• Widowhood bereavement
• Chronic disabling illness
• Access to lethal means

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Protective Factors

• Positive social support
• Reasons for living/future plans
• Positive coping skills
• Psychological strengths
• Absence of psychiatric illness, or having an
  illness that is treatable
• Desire for help/ positive therapeutic
  relationship
• Spirituality/ life satisfaction

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Progression of Suicidal Behavior

• Thoughts - having thoughts about killing oneself
• Gestures - self-directed, potentially harmful
  behaviors which do not result in injury
• Parasuicides - self-inflicted harm in which a
  person's intent was something other than suicide
• Attempts - self-inflicted harm in which a
  person's intent was to kill him/herself but was
  unsuccessful in doing so.
• Completions - a suicide attempt which results in
  death

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Lethality Assessment 101

• Questions to ask
• Have you ever thought about suicide?
• Do you have a plan?
• Do you have access to the means?
• Do you have a gun at home?
• Is it loaded?
• Always take suicidal statements seriously.

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KEY FACTS SUBSTANCE ABUSE
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Substance Abuse 3 key areas

1. Use of illicit drugs
2. Alcohol abuse
3. Misuse of prescription drugs

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Illicit Drug Use Among Older Adults

• In 2000, an estimated 568,000 persons aged 55 or
  older used illicit drugs in the past month
• The number of illicit drug users among older
  adults is likely to increase in the coming years
  due to the aging of the "baby boom" generation

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Aging and Alcohol

• 2-4 of the elderly meet current criteria for
  alcohol abuse or dependence.
• Over 5 million are "binge" alcohol users,
  including more than 1 million who are heavy
  alcohol users
• An additional 10-15 meet criteria for at-risk
  drinking.
• 2 patterns early onset, late onset

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Treatment of Older Adults for SA

• 4 out of 5 older people who seek substance abuse
  treatment do so because of alcohol problems
• from 1995 to 2005, alcohol was the most
  frequently reported primary substance of abuse
  for SA treatment admissions aged 65 or older.
• The of SA treatment admissions among persons
  aged 65 or older decreased by 7 from 12,100 to
  11,300 admissions.
• --SAMSHA data

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Misuse of Prescription Drugs

• Prescription drug abuse and/or misuse among the
  elderly are a unique and dangerous trend that
  warrants national attention. (Bio and Medicine)
• the incidence of adverse events related to drug
  reactions is 2-3x higher in older adults
  (National Institute on Drug Abuse)
• Increased drug prescription
• costs ? misuse (Patterson, 2004)

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KEY FACTS DEMENTIA
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Severe Memory Impairment, 65
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Alzheimers Disease

• An estimated 4 million Americans currently suffer
  from AD or a related form of dementia.
• Nearly 10 of those over age 65 and up to half of
  those over age 85 are thought to have AD or
  another form of dementia.
• Over 19 million Americans have a family member
  with Alzheimer's.
• Approximately 360,000 new cases occur each year.

Should I be concerned?If youve noticed memory
changes that are worrying you, call any time at
1.866.ALZ.4199.
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Warning Signs for AD

• Memory loss
• Difficulty with familiar tasks
• Language problems
• Disorientation to time and place
• Poor/ decreased judgment

• Problems with abstract thinking
• Misplacing things
• Mood changes
• Personality changes
• Loss of initiative
• --Alzheimers Association

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Someone with Alzheimer's disease symptoms Someone with normal age-related memory changes
Forgets entire experiences Forgets part of an experience
Rarely remembers later Often remembers later
Is gradually unable to follow written/spoken directions Is usually able to follow written/spoken directions
Is gradually unable to use notes as reminders Is usually able to use notes as reminders
Is gradually unable to care for self Is usually able to care for self

Source www.alz.org
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BARRIERS To HELPING

• O

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Barriers to Intervening

• Stigma shame
• Inadequate assessment/ Improper use of
  instruments
• Lack of awareness of cultural differences
• Failing to ask about access to lethal means
• Not recognizing or dismissing depression
• Decline in physical health (mobility issues)

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Barrier 1 Medical Model

• Pills as primary
• Polypharmacy is a major cause of mental health
  symptoms in older adults
• Little understanding of how to safely reduce
  polypharmacy

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Barrier 2 Resistance

• Older adults resistance to mental health
  treatment
• Provider resistance to treating mental health
  problems in older adults

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Barrier 3 Policy

• Policy Impediments
• 20 co-pay medical interventions
• 50 co-pay psychosocial interventions
• Policy needs to catch up with
  science
• 
  -Alexopoulos, 2005

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Barrier 4 AGEIST ATTITUDES

• therapeutic pessimism expecting decline
  problem-focused
• Ageist behaviors-
• patronizing
• using condescending language
• protecting
• failing to consult the older adult
• disempowering
• ignoring
• neglecting
• stereotyping
• Are we guilty of professionalized ageism?

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BARRIER 5 NOT RECOGNIZING OLDER ADULTSNEED TO
CONTRIBUTE

• dis-ease (Marcel, 1950)
• forgetfulness of being (Heidegger, 1962)
• existential-meaning vacuum (Frankl, 1959)
• Do I matter? Why do I exist? Who cares?

Without meaning, whats left?
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• RECOMMENDATIONS FOR HELPING

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How to Help

• Listen
• Ask questions
• Speak in private
• Trust your instincts
• Express empathy and concern
• Share your observations
• Be prepared for anger or resistance
• Find out if the person will accept help

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More ways to help.

• Involve family friends
• Dont promise confidentiality
• Share information about resources
• Encourage treatment
• Educate yourself

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RESOURCES
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• Positive Aging Act Provisions included in the
  Older Americans Act Reauthorization On Sept
  30, 2006 Congress reauthorized the Older
  Americans Act (H.R. 6197) with significant
  language from the Positive Aging Act.
• New provisions authorize
• an officer at AoA to be responsible for mental
  health services under OAA
• competitive grants to states for developing
  mental health screening and treatment services
  for older adults
• grants to states to increase public awareness,
  reduce stigma, and reduce age-related prejudice
  and discrimination regarding mental disorders in
  older adults.

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• The Geriatric Mental Health Foundation
  -established by the American Association for
  Geriatric Psychiatry to
• raise awareness of psychiatric and mental health
  disorders affecting the elderly,
• eliminate the stigma of mental illness and
  treatment, promote healthy aging strategies, and
• increase access to quality mental health care for
  the elderly.

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Available on the GMHF website.

• A Guide to Mental Wellness in Older Age
  Recognizing and Overcoming Depression

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• Mission Statement
• The mission of the Older Americans Substance
  Abuse and Mental Health Technical Assistance
  Center is to enhance the quality of life and
  promote the physical and mental well-being of
  older Americans through the provision of
  technical assistance by reducing the risk for and
  incidence of substance abuse and mental health
  issues late in life. Through partnerships with
  state and federal agencies and community health
  care providers, the Center will serve as a
  national repository to disseminate information,
  training, and direct assistance in the prevention
  and early intervention of substance abuse and
  mental health problems.

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TAC Priorities

• Provide technical assistance for the prevention
  and early intervention of
• Substance abuse
• Medication misuse and abuse
• Mental health disorders
• Co-occurring disorders
• Dissemination and implementation of
  evidence-based and promising practices

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Coming soon.

• Implementation Resource Kits for Depression in
  Older Adults
• Guide to Implementing Evidence-Based Practices
  to Prevent Substance Abuse and Mental Health
  Problems among Older Adults
• PHQ-9 Patient Health Questionnaire

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Congress Passes Mental Health ParityAug 2008

• In an historical move, Congress enacted mental
  health parity in Medicare.
• The law provides Medicare mental health equity,
  by phasing in a reduction in the 50 mental
  health copayment to the 20 required for all
  other outpatient services.
• Cost sharing will be phased in starting in 2010
  
• 45 in 2010 2011
• 40 in 2012
• 35 in 2013
• 20 in 2014 and thereafter.

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Web Resources

• Alzheimers Association
• www.alz.org
• American Association of Suicidology
  www.suicidology.org/
• American Association for Geriatric
  Psychiatrywww.aagpgpa.org
• Geriatric Mental Health Foundation
• http//www.gmhfonline.org/gmhf/

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More Web Resources

• National Coalition on Mental Health Aging
• http//www.ncmha.org/
• National Institute on Aging
• http//www.nia.nih.gov
• NIH Senior Health
• www.nihseniorhealth.gov
• Older Americans SA MH Technical Assistance
  Center
• www.samhsa.gov/olderadultsTAC

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The progress of a nation may be marked by its
ability to allow citizens of all ages and
backgrounds to contribute as well as receive
needed care.