Shirley Aston CMHN Country Liaison Officer

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Shirley Aston CMHNCountry Liaison Officer

• ROYAL ADELAIDE HOSPITAL
• Glenside Campus Mental Health Services For Older
  PeopleCountry Liaison Service

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Riverland Presentation

• It covers the areas of
• The relationship between physical and mental
  health
• Staying connected socially
• Money Matters
• Medication
• Depression
• Dementia
• Other

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The Relationship Between Physical and Mental
Health

• There is evidence that regular exercise helps us
  to deal with stress.
• Physical exercise can help to keep a healthy
  cardiovascular system, This can help to avoid
  strokes and some types of dementia (vascular).
• There is evidence that exercise can help recovery
  from depressive illness.
• If you can avoid or control many of the illnesses
  of old age you can also avoid the mental health
  problems that go with them (some examples are MI
  and depression, stroke and depression).
• Avoiding some of the problems associated with the
  medications needed to control physical illness
  (side effects and delirium).

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So Does This Mean You All Need to Start
Preparation for a Marathon Run?
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NO --- But Some Sensible Actions Are

• Getting an annual check up from your GP
• Identifying and treating health problems promptly
• Eating a sensible diet
• Keeping weight down
• Avoiding excessive alcohol
• Stop or reduce smoking
• Moderate and regular aerobic exercise (walk,
  swim)
• Exercising joints (Yoga or stretching)
• Staying relaxed (Tai Chi, Yoga, relaxation)

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The Barriers

• What are the barriers to taking some of these
  actions?

• Cost
• Motivation
• Existing disability
• Im too old

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Staying Socially Connected
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Staying Socially Connected

• Evidence suggests that those who have strong and
  wide social networks do better in terms of mental
  health.
• For example, loneliness is a risk factor for
  depression.
• Clinical experience suggests that socially
  isolated people are more prone to anxiety.

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Staying Socially Connected cont.

• Sensible measures
• Maintaining regular contact with family and
  friends.
• Planning retirement so old networks are kept or
  new ones developed.
• Negotiating a positive role in family.
• Using technology to stay in touch and meet new
  people (phone, internet).
• Staying active in the community (volunteer work,
  clubs and associations).

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Staying Socially Connected cont.

• Sensible Measures. cont.
• Taking up new interests and hobbies (painting,
  fishing, men's groups, cards, contact old school
  friends, research your family tree study for a
  degree?).
• At times of change can others help? (Grief,
  coping with being a carer).
• Become an asset. Could you be the local expert
  on the history of the town or the local fishing
  guru?

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Brief Discussion

• What opportunities exist in this community to
  stay
• socially connected?

• Church Groups
• Community Clubs / Associations
• Government Services

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Managing Money

• Financial problems can cause ongoing worries and
• concerns.

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Managing Money

• Planning prior to retirement
• Learning to live in a positive way within your
  means
• Preparing your home as low cost and low
  maintenance
• Learning to budget
• Learning to eat well but inexpensively
• Knowing what you are entitled to and claiming it
  (many people do not claim benefits they are
  entitled to)
• Can you increase your income (some people start
  new work or small business)

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Discussion

• Is it too late to make any difference once you
  have already retired?

• Talk it over with a Financial adviser.

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Medication
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Medication cont.

• Over the last century the introduction of
  medications has improved the lives and prevented
  the death of many people.
• However, as you age, keeping a sensible check on
  the medications you take can help you avoid
  problems.
• It is important to weigh the benefits against the
  cost of taking medication.

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Some Facts

• People over 65 constitute 18 of the population
  but receive 39 of prescribed drugs (i.e. twice
  as many as younger people).
• Chronic illness and multiple pathology increase
  with age, leading to polypharmacy.

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Some Facts

• The way drugs act on the body, and the way the
  body metabolizes and excretes drugs may be
  altered by age and disease.
• 1,2 and 3 above increase susceptibility to
  adverse drug reactions (ADRs). These may include
  delirium, confusion depression and anxiety.

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Benefits and Costs

• Because of these factors it is very important to
  weigh the benefits and costs.

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The Types of Medication Older People Take

• Diuretics 25
• Analgesics 20
• Hypnotics, sedatives and anxiolytics 15
• Antirheumatic drugs 15-20
• ß-Blockers 11
• Digoxin 6
• These are the very medications most likely to
  cause side effects either singly or in
  combination.

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Some Problems Encountered

• Duration and review of treatment
• Prescription errors
• Comprehension and compliance
• Concordance

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Drugs And The Patient

• As we age the way medications are absorbed,
  metabolized and stored may change.
• This is called
• Pharmacokinetics
• (What the patients body does to the drug)
• Also the way the drug acts on the body may also
  change.
• This is called
• Pharmacodynamics (What the drug does to the
  patient)

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Adverse Drug Reactions

• Often present with non-specific symptoms such as
  confusion, incontinence, falls.
• 10 acute geriatric medicine admissions solely or
  in part due to drug side effects.
• Drugs commonly associated with ADRs - diuretics,
  digoxin, antihypertensives, analgesics,
  non-steroidal anti-inflammatory,
  anti-Parkinsonian drugs, psychotropics.

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Medication Compliance

• Compliance - poor in about 30 of patients.

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Medication Compliance

• Poor motivation - especially if asymptomatic
• Lack of understanding - complex regime,
  forgetful, running out of tablets
• Practical problems - taste, size, 'sticking',
  vision, dexterity (bottle tops, inhalers)
• "Intelligent" non-compliance
• Pills "sticking"
• Im better now so Ill stop medications

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The Role of the Pharmacist

• Over-the-counter (OTC) medicines taken by about
  20 of elderly people
• Childproof containers are often also elder-proof
• Typed labels are now mandatory "as before/as
  directed/as required"
• The pharmacist has a vital role in contributing
  to patient education and in maintaining a 'check'
  for incorrect dosages, interactions, etc

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The Role of the Doctor

• Safe and effective prescribing.
• Maximum benefit with minimum hazard
• Full diagnosis consider patients reaction
• Start with low doses and adjust cautiously
• Prescribe known drugs
• Monitor and record response (or lack of it)
• Monitor compliance
• Review drugs regularly
• Careful drug history

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Role of Care Staff

• The hand that jogs the doctors elbow
• Medications have a role but are not magic bullets
• Try education life style changes first
• Help clients to understand what medications are
  for and side effects
• Help clients to manage their medications
• Help clients develop and complete list of their
  medications what, when, when prescribed, what
  for, how to take, what to watch out for

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Conclusions

• ASK QUESTIONS of the
• Doctor
• Pharmacist
• Client
• Carers
• ENSURE REGULAR REVIEW OF MEDICATION OCCURS
• CHECK OTC MEDICATIONS

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SUMMARY

• Remain as physically fit as possible
• Keep in contact with family and friends
• Maintain financial independence
• Keep accurate records of all medications taken

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Depression In The Elderly

• Why Focus On Depression In The Elderly?

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Depression Definition

• A pervasive and persistent change in mood
  characterised by depressed mood and loss of
  interest or pleasure in life.

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Depression In The Elderly Is Often Under-
diagnosed and Under -treated

• This may be because the symptoms are regarded as
  normal in this age group.
• It may be because this group are reluctant to ask
  for help.
• It may be that physical illness masks the
  picture.

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Depression In The Elderly Is Often Under-
diagnosed and Under -treated

• It may be because depression in older people does
  not present with the standard picture.
• The result is that many elderly suffer
  needlessly.
• If detected and treated the elderly have the same
  response to treatment and have good prospects of
  recovery.

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What Is Depression?

• Clinical Depression Is Different From Everyday
  Blues
• How Long
• How Pervasive
• Impact On Life
• Sadness
• Loss Of Interest
• Loss Of Energy
• Loss Of Appetite And Weight

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What Is Depression?

• Sleep Disturbance
• Inner Feeling Of Restlessness
• Avoiding Other People
• Loss Of Confidence Or Self Esteem
• Feelings Of Being Bad, Worthless Or Guilty
• Thoughts Of Death And Suicide

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How Does a Depressed Person Look and Act?

• Poor eye contact
• Sad face, no smiles, mouth turned down
• May act as if irritable
• May look untidy, unshaven not made up
• Talk and move slowly
• Cry, call out
• Ask for help

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How does a depressed person look and act?

• Act distressed and fearful
• Say they want to die, complain or being
  worthless, helpless, hopeless
• Say they feel guilty
• Complain about pain or illness
• Complain about poor memory or concentration

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Conclusions

• Get an early diagnosis
• Ensure appropriate treatment is used
• Seek counselling if required
• Remember it can be successfully treated

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Delirium - Definition

• A clinical state characterised by an acute,
  fluctuating change in mental status, with
  inattention and altered levels of consciousness.

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Delirium - Key Features

• Acute, rapid onset over minutes to days
• Consciousness is clouded
• Usually rapid or slow speech
• Enhanced startle response
• Disturbed sleep/wake cycle with insomnia
• Confusion worsens toward evening
• Nightmares and/or visual hallucinations and/or
  delusions
• Symptoms fluctuate over the course of a day or
  even over minutes

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Delirium - Key Features cont.

• Distressing and unpleasant for the sufferer
• Frightened, irrational and unpredictable
  behaviour
• Awareness of the surrounding environment is
  reduced
• Impaired ability to focus, shift or sustain
  attention
• Impaired immediate recall and short term memory
• Disorientation in time, place or person
• Rapid shifts from under to over activity
• Slowed reactions

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Delirium - Vulnerability

• Most common causes are Medications and
  Infections.
• The elderly.
• Older people post GA.
• Dementia sufferers.
• Older persons with
• Strokes and Transient Ischaemic attacks
• Cardiac failure/arrhythmias
• Anaemia
• Hypoxia from respiratory failure

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Delirium Vulnerability cont.

• Uraemia
• Liver or kidney failure
• Electrolyte imbalance
• Acidosis or alkalosis
• Pre or post epileptic seizure
• Hypo or hyper Thyroidism
• Hypo or hyperglycaemia
• Concussion or sub-dural haematoma following a
  fall
• Blood loss

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Delirium - Management

• Diagnosis and treatment of underlying disorders,
  removal of contributing factors.
• Behavioural and environmental strategies, and
  support of the patient and family.
• Cautious use of medications to minimise
  challenging behaviours.

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Delirium - Alerts

• Is associated with significantly increased
  resource utilisation, morbidity and mortality.
• Attempting to manage challenging behaviours with
  certain medications will lead to a worsening of
  the delirium.
• If mistaken for a non reversible dementia then
  premature placement in a residential care
  facility may occur.
• Unresolved delirium can result in death.

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Delirium Management Guide

• Useful Strategies Include
• Simple, but firm communication
• Adequate lighting
• Reduction of intense stimulation
• Unit-wide noise reduction
• Diurnal variation in noise and lighting
• Reality orientation

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Delirium Management Guide cont.

• Presence of a relative
• Hydration and nutritional support
• Use of sensory aids
• Use of single room
• Maintain activity levels
• Medication - as a last resort

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Dementia - Definition

• Not a single disease but a syndrome of which
  there are many causes.
• The development of multiple cognitive deficits
  including memory impairment and one or more of
  the following
• Aphasia loss of the ability to use/understand
  words.
• Apraxia loss of the ability to execute or carry
  out learned. (familiar) movements.
• Agnosia a failure of recognition, visual,
  auditory or tactile.
• Disturbance in executive functioning problem
  solving, planning skills.

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Dementia - Key Features

• Decline in memory and other areas of thinking
• Tendency to over estimate cognitive functioning
• Decline in social domestic occupational
  functioning
• Changes in personality
• Changes in behaviour

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Dementia - Management

• Medical referral to diagnose and treat reversible
  causes
• Possible referral to specialist for medication
  (Alzheimers)
• Care and education to individual referral to
  support services
• Education and support to family
• Planning for the future

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Dementia - Alerts

• Depression may occur / coexist
• Safety needs to be considered
• Psychotic and behavioural issues are common
•  

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Delusional Disorder - Definition

• A delusion is a false belief which is
  inconsistent with the persons sociocultural
  background and held with absolute and unshakeable
  conviction.

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Delusional Disorder - Key Features

• The nature of the disorder ensures that sufferers
  are quite insightless and cannot be talked out of
  their peculiar beliefs, which they are often keen
  to share and may include
• Persecutory delusions are most common e.g.
• Being watched by others
• Punished or treated badly by others
• Possessions are being stolen
• Jealous preoccupation with presumed infidelity of
  a spouse
• Grandiose delusions are less common but can occur
• Convictions that some physical disease or defect
  is present
• Are often bound up with the persons home
  environment

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Delusional Disorder - Vulnerability

• Female with the following
• Socially isolated
• Have impaired hearing
• Have had a suspicious, sensitive premorbid
  personality
• Dementia sufferers ( Lewy Body)
• Those with Depression
• Past history of a psychotic disorder e.g.
• Schizophrenia
• Bipolar Affective Disorder

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Delusional Disorder - Management

• Establish differential diagnosis.
• Treat underlying causes.
• Maintain safety of client and others - person may
  act on their delusional beliefs.
• Rather than confronting the beliefs directly it
  is preferable to concentrate on the distress
  experienced by the sufferer.

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Delusional Disorder - Alerts

• Person may act in a way that is appropriate to
  their delusional beliefs and can include
• self harm
• harming others
• making decisions based on delusional beliefs
• If not correctly diagnosed. then a depressive
  disorder or dementia may be left untreated.
• If not correctly diagnosed, the medications
  selected can lead to a worsening of the
  situation. e.g. Lewy Body Dementia.

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SUMMARY
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Depression - Suspect If -

• A person looks or acts sad
• Looses interest in activities
• Complains of loss of energy
• Expresses suicidal ideas or thoughts of life not
  being worth living
• Makes frequent complaints of physical problems
  with no physical basis

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Delirium - Suspect If -

• Rapid onset of symptoms, i.e. over hours or days
• Fluctuating level of consciousness, may vary hour
  to hour
• Difficulty in engaging and maintaining the
  persons attention
• Disturbed sleepwake cycle
• Recent history of physical illness, medication
  changes, trauma

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Dementia - Suspect If -

• Loss of memory, particularly short term memory
• Confusion
• Disorientation
• Change in ADL or Executive functioning

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Delusional Disorders

• A belief system which is inconsistent with the
  persons sociocultural background, (i.e. it seems
  highly unlikely that the belief is true) and
  guides and determines behaviour.
• Is held with absolute and unshakeable conviction,
  i.e. the person refuses to consider alternative
  explanations.
• Delusions may be a feature of Depression or
  Dementia
• In dementia, delusions are most often of theft
  and suspicion.
• In Depression, delusions are most often of
  poverty, guilt, nihilistic ideas that bodily
  parts are absent, rotting or shrinking.

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Difficult behaviors

• Medication should not be the first approach
• Environmental management first
• Then behavioral management
• Then is the problem likely to respond to
  medication
• Weigh benefits and costs
• Prescribe low and slow
• Gauge effects
• Stop when indicated

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Paranoia -- The Word

• Paranoia is a term used by mental health
  specialists to describe suspiciousness (or
  mistrust) that is either highly exaggerated or
  not warranted at all.