Bridging Communities: Helping Older Adults in Crisis

1
Bridging Communities Helping Older Adults in
Crisis

• Linda K. Shumaker, RN-BC, MA
• Pennsylvania Behavioral Health and Aging Coalition

2
Aging of America

• Growth will be from 12 to 21 of the population
  by 2030 estimated 70.1 million.
• Rapid growth is expected to occur among the
  oldest frailest population groups.
• More diverse racially and ethnically
• Will live longer
• Will have multiple complex health problems
• Need for the inter-disciplinary team approach!

3
The Dilemma

• Mrs. Smith is an 86 year old widowed woman who
  lives with her son in his home. She has been
  receiving services through the county office of
  aging due to increasing cognitive problems and
  safety concerns. She has no previous mental
  health treatment history. The son noticed over
  several days that his mother was becoming
  increasingly suspicious in the early evening. He
  returned from work one evening and discovered her
  in the kitchen with a knife stating that the
  people next door were trying to take her money.
  He was unable to redirect her as she became
  increasingly agitated. He contacted the County
  Aging Protective Service Worker on call who
  directed him to take her to the nearest emergency
  room.

4
The Dilemma

• Upon arriving at the emergency room Mrs. Smith
  refused to get out of the car. The son proceeded
  into the ER and discussed with staff who stated
  there was nothing they could do. The son once
  again contacted the Aging Protective Service
  worker who suggested driving his mother around
  the block and to attempt to re-enter the
  emergency room. When the son went back to the
  car he had found his mother had a knife with her
  and had sliced the seats in the car.

5
Crisis Response?Criteria for 302?
6
Barriers to Care!
7
Patient and Family Barriers

• Isolation
• Ageism belief that depression, confusion are
  normal conditions of aging
• Preference of primary care
• Focus on somatic complaints
• Stigma
• Reluctance to discuss psychological symptoms
• Lack of /misinformation

8
Provider Barriers

• Ageism normal aging
• Training barriers
• Focus on medical issues
• Lack of awareness of geriatric-specific
  clinical symptoms
• Complexity of treatment issues
• Reluctance to inform patients of diagnosis
• Lack of access to psychiatric care
• Lack of /misinformation

9
System Barriers

• Fragmentation
• Intersystem boundaries including exclusion of
  dementia from many community mental health
  programs
• Time constraints
• Lack of access to geriatric specific services/
  treatment
• Reimbursement issues including a mismatch
  between covered services and a changing system of
  long-term and community based care
• Cultural diversity needs

10
Pennsylvanias Approach to Collaboration

• Memorandums of Understanding (MOU) between the
  Office of Mental Health and Substance Abuse
  Services (OMHSAS) and the Pennsylvania Department
  of Aging (PDA) State and County agreements

11
PDA OMHSAS Memorandum of Understanding (MOU)

• The 2006 Program Directive MOU required PDA
  Office of Community Services and Advocacy and the
  OMHSAS to collaborate and to develop MOUs between
  each countys MH/MR program and the countys
  Area Agency on Aging.

12
Pennsylvanias Cross System Approach

• 2006 - Mental Health Bulletin was released from
  the Deputy Secretary of Mental Health on the
  rights of older adults, even those with dementia,
  to receive mental health treatment. Service
  Priority Older Adult Population. (Bulletin
  issued, February 2006.)

13
Pennsylvanias Cross System Approach

• 2006 Cross System development with the
  Pennsylvania Department of Aging and Office of
  Mental Health and Substance Abuse Services, of a
  Suicide Prevention Strategy for Pennsylvania that
  specifically addresses the needs of older adults.
  

14
Pennsylvanias Cross System Approach

• Cross systems collaboration is necessary to serve
  the older adult population.
• MOUs between behavioral health and aging provide
  an agreed-upon roadmap to establish and build
  collaboration.

15
Psychiatric Issues of Aging

• Depression/ Late Life Depression
• Caregiving and Depression
• Behavioral and Psychological or Neuropsychiatric
  symptoms of Dementia
• Anxiety-based behaviors

16
The Dilemma

• Mr. Johnson is an 81 year old widowed gentleman
  who resides in a senior apartment building. On
  Friday afternoon at 430 he wandered into the
  managers office, confused and distraught over
  not being able to find his wife. When the manager
  reminded him of his wifes death 10 years ago, he
  became agitated, combative and threatened
  suicide.

17
The Dilemma

• The apartment manager contacted Mr. Johnsons
  daughter regarding her fathers confusion and
  suicidal comment. Her concern was that her
  father collects guns and had numerous weapons in
  his apartment. Due to the daughter residing out
  of state, the manager also contacted the Office
  on Aging for assistance. She was told to call
  Crisis Intervention due to the suicidal comment.
  On doing so the manager was told that he had
  dementia and could not be psychiatrically
  hospitalized.

18
Crisis Response?Criteria for 302?
19

• Late Life Depression

20
Depression and the Older Adult

• 7 million adults aged 65 years and older are
  affected by depression (Steinman, 2007).
• 15 20 of adults older than 65 have
  experienced depression. (GMHF)
• Affects approximately 15 out of every 100 older
  adults age 65 and older higher percentage in
  hospitals and nursing homes.
• Affects more older adults in medical settings,
  up to 37 older patients in primary care
  approximately 30 of these patients have major
  depression the remainder have a variety of
  depressive syndromes that could also benefit from
  medical attention (Alexopoulos, Koenig ).

21
Depression and the Older Adult

• Chronically ill Medicare beneficiaries with
  depression have significantly higher health care
  costs than those with chronic disease alone
  (Unützer, 2009).

22
Depression in Older Adults

• Causes may be physical, social, or psychological
  in origin, including
• Specific events in a person's life, such as the
  death of a spouse, a change in circumstances, or
  a health problem that limits activities and
  mobility
• Medical conditions - Parkinson's disease,
  hormonal disorders, heart disease, or thyroid
  problems
• Chronic pain
• Nutritional deficiencies
• Genetic predisposition to the condition
• Chemical imbalance in the brain

23
Depression and the Older Adult

• Individuals who get depressed for the first time
  in later life have a depression that is related
  to medical illness
• Untreated depression can lead to disability ,
  worsening of other illnesses, institutionalization
  , premature death and suicide (GMHF)
• Community surveys have found that depressive
  disorders and symptoms account for more
  disability than medical illness
• With proper diagnosis and treatment more than 80
  of individuals with depression recover and return
  to normal lives (GMHF)

24
Late Onset Depression

• Depression occurring for the first time in late
  life onset later than age 60
• Usually brought on by another medical illness
• When someone is already physically ill,
  depression is both difficult to recognize and
  treat
• Greater apathy/ anhedonia
• Less lifetime personality dysfunction
• Cognitive deficits more pronounced
• May be a precursor to dementia

25
Depression

• Major Depressive Episode
• Depressed mood
• Loss of interest or pleasure
• Appetite disturbance
• Insomnia or hypersomnia
• Psychomotor agitation or retardation

26
Depression

• Major Depressive Episode
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Decreased concentration indecisiveness
• Thoughts of death or suicide
• Impaired level of functioning

27
Older Adults at Risk for Depression

• Those with co-morbid disorders
• Frail elderly
• Older adults residing in care facilities
• Caregivers of older adults
• Isolated older adults

28
Depression and Dementia

• Depressive symptoms of various intensity occur in
  approximately 50 of demented patients
• Symptoms can include
• Abrupt loss of interest, increased irritability,
  refusal to eat, crying, and sudden deterioration
  in skills (Rovner)

29
Psychiatric Issues in Dementia - Depression

• Depression
• Behavioral symptoms of depression includes
  appetite changes, sleep disturbance,
  irritability/ agitation, refusal of care,
  inability to make a decision, social isolation,
  withdrawal, tearfulness, and sad mood.

30
Depression and Alzheimers Disease

• Depression that can occur with AD may be
  different than other depressive disorders in that
  the neuropathology of AD plays a role in the
  development of depression
• Olin, Katz, Lebowitz, et al Provisional
  Diagnostic Criteria for Depression of Alzheimer
  Disease Rationale and Background, American
  Journal of Geriatric Psychiatry, 2002

31
Depression, Suicide and Older Adults

• NIMH - Older adults with depression are at risk
  for suicide. In fact, white men age 85 and older
  have the highest suicide rate in the United
  States.
• American Association of Suicidology - Suicide
  rates for elderly males are the highest risk at a
  rate of 29.0 per 100,000 (2010)
• The Centers for Disease Control and Prevention
  2012 statistics state 51 out of every 100,000
  white men over 85 (the old-old) were at the
  greatest risk of suicide. The national average
  for all ages was 12. 6.

32
Suicide in Older Adults

• APA 20 of Older Adults who committed suicide
  saw their physician within the prior 24 hours,
  41 in the past week and 75 within the past
  month
• The risk of depression in the elderly increases
  with other illnesses and when ability to function
  becomes limited.
• Hybels CF and Blazer DG. Epidemiology of
  late-life mental disorders. Clinics in
  Geriatric Medicine, 19(Nov. 2003)663-696.
• Associated with late-onset depression

33
Assessing Suicide Risk(SAD PERSONS)

• S ex (Male)
• Age (Elderly or adolescent)
• Depression
• Previous Suicide
• Ethanol Abuse
• Rational Thinking loss (psychosis)
• Social Support lacking
• Organized Plan commit suicide
• No Spouse (divorcegtwidowedgtsingle)
• Sickness Physical illness

34
Older Adults who take their own lives are more
likely to have suffered from a depressive illness
than individuals who kill themselves at younger
ages
35
Depression and the Nursing Home

• Occurrence 10 times higher than those elderly
  residing in the community (Rovner)
• NIMH April 2002 up to 50 of nursing home
  residents are affected by significant depressive
  symptoms
• Associated with distress, disability and poor
  adjustment to the facility (Rovner)
• Most common cause of weight loss in long term
  care (Katz)

36
The Dilemma

• Mr. Johnson is an 82 year old gentleman who
  resides on a dementia unit at a local nursing
  home. He was recently placed there due to his
  wifes inability to care for him as her health
  concerns have worsened. One evening shortly after
  his admission Mr. Johnson became agitated as his
  wife was leaving the unit. He yelled that he
  needed to take care of her and go home with her.
  He threatened the staff verbally and became
  physically intimidating.

37
The Dilemma Cont.

• The staff attempted to redirect him, but Mr.
  Johnson became belligerent, stating they dont
  know what they are talking about and his wife is
  sick. The staff were concerned about the other
  residents on the unit becoming upset or even
  getting injured. The medical director of the
  facility instructed the staff to contact crisis
  intervention or take the resident to the
  emergency room. EMS had difficulty upon
  arriving, as Mr. Johnson would not get on the
  stretcher to go in the ambulance. Crisis
  intervention was contacted to come to the
  facility.

38
Crisis Response?Criteria for 302?
39

• Neuropsychiatric or Behavioral and Psychological
  Symptoms of Dementia

40
Dementia

• Irreversible chronic brain failure.
• Loss of mental abilities.
• Can involve memory, reasoning, learning and
  judgment.
• All patients with dementia have deficits, but how
  they are experienced depends on their
  personality, style of coping and their reaction
  to the environment.

41
Psychiatric Symptoms of Dementia

• Dementia is the greatest risk factor for the
  development of psychotic symptoms in the older
  adult population.
• Dementia process itself and
• An increased vulnerability to delirium
• Brown, FW. Late-life Psychosis Making the
  Diagnosis and Controlling Symptoms. Geriatrics
  1998.

42
Behavioral and Psychological or Neuropsychiatric
Symptoms of Dementia

• Affects up to 90 of all individuals with
  dementia over the course of their illness
• Causes psychological, social and biological
  factors?
• Recent research has emphasized the role of
  neuropathological and genetic factors underlying
  the clinical manifestation.

43
Psychiatric Symptoms of Dementia

• More than half of individuals with dementia
  experience psychotic symptoms during the course
  of their illness.
• Delusions are the most common (up to 70)
• House is not their house
• Spouse not their spouse (Capgras syndrome)
• Infidelity
• Hallucinations (up to 50) usually visual
• Lewy Body Dementia up to 80 experienced visual
  hallucinations, usually early on in the disease.
• Brendel, R., and Stem, T. Psychotic Symptoms
  in the Elderly, Primary Care Companion,
  Journal of Clinical Psychiatry, (2005) 7 (5)
  238-241.

44
Psychiatric Symptoms of Dementia

• Hallucinations and delusions are commonly
  associated with aggression, agitation and
  disruptive behaviors.
• Psychotic symptoms are associated with more
  caregiver distress.
• Associated with institutionalization.
• Psychotic symptoms disappear in the more advanced
  stages of the disease.

45
Behavioral and Psychological or Neuropsychiatric
Symptoms of Dementia

• Symptoms of disturbed perception, thought
  content, mood or behavior that frequently occur
  in persons with Dementia
• BPSD are treatable!
• BPSD can result in
• Suffering
• Premature Institutionalization
• Increased Costs of Care
• Loss of quality of life for the person and
  caregivers
• Finkel et al 1996

46
Behavioral and Psychological or Neuropsychiatric
Symptoms of Dementia

• Hallucinations (Usually visual)
• Delusions
• People are stealing things
• Abandonment
• This is not my house
• You are not my spouse
• Infidelity

47
Behavioral and Psychological or Neuropsychiatric
Symptoms of Dementia

• Misidentifications
• People are in the house
• People are not who they are
• Talk to self in the mirror as if another person
• Events on television

48
Behavioral and Psychological or Neuropsychiatric
Symptoms of Dementia

• Depressed Mood
• Anxiety
• Apathy
• Decreased social Interaction
• Decreased facial expression
• Decreased initiative
• Decreased emotional responsiveness

49
Behavioral and Psychological or Neuropsychiatric
Symptoms of Dementia

• Wandering
• Checking
• Attempts to leave
• Aimless walking
• Night-time walking
• Trailing
• Excessive activity

50
Behavioral and Psychological or Neuropsychiatric
Symptoms of Dementia

• Verbal Agitation
• Negativism
• Constant requests for attention
• Verbal bossiness
• Complaining
• Relevant interruptions
• Irrelevant interruptions
• Repetitive sentences

51
Behavioral and Psychological or Neuropsychiatric
Symptoms of Dementia

• Verbal Aggression
• Screaming
• Cursing
• Temper Outbursts

52
Behavioral and Psychological or Neuropsychiatric
Symptoms of Dementia

• Physical Agitation
• General Restlessness
• Repetitive Mannerisms
• Pacing
• Trying to Get to a Different Place
• Handling Things Inappropriately
• Hiding Things
• Inappropriate Dressing or Undressing

53
Behavioral and Psychological or Neuropsychiatric
Symptoms of Dementia

• Physical Aggression
• Hitting
• Pushing
• Scratching
• Grabbing Things
• Grabbing People
• Kicking and Biting

54
Behavioral and Psychological or Neuropsychiatric
Symptoms of Dementia

• Disinhibition
• Poor Insight and Judgment
• Emotionally Labile
• Euphoria
• Impulsive
• Intrusiveness
• Sexual Disinhibition

55
The Dilemma

• Ms. Moore, 73, was admitted to the
  geriatric-psychiatry unit from a local personal
  care home for withdrawal, decline in personal
  hygiene, poor appetite and disorientation. Upon
  admission it was determined that her
  symptomatology was due to pneumonia. She quickly
  responded to treatment, was discharged back to
  the personal care home however shortly after
  readmission she fell and fractured her hip. She
  became suspicious of medical providers and
  refused to go in the ambulance.

56
The Dilemma

• Ms. Moore, who suffers from schizophrenia,
  retired from state government at 69 and resided
  at home with her mother until her death 3 years
  ago. After her mothers death she was
  hospitalized, re-stabilized on medication and
  discharged to a small, local, personal care home.
  Ms. Moore functioned well until her recent
  medical illness and subsequent hip fracture.
  Discharge planning for rehabilitation also became
  difficult as long term care facilities were
  hesitant to take a patient with a psychiatric
  diagnosis.

57
Crisis Response?Criteria for 302?
58

• Hoarding Behaviors

59
Characteristics of Compulsive Hoarding Behaviors

• Excessive acquisition and retention of
  apparently useless things and animals.
• Cluttered living spaces that limit activities for
  which these spaces were designed.
• Significant distress or impairment is caused by
  the hoarding behaviors.
• Frost and Hartl (1996)

60
Hoarding Statistics

• It is a hidden problem.
• Estimates are that hoarding behaviors effects
  between 2 - 5 of the population!
• Recent research states there is no gender
  differences.
• Though it is thought to begin in adolescence, due
  to the progressive nature of hoarding behaviors
  there are increasing problems as individuals age.

61
Risk Factors for Hoarding

• Age begins in adolescence
• Stressful life event often precedes behavior
• Lower socioeconomic income
• Tendency to be single or divorced
• Hereditary issues 50 80 of individuals who
  had hoarding behaviors had first degree relatives
  who were considered pack rats or hoarders.

62
Risk Factors for Hoarding

• Stressful Life Events
• Some individuals develop hoarding behaviors after
  experiencing a stressful life event such as a
  motor vehicle accident, death of a love one,
  sexual abuse, rape or witness to a crime.
• Behavioral Research Therapy 1996 34341-350.
• Behavioral Research Therapy 2005 43269-276.
• Journal of Anxiety Disorders January 2005
  675-686.
• Clinical Psychiatry News, June 2006.

63
Risk Factors for Hoarding

• Stressful Life Events Cont.
• Significant correlation of hoarding in females to
  a history of interpersonal violence 76 compared
  to 32 in the general populations (Tolin and
  Meunier et al., 2010).
• Childhood adversities
• Parent with psychiatric symptoms
• Homebreak-ins
• Excessive physical discipline
• (Samuels, Bienvenu, et al., 2008)

64
Co-Morbidity

• Depression 57
• Anxiety - Generalized, Social, Posttraumatic
  Stress
• Obsessive Compulsive Disorder
• Attention Deficit Hyperactivity
• Dementia

65
Individuals Who Have Hoarding Behaviors

• Have significant emotional attachment to items.
• Feel the items they collect will be needed or
  will have value in the future.
• Feel safer when surrounded by the things they
  collect!

66
Hoarding Research

• Functional imaging suggests the medial
  prefrontal area of the brain plays an important
  role.
• PET Scans show lower than normal activity in the
  anterior cingulate gyrus. This area is associated
  with such tasks as focused attention and decision
  making.

67
Hoarding and the DSM 5

• Now considered a distinct disorder
• Previously was a Subtype or symptom of Obsessive
  Compulsive Disorder
• Hoarding behaviors may also seen in individuals
  with Generalized Anxiety Disorder, Social
  Phobias, Schizophrenia, Dementia, Eating
  disorders and Mental Retardation
• Those with significant hoarding symptoms are more
  likely to suffer from co-morbid depression

68
DSM 5 Hoarding

• Persistent difficulty discarding or parting with
  possessions, regardless of their actual value.
• This difficulty is due to a perceived need to
  save the items and distress associated with
  discarding them.
• The symptoms result in the accumulation of
  possessions that congest and clutter active
  living areas, and substantially compromise their
  intended uses. If living areas are uncluttered,
  it is only because of the interventions of third
  parties.

69
DSM 5 CONT.

• The hoarding causes clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning
  (including maintaining a safe environment for
  self and others).
• The hoarding is not attributable to another
  medical condition (e.g. brain injury,
  cerebrovascular disease, etc.).

70
DSM 5 CONT.

• The hoarding is not better accounted for by the
  symptoms of another DSM 5 disorder (e.g.
  hoarding due to obsessions in Obsessive
  Compulsive Disorder, decreased energy in Major
  Depressive Disorder, delusions in Schizophrenia,
  restricted interests in Autism Spectrum Disorder,
  etc.).

71
Assessment

• Saving Inventory-Revised tool (Frost)
• Saving Cognition Inventory (Frost, Steketee)
• Hoarding Rating Scale Assessment Tool (Frost)
• Clutter Image Rating Scale (Frost)
• Activities of Daily Living (ADL)

72
Treatment

• Treatment is challenging and has mixed success
• Cross system collaboration helpful
• Medication
• Psychotherapy

73
Treatment -Therapy

• Behavioral Therapy
• Cognitive remediation
• Focus on building concrete skills

74
Cognitive Behavioral Therapy

• Cognitive Behavioral Therapy is the most
  commonly cited approach and has been shown to be
  effective up to 50 of individuals.
• Muroff, J., Steketee, G., Bratiotis, C., et al.
  Group cognitive and behavioral treatment for
  compulsive hoarding a preliminary trial,
  Depression and Anxiety, 2009 26 (7) 634-640.
• Steketee, G., Tolin, DF., Cognitive-behavioral
  therapy for hoarding in the context of
  contamination fears, Journal of Clinical
  Psychology 2011 67 (5) 485-496.

75
Treatment -Therapy

• Frost and his colleagues found that 26 sessions
  of behavioral therapy, including home visits,
  over a 7 to 12 month period helped half of the 10
  hoarders who completed a cognitive behavioral/
  psychotherapeutic program become "much improved"
  or "very much improved.
• Randy Frost, PhD, Israel Professor of
  Psychology, Smith College, Northampton, Mass.

76
Community-Based Interventions

• Cross system collaborative approach
• Multiagency Hoarding Teams (MAHT)
  coordination of public sector approaches
• Hoarding Task Forces

77
Hoarding Task ForcesKey Issues

• A comprehensive, multi-agency approach best
  serves the interests of the owner/ occupant.
• Each agency must have an understanding of
  services and capabilities of other agencies.
• Hoarding behaviors can create unsafe living
  conditions action must be taken to protect life,
  health, and safety.
• Fairfax County, Virginia Hoarding Task
  Force, Annual Report, 2009

78
Hoarding Task ForcesKey Issues

• Significant staff resources may be required.
  Enforcement, follow-up, remediation, and court
  action may require many hours and there is no
  guarantee that the behavior will not reoccur.
• A compassionate, professional, and coordinated
  approach must be developed to provide a chance of
  recovery for the owner/ occupant and the
  community. Fairfax County, Virginia Hoarding
  Task Force, Annual Report, 2009

79
Cross System Collaborative Approach

• Area Agency on Aging
• Mental Health Centers/ Providers
• Crisis Intervention/ emergency services
• Inpatient Psychiatric Services
• Department of Health
• Humane Society
• Vector Control
• Biohazard
• Private consultants professional organizers

80
Evidenced-based Practices for Older Adults
with Behavioral Health Issues
81
Evidence-based Practices for Older Adults with
Behavioral Health Issues

• Psychosocial and pharmacological treatment for
  depression and dementia.
• Integrated mental health services in primary
  care.
• Mental health outreach services.
• Brief alcohol interventions for at-risk use.
• Family/ caregiver support interventions.
• Draper, 2000 Unutzer, it al., 2001
  Schulberg, et al., 2001 Sorenson, et al.,
  2002 Bartels, et al., 2002, 2003

82
Collaborative Approaches for Older Adults with
Behavioral Health Issues

• Healthy Aging Initiatives
• Building Healthy Communities for Active Aging
  EPA
• The Healthy Brain Initiative CDC and the
  Alzheimers Association National Public Health
  Road Map to Cognitive Health
• Chronic Disease Self-Management Program (CDSMP)
  Physical, emotional and health-related quality of
  life, healthcare utilization and costs

83
Evidence-Based Practices for Older Adults with
Behavioral Health Issues

• Depression in Older Adults
• Healthy IDEAS - (Identifying Depression,
  Empowering Activities for Seniors) Integrates
  depression awareness and management into existing
  case management services.
• Screens, educates, links to services and utilizes
  behavioral approaches.
• Evidenced based Disease Self Management for
  Depression NCOA Model Health Program.

84
Evidence-Based Practices for Older Adults with
Behavioral Health Issues

• Depression in Older Adults
• PEARLS -(Program to Encourage Active Rewarding
  Lives for Seniors) Utilizes existing
  community-based programs.
• Problem solving treatment, social and physical
  activation, PEARLs counselor offers visitation.
• Gatekeeper Program Trains non-traditional
  sources to identify and refer older community
  residing elders to services.

85
Collaborative Approaches for Older Adults with
Behavioral Health Issues

• Outreach Programs
• Multidisciplinary outreach services takes
  services to where older adults reside home and
  community based settings
• Psycho geriatric Assessment and Treatment in City
  Housing (PATCH) Baltimore, MD Gatekeeper
  program with assertive community treatment.

86
Evidence-Based Practices for Older Adults with
Behavioral Health Issues

• Depression in Older Adults
• Interventions for Family Caregivers (Mittelman)
  combination of counseling sessions, support
  group, education and ongoing support.
• Assists in delaying nursing home placement.
• Improved caregiver depression and health outcomes.

87
Integrating Mental Health Services in Primary
Care

• PRISM-E (SAMHSA) (Primary Care Research in
  Substance Abuse and Mental Health for the
  Elderly) comparing two types of care models for
  delivery of mental health services to older
  adults.
• 50 clinical settings managed care, community
  health clinics, VA system and group practice
  settings.
• Diverse ethnic/ minority and rural/ urban
  populations.
• Largest study of depression and alcohol uses in
  older adults.
• The firsts effectiveness study of integration in
  older adults.

88
Evidence-Based Practices for Older Adults with
Behavioral Health Issues

• Suicide Prevention
• Supportive interventions including screening,
  psycho-education and group activities.
• Telephone-based supportive interventions.
• Protocol driven treatment delivered by a case
  manager (IMPACT PROSPECT).

89
Integrating Mental Health Services in Primary
Care

• IMPACT (Hartford Foundation) - (Improving Mood
  Promoting Access to Collaborative Treatment for
  Late Life Depression)
• Identification of older adults in need.
• 12 month access to depression care manager and
  support.
• PCP manages anti-depressant medications.
• Brief psychotherapy.
• Case supervision by a psychiatrist.

90
Integrating Mental Health Services in Primary
Care

• PROSPECT (NIMH) - Prevention of Suicide in
  Primary Care Elderly Collaborative Trial
• Sought to decrease risk factors including
  barriers to accessing health care and the
  presence of untreated mental illness.
• Identification of older adults in need.
• Case management links to appropriate service.
• Depression care management and suicide
  prevention.

91
Collaborative Approaches for Older Adults with
Behavioral Health Issues

• Colorados Senior Reach
• Community-involved identification of older adults
  who need emotional or physical support and
  connection to community services.
• 70 of seniors previously had fallen through
  the cracks.

92
Collaborative Approaches for Older Adults with
Behavioral Health Issues

• Colorados Senior Reach Cont.
• 90 who were referred have accepted mental
  health services.
• Program enables individuals to access service
  before serious problems arise.
• Senior Reach has found that building strong
  collaborative community relationships that
  enhance ongoing services to older adults is the
  key to prevention of more serious problems.

93
Behavioral Health Needs of Older Adults

• Multidisciplinary approach
• Consumer input
• Stakeholder-generated principles CSP/CASSP
• Culturally competent
• All levels of interagency collaboration
• Toward the aim of dispelling stigma
• Integrated at the community level
• Continuum of care from prevention to treatment
• SAMHSA Strategic plan Substance Abuse and
  Mental Health Issues facing Older Adults 2001
  - 2006

94
Resources

• Alzheimers Association www.alz.org
• ADEAR (NIA) adear_at_alzheimers.org
• Family Caregiver Alliance www.caregiver.org
• Geriatric Mental Health Foundation
  www.gmhfonline.org
• PA Behavioral Health and Aging Coalition
  www.olderpa.org

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Resources

• Medline Plus (NIH) www.medlineplus.gov
• American Federation of Suicide Prevention
  http//www.afsp.org/
• Pennsylvania Behavioral Health and Aging
  Coalition - www.olderpa.org

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What makes the engine go?Desire, desire,
desire.The longing for the danceStirs in the
buried life.One season only, and its
done. Stanley Kunitz