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. Pennsylvania’s 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 county’s MH/MR program and the county’s Area Agency on Aging.

12. Pennsylvania’s 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. Pennsylvania’s 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. Pennsylvania’s 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 4:30 he wandered into the manager’s office, confused and distraught over not being able to find his wife. When the manager reminded him of his wife’s death 10 years ago, he became agitated, combative and threatened suicide.

17. The Dilemma The apartment manager contacted Mr. Johnson’s daughter regarding her father’s 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 Alzheimer’s 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 (divorce>widowed>single) 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 wife’s 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 don’t 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