Jennifer Heffernan MD Assistant Professor of Medicine Division of Geriatrics

Transcription

1 Jennifer Heffernan MD Assistant Professor of Medicine Division of Geriatrics

2 Explain tools used to differentiate mental illness from dementia Consider places people present with mental illness Become familiar with the role of Adult Protective Services (APS) in meeting the needs of the mentally ill with dementia Identify specific resources available to meet the needs of this special population

3 Approximately 20 percent of the 55+ population experience illnesses such as depression, Alzheimer s disease, substance abuse, anxiety, and late-life schizophrenia. Mental disorders can be treated to reduce symptoms and improve the quality of life for individuals and their caregivers. Early detection and diagnosis are critical. Yet, social stigmas often cause health care professionals, as well as patients and families, to inaccurately attribute abnormal behavior to the aging process instead of recognizing symptoms of disease.

4 The consequences of under- diagnosis and lack of appropriate treatment can be severe, especially in cases of depression. There is a relationship between depression and suicide. Among those 65 and older, suicide rates are higher than any other age group.

5 Depression Bipolar disorder Substance abuse (EtOH and Rx) Schizophrenia Delusional disorders Personality disorders

6 Gateway symptoms (must have 1) Depressed mood Loss of interest or pleasure (anhedonia) Other symptoms Appetite change or weight loss Insomnia or hypersomnia Psychomotor agitation or retardation Loss of energy Feelings of worthlessness or guilt Difficulty concentrating, making decisions Recurrent thoughts of suicide or death

7 Minor depression is common 15% of older persons Causes use of health services, excess disability, poor health outcomes, including mortality Major depression is not common 1% 2% of physically healthy community dwellers Elders less likely to recognize or endorse depressed mood

8 More often report physical symptoms Less often report depressed mood, guilt May present with masked depression cloaked in preoccupation with physical concerns and complicated by overlap of physical and emotional symptoms

9 Elevated, irritable or expansive mood persisting for at least 1 week, plus; Three of the following: Inflated self-esteem, grandiosity Hypersexuality Marked increase in activity Pressured speech Racing thoughts, flight of ideas Distractibility Marked decreased need for sleep

10 Grandiose or paranoid delusions may be present Older patients are more likely to have a mixture of depression that presents as irritability

11 using a psychoactive substance to such an extent that it interferes with health, occupational, or social function. Blackouts are a form of amnesia, in which the patient is unable to recall events that occurred during a bout of drinking even though he or she was conscious and active during this time. can last for several minutes or for days their frequency is an index of the severity and duration of alcoholism. occur in 64-94% of alcoholics

12 A mental illness in which a person cannot tell what is real from what is imagined Can come and go in phases, or they can happen only once or twice in a lifetime. Psychotic symptoms are usually sudden and severe. During psychotic phases, the person may still understand parts of reality. He or she may lead a somewhat normal life, doing basic activities such as eating, working and getting around. In other cases, the person may be unable to function. Symptoms during psychotic phases include: Seeing, hearing, feeling or smelling things that are not real (called hallucinations) Having strange beliefs that are not based on facts (called false beliefs or delusions) -- For example, the person may believe that people can hear his or her thoughts, that he or she is God or the devil, or that people are putting thoughts into his or her head. Thinking in a confused way, being unable to make order out of the world, shifting quickly from one thought to the next

13 Have a lot of energy or be overly active, or become "catatonic," a state in which the body becomes rigid and cannot be moved Talk in sentences that do not make sense Not wash or groom Cut themselves off from family, friends and the outside world Be unable to function in school, work, or other activities Lose interest in life Behave in strange ways Be very sad (depressed) or have mood swings Have dulled emotions Be inactive

14 Presence of delusions unshakable beliefs in something that is untrue. involve situations that could occur in real life, such as being followed, poisoned, deceived, conspired against, or loved from a distance. involve the misinterpretation of perceptions or experiences. In reality, however, the situations are either not true at all or highly exaggerated. Continue to socialize and function quite normally, apart from the subject of their delusion, and generally do not behave in an obviously odd or bizarre manner. Delusional disorder itself is rare, most often occurs in middle to late life.

15 Long-standing patterns of thinking and acting that differ from what society considers usual or normal. The inflexibility of their personality can cause great distress, and can interfere with many areas of life, including social and work functioning. Have poor coping skills and difficulty forming healthy relationships. Are not aware that they have a problem and do not believe they have anything to control. Therefore they often do not seek treatment.

16 Now that we have discussed different types of mental illness, lets look at dementia.

17 The development of multiple cognitive deficits manifested by both of the following: 1. Memory impairment (inability to learn new information and to recall previously learned information) 2. At least one of the following cognitive disturbances: a. Aphasia (language disturbance) b. Apraxia (inability to carry out motor activities despite intact motor function) c. Agnosia (failure to recognize or identify objects despite intact sensory function) d. Disturbance in executive functioning (ie, planning, organizing, sequencing, abstracting) Copyright 2000 by The McGraw-Hill Companies, Inc. All rights reserved.

18 Personality disorders typically worsen 30-50% of patients with Alzheimer s experience symptoms of depression 12 month mortality is higher for mildly demented persons with depression Poor quality of life Increase doctor/hospital visits/other healthcare adverse effects on caregivers

19 Sudden onset Vegetative signs common Patients expose cognitive deficits Patients often respond "I don't know" Variability in cognitive performance Inconsistent effort Recent and remote memory may be equally poor Sundowning uncommon Gradual onset Vegetative signs less common Patients conceal cognitive deficits Patients attempt to answer questions Consistently poor cognitive performance Consistent effort Recent memory worse than remote memory Sundowning common

20 Impaired function, abstract thinking, & judgment Function may improve with treatment Presents at an early age, i.e s May be late onset Fluctuates Psychosis early Impaired function, abstract thinking, & judgment Function does not significantly improve Onset later on in life, i.e years old. May be early on-set Progressive Psychosis late

21 more bizarre delusions commonly seen in schizophrenia. Auditory hallucinations are more common Delusions are frequently of a persecutory nature and tend to address core environmental issues, for instance, accusing a family member of stealing. Visual hallucinations occur more frequently than auditory hallucinations, but may be difficult to distinguish from illusions, eg, reflections on windows interpreted as strangers in the house.

22 Alzheimer s dementia (45-65%) Prevalence is 1% at 65 years of age, and doubles every 5 years Vascular dementia (10-40%) Multi-infarct dementia Alcohol-related dementia Parkinson s disease Lewy body dementia Frontal lobe dementias

23 Typically behavioral aggression, psychomotor agitation, frank psychosis, and affective or personality changes later on in the disease Visual hallucinations are more common than auditory hallucinations

24 Texas Alzheimer s Research Consortium (TARC) Dr. James Hall Mild stages of dementia Dysphoria Meaninglessness Moderate stages of dementia Apathy

25 A history of depression increases risk of developing AD Those with a depression history developed dementia at an earlier age? Late-life depression really a sign of on-coming demenia? AD and depression share the presence of proinflammatory cytokines.

26 Frontal lobe behavioral syndromes (eg, apathy, disinhibition) can be frequently seen Behavioral manifestations are variable depending on the vascular region involved

27 severe memory loss Confabulation invented memories which are then taken as true due to gaps in memory sometimes associated with blackouts meager content in conversation lack of insight apathy- the patients lose interest in things quickly and generally appear indifferent to change.

28 Hallucinations and delusions as a side-effect of medications used to treat Parkinson s disease. Hallucinations are usually visual and very vivid May or may not be disturbing

29 personality and behavioral changes Disinhibition deterioration of social skills typically presents between the ages of 50 and 60 years

30 distinguishing dementia from depression, delirium, or the cognitive changes of normal aging. Chronically mentally ill patients may also be incorrectly diagnosed with dementia. Can chronic schizophrenia cause dementia? A chronic schizophrenic patient with profound social regression and severe negative symptoms may be difficult to distinguish from a patient with dementia.

31 Delirium Urinary tract infection Pneumonia Medications or withdrawal from medications Alcohol withdrawal Constipation Urinary retention Sensory deprivation

32 Clinical presentation Onset, duration, types to hallucinations/delusions, progression (slow/intermittent) Response to treatment Psychiatric evaluation Neurocognitive testing

33 Emergency room Psychiatric hospital Primary care office Psychiatrist/psychologist office Long-term care services Adult Protective Services Homeless shelters

34 Mental Health and Mental Retardation Provided through the Texas Dept of Aging and Disability Services (DADS) Goal is to educate! remove the negative social stigmas associated with mental illness among older adults. detect signs and symptoms of mental illness when to seek help from a mental health professional

35 Available mental health and substance abuse programs and services. Support services through HHS agencies. Educate health care providers about strategies to assess mental illness, (i.e., depression, dementia, substance abuse, and medication misuse) in their older patients.

36 Individuals 65 and older are less likely than younger populations to use available community mental health services. Financial barriers that exist with standard health insurance policies or federally-funded programs. Medicare does not adequately cover mental health screening, diagnosis, community services, and medication. As a result, many older patients who could benefit from treatment do not receive needed care services due to financial constraints.

37 Texas Department of Family and Protective Services APS is responsible for investigating abuse, neglect, and exploitation of adults who are elderly or have disabilities. The major components of APS; In-home Investigations Facility Investigations.

38 Provided directly by caseworkers, through arrangements with other community resources, or purchased by APS on a short-term, emergency basis. Financial assistance for rent and utility restoration Social services Health services Referrals to the Texas Department of Aging and Disability Services (DADS) for guardianship services Referrals to other state or community services

39 (all names in this scenario are fictitious): Mrs. Gregg was admitted to the hospital with a ruptured left eye due to untreated glaucoma. Her hair was matted and her clothes were soiled. She had sores on her legs and her toenails were so long they curved over and under her feet. Mrs. Gregg lived with a daughter who had a history of mental illness. APS found that their home was infested with roaches and cluttered with trash inside and out. A nephew, who was representative payee, was grossly exploiting both mother and daughter.

40 APS arranged, through other state and community agencies, home-delivered meals in-home care ongoing medical treatment direct deposit of the clients' social security checks for the daughter to be taught to write checks and manage money.

41 Adult Day Services Assisted transportation Caregiver education, training, & Support Respite care Care coordination Chore maintenance Meals Emergency response system Home health services Health screening Homemaker Housing placement Legal assistance Mental health services Nutrition education Personal care assistance Residential repair Senior Centers

42 The Guardianship Services, Inc. staff trains volunteers to serve as court-appointed guardians for adults 18 years and older who have been declared incapacitated by a Judge with Probate jurisdiction. Advocating the needs of the client by arranging for needed social services and monitoring the quality of care provided. Managing the client's financial affairs by receiving payments, paying bills, maintaining financial records and securing and managing assets. Caring for the health needs of the client by arranging form and authorizing medical treatment. Visiting the client regularly.

43 Reads and sorts mail Pays bills Writes checks (all checks are signed by the client) Balances check register to bank account Maintains records and files Reports to GSI The client maintains control and makes decisions concerning his or her finances. The volunteer assists exclusively with tasks the client is unable to perform.

44 Baylor AllSaints Psychiatric In-patient unit JPS In-patient psychiatric unit Behavioral Health Clinics Millwood In-patient psychiatric hospital UNT Health Psychiatry and psychology departments Geriatrics Clinic Geriatric Mental Health Services psychology

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