Our Senior Clients Clinical Issues Treatment Implications Interventions
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1 Our Senior Clients Clinical Issues Treatment Implications Interventions Presented by Dr. Christine A. Cauffield, CEO, LSF Health Systems Learning Objectives Identify key characteristics of Major Depressive Disorder Recognize behavioral characteristics of Dementia Learn referral sources necessary to provide appropriate evaluation for both disorders Identify key parts of the brain responsible for various clinical behavioral presentations Who are Older Adults? According to the 2000 U.S. Census, 12.4 percent of all Americans are age 65 or older. The Centers for Disease Control and Prevention has projected that by 2030, the number of older adult Americans will double to 70 million people, or one in every five Americans. In 1940, it was expected that the average 65-yearold might live an additional 12½ years; today, it is anticipated that 65-year-olds will live an additional 17½ years. 1
2 Mental Health and Aging Key Issues: Depression Suicide Cognitive Impairment Substance Use and Misuse Grief Mental Health and Aging Key Topics: Cohort Characteristics Clinical Implications Interventions Cohort Characteristics 8 th Grade Education Low Divorce Rate Shame Domestic Violence/Circle of Violence Elder Abuse Males age 60 and over = neglect/passive aggressive abuse Long Term Marriage Nursing Homes - Shame Psychiatric Help Shame to family 2
3 Depression More than 5 million of the 34 million elders age 65 and older suffer from some form of depression. According to the American Psychological Association, an estimated 20 percent of older adults within the community suffer from depression while approximately 50 percent of nursing home residents suffer from depression. They can also suffer from anxiety disorders, which tend to go undiagnosed as their physical illnesses mask or distract attention from the underlying or co-occurring psychiatric condition Depression In a study conducted by the AHCPR, 16% of older adults surveyed displayed one or more tendencies for depression Primary care physicians (PCPs) miss diagnosing depression in half of older adult patients they see PCPs are 2.5 times more likely to diagnose depression in women patients over 65 than males Source: Agency for Health Care Policy and Research Depression Seniors with depression have a higher risk of developing other physical illnesses. Chronically depressed seniors have an 88% higher risk of contracting cancer than do seniors who are not depressed. Many seniors simply do not know about the illness of depression or that treatment is available. 3
4 Suicide Suicide rates increase with age and are highest among elders age 65 and older. Men accounted for 85% of suicides among people age 65 and older in From , the largest relative increase occurred among those years of age. The rate for men in this group increased 17%. Suicide rates among older adults are highest among those who are divorced or widowed Source: Centers for Disease Control & Prevention Suicide Caucasian men over the age of 85 are at the greatest risk of all age-gender-race groups. Contrary to popular belief, only a small percentage (2-4%) of suicide victims have been diagnosed with a terminal illness at the time of their death. 66% - 90% of elderly suicides have at least one psychiatric diagnosis. Older persons are less likely to reach out by calling a crisis line than their younger counterparts. Suicide Approximately 75% of older adult suicide victims visited their primary care physician in the month prior to committing suicide. Twenty percent of these individuals reported visiting their physician within 24 hours of committing suicide. Older persons tend to make fewer attempts per completed suicide and use highly lethal methods. Seventy-one percent of older adults who committed suicide in 1998 used a firearm; 11 percent overdosed on liquids, pills, or gas; and 11 percent suffocated themselves. Source: National Strategy for Suicide Prevention 4
5 Cognitive Impairment Symptoms of cognitive impairment: Memory loss Language disturbance Decline in judgment and reasoning Personality change Cognitive Impairment Cognitive impairment is a risk factor and precursor for Dementia and Alzheimer s Disease Approximately 4 million Americans have Alzheimer s and will live an average of 8 years up to 20 years from the onset of symptoms Cognitive Impairment One in 10 persons over 65 and nearly half of those over 85 have Alzheimer s or other forms of Dementia. More than 7 out of 10 people with Alzheimer s disease live at home. Almost 75% of home care is provided by family and friends 5
6 Neuropsychological Issues Frontal Lobe Disinhibition Incontinence = Disease Vascular Dementia Latency Psychiatric Sequelae Transient Ischemic Attacks Sense of Taste/Smell Alzheimer s Disease Misdiagnosed Lack of Geropsych Beds Substance Use and Misuse In 2000, an estimated 568,000 persons aged 55 or older (1% of all older adults in the United States) had used illicit drugs In 2000, over 5 million were binge alcohol users, including more than 1 million who were heavy alcohol users Among older adults, Caucasians had higher rates of illicit drug use compared with Hispanics and had higher rates of alcohol use compared with either Blacks or Hispanics Types of Substance Abusers Types of Precipitating Factors: Chronic life of habitual consumption and lack of alternative activities Reactive response to the stresses of aging Cognitive/Behavioral often an issue of psychiatric co-morbidity 6
7 Prescription Drug Use and Misuse Older Adults Consume 25% to 40% of the Nation s prescription drugs Fill an average of 15 prescriptions per year Often take up to 10 different prescriptions at one time Prescription Drug Use and Misuse It is estimated that: 85% of older adults take at least one prescription drug daily 76% use more than one prescription drug 70% use over-the-counter drugs daily 21% of hospitalized adults over age 40 have a diagnosis of alcoholism with related hospital costs as high as $60 billion annually Prescription Drug Use and Misuse Older adults develop problems of misuse of prescription medications as a result of: Their own well-intentioned noncompliance Physician prescribing too high a dose Lack of physician coordination of medications Financial constraints (medication vs. food) Cognitive Impairment 7
8 Risk Factors Life changes can make older adults more susceptible to alcohol use Retirement Relocation Widowhood Death of Close Friend Role in Family Changed Decision Maker to Dependency Loss of Physical or Mental Abilities Chronic Disease Risk Factors Sleep problems Gender Men tend to drink more than women Women experience more negative effects of alcohol than men Women who drink tend to increase drinking later in life Current or Past Psychiatric Disorder The CAGE Questionnaire This is a tool used by physicians to determine whether someone is having a drinking problem: C : Have you ever tried to cut down your intake of alcoholic beverages? A: Have you been annoyed by criticism of your drinking? G: Have you ever felt guilty regarding your drinking? E: Have you ever felt the need for an eye opener in the morning? Optimal Aging Manual, Chapter 27 Alcohol Abuse Checking 2 or more may indicate a problem 8
9 Emotional Effects Levels of Grief Sadness Guilt Anxiety - Fear Helplessness - Vulnerability Physical ailments Memories of prior loss/trauma Cognitive Effects Levels of Grief Disorientation Unable to make decisions Unable to concentrate - Confused Experience memory loss Physical Effects Sleep disturbance Loss of energy Reduced appetite Altered immunity Levels of Grief 9
10 Behavioral Effects Levels of Grief Increase in alcohol intake Overuse of prescription/nonprescription medications Irritable Moody Marked changes in usual behavior Levels of Grief Spiritual Effects Lapses in spiritual practice/faith Blaming God Questioning the meaning of life Isolation and despair over temporary loss of faith Risk Factors Recent or multiple losses Self-destructive behavior Symptoms similar to medical illness of deceased History of trauma/abuse Progressive social isolation Anger leading to paranoia Chronic health ailments 10
11 Elders and Grieving Bereaved older individuals Often rate their health as poor Experience increased rates of hospitalization Are eight times more at risk for death Elders and Grieving Other losses which cause grief Loss of a beloved pet Retirement Loss of identity Loss of stature Loss of daily routine Camaraderie with colleagues Loss of health or physical abilities Methods of Treatment Normalize Facilitate Process letters, memorials Empty Chair Technique Explorations of existential and spiritual issues Reminiscence Therapy Restore meaning 11
12 Methods of Treatment Support Groups Monitor Major decisions Potential for increase in addictive behaviors Potential for increase in suicidal risk Clinical Implications Medical History paramount Risk factors for Dementia Prior Head Trauma/Injuries History of Depression Vascular Issues Cardiac Events TIAs Prior Surgeries Differential Diagnosis Clinical Implications Aware of best scans MRI, PET, SPEC Suicide Always Assess Dementia Pre-morbid functioning determines ability to mask Denial & Co-dependency issues Meet with Patient and Caregiver MSE High functioning can score high yet have serious deficits 12
13 The Need for Elder-Specific Interventions Dementia and the Law Senior Court Reminiscence Therapy Use of Alternate Modalities Touch is important Safety Issues: Elder Abuse Driving Geriatric Unit required for inpatient care Develop Programs to Address Risk Factors Grief/Loss Counseling Reminiscence Therapy In-Home/On-Site (counteract shame) Increase socialization to decrease isolation Educate Seniors focus on health issues Educate healthcare professionals Educate law enforcement Raise community awareness dispel myths Medicine Bag campaign Community Resources Outpatient Services In-home/on-site programs Senior Friendship Centers Private Therapists Referrals: Neuropsychologist Psychiatrist Geriatrician 13
14 OUR SENIOR CLIENTS Presented by: Dr. Christine Cauffield CEO, LSF Health Systems 14
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