Aging As An Asset: 4/24/2018. Today s Objectives. Overview. Reducing Suicide in the Aging Population Through Restoring Purpose, Meaning and Joy

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1 Aging As An Asset: Reducing Suicide in the Aging Population Through Restoring Purpose, Meaning and Joy Kesha Marson, LCSW Clinical Therapist; Amery Behavioral Health Center Today s Objectives 1. Increased understanding of unique experiences of the aging population and how these experiences contribute to suicide deaths. 2. Ability to identify suicide risk factors in the aging population and how they differ from other age groups. 3. Increased understanding of the role that early detection in preventing suicide deaths in the aging population. 4. Ability to identify personal beliefs and biases that may contribute to barriers in early detection of suicide risk and subsequent work with aging population. 5. Increased knowledge of treatment modalities and interventions aimed at restoring purpose, meaning, and joy. Overview Role of ageism/personal biases/myths Suicide in aging adults (facts, statistics, risk factors) Common factors in suicide deaths among aging population Detection of suicide risk (warning signs-looks like, feels like, sounds like) Treatments, interventions, and outcomes 1

2 How Do We Define Aging Historically defined by age for purposes of various benefits and resources (insurances, discounts, community resources, treatments, etc.) Individually defined based on capabilities- You re only as old as you feel. Age is just a number. Defined by daily tasks/ phase of life activities (retirement, kids moving out of the home, increase in health concerns, certain hobbies/interests, etc.) Other definitions? What s so magic about 45? Health care benefits to access therapy services Life transitions begin to occur at this age both planned and unplanned Statistically speaking highest rate of suicide between Reflection on life thus far and may experience the shoulda woulda couldas Today it is socially unacceptable to ignore, ridicule, or stereotype someone based on their gender, race, or sexual orientation. So why is it still acceptable to do this to people based on their age? Ageism creates a negative reality of aging. ~JoAnne Jenkins Disrupt Aging: A Bold New Path to Living Your Best Life at Every Age 2

3 True or False? Mental health disorders are inherent to the aging process? The blues or sadness is just a part of normal aging? There are no treatments available to support the mental health needs of older adults? Older adults are set in their ways therefore cannot benefit from treatment? Confusion and memory loss are a normal part of aging? A decline in daily functioning is consistent with aging? Older Adults are not capable of making good decisions? Older adults grow out of mental health symptoms as they age? Understanding The Experience Words, thoughts, or phrases that come to mind when you hear old and aging. Images you have seen that depict old and aging. Cards, magazines, newspapers, advertisements, cartoons, etc. Stroke Simulation Ageism What are some common phrases/messages around aging? Where do we get messages about aging from? What do those messages convey? What is the impact of these messages? What personal beliefs do you have around aging and how to they impact your work with the aging population? How do we encourage new directions and outlooks on what it means to age in the 21 st century? 3

4 2016 Suicide Statistics Nationally 44,965 people died by suicide Equates to one suicide death every 11.7 minutes 3.4 male suicide deaths to female suicide deaths (34,727 versus 10,238) Females are attempts suicide 4 times more than males 10 th leading cause of death For every suicide death there are 25 attempts; equates to 1,124,125 annual attempts in U.S, or one attempt every 28 seconds 5.2 million survivors of suicide; 1 out of every 62 people, which means 6 new survivors every 11.7 minutes When Numbers Are Important In Aging per 100,000 people Women at increased risk; but decreased risk after 60 Represented 16,196 deaths; accounts for 44 deaths per day Highest risk group 85 and older 19.0 per 100,000 people Men at increased risk Second highest risk group per 100,000 people Men at increased risk 4

5 Suicide is not an expected or normal response to the stressors of aging Knowing the difference means a life saved. Overall less attempts, but higher death rates Use more lethal means Have access to lethal means Less likely to survive suicide attempts More isolated so less likely to be rescued More intentional in planning, more determination, and less impulsive Tend to give off less warning signs/clues prior to death More likely to deny or minimize suicidal ideation or past attempt despite presence of significant risk factors 5

6 May be more at peace with their decision based on age; less fear around death Generational beliefs/values around preserving autonomy, dignity, and responsibility Fears around losing mental capabilities and daily functioning, purpose and worth, burden, and being defined by age Often times don t have the language to describe how they feel and associate feelings as a normal part of aging. More somatic in nature Joiners Interpersonal Psychological Theory of Suicide Individuals will engage in serious suicidal behavior if one has both the desire to die and the capability to act on that desire. Based on two interpersonal states: Perceived Burdensomeness: Misperception that the self is so incompetent that one s existence is a burden on friends, family members, and society. May lead to the belief that their death is worth more than their life. Thwarted Belongingness: Feeling alienated from friends, family, or others valued social circles. Further suggests that individuals must also have the capability to engage in serious suicidal behavior, which is acquired through repeated exposure and habituation to painful and provocative experiences. Results in higher levels of pain tolerance and decreased fear around death. Exposure can be both direct and indirect 6

7 Joiner s Suicide Theory Factors Mental health symptoms; Burden, Capable Previous suicide attempts; Capable Social isolation (strongest and most reliable predictor of ideation, attempts, and death); Belonging Physical health and illness; Burden, Capable Unemployment; Belonging, Burden Family conflict; Belonging Loss (death, independence, housing, financial, etc.); Belonging, Burden, Capable Low self-worth (belief that they make things worse for other people or I hate myself. ; Belonging, Burden Hopelessness; Burden Helplessness; Burden Combat exposure; Capable Homelessness; Capable, Belonging, Burden Past abuse and/or trauma; Capable Mental Health Factors Mental health was a factor in 71%-97% of suicide deaths (Depression, Anxiety, Bipolar, PTSD, Schizophrenia, Substance Abuse) Depression was a factor in 80% of suicide deaths Many are misdiagnosed or underdiagnosed Lack of understanding among professionals about mental health in aging population versus other populations Lack of studies surrounding aging, mental health, and suicide Overall stigma of mental health Impact of ageism/stigma around aging Physical Health Factors Physical conditions are a factor, but varied based on one s perceived meaning of those illnesses, their impact on function, pain, and threats to autonomy and personal integrity Cancer, Parkinson s, Dementia, Multiple Sclerosis, HIV Higher rates associated with cancer, seizure disorders, pain, COPD, stroke Multiple conditions tends to result in multiple medications and increased risk for adverse reactions More likely to seek out care in primary care settings (doctor) than in mental health settings Most had seen their doctor 3-4 weeks prior to death; 1/3 within a week of death Tend to not have the language to describe how they feel; mistaken for somatic concerns versus mental health 7

8 Social Factors Family discord Social isolation (limited activities); differs from loneliness Living alone; living less with family members Limited to no hobbies Functional impairments Lack of daily structure and routine Loss of independence Life transitions Retirement; job loss Role changes Resource depletion; not enough input Early detection saves lives. Do you know the signs? Typical Symptoms Across Lifespan Persistent sad, anxious, or empty mood. Loss of interest or pleasure Feelings hopeless, helpless, like a burden Decreased energy, fatigue, being slowed down Difficulty concentrating, remembering things, making decisions Sleep disruption Appetite changes Crying spells Restlessness, irritability, anger outburst Pain (headaches, aches or pains, cramps) Digestive problems Neglecting self-care and household tasks Social Isolation 8

9 Looks Like Less affective symptomology More somatic in nature (headache, nausea, GI concerns, pain) Cognitive changes (concentration, attention, memory, decision making, brain fog ) Decreased energy, fatigued, being slowed down Sleep disruption Appetite changes (more so women) Not following up and/or scheduling medical appointments Electing to not refill medications Putting final affairs in order Agitation and irritability (more so men) Increased visits to doctor of frequent Emergency Room visits (39 visits per year) Decreased compliance with medical treatment Themes in language Hopelessness Overwhelmed Helpless Burdon Worthlessness Purposelessness Excessive Guilt and regrets Sound Like Death ( People would be better off with out me. I wish I could go to sleep and not wake up. I m ready to die because it s my time. What am I really trying to say? I feel gloomy/blue. I can t shake this feeling. I just don t feel well. I feel so tired. I just hurt. It s just too much trouble. I don t know what s wrong with me. I feel like I m on pins and needles all the time. Everything is so frightening these days. I just don t have a reason to get up. It s just too confusing for me to go. 9

10 Behavioral Stockpiling medications Purchasing a firearm Number one means of death; 42% of PCP s treating aging adults with depression and suicide did not ask about firearms. Making funeral plans Giving away possessions/money Scheduling an appointment with physician for no apparent reason Changing a will Withdrawing from activities and people Increase in substance use/misuse of medications Ceasing medical cares or treatment Sudden interest or disinterest in religion Calling family members out of the blue. Situational Financial stressors (within 24 months) Recent move New diagnosis of physical health condition Loss of a loved ones (family, pets, friends) Retirement Disability determination Family discord Caregiving duties Life transitions Limited supports Role changes Loss of independences Early detection, now what? 10

11 Intervention and Treatment Always rule out medical first (conditions and medication interactions) Historically lacking specific research around evidenced based treatments for aging adults along with suicide Overall lack of specific training to clinicians resulting in diminished therapy outcomes Resorting to using traditional treatments for depression, anxiety, and suicidal behavior commonly used in younger adults Current studies indicate positive outcomes: Cognitive behavioral therapy Behavioral therapy Reminiscence therapy Problem-Solving Therapy Brief Counseling Tele-therapies Case Management Models Integrative Models Promising Outcomes Depression Increase compliance with medical treatments, management of daily stressors, and chronic conditions (insomnia, pain, etc.) Cognitive Behavioral Therapy found to be most effective when comparted to other interventions of social support and psychoeducation Outcomes varied based on environmental factors (living alone versus community based setting, training of supports and staff) Anxiety Relaxation and meditation most effective Case management services effective managing daily needs Adjustment Disorders Friendly visitor programs Computer and internet training Treatment Modalities Something is better then nothing mentality Group therapy had the most promising results Supports increased socialization, mutual support, reciprocal validation, accountability, sense of purpose and ownership, human connectedness Can be supportive, educational, or psychotherapy Interventions around cognitive restructuring, relaxation techniques, problem-solving, communication, managing stress, etc. Goals of increasing empowerment, coping and adaptive behavior, social skills, self-esteem, sense of belonging, hope, reasons for living, and meaning for life 11

12 The afternoon of life is just as full of meaning as the morning; only it s meaning and purpose are different. ~Carl Jung Why Purpose? A study of intergenerational volunteering suggested heightened sense of well-being and associated aging with staying active, not worrying about problems, and feeling young. In a 2013 study, volunteers experienced reduced risk of hypertension, delayed physical disability, enhanced cognition, an reduced mortality. Three year study on a federally funded Foster Grandparents Program, 71% reported never feeling lonely compared to 45% of people who were on the waiting list. In a 2013 United Health Group survey older adults reported volunteering contributed to emotional and physical well-being, less stress, better management of chronic conditions, and improved meaning of life. Studies supports that older adults who viewed aging with a positive perspective more likely to recover from illnesses, practice preventative health behaviors, and lived an average of 7.5 years longer. Aging with Purpose Aging with purpose offers solutions not just inherit to the aging process, but to an array of others challenges Overall want a sense of purpose on their remaining years; they want to contribute Providing opportunities for growth Identifying new roles New responsibilities Meaningful relationships Identifying strengths and assets Focus of aging as an asset versus aging with limitations Instill a sense of hope and excitement for future versus dread and dwelling 12

13 How do we do it? Must clearly re-define (no define) purpose, roles, and identities Cognitive restructuring Beliefs of aging Generational beliefs and values based on family dynamics Acceptance of current capabilities versus denial or self-judgement Willingness to creatively problem-solve and address barriers What would it take? What would be different? What would need to happen? Adding back quality, meaning, and joy into life Values clarification What purpose do I have? Purpose Role Identity 13

14 What s My Purpose? Purpose: Reason we exist or object toward which we strive; Done with intention, aim, or goal based on personal values Role: Socially defined; Status or set of expectations; more fluid Identity: Personally defined; Occupy a role and we personalize it Structured Outpatient Program (SOP) Attend group therapy 3 days per week from 8:30a-12:30a Common diagnoses: depression, anxiety, bipolar disorder, personality disorders Common presenting situations: suicide ideation and/or attempt, grief and loss, chronic health conditions, family discord, retirement/unemployment, disability, insomnia, situational stressors, social isolation Group therapy, medication management, individual and family therapy as needed, and after care group Open group versus closed group Serve ages 45 and older Average length of stay 4-5 months Psychiatric monitoring Group Therapy vs Individual Therapy Supports sense of purpose, meaning, and belonging Socialization with others Sense of I m not alone. Accountability Increases motivation and confidence Adds structure and routine Role models healthy boundaries Increases follow through in other areas of life (medical conditions) 14

15 Group Topics Socialization Loneliness Shame & Guilt Fear Trust Self-esteem Forgiveness Acceptance Coping with triggers Coping with Holidays Anger Loss of independence Purpose, roles, and identities Coping with suicidal thoughts Unhelpful thinking styles Dealing with disappointment Motivation Improving communication Setting effective goals Trauma Expectations of self and others Healthy aging Stress Chronic health conditions Interventions Address areas of grief and loss (hopes and dreams) Shift focus to what one can control and do (hula hoop) Re-defining purpose, roles, and identities Focusing on capabilities and strengths Vison Boards Meditation and Mindfulness (phone apps) Coping skills ; Coping Cards Volunteer, mentor, work, speaking opportunities Attitude of gratitude Acceptance Life Satisfaction Time Management, organization, etc. Healthy Lifestyle Habits (sleep, diet, exercise/movement) Realistic expectations of self and others Values clarification Resiliency Positive self-talk; Self-esteem Cards Willingness +Intentionality=Change 2017 PHQ-9 Scores 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Initial 60 Day Discharge 0-4 (Remission) 5-9 (Mild) (Moderate) (Moderately Severe) 20+ (Severe) 15

16 Average PHQ-9 Scores Initial 60 Day Discharge % 2017 GAD-7 Scores 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Initial 60 Day Discharge (Mild) (Moderate) 15+ (Severe) Average GAD-7 Scores Initial 60 Day Discharge

17 Carl the Cactus Age Defying Gravity Questions? Kesha Marson, LCSW Clinical Therapist Amery Behavioral Health #