Mental Disorders, Older Adults and Caregivers Presented by: Kate Mattias, MPH, JD Executive Director, NAMI Connecticut Paloma Bayona Program Director, NAMI Connecticut
What Is NAMI? National Alliance on Mental Illness Connecticut
NAMI s Mission Support, education & advocacy, for people living with mental illnesses, their family, friends, professionals and the public
Audiences We Serve People living with mental illness Family members/friends of loved ones with mental illness adults & children Policy makers and other community stakeholders Estimated that one in five families are impacted by serious mental Illness each year
Overview Truth about Mental Illness
Mental Illness A medical condition that impacts centers of the brain; Biologically based, with genetic links and environmental factors; Cannot be overcome through "will power ; Not related to "character" or intelligence; Affects the chemicals of the brain that determine our moods, thoughts, and perceptions; One s situation or environment can bring on stressors that can activate or worsen mental illness.
Who is Most Vulnerable? Mental illnesses often strike individuals in the prime of their lives: adolescence and young adulthood; often when someone is starting higher education or employment; AND older individuals; most common is depression but anxiety disorders are common too; can co-occur with physical illnesses and substance use.
Diagnosing Mental Illnesses
General Categories of Serious Mental Illness Mood Disorders Anxiety Disorders Thought Disorders: Schizophrenia
Diagnosing Mental Illnesses No blood test No brain scan No typical behaviors or signs No universal medication(s) Providers have to go on: The behavior(s) being exhibited The person s mood(s) The person s thoughts The length of time the person has experienced unusual thoughts or behaviors
Where Adults are Diagnosed Emergency Departments Rehab Hospitals Other Health Facilities Primary Care Providers Psychiatric Providers Family Concerns Court/Law Enforcement
Why Some Older Adults Don t Ask for Assistance Stigma in seeking help Not high on list of medical priorities Concern over loss of independence or control over their life Fear of being placed in a nursing home or on a mental health floor Don t want to be a burden Fear cost of services and medications Fear they may be exploited financially
Caregivers Who Are They?
Caregivers Who Are They?* 8.4M provide care to adult with an emotional health issue; In their role an average of 8.7 years (4 yrs average for any other kind of condition); 33% have been providing care for 10 or more years; Loved one typically has serious mental health issues; typically bipolar disorder, schizophrenia or depression; Nearly all help with Instrumental Activities of Daily Living transportation, meals, shopping, arranging services; Average 31.8 hrs a week assisting loved one (typical caregiver averages 24.4); 20% provide care to someone older than 65 *(On Pins and Needles: Caregivers of Adults with Mental Illness; National Alliance for Caregiving; 2016)
Caregivers Who Are They?* One in seven care for a parent; 11% care for a spouse; 9% assist with a sibling; 45% say their loved one lives with them; 25% are within 20 minutes; 51% caring for a male; Average caregiver age 54.3 years of age; 82% of care recipients take prescription medication; 25% of caregivers feel the condition not well managed by the medication; 33% caregivers indicate difficulty in getting their loved one to take prescribed medication *(On Pins and Needles: Caregivers of Adults with Mental Illness; National Alliance on Caregiving; 2016)
Caregivers* 80% help loved one manage finances or paperwork; 50% indicate their loved one is financially dependent upon family or friends; 33% have some kind of legal responsibility power of attorney, guardianship; 40% have had any kind of mental health caregiver training; 53% indicate they need help with own emotional and physical stress (vs 40% for caregivers of adults without mental health issues); * (On Pins and Needles: Caregivers of Adults with Mental Illness; National Alliance on Caregiving; 2016)
Caregivers* 30% would like a care navigator to assist with accessing appropriate services and supports; Services difficult to find; Most are employed; Stigma isolates caregivers * (On Pins and Needles: Caregivers of Adults with Mental Illness; National Alliance on Caregiving; 2016)
Burnout What it Looks Like Poor sleeping habits; Abandoning leisure activities caregiver used to enjoy; Losing touch with close friend or family; Irritability, including towards the care recipient; Lack of energy for regular activities: cleaning, cooking, etc. Difficulty concentrating; Use of alcohol or drugs to relax; Headaches, body aches; Sense that no one cares for the caregiver; Sense of hopelessness for the future; Depression, anxiety
Issues Caregiver s Face Co-occurring disorders, both physical and mental/substance use; Difficulty getting an accurate diagnosis; Appropriate medication; medication compliance; Lack of information and support; Personal health and mental health concerns; Personal Employment most are employed Stigma; Isolation; Fractured healthcare system; Too few geriatric mental health providers and support services
Caring for the Caregiver Taking care of yourself. Scheduling (and keeping!) doctors appointments. Asking for help. Taking a break. These are vital steps caregivers can take to stay healthy. Self-Care Important to acknowledge that stress is a normal, sometimes difficult but definitely manageable, part of caregiving. Stress can manifest itself in both a physical and emotional way; it is vital to find an outlet to relieve it! Caregiver may need to give him/herself permission to take care of themselves. That is fine, and good, and necessary!
Caring for the Caregiver Self-care/stress management can be achieved in many ways: General attention to daily activities like healthy eating, exercising, sleeping, and talking with friends, is vital. Even for the busiest of caregivers, mini-breaks can be lifesavers. Go to a quiet room or step outdoors and just breathe for ten minutes; clear the mind and focus only on the breath. Write in a journal. Say a positive affirmation. Light a candle. Listen to music. Call a good friend. You might consider attending a support group. Groups of individuals who share a common experience and provide each other with various types of help, i.e., information, resources, and emotional support.
Mental Illnesses and Older Adults
Mental Illnesses and Older Adults Dramatic recent and projected growth in population; Population aged 65 and older will increase from 20 million in 1970 to 69.4 million in 2030; Major direct and indirect impact on health outcomes, service use and costs; We know treatment works, but effective services are not reaching those in need; Lack of rehabilitative interventions; An alarming under-investment in knowledge dissemination, service development, and research to meet future need. Source: Dartmouth Psychiatric Research Center
Poor Quality of Care for Older Persons with Mental Disorders Increased risk for inappropriate medication treatment (Bartels, et al., 1997, 2002) > 1 in 5 older (20%) persons given an inappropriate prescription (Zhan, 2001) Research shows older adults are getting medication but inconsistent follow up by providers (Psychiatric News; Jan. 2013) Less likely to get psychotherapy services;(bartels, et al., 1997) Lower quality of general health care and associated increased mortality(druss, 2001)
Mental Disorders in Older Adults: The Silent Epidemic Alzheimer s and other memory disorders (30-40% co-occurring depression or psychosis); Most common: depression, anxiety disorders, severe mental illness, alcohol abuse; Often overlooked by community providers and clinicians; Majority of individuals over age 65 who commit suicide saw primary care provider the week before.
Dimensions of the Challenge Less than 3% of older adults receive outpatient mental health treatment by specialty mental health providers; (Olfson et al, 1996). Only 1/3 of older persons who live in the community and who need mental health services receive them. (Shapiro et al, 1986). Older adults with mental illness on target to reach 15 million in 2030. (Jeste, et al., 1999; www.census.gov)
Dimensions of the Challenge Community Mental Health Services Under-serve older persons Lack staff trained to address needs of older adults Often lack age-appropriate services Principal Providers: Primary Care and Long-term Care insufficient depth of knowledge about mental illness; False belief that MH Services are not covered by Medicare.
Late Life Depression
Co-Existing Medical Conditions About 25% of people who have heart attacks suffer from depression post event; 20 50% of people who have a stroke will develop depression within one year; In one study, elderly people who were depressed were 4x as likely to die within four months of a heart attack than those without depression. Abebaw Mengistu Yohannes, PhD and Robert C. Baldwin, MD ; Medical Comorbidities in Late-Life Depression; Dec 1, 2008 Psychiatric Times. Vol. 25 No. 14;
Co-Existing Medical Conditions Dementia About 17% with Alzheimer s also have major depression; Symptoms of depression may precede development of dementia or Alzheimer s; When depression and cognitive impairment develop simultaneously, deficits may be mistaken for dementia or a problem known as pseudodementia ; Cognitive function may improve if depression treated.
Substance Use
Numbers of Older Adults Impacted by Depression 1-5 % - who live in the community; 12% - who are hospitalized; 14% - who require health care at home; 29-52% - who live in nursing homes; 39-47% - being treated for cancer, heart attack, or stroke.
Risk Factors for Late Life Depression Female gender Widowed or divorced; loss of close friends or poor family relations; Chronic & disabling illness; Lack of social support; Recently bereaved; Prior history of depression; family history of mental illness; Lack of regular physical activity; Recent placement in nursing home
Late Life Depression Clinically significant depression affects 15-20% of older adults (2M with clinical depression; 5M with less severe condition that impacts quality of life) Late life depression associated with: Lower physical functioning; Poorer adaptation to medical illness; Lower quality of life; Higher health care costs; Dementia and Heart Disease Increased mortality from suicide and illness.
Depression Symptoms in Older Adults Symptoms different than that of younger person; An older person more likely to have sleep or eating problems (insomnia is a risk factor); Ambien and Lunesta increasingly prescribed for older individuals instead of Klonopin or Xanax; Tends to last longer period of time in older adults; may increase risk for physical health problems or death; Depression in older adults is more likely to lead to suicide. Risk of suicide is serious. Elderly white men are at the greatest risk, and those ages 80-84 have a suicide rate more than twice that of the general population. Depression is a predictor of suicide
Depression Symptoms in Older Adults Somatic or physical symptoms more common than in other age groups, including heart palpitations, restlessness, fatigue, aches and pains, nausea and vomiting, dizziness, tremors, shortness of breath, fainting; Because physical symptoms are common, many providers overlook or don t consider screening for depression; Cognitive problems, including inability to concentrate or remember things; Mood disturbances, including irritability, anxiety, or preoccupation with death.
Late Life Depression No one cause; onset of late-life depression can be attributed to genetic, biological, or neurological factors; life changes; illnesses; or a combination; Some older adults with depression have suffered from the illness for most of their lives and gone undiagnosed; Depression in late life is more common in women, widowed individuals, those who lack a supportive social network, and those with physical health problems; Important to recognize that the depression is NOT just being down about one s condition.
Treating Late Life Depression Only 10 to 40 percent of elderly patients with depression are prescribed antidepressant medication; Underuse or misuse of antidepressants and prescribing inadequate dosages are common mistakes physicians make when treating the elderly with depression; Treatments believed to be beneficial in late-life depression include antidepressants, psychotherapy, electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS); http://www.narsad.org/dc/pdf/facts.latelifedep.pdf
Treating Late Life Depression More than 20 antidepressants available; Some antidepressants may not be as effective for people over age 60 as they are for younger persons; Treatment may take longer to work; may need to take higher doses; Treating physician needs to know all the medications someone is taking including vitamins, herbal supplements, alcohol and tobacco, and recreational drugs combination of medications can impact the effectiveness of treatment.
Treating Late Life Depression Support and education important part of depression treatment for individual and caregivers; Studies show older patients with depression benefit most from aggressive, persistent treatment; therefore, therapy for older patients should be continued for a sufficient duration; www.narsad.org/dc/pdf/facts.latelifedep.pdf Psychotherapy can involve just the person or a whole family; Cognitive therapy especially helpful with older adults once depression is under control; Group therapy can provide a communal experience of guidance and education; What works is what is important
Community Response to Late Life Mental Illness
Depression Screening Agencies and staff serving home or facility-bound individuals need to provide information on late life depression to clients and family members; Screening results can provide the physician/provider with a reason to discuss depression and/or other mental illnesses
Depression Screening Community support to reduce stigma; Primary care, geriatric physicians, psychologists and psychiatrists use special assessments, such as the Geriatric Depression Scale; Touted as a best practice in primary care settings; Caregivers and Older Adults may need to ask that a screening be performed; Primary Care physicians need to know where mental health resources are in the community; Community agencies need to know about resources.
Evidence-Based Practices Mental health outreach services key role for community agencies and providers Integrated service delivery in primary care Mental health consultation and treatment teams in long-term care Family/caregiver support and education interventions Psychological and pharmacological treatments Draper, 2000; Unützer, et al., 2001; Schulberg, et al., 2001; Bartels et al., 2002, 2003; Sorenson, et al., 2002;
Successful Mental Health & Aging Coalition Education of Primary Care Physicians/Community Social Service Providers Educational Seminars Brochures on Aging Mental Health Issues Community Resources Peer Organizations share successful treatment programs Education of primary caregivers NAMI s Family to Family course Introduction to easy screening tools to de-mystify process Public Education Public Service Announcements Speakers Bureau Library Focus National Depression Day; Mental Illness Awareness Day Aging Mental Health Conferences
Resources
NAMI: www.nami.org; Education Courses for Family Members Support Groups for Family Members and People living with Mental Illness Professional Education Older Americans Substance Abuse and Mental Health Technical Assistance Ctr. www.samhsa.gov/olderadultstac National Institutes of Mental Health (NIMH) Mental Health Connecticut (MHC)
Questions and Answers NAMI Connecticut www.namict.org