recognizing mental health issues in older adults fuqua center for late-life depression emory...

RECOGNIZING MENTAL HEALTH ISSUES IN OLDER ADULTS

Fuqua Center for Late-Life DepressionEmory University

Jocelyn Chen Wise, LCSW, MPH

What is the Fuqua Center for Late-Life Depression?

Mr. JB Fuqua Emory University School of Medicine

Purpose

Describe three conditions commonly seen among older adults.

Goal

Audience learns to recognize signs and symptoms of these conditions.

Audience feels better equipped to take first steps toward treatment for these conditions.

Case study

Ms. Smith is a 74 year old, African American, retired teacher who lives independently. Recently, she’s been looking tired and is less talkative than usual. Ms. Smith denies feeling sad but reports that she has “bad nerves.” She explains that she has trouble sleeping due to getting up frequently to use the bathroom at night. Her adult daughter reports that Ms. Smith has had difficulty remembering things lately like appointments and names.

What could be going on?

The Three D’s Dementia Depression Delirium

Under-recognized, under-treated Often occur simultaneously with

overlapping symptoms

DEPRESSION

What is Depression?

A physical disorder of the brain Impacts more than 6.5 million people

age 65+ Not a normal part of aging High rates of depression among people who

have had heart attack, cardiovascular disease, stroke, cancer, diabetes

20% of persons with Alzheimer’s The most common treatable risk factor for

Alzheimer’sBlazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci 2003. Andreescu et al, American Journal of Geriatric Psychiatry, 2007.Lenze et al, Depression and Anxiety, 2001.

Symptoms of Major Depression

Core symptoms: 1) Depressed mood and/or 2) Lack of interest

Other symptoms Feelings of worthlessness or guilt Poor concentration or ability to make decisions Fatigue Agitation or retardation Problems with sleep Change in weight or appetite Recurrent thoughts of death or suicidal ideation

Suicide Rate by Age, Sex, and Raceusing National 1999-2010 data

National Center for Health Statistics, CDC Wonder

Risk Factors for Suicide

Mental health diagnosis, particularly depression and substance abuse

Age Chronic illness or pain Previous attempts or family history of

suicide Recent loss of loved one History of impulsive behavior (alcohol,

drugs, lack of responsibility)

Myths and Facts About Suicide

Asking about suicide may give someone the idea to kill themselves.

The opposite is true. Asking someone directly about their suicidal feelings will often lower their anxiety level and act as a deterrent to suicide.

MYTH FACT

Myths and Facts About Suicide

Most people who kill themselves give definite warning signs of their suicidal intentions.

Talking about suicide is usually a cry for help.

FACT MYTH

8 out of 10 give signs. All threats and attempts should be taken seriously.

Is Late-Life Depression Different?

May not endorse sadness, rather irritability or “nerves” Hard to explain feelings Stigma Cultural beliefs

Somatic or physical complaints more common

More problems with cognition

Gallo JJ et al. Depression without sadness: functional outcomes of nondysphoric depression in later life. J Am Geriatr Soc. 1997 May;45(5):570-8.

Screening for Depression

Patient Health Questionnaire 9 (PHQ-9) Geriatric Depression Scale (GDS) Cornell Depression Scale for Depression

in Dementia Relies on input from family or caregivers

Depression Screening: PHQ-9

Depression Screening: PHQ-9

PHQ-9 Scoring

PHQ-9

Patient Health Questionnaire 9 (PHQ-9)

http://phqscreeners.comor

http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf

Free and available to public

DEMENTIA

Definition of Dementia

A chronic and progressive loss of intellectual functions severe enough to interfere with everyday life.

Bonifas, R. Depression, Dementia, and Delirium Teaching Module. CSWE Gero Education Center. Arizona State University.

Dementia

Alzheimer’s Disease60-80% Vascular dementia

Lewy Body dementiaParkinson’s dementia

Frontotemporal dementia

Types of Dementia

What is Alzheimer’s Disease? Begins gradually Progression different for everyone Symptoms

Forget recent events Have difficulty performing familiar tasks Confusion Personality and behavioral changes Impaired judgment Communication difficulties

Changes that can come with dementia

Memory Language: voice and written Sensory perception: vision, hearing, touch,

taste, smell Organization: sequencing Abstraction Attention / concentration Judgment Changes in personality Loss of initiative

Screening Tools

Montreal Cognitive Assessment (MoCA)http://www.mocatest.org

Mini-Mental Status Exam (MMSE)

Mini-Cog: clock draw, orientationhttp://www.alz.org/documents_custom/minicog.pdf

DELIRIUM

What is Delirium?

A mental disturbance characterized by sudden changes in mental functioning or acute confusion and fluctuating levels of consciousness.

Delirium is the most acute condition of the three D’s and is a true medical emergency.

Bonifas, R. Depression, Dementia, and Delirium Teaching Module. CSWE Gero Education Center. Arizona State University.

Symptoms of Delirium

Disorganized thinking Disorientation to time and place Reduced level of attention (drowsiness) Person may fall asleep during an interview Increased or decreased psychomotor activity Apathy - sometimes mistaken for depression Increased agitation Disturbances in sleep cycle

Bonifas, R. Depression, Dementia, and Delirium Teaching Module. CSWE Gero Education Center. Arizona State University.

Types of Delirium

1. Hyperactive: psychomotor agitation, increased arousal and delusions, may see some cognitive impairment

2. Hypoactive: withdrawal, lethargy and reduced arousal

3. Mixed: Characteristics of both

Bonifas, R. Depression, Dementia, and Delirium Teaching Module. CSWE Gero Education Center. Arizona State University.

Criteria for Delirium Diagnosis Four criteria are assessed in diagnosing

delirium. Delirium diagnosis includes:1. Acute onset and fluctuating course and

2. Inattention, then either 3. Disorganized thinking or4. Altered level of consciousness

Bonifas, R. Depression, Dementia, and Delirium Teaching Module. CSWE Gero Education Center. Arizona State University.

Causes of Delirium

The primary causes are underlying medical conditions, medications, or drug withdrawal: Infections: urinary tract infections, pneumonia Reaction to prescribed medications or illicit drugs Low blood pressure Head injuries or falls Dehydration Alcohol withdrawal Sensory deprivation (often experienced by

hospitalized seniors, those having hearing impairments, or other sensory input limitations)

Bonifas, R. Depression, Dementia, and Delirium Teaching Module. CSWE Gero Education Center. Arizona State University.

Why is delirium an emergency? 1 year mortality rate is 35-40% Often there is an underlying medical

issue causing delirium Check for adequate treatment

Bonifas, R. Depression, Dementia, and Delirium Teaching Module. CSWE Gero Education Center. Arizona State University.

SEEKING TREATMENT

Red Flags

Sudden change in cognitive status Feeling suicidal Violent Recent hospitalization Medicine changes

Emergency Treatment

911 Hospital or Emergency Room Primary care physician

Georgia Crisis & Access Linehttp://www.mygcal.com

1-800-715-422524 hour hotline of mental health professionals available

to discuss situation, find clinics or hospitals based on insurance and geography, or send mobile assessment

team

Non-emergency Treatment

Medical doctor Primary care Neurologist Psychiatrist

Talk therapist (does not prescribe medicine) Psychologist Marriage and family therapist (MFT) Licensed clinical social worker (LCSW) Licensed professional counselor (LPC)

Evaluation

Psychosocial history Medical evaluation

Lab tests Medical history

Substance use assessment Collateral information!

Laboratory Tests

TESTS Rule out…

Urinalysis Kidney dysfunction, toxic encephalopathy

CBC, sedimentation rate, electrolytes Anemia, electrolyte imbalance

Blood Urea Nitrogen (BUN)/creatinine, liver function test

Liver dysfunction

Thyroid function Thyroid dysfunction

Serum B 12 Vitamin deficiency

Syphilis serology Syphilis

HIV test AIDS dementia

Neuroimaging studies: CT or MRI Tumor, subdural hematomas, abscess, stroke, or hydrocephalus

Summary

Dementia Delirium Depression

Onset Gradual Acute Recent

Reversibility Usually irreversible (95%)

Usually reversible (90%)

Reversible with treatment

Alertness Usually constant

Inattention is more common

Often c/o memory loss

Other info Collateral information

Patients with dementia are at higher risk for delirium

Evaluate for family history of depression

Tips

Accompanied to medical appointment Bring current medications Let the clinician know what you are concerned

about Call the medical office if don’t see improvement

or if gets worse Request an order for a home health nurse or

social worker Make sure medical office understands the level

of care the person has (or doesn’t have) at home

Starting the Conversation

Listen nonjudgmentally Give reassurance and information Encourage professional help Encourage self-help Assess for risk of suicide or harm

Encouraging Professional Help “Have you felt this way before?” “Was there something or someone that

helped you in the past?” “Would you be ok speaking to someone

about what’s going on?”

Mental Health Services in Georgia

www.fuquacenter.org

Questions?

Thanks!

Fuqua Center for Late-Life DepressionJocelyn Chen Wise

Office: 404-712-6943jchen86@emory.edu

www.fuquacenter.org