Transcript PowerPoint - National Association of States United for Aging and

Physical Illness and Co-occurring
Mental Disorders
Developed by DATA of Rhode Island through a special
grant from the RI Department of Human Services
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Training Goals
Discuss and identify behavioral health
issues for adults with persisting health
conditions
Identify implications of the co-occurrence of
physical and mental illness
Identify the most common co-morbid health
and mental health conditions
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Mental disorders and physical
illness
Relationships are varied & include:
(1) Mental disorder biologically due to physical illness
(2) Psychological reaction to physical illness/disability
(3) Mental disorder due to medications
(4) Mental disorder causes physical disorder
(5) The conditions are coincidental
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Stress and Physical illness
Major health problems are stressful
Response to this stress dependent upon
individual
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Perception / Beliefs of illness
Vulnerability
Coping ability
Response of others
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Individual Vulnerability
Personality traits make a difference (e.g.
tendency to worry about illness)
Prior experience of illness within a family
An individual’s psychological state at the
time of the illness
Previous experience of trauma, or a
neglected or abusive childhood
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Selected Medical Conditions
associated with Mental Disorders
Condition
Associated Mental Disorders
Parkinson’s disease
Depression, Psychosis, Dementia, Delirium
Stroke
Depression, Psychosis, Dementia, Anxiety,
Delirium, Mania
Thyroid disorders
Depression, Psychosis, Dementia, Anxiety,
Delirium, Mania
Chronic Airways
Disease
Depression, Anxiety, Delirium, Cognitive
impairment
Cancer
Depression, Delirium, Anxiety
Vitamin deficiencies
Depression, Psychosis, Dementia, Mania
Injury with Pain
Depression, Substance Dependence
Metabolic disorders
Depression, Delirium, Psychosis
HIV @ HCV
Depression, Psychosis, Delirium, Anxiety,
Substance Dependence
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Depression is most common in
medical illness
All depressive disorders 15-36%
Each problem alone may have major implications for
how an individual functions
Issues together often are interactive and can have
overwhelming effects when they coexist.
Managing co-occurring mental health problems not only
improves mental status health status is improved
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Mental Health Issues and our Aging
Population
Significant continuous growth in near future
By 2030, U.S. population >65 years old = 70 million
2030, >65 years old = 20% of U.S. population
Age bracket w/ most growth: >100 years old
Current healthcare system not able to support growth
Increased need for specialized healthcare
professionals and housing
www.research.aarp.org
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The Myths of Aging
Adults over 70 do not have sex.
Older persons can’t really learn or change.
To be old is to be sick.
Older people are unproductive in society
Older people are rigid and cranky
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Mental Health Issues and Elders
Relocation Stress Syndrome
Anxiety, restlessness, apprehension
Insecurity, vigilance
Confusion
Depression, withdrawal, loneliness
Sleep disturbance
Change in eating habits, weight change
Unfavorable comparison of pre-transfer and
post-transfer staff
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Geriatric Depression
Depression is not a normal part of aging
Approx. 6 million people 65+
women>men1
15% community; up to 25% in residents
Can be triggered by medical condition, drugs, losses,
nothing at all
“I think I’m going crazy!”
Reoccurrence rate is a concern
Can exacerbate other medical conditions
1 The Brown University Long-Term Care Quality Advisor, vol 9, no 13, p.5. July 14, 1997.
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Geriatric Depression
Signs & Symptoms
Mid-Life
depressed mood
diminished pleasure
weight,  appetite
insomnia
negative attitude
guilt, worthlessness
 concentration
suicidal ideation
Late-Life
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irritable, critical of others
isolation, withdrawal
 weight,  taste, swallow
early A.M. awakening
hypersomatic
“the end”, burden, anxiety
confusion, crazy
not overtly expressed
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Suicide in the Older Adult
Greatest Risk: older white male
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More lethal attempts, successful often
1:4 success rate
May not discuss the desire to die
> 50% visited physician within 1 week of death
Be direct when questioning
Fear of moving to supervised housing, pain, loss, incapacity,
finances
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Dementia
Approximately 4 million Americans have AD
In 2050 ~ 14 million Americans will have AD
Greatest risk: Advancing age
10% >65 years old
50% >85 years old
Family history: ? Genetics
Duration range 3 - 20 years, avg. 8 years
Family disease: patient & family are = victims
www.alz.org/AboutAD/Statistics.htm
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Dementia
Neuropathological syndrome with
progressive deterioration of intellectual
functioning, problem solving, and learning
new skills
Irreversible and progressive
Secondary: A result of other processes
65% - Alzheimer’s
Higher occurrence in women, Down’s and
head injuries
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Dementia
with Reversible Causes
Depression
Medications
Thyroid disease
Tumor
B-12 deficiency
Malnutrition
Infection
Hypo/hyperglycemia
Dehydration
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Dementia
Signs & Symptoms
Memory Impairment
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impaired ability to learn new info
Functional Impairments (acts)
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ADL’s,  social
significant decline from previous LOF (gradual onset)
Cognitive Impairment (thinks)
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aphasia - comprehension & speech
apraxia - motor activities (eating, brush teeth, comb hair)
agnosia - inability to recognize familiar objects
disturbance in executive functioning (organizing, planning,
sequencing, abstracting)
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Progression of Dementia
Decline in everyday life activities
Failure of memory and intellect
Disorganization of the person
Psychotic changes
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Dementia: Process and Characteristics
Behavior (gradual/insidious)
Causes
Infections
Degenerative
neurological
disorders
Vascular disorders
Structural disorders
of brain tissue
Multiple cognitive deficits
Memory impairment
Aphasia
Apraxia
Agnosia
Disturbed executive
functioning
Catastrophic reactions
Perceptual alterations
Wandering
Disinhibition
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Progression of Alzheimer’s
Early Stage:
Difficulty remembering names,
appointments, where things are.
Emotionally unstable, new onset
depression
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Progression of Alzheimer’s
Second Stage (2 ½ years):
Recent memory deficit
Decrease in orientation
Restless nights, wandering
Beginning of catastrophic reactions
Misperceptions cause paranoia
May blame family/staff for stealing lost objects
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Progression of Alzheimer’s
Final Stage
(months to 5 years)
Severe disorientation
Psychotic symptoms
Severe emotional disregulation
Blunted emotions
Inability for self-care
Does not recognize family/staff
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BEHAVIORAL SUPPORTS IN
DEMENTIA
Calm consistent environment
Cuing and reminding or validation
Emphasize cognitive strengths
Music, familiarity
Watch for changes in functioning
Provide safe environment
Daytime exercise, minimize naps
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Delirium
Acute, reversible etiologies
Most of the time secondary to underlying medical
condition, medication reactions or intoxication
Most often seen in children and adults over age 65
If untreated may progress to dementia, coma or
death
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Delirium
Triad of Symptoms
Onset
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Acute, hours - days
Lasting hours - weeks
Disturbance in Consciousness
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↓ awareness of environment
Lethargic or hypervigilant (agitated)
Changes in Cognition/Perceptual Disturbance
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Memory impairment
Sensory changes
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CLINICAL FEATURES OF
DELIRIUM vs Dementia
Cognitively impaired
Medically ill
Acute/sudden onset
Disorientation
Hallucinations
Delusions
Visuospatial deficits
Apraxias
Lethargy
Comprehension
deficits
Altered level of
consciousness
Agitation, irritability
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Etiology & Risk Factors for
Dementia
General medical condition
Substance use/abuse
Drug intoxication, polypharmacy
Systemic infections
Dehydration, fluid & electrolyte imbalance
Hepatic or renal disease
Hypoxia
Metabolic Disorders
Nutrition deficiencies
Limited mobility
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MANAGEMENT OF DELIRIUM
Schedule appt w/ MD or 911
Re-orient patient
Quiet, less stimulating environment
Maintain resident and staff safety
1:1 observation if possible until managed by medical
personnel
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Geriatric Substance Abuse
~2-3% women, ~10% men >60yo
Early Onset (<60yo)
About 2/3 of geriatric alcohol use disorders have been abusing throughout adult life
Greater financial, legal and social problems than later onset
Heavier drinkers than later onset patients
Late Onset (>60yo)
About 1/3 of geriatric alcohol use disorders begin after 60
Aging social drinkers more intoxicated with same dose
Cognitive disorder in heavy drinkers
Social drinkers who increase drinking after losses
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Medical Complications of Substance Use
Worsening dementia
Anxiety
Psychosis
Alcohol-induced mood disorder
Dementia-like symptoms from mood disorder
Suicide
Exacerbation or worsening of existing medical
conditions, ie, diabetes, blood pressure
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Possible Warning Signs
Cognitive decline or self care neglect
Family estrangement
Unexpected delirium after hospitalization (withdrawal)
GI problems
Frequent injuries, falls, “accidents”
Does not attend medical appointments
Socially Withdrawn
Poor appetite
Depression
Difficulty sleeping
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Contributing Factors
Loss of spouse/pet/loved one
Financial problems
Retirement
Sale of home, move to supervised housing
Loss on independence/control
Depression
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Conclusions
Adults with certain medical conditions are
at greater risk of co-occurring mental
illness problems
The mental illness is frequently under
diagnosed
Identification and intervention with these
problems can help both the patients
mental status and health status
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Questions
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