Transcript The Case of Older Adults With Mental Illness

Bridging from Diagnosis to
Advanced Direct Practice: The
Case of Older Adults With Mental
Illness
Course: Health Care
Adelphi University School of Social Work
Acknowledgement
The development of this gerontology
teaching module was made possible through
a Gero Innovations Grant from the CSWE
Gero-Ed Center's Master's Advanced
Curriculum (MAC) Project and the John A.
Hartford Foundation.
Adelphi University Project Team: Judy
Fenster (Principal Investigator), Philip
Rozario, Patricia Joyce, and Bradley Zodikoff.
A Phone Call from Mr. Shea
Mr. Shea, a widowed 74 year old man of IrishAmerican background, phones to say he won’t be
at your bereavement group this week. He won’t
leave the house because the last two times he
rode the bus, he felt like he was choking, got
dizzy and felt like he was going crazy. He tells
you that he would like to go to his doctor, but he
rides the bus there, too. He hasn’t left the house
for two weeks. These feelings on the bus started
about six weeks ago, and for a month he “just
dealt with it.” His neighbors shop for him, but he
feels embarrassed to tell them or his daughters
about his “riding the bus problem. I don’t want to
be one of those weird crazy people.”
Why Focus on Understanding Mental
Health Issues in Older Adults?

Growth in Elderly Population
 1900—4% of U.S. population was
age 65+
 2006—13% of U.S. population was
age 65+
 2030—20% predicted
 Also: by 2030, the number of
elderly 85+ is expected to double
Bridging from Diagnosis: Older
Adults
 Co-morbid Medical & Psychiatric Conditions
 ↑ Use of Prescription Drugs among elderly,
combined with mental disorders
 ↑ Dementia and other Cognitive Deficits,
combined with mental disorders
 ↑ Risk of Depression/Suicide among certain
older adults (white males
Mental Illness Prevalence: Older
Adults
 Prevalence of mental illness in US population age
55+, from the Epidemiological Catchment Area
Study:
 Any Anxiety Disorder: 11.4%
 Simple Phobia: 7.3%
 Social Phobia: 1.0%
 Agoraphobia: 4.1%
 Panic Disorder: 0.5%
 Any Mood Disorder: 4.4%
Source: L.N. Robins & D.A. Regier (Eds.). (1991). Psychiatric disorders in America: The
Epidemiologic Catchment Area Study. New York: Free Press.
Older Adults and Mental Illness
 Older adults are actually LESS likely to
meet diagnostic criteria for a mental
disorder than are young or middle aged
adults
 It may be that life experience protects
against some forms of mental illness
Protective Factors and MI in Older
Adults
 For some older adults, research shows
that integrity and hope serve as
protective factors against late life
depression
 Think about these factors in connection
with your foundation year HB courses on
older adulthood
Older Adults’ Perceptions of MI
 Like Mr. Shea did, many older adults
perceive the mentally ill as being
embarrassing and having poor social
skills
 Older adults don’t think that mental
illness only occurs in younger adults,
don’t see mental illness very differently
than younger adults and don’t report
that they will never seek help
Older Adults with MI in the
Community
 Much more research needs to be done on
the treatment needs of older adults with
mental illness who live in the community
 For example, research shows that
increasing numbers of older adults with
schizophrenia live in the community
rather than in institutions, but little is
known about their service use
Effective Treatments with Older
Adults
 Many evidence based practices work with
older adults
 For example, research indicates that
cognitive behavioral therapy can be
adapted to effective use with older
adults
Which Diagnoses Co-occur for Older
Adults?
 Research shows that late life
generalized anxiety disorder is often
seen along with a diagnosis of major
depression in older adults
Putting Together the Pieces for Mr.
Shea
 First, you would want to address your
own values and biases about aging
 For example, you might want to examine
your own thoughts and feelings about Mr.
Shea’s life experiences, his widowhood,
his expectations for the future
 Does he have the right to be happy after
his wife’s death?
 Do you think he will benefit from
treatment?
Using Self Awareness to Deepen
Practice
 Based on your examination of your own
values and biases about aging, do you
 Think that Mr. Shea may have internalized
some of these about himself and his own
situation?
 Think that his family members, friends
and neighbors may harbor similar values
and biases about aging?
Applying Ethical Principles
 Next, think about who makes decisions
for older adults
 Mr. Shea has full decision making
capability, but what if he didn’t?
 Would he still be offered treatment for his
difficulties?
Comprehensive Biopsychosocial
Geriatrics Assessment
 Be aware that assessment is the first step
 After a full assessment, the practitioner
will need to know what kind of treatment
Mr. Shea will benefit from, and be able to
find resources for him, and discuss
treatment options with him
 A full assessment includes health status
and physical functioning
Diagnosing Mr. Shea
 You will need to assess his cognitive
functioning (how he thinks) and
 His mental health status
 What are his symptoms?
 Choking, dizziness, feeling of going crazy
might be symptoms of a panic attack
 The fear of another attack may what’s
preventing him from leaving the house,
which may indicate agoraphobia
Possible Diagnosis
 So, based on your knowledge of the
DSM-IV criteria for Panic Attacks with
Agoraphobia, Mr. Shea might meet
criteria for this diagnosis
 But, you need to think as well about…
Co-occurring Diagnoses with
Anxiety Disorders in Older Adults
 Frequently mood disorders are seen along
with anxiety disorders throughout the
lifespan, including older adulthood
 So, you would want to assess whether
Mr. Shea meets criteria for a mood
disorder
Overdiagnosing and Misdiagnosing
 But Mr. Shea lost his wife in the past
year, so be aware that grief or mourning
can often look much like one of the most
common mood disorders, depression
 But you will remember that there are
time factors involved in making a
differential diagnosis of depression vs.
grief. Be sure to review these!
Your Assessment Isn’t Over Yet!
 Remember to include Mr. Shea’s social
functioning in your assessment
 This will include his social skills, his social
activity level and what kinds of social
supports he has in his life
The Whole Picture
 If Mr. Shea meets criteria for a DSM-IV
diagnosis, what then?
 Based on your working relationship with
him, you can
 Discuss treatment choices, which may
include psychotherapy alone, or
psychotherapy along with psychiatric
medications or medications alone
Working Together with Mr. Shea
 Together, you can help Mr. Shea make
informed and thoughtful choices that will
help him continue to grow and develop in
a rich and meaningful way