Download Mental Health Services

Mental Health and
Mental Disorders
Chapter 7
McGraw-Hill/Irwin
© 2013 McGraw-Hill Companies. All Rights Reserved.
Mental Health
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The ability to engage in productive activities
and fulfilling relationships and cope
successfully with change and adversity
Healthy behavior is culturally defined
Mental health varies throughout the life cycle
One developmental task of old age is
acceptance
7-2
Psychological Changes with
Age
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To study changes we can use:
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Cross-sectional studies
Longitudinal studies
But how well do these studies really measure
the effects of age on personality, cognition
and memory?
7-3
Psychological Changes
with Age – Cognition
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Most aspects of intelligence decline with age
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ability to learn new tasks
ability to perform motor skills
Perhaps experience can help compensate
Terminal Drop occurs just before death
Intelligence can be stimulated through
crossword puzzles, debate, etc.
Cognitive losses are accelerated with
depression, surgery, etc.
7-4
Psychological Changes
with Age – Memory
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Elders perform poorly on memory
tasks that require speed or focused attention
but most affected is the episodic memory
Least affected is reminiscing
Often memory lapses are caused by anxiety,
lack of sleep or drug side effects
Mnemonics can be a helpful memory
technique
7-5
Psychological Changes
with Age – Personality
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Personality is a a collection of
individual traits that are consistent over
time and across situations and are the
essence of the person
Personality remains remarkably stable
over time
Elders have better coping skills – often
they “mellow” out
7-6
Transitions in Later Life
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Many transitions are characterized by loss
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Physical losses
Psychological losses
Social losses
Economic losses
Interpersonal losses
Other transitions are joyful: watching grandchildren grow, having more leisure time, etc.
7-7
Transitions in later life –
Retirement
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Retirement can signal the beginning of a life of
leisure, or can be fraught with the loss of
income
Social Security and Medicare help with the
financial loss, pensions and retirement
savings
Retirement is hardest on single women and
minorities who may not have pensions or did
not pay into Social Security
7-8
Transitions in later life –
Relationships with adult children
and grandchildren
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Elders usually derive much strength and
support from their adult children
Roles may reverse as elders need more
support, causing the children to become
“parents”
Many grandparents raise or care for
grandchildren
7-9
Transitions in later life –
Marital transitions
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Adjustments to divorce, widowhood and
remarriage can all be experienced in the later
years
The illness of a spouse is a major transition
and can prompt many changes – often
negative
Widowhood has many changes: financial,
living situation, friendships and sexual
relationships change
7-10
Factors Affecting Adjustment
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Personality, health status, financial situation,
social support and ability to cope with stress all
affect adjustment
The emotional health of the elder is important
The elder’s perception of their own health is a
factor
Even though elders have so many changes,
they report less stress than any other age
group
7-11
Mental Disorders
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Mental disorders cause changes in thought,
mood or behavior that result in distress or
impairment in function
Elders who have sustained multiple losses,
who have little support or who do not adapt
well are vulnerable to mental disorders
Diagnoses of common mental disorders
decline among elders, but cognitive
impairment increases with age
7-12
Mood disorders –
Depression
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Criteria for clinical depression is much
different than just feeling sad
Other illnesses besides major depression:
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Dysthymia
Seasonal affective disorder
Reactive depressive disorder
Major Depression is the leading cause of
disability on the US
7-13
Mood disorders –
Depression
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Psychotic depression may include loss of
contact with reality or hallucinations
Differentiating between depression and
dementia can be difficult
Treatment can include therapy, medications,
electroconvulsive (shock) therapy or time
Elders with depression are at a greater risk
for suicide
7-14
Anxiety disorders
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May be a disorder or a symptom of another disorder
Types of anxiety disorders:
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Generalized anxiety disorder
Panic disorder
Obsessive-compulsive disorder
Anxiety disorder due to general medical condition
Difficult to diagnose because symptoms mimic
symptoms of illnesses
Treatment can be therapy, medication and/or
desensitization therapy
7-15
Psychotic disorders
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Psychosis is the inability to distinguish what
is real from what is not. Including:
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Delusions
Paranoia
Hallucinations (audio or visual)
Schizophrenia is a common type of
psychosis, most have had it from a young
age
Medications are a treatment, but not a cure
7-16
Sleep disorders
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There are more than 100 known sleep
disorders
Sleep disorders can be short-term or chronic
Extremely common: affects 1/3 of all adults
Some disorders are due to age-related
changes in sleep patterns
Elders are high users of sleeping pills
Restless leg syndrome and sleep apnea are
types of sleep disorders
7-17
Substance abuse disorders
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Substance abuse is the use of a substance
despite negative health and social
consequences
Substance dependence is the prolonged
use of a substance that requires a higher
dose for the same effect
Includes alcohol, tobacco, illegal drugs and
prescription drugs such as painkillers or
sedatives
7-18
Substance abuse disorders –
Alcohol abuse and dependence
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Alcohol use usually declines with age
Persons become more susceptible to intoxication
with advancing age
Alcohol abuse
Alcohol dependence (alcoholism)
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A progressive, debilitating chronic illness
Can be fatal and causes problems in nearly every organ
system
Difficult to diagnose and detect since many elders
do not have bosses or spouses to detect the
problem, elders are not usually disruptive socially
7-19
Substance abuse disorders –
Nicotine abuse and dependence
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The proportion of people who have quit
smoking increases with age
Physicians should continue to encourage
elders to quit
Smoking is the number one cause of
premature death and disability in the US
Drugs and programs can help elders quit
7-20
Cognitive disorders – Dementia and
dementia of the Alzheimer’s type
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Dementia: progressive brain impairment that
interferes with memory and normal functioning
Alzheimer’s is the most common; Multi-infarct
dementia (series of small strokes) is the second
Increases with advancing age; some dementias
are reversible
Symptoms include losing memory and language
skills, the ability to care for one’s self; advanced
dementia includes behavior problems
7-21
Dementia and dementia of the
Alzheimer’s type
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Sundowning is a worsening of symptoms in the
evening hours
Diagnosing dementia may take time and is
often difficult
No one knows the cause of Alzheimer’s
Alzheimer’s and other dementias are deadly
Age is the greatest risk factor for dementia
Treatment is mostly supportive, some drugs
can help, therapy supports the patient
7-22
Cognitive disorders – Delirium
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The sudden appearance of a state of confusion;
mostly in frail elders; often due to infection
Symptoms include agitation, confusion, memory
loss, decreased attention span
Symptoms may fluctuate or be subtle, elders may
hallucinate or be very frightened or sleepy
Treatment should be for the root problem: infection,
heart failure, dehydration
7-23
Psychological
Treatments
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Psychotherapy is a good treatment for most
mental disorders discussed
Experts believe that therapy with older adults
should be brief and focus on problem solving
Group therapies can also work, alternative
therapies such as art, or self-help groups
Peer counselors can be beneficial
7-24
Mental Health Services –
Nursing homes
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Nursing homes have become the most
common place for mentally ill elders – but
the homes may not be set up for mentally ill
patients
Some states require more dementia training
for nursing home personnel
A person-centered care movement has
advanced care for elders with dementia
Advantage of nursing homes is 24-hour
care
7-25
Mental Health Services
Public Mental Institutions
• Approximately 1 in 3
patients in mental
institutions is an elder
• Most elders are there
with schizophrenia, or
alcoholism or
depression
• Many have been there
since early adult years
Psychiatric Units in
Hospitals
• Primary providers for
acute mental problems
• Hospitals offer a high
staff-to-patient ratio
and close-to-home
treatment
• Units are not designed
for counseling
7-26
Mental Health Services –
Community Mental Health Centers
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Centers are in communities with populations of
70,000 to 200,000
Centers offer five basic mental health services:
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Inpatient and outpatient care
24-hour emergency services
Partial hospitalization
Consultation
Education
Centers are publicly funded with sliding-scale
costs for services
Most centers do not meet the needs of elders very
well
7-27
Mental Health Services
Private Therapists and
Psychiatric Outpatient
Clinics
• Usually cost-prohibitive
for elders
• Elders comprise less
that 5% of private
clients
Halfway Houses
• Excellent for those who
can meet most of their
own needs with support
or supervision
• Can prevent / postpone
institutionalization
• Some are good, some
are bad: be careful
7-28
Mental Health Services
Case management
services
• Case managers are
trained to know the local
services and how to use
them to support mentally
ill patients
• Typically, they attempt to
delay institutionalization
Protection and Advocacy
• Mentally ill elders are
vulnerable to abuse;
each state most
protect their patients
• LPS conservatorship
ensures that mentally
ill elders are cared for
• Nursing home
ombudsmen can help
7-29
Financial Reimbursement for
Mental Health Care – Medicare
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Medicare works like private insurance
Medicare Part A helps cover costs for:
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Acute psychiatric hospitalization
Hospitalization in a psychiatric hospital (190
days)
Medicare Part B helps cover costs for:
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Inpatient mental health services
Outpatient mental health services
There is a $1,100 cap/year on mental health
services
7-30
Factors Limiting Elders’ Use
of Mental Health Services
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Elder beliefs
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Professional biases
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Hard to admit you need help
May attribute symptoms to illness or age
“Can’t teach an old dog new tricks”
System Barriers
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Medicare doesn’t pay for enough services
Dementia is often excluded altogether
Often not enough doctors in a community trained
in geriatric mental health
7-31
Advocacy Efforts
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Reforms happen in each era moving us
toward a stronger mental health system
Drugs have become easier to take with
less side effects
Advocacy groups have strengthened care
and knowledge
“Whole person” care was developed
Going forward, we need to continue to do
more
7-32
Mental Health and Mental Disorders
Chapter 7