Download Testimony SB121 Behavior-Mental Health Issues_ Jeffrey Klein

Testimony In Support of SB 121 Behavioral Health and Cognitive Care Needs of Older Persons
before the Senate Committee on Legislative Operations and Elections
February 22, 2017
Jeffrey B. Klein FACHE
Chairman, Commission on Aging, Legislative Subcommittee
President & CEO, Nevada Senior Services
On behalf of the Nevada Commission on Aging, Legislative Subcommittee we urge your strong approval of
SB121. Nevada urgently needs an in-depth study of behavioral and cognitive issues associated with older
adults including health services delivery, caregiver support and training for our health care delivery workforce
in the screening, diagnosis and treatment of behavioral and cognitive health diseases impacting our aging
community.
Briefly stated:
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Currently over 366,000 Nevadans who are 65+ years of age
Our state is aging at a rapid rate
Conservative estimates are that over 25% of these seniors (91,500) are impacted by a mental health or
cognitive disorder including those who: a) are diagnosed with chronic psychiatric illnesses; b)
experience cognitive changes due to illnesses such as dementia or stroke; and, c) effected by mental
health disorders as a result of age-related disabilities
Nevada has one of the highest senior suicide rates in the US
Caregivers (over 500,000 statewide) are at significant risk for depression and other mental and
physical health issues
SB269 provides a responsible path to assisting Nevada to:
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Address stigma associated with mental health services, increase awareness of warning signs and
existing resources for community-at-large
Implement and promote education and training programs for health care and mental health
professionals in screening, diagnosis and treatment of mood disorders affecting older adults
Identify gaps in existing community-based mental health resources. Assess specialized care options to
address the mental health needs of older adults, availability of evidence-base protocols, effectiveness
of treatment, accessibility of existing resources, opportunities for input from older adult and
affordability of care
Offer a continuum of care with service options appropriate to level of need
Create “no wrong door” access to the service delivery system
Integrate evidence-based protocols and best practices at every level of care
Address to need for affordable care options for consumers and adequate reimbursement for providers
Offer specialized options to manage aggressive and disruptive behaviors
Nevada Senior Services, Inc.
901 North Jones Boulevard, Las Vegas, Nevada 89108 ~ Phone (702) 648-3425
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Provide education and training for health care and mental health professionals to manage cognitive
and behavioral symptoms
Offer support and respite for caregivers and families
Reduce the risk of premature and unnecessary nursing home placements
Nevada Commission on Aging Legislative Subcommittee appreciates the opportunity to come before the
Senate Committee on Legislative Operations and Elections and express our strong support of SB269 and hopes
that it will be enthusiastically approved with our suggested modifications.
FOR THE RECORD: OUTLINING THE CASE
BEHAVIORAL AND COGNITIVE ISSUES IMPACTING OLDER PERSONS IN NEVADA
1) Problem Summary:
The prevalence and complexity of behavioral/mental health issues for individuals age 60 and older poses
unprecedented challenges for our community and its health care delivery systems. Key factors include the
longevity of the older population and the extraordinary growth of this age cohort in Nevada. Age is a primary
risk factor for many illnesses which affect cognitive and behavioral health including stroke and dementia. The
health care system has not evolved to meet the changing and burgeoning demand for these services.
The dramatic increase in life expectancy, from 50 years in 1900 to nearly 80 today, is a significant factor in the
rising number of individuals impacted by mental health disorders. Nevada has one of the nation’s fastest
growing older adult populations, with approximately 500,000 individuals over the age of 60, representing 18% of
the state’s population (U.S. Census Bureau, 2009 Projections). The most rapidly increasing subset are those over
the age of 85 who are most likely to be frail, with declining physical health and mental health challenges.
Researchers estimate that 20 – 25 percent of those over the age of 65 have a mental health disorder (Karel, Gatz
& Smyer, 2012 APA, Jeste et.al., 1999 Mentally Healthy Aging). This cohort is comprised primarily of 3
subgroups; individuals who:
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Have been diagnosed with chronic psychiatric illnesses earlier in their adult years
Experience the onset of cognitive and/or behavioral symptoms due to an illness such as
dementia or stroke
Are affected by mental health disorders due to age-related disabilities and circumstances
including caregiving
Older adults can experience a wide range of disorders that impact their mental health including depression,
dementia, psychosis and anxiety. Risk factors include: declining physical health; diagnosis and progression of
chronic illness; loss of independence; medication interactions; caregiving; loss of a loved one; substance abuse;
poor nutrition; pain; social isolation; and, sleep problems. Approximately one-third of individuals age 65 and
over report having a disability (Nevada Aging and Disability Services Division, State Plan 2012). Dementia affects
one in 9 over the age of 60 and almost 50% of those 85 and older. Caregiving is also recognized as a risk factor
for depression, anxiety and other mental health illnesses.
Nevada Senior Services, Inc.
901 North Jones Boulevard, Las Vegas, Nevada 89108 ~ Phone (702) 648-3425
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Nevada’s current system of care is inadequate to effectively meet the specialized needs of older adults with
behavioral/mental health issues. As a result, mental health and cognitive disorders go undiagnosed,
underreported and untreated. Individuals who exhibit behavioral manifestations face even greater challenges in
securing a diagnosis and receiving appropriate ongoing care.
The challenges to improving mental health care options are myriad and include:
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Lack of knowledge and misconceptions about the normal aging process and diseases affecting
older adults
Insufficient community-based care options and inpatient facilities that specialize in care
modalities proven effective for older individuals
Training for medical and mental health professionals in diagnosis, treatment and behavior
management specific to common diseases and disorders
Implementation of evidence-based models of care
Medication management of prescription drugs, over-the-counter products and supplements
Education/training for caregivers and families in support of their caregiving tasks including nonpharmacological behavior management
Community-based mental health services that are affordable and accessible
The development and implementation of specific steps to solve these challenges is imperative. Changes and
improvements in the current system will result in the delivery of more cost-efficient quality care, reduce the use
of emergency services and decrease premature institutional placements. Most importantly, a more effective
system to deliver behavioral and cognitive health care will assist older individuals in their quest to remain
independent and reside in the community for as long as possible.
2) Mood Disorders: depression, anxiety
Overview:
There are a range of mental health disorders that are prevalent in the older adult population. This section
addresses two of the most common mood disorders: depression and anxiety.
Depression is not a part of the normal aging process. However, this mood disorder is the most prevalent
mental health problem among older adults. The estimated incidence is 5% affected by major depression
and 15% with symptoms that meet the criteria for minor depression. The presence of one or more medical
illniillnesses increases the occurrence of depression significantly. Other risk factors include: chronic pain;
side effects of medications; drug interactions; alcohol or drug misuse; bereavement; social isolation;
loneliness; and, decline in the ability to function independently. Symptoms of depression are sadness, loss
of interest in activities, changes in weight, feelings of worthlessness, poor sleep, low energy, impaired
cognitive function and thoughts of suicide or death. Depression in older adults is highly treatable yet often
undiagnosed and untreated. Depression can also interfere with the effectiveness of medical treatments and
increase visits to physicians and emergency services.
Nevada Senior Services, Inc.
901 North Jones Boulevard, Las Vegas, Nevada 89108 ~ Phone (702) 648-3425
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Anxiety disorders, characterized by distress that interferes with daily activities are also not a part of normal
aging. These disorders cause excessive worry, nervousness, fear and apprehension. It is estimated that in the
U.S., three to fourteen percent of older adults have symptoms consistent with an anxiety disorder however
other factors such as medical illness, memory loss and major life adjustments due to loss of a spouse or a new
living arrangement may increase the percentage affected. Other risk factors include poor sleep, medication side
effects or interactions, alcohol or drug misuse, poor coping skills, lack of social support and a high level of stress.
Depression and anxiety disorders may occur together and can exacerbate the symptoms. As with depression,
anxiety disorders are often undiagnosed and untreated in older adults.
Screening tools specifically designed for older adults and evidence-based treatment programs which
effectively treat mood disorders have been developed. These programs can be implemented in various
settings by different types of providers (primary care, mental health, psychologists and social workers) and
may include both psychotherapy and medications.
While the exact number of older individuals affected is difficult to measure, it is clear that those who suffer
from mood disorders experience an increase in physical symptoms, utilize a greater proportion of health
care resources including emergency services and are more likely to attempt suicide.
Sources: Administration on Aging and Substance Abuse and Mental Health Services Administration. Older
Americans Behavioral Health Issue Brief 6: Depression and Anxiety: Screening and Intervention. Older
Americans Behavioral Health Technical Assistance Center, 2013.; Centers for Disease Control and Prevention
and National Association of Chronic Disease Directors. The State of Mental Health and Aging in America
Issue Brief 1: What Do the Data Tell Us? Atlanta, GA: National Association of Chronic Disease Directors;
2008.
3) Suicide
Overview:
Suicide is a significant mental health concern for older individuals and major public health issue. Suicide
rates increase with age, with the highest rates for those over the age of 85. The rate declines in older
women and increases in older men who die by suicide at a rate that is seven times higher. Older white men
are at great risk with 30 suicides per 100,000. Firearms are the most common method used to carry out a
suicide. Risk factors specific to the older adult population include: depression, prior suicide attempts,
diagnosis or progression of chronic disease(s), pain, loss of ability to function independently, lack of support
system, major loss such as death of spouse, alcohol or medication misuse and cognitive decline. Research
studies have documented that the vast majority of older adults had been seen by their primary care
physician within one year of their death, with over half visiting their physician within the month of their
death by suicide. Only a small percentage with suicidal ideation were detected by their primary care
physicians. As with younger age cohorts, stigma prevents many from reaching out for family and health care
professionals for assistance and support.
Nevada Senior Services, Inc.
901 North Jones Boulevard, Las Vegas, Nevada 89108 ~ Phone (702) 648-3425
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For decades, Nevada has had one of the highest suicide rates for older adults in the United States. From
2004 – 2008, there were 35.8 suicides per 100,000 in the population age 75+, a rate which significantly
exceeds the national (21.7) and regional (27.9) averages. Consistent with national data, Nevada’s oldest
adults have significantly higher suicide rates than the majority of other age cohorts. Between eleven and
eighteen percent of the State’s residents age 50 and older reported that they rarely or never receive the
social support they need, one of the highest rate in the nation and a risk factor for suicide.
Sources: Centers for Disease Control and Prevention and National Association of Chronic Disease Directors. The
State of Mental Health and Aging in America Issue Brief 1: What Do the Data Tell Us? Atlanta, GA: National
Association of Chronic Disease Directors; 2008.; Nevada Suicide Prevention Plan, 2007-2012, Office of Suicide
Prevention; Older Americans Behavioral Health, Issue Brief 4: Preventing Suicide in Older Adults, AoA, SAMHSA,
2012.; Policy Academy State Profile, Nevada Profile, August 7, 2012.
4) Cognitive changes and challenging behaviors resulting from neurodegenerative illness
Overview:
Dementia is a loss of brain function that affects a person’s ability to carry out daily activities. It is not a part
of normal aging. Alzheimer’s is the most common form of dementia; other types are vascular, Lewy body,
and frontotemporal dementia. Dementia is characterized by cognitive and psychiatric symptoms. Cognitive
changes may include difficulties in remembering new information or recent events; communicating
information and emotions; and engaging in critical thinking, following instructions or judging situations
accurately. Common psychiatric symptoms are changes in personality, depression, hallucinations, delusions
and aggressive behaviors.
According to the Alzheimer’s Association, there are an estimated 37,000 (2014) individuals in Nevada with
Alzheimer’s disease, which is projected to increase to 64,000 by 2025, representing one of the top growth rates
in the U.S. The vast majority of individuals reside in the community and are cared for by family, friends or
neighbors. The Alzheimer’s Association’s annual report cites dementia as one of the most expensive illnesses to
treat, with Medicare costs three times higher and Medicaid nineteen times higher for individuals with dementia.
Given the pervasive impact of cognitive and psychiatric symptoms, individuals with dementia require a
significant level of care and support over the course of their disease. The current practice of delivering services
to this population is fragmented and inadequate to meet their wide-ranging needs.
Nevada Senior Services, Inc.
901 North Jones Boulevard, Las Vegas, Nevada 89108 ~ Phone (702) 648-3425
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