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Transcript
RECOGNIZING MENTAL HEALTH
ISSUES IN OLDER ADULTS
Fuqua Center for Late-Life Depression
Emory 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’s
Blazer 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 Race
using 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
MYTH

Asking about suicide
may give someone the
idea to kill themselves.
FACT

The opposite is true.
Asking someone
directly about their
suicidal feelings will
often lower their
anxiety level and act
as a deterrent to
suicide.
Myths and Facts About Suicide
FACT


Most people who kill
themselves give
definite warning signs
of their suicidal
intentions.
8 out of 10 give signs.
All threats and
attempts should be
taken seriously.
MYTH

Talking about suicide is
usually a cry for help.
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.com
or
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.
Dementia
Alzheimer’s Disease
60-80%
Vascular dementia
Parkinson’s dementia
Frontotemporal dementia
Lewy Body dementia
Bonifas, R. Depression, Dementia, and Delirium Teaching Module. CSWE Gero Education Center.
Arizona State University.
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, orientation
http://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.
2.
3.
Hyperactive: psychomotor agitation, increased
arousal and delusions, may see some cognitive
impairment
Hypoactive: withdrawal, lethargy and reduced
arousal
Mixed: Characteristics of both
Bonifas, R. Depression, Dementia, and Delirium Teaching Module. CSWE Gero Education Center.
Arizona State University.
Criteria for Delirium Diagnosis

1.
2.
3.
4.
Four criteria are assessed in diagnosing delirium.
Delirium diagnosis includes:
Acute onset and fluctuating course and
Inattention, then either
Disorganized thinking or
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 Line
http://www.mygcal.com
1-800-715-4225
24 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
Less
common
Common 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 Depression
Jocelyn Chen Wise
Office: 404-712-6943
[email protected]
www.fuquacenter.org