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Physical Illness and Co-occurring Mental Disorders Developed by DATA of Rhode Island through a special grant from the RI Department of Human Services 1 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 2 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 3 Stress and Physical illness Major health problems are stressful Response to this stress dependent upon individual Perception / Beliefs of illness Vulnerability Coping ability Response of others 4 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 5 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 6 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 7 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 8 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 9 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 10 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. 11 Geriatric Depression Signs & Symptoms Mid-Life depressed mood diminished pleasure weight, appetite insomnia negative attitude guilt, worthlessness concentration suicidal ideation Late-Life irritable, critical of others isolation, withdrawal weight, taste, swallow early A.M. awakening hypersomatic “the end”, burden, anxiety confusion, crazy not overtly expressed 12 Suicide in the Older Adult Greatest Risk: older white male 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 13 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 14 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 15 Dementia with Reversible Causes Depression Medications Thyroid disease Tumor B-12 deficiency Malnutrition Infection Hypo/hyperglycemia Dehydration 16 Dementia Signs & Symptoms Memory Impairment impaired ability to learn new info Functional Impairments (acts) ADL’s, social significant decline from previous LOF (gradual onset) Cognitive Impairment (thinks) 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) 17 Progression of Dementia Decline in everyday life activities Failure of memory and intellect Disorganization of the person Psychotic changes 18 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 19 Progression of Alzheimer’s Early Stage: Difficulty remembering names, appointments, where things are. Emotionally unstable, new onset depression 20 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 21 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 22 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 23 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 24 Delirium Triad of Symptoms Onset Acute, hours - days Lasting hours - weeks Disturbance in Consciousness ↓ awareness of environment Lethargic or hypervigilant (agitated) Changes in Cognition/Perceptual Disturbance Memory impairment Sensory changes 25 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 26 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 27 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 28 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 29 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 30 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 31 Contributing Factors Loss of spouse/pet/loved one Financial problems Retirement Sale of home, move to supervised housing Loss on independence/control Depression 32 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 33 Questions 34