Family presentation

Interventions for Geriatrics in Mental Health

By: Amber Knight, Sibyl Kirkland, and Heather

Zimmerman

Geriatrics

• Population in United States 2012– US residents age 65 and over: 41.4 million

• Life expectancy– Men at 65 years: 17.7 years/Women at 65 years:20.3 years

• Heath Status– Non-institutionalized persons age 65 and over in fair or

poor health: 24.7%– Non-institutionalized s age 65 who needs help with

personal care from others: 7.3%

(CDC, 2012)

Geriatrics

• Aging is not associated with significant cognitive decline, but minor memory problems can occur a normal part of aging.

(Sadock & Sadock, 2008).

Neurocognitive Disorders

• DSM – 5 defines the cognitive domains which identifies the criteria of the disorders , their levels and the subtypes to diagnosis.

• Five domains includes:– Complex attention– Executive function– Learning and memory– Language– Perceptual –motor– Social cognition

(American Psychiatric Association, 2013)

Neurocognitive Disorders

• Delirium• Major & Mild Neurocognitive disorders

– Alzheimer’s disease– Frontotemporal lobar degeneration– Lewy body disease– Vascular disease– Traumatic brain injury– Substance/medication use– HIV Infection– Prion disease– Parkinson’s disease– Huntington’s disease

(American Psychiatric Association, 2013)

Dementia• Not a specific disorder but an universal term to describe the vast

range of symptoms• Defined as an acquired, persistent , and progressive impairment in

multiple cognition leading to significant functional decline.• 1 of 3 US residents 55 years of age and older & 1 of 5 at least 65

years of age by the year 2030.• Dementia prevalence increases with age

– 5 % in 71 to 79 years of age– 37.4 % in 90 years of age and greater

• “Elderly patients with dementia and other psychiatric disorders are most often cared for by their primary care.”

(McCarron, Xiong, & Bourgeois, 2009)

Treatment

• Early diagnosis and treatment of dementia is important to slow cognitive and functional decline.

(McCarron, Xiong, & Bourgeois, 2009)

Delirium

• Defined as an acute decline in attention and cognition , is a common, life-threatening and potentially preventable clinical syndrome in older adults.

(Ramaswamy et al, 2010)

Characteristics

• Rapid onset • Most common psychiatric syndrome in general

medical setting and associated with significant mortality and morbidity both during and post hospitalization Results from urinary and upper respiratory infections, dehydration, and medication-related mishaps

• Preventable and treatable• Not always transient and reversible

(Tusaie & Fitzpatrick, 2013) (Ramaswamy, et al., 2010)

Additional Characteristics

• Up to 2/3 of all cases of delirium in the elderly increases the risk for dementia.

• More than 20% of hospitalized patients aged 65 years and older each year increases hospital costs by $2,500 per hospital stays.

• Admission ranges 14% to 24% whereas incidence during hospitalization can be as high 56%.

(Ramaswany et al, 2010)

Assessment Tool

•Delirium Observation Screening Scale

• CAM- Confusion Assessment Tool

• CAM - ICU

•Other tools: MDAS, ICDSC, Cognitive Test for delirium; DSI

(Tusaie & Fitzpatrick, 2013)

Treatment• Non pharmacological

strategies first line of treatment

• Reorientation and behavioral intervention

• Clear instructions with frequent eye contact with patients

• Minimized sensory impairments in vision and hearing loss by providing the assist tools.

• Avoid physical restraint ( decreases mobility, increased agitation, prolongs delirium

• Limited room and staff changes provide a quiet setting with low level lightning at night. (Ramaswamy, et al., 2010)

• Pharmacological • Haloperidol, Risperidone,

Olanzapine, Quetiapine– widely used drugs for the treatment of

delirium-related agitation

• Lorazepam– Reserved for treatment of drug withdrawal,

diffuse Lewy body disease

• Use of drugs for hypoactive delirium must be warranted

– Increase sedative effects

(Ramaswamy, et al., 2010)

Alzheimer’s Disease

• Defined as an degenerative progressive neuropsychiatric disorder resulting in global impairment of cognition, emotions, and behavior leading to physical and functional decline and death.

(Tusaie & Fitzpatrick, 2012)

Characteristic

• Insidious and progressive onset• Current estimates suggest that 1 in 8 persons

over 65 have Alzheimer’s disease and a total of 5.3 million Americans have Alzheimer’s disease. (Alzheimer's, 2009)

• 6th leading cause of death in the United States overall and 5th leading cause of death for those age 65 and older. (Alzheimer's Association, 2013)

Impact on Caregivers.

• An estimated 11 million caregivers provide 12.5 billion hours of care each year to an estimated 5 million persons with dementia

• 15.4 million caregivers provided more than 17.5 billion hours of unpaid care valued at $216 billion.

• 40% to 70% of caregivers exhibit significant symptoms of depression, with 25% to 50% meet the criteria of major depressive disorder.

(Alzheimer’s Association, 2011; Hoch, 2009; Nichols, Martindale-Adams, Burns, Graney, & Zuber, 2011 as cited in Easom, Alston, & Coleman, 2013) (Alzheimer's Association, 2013)

Screening Tools

• Folstein’s Mini Mental State Examination• Short, Portable Mental Status Questionnaire• Clock Draw Test• Minicog• MoCA• Functional Assessment Screening Tool

Tusaie&Fitzpatrick, 2013

Interventions

• Safety Assessments• Care for Caregivers• Psychosocial – Cognitive rehabilitation, memory training, and

engagement in pleasurable activities– Sensory stimulation– Recreational activities and social interaction– ABC behavioral model

(McCarron, Xiong, & Bourgeois, 2009)

TreatmentCholinesterase Inhibitor (ChEIs)

Donzepril(Aricept)

Rivastigimine ( Exelon)

Galantamine ( Razadyne)(McCarron, Xiong, & Bourgeois, 2009)

N-methyl-D-aspartate (NMDA)

• Memantine ( Namenda)(McCarron, Xiong, & Bourgeois,

2009)

Depression

• 25% of patients with AD may experience major depression.

• May contribute to cognitive impairments.• Dementia, delirium and depression are not mutually

exclusive conditions all three conditions can be present in the same individual and any given time.

• Increased risk for suicide if depression is not detected in older adults with chronic illness and those with new dx of dementia.

(Sadock & Sadock, 2008) (McCarron, Xiong, & Bourgeois, 2009)& (Tusaie & Fitzpatrick, 2013)

Depression and the Older Adult

• 15% of older adults have depressive symptoms

• Age itself is not a risk factor

• Being widowed or having a chronic illness increase risk for depressive disorder

• Presenting symptoms in older adults may differ from those of younger adults

• Increased emphasis on somatic complaints in older adults

Co morbidity of Depression

• Co morbidity of depression with physical disorders is common

• Negatively influences the course of the depression

• Increases functional impairment, health costs, and use of health services

• Common conditions associated with depression

Depression and Suicide

• 20% is the suicide rate among older adults

• White males over 85 have the highest suicide completion rates

• Males over 80 take their lives at twice the rate of women

• Over 70% of older suicide victims had had contact with PCP in the 3 months prior to the suicide

Risk Factors for Suicide Among Older Adults

• Medication

• Demographics

• Clinical

Suicide Management in Older Adults

• Promote connection with personal, family, and community to prevent suicide

• Treatment doesn't differ from treatment in younger adults

Geriatric Depression Scale

• Scales specific for adults 60+

• Available in long and short form

• Can be downloaded at:

www.stanford.edu~yesavage/Testing.htlm

Treatment

• Same medications are used just in lower dosages, emphasis upon self-efficacy, activities and social involvement in psychotherapy in the geriatric population.

(Tusaie & Fitzpatrick, 2013)

Pharmacological Treatments

• Treatment basically the same as in younger adults

• Antidepressants

• SSRIs and TCAs most common in older adults

•Older adults are at increased risk for drug interaction

• Lower doses of medication are needed

Non-Pharmacological

• Cognitive Behavioral Therapy

• Cognitive Bibliotherapy

• Problem-Solving Therapy

• Brief Psychodynamic Therapy

• Reminiscence Therapy

Loss

• Loss is an "absence of an object, position, ability, or attribute. –Loss of someone or something that is significant to that individual.–Independence (precious commodity, feel value less or useless)–Deprivation (fewer opportunities, physical frailty, shrinking of individual's feeling of competence and self-esteem

(Ferrell & Coyle, 2006)(Harris, 2011)

Grief

• Grief is a "person's emotional response to the event of loss"; " state of mental and physical pain that is experienced when the loss of significant object, person, or part of the self is realized".

(Ferrell & Coyle, 2006)

Grief

• Major categories of grief– anticipatory grief

– uncomplicated grief

– complicated grief

– disenfranchised grief

– Unresolved grief(Ferrell &

Coyle, 2006)

Characteristics

• Symptoms of grief• Physical

• Cognitive

• Emotional

• Behavioral

Assessment

• The bereaved are often exhausted and fatigue from caring for the love one who died and forgo their own needs. NP’s should– Inquire of routine physical exams, social networks,

family roles, and major changes within self.– Be aware of clinical depression, prolonged deep

grief, self destructive behavior, increased use of alcohol and/or drugs, preoccupation with the deceased to the exclusion of others.

(Ferrell & Coyle, 2006)

Interventions

• No medications exist to treat symptoms of grief because grief is not consider an illness.

• Use of antidepressant and sleep medications may help with severe and complicated grief

• Support Groups

• Counseling

(Rainer, 2013, p.56)

Anxiety and the Older Adult

• Anxiety is a common and a major problem in older adults

• Receives less attention then depressive disorders

• 15.3% of adults over the age of 60 are diagnosed with anxiety disorders

• In older adults anxiety is a risk factor for greater disability

DSM Anxiety Disorders in Older Adult

• Most common

–GAD

–Phobias

• Less common

–OCD

– Panic Disorders

Medical Co morbidities

• Studies have shown an association between anxiety and medical illnesses including but not limited to:• Diabetes

• Dementia

• Coronary heart disease

• Cancer

• COPD

• gastrointestinal disorders

• Parkinson's disease

Anxiety and Depression

• Anxiety in older adults often co-occurs with depression

• 50% of older adults with depression had co morbid anxiety

• An increased risk for poor outcomes in cases of co morbid anxiety and depression

• Older adults with anxious depression report increased suicidality

• Anxiety more commonly precedes depression

Diagnostic Difficulties

•Medical Conditions

•Dementia

•Depression

Geriatric Anxiety Inventory

• Specific scale for older Adults

• Sound psychometric properties specific for older adults

• 20 item self report

• Greater then 10 “agrees” may indicate an anxiety disorder

Pharmacological Treatment

• Use with caution in older adults

• Benzodiazepines–Most common

• Antidepressants– SSRIs

–MAOIs

– TCAs

Non-Pharmacological

• Evidenced-based psychological treatments in older adults

•Relaxation Training

•Cognitive Behavioral Therapy (CBT)

•Supportive Therapy

Behavioral Health and the Older Adult

• Insomnia• Insomnia is one of the most dominant behavioral health issue that older

adults face. • 30-60% of all older persons have one or more sleep complaint

(McCurry, 2007)• Sleep complaints for most older adults include:

– Difficulty falling and staying asleep

– Early morning awakenings

– Excessive day time sleepiness

– Day time fatigue • (APA, 2005)

Behavioral Health cont…..DSM-5 Insomnia Disorders

o Is defined as, “A predominant complaint of dissatisfaction with sleep quantity or quality” and is associated with one or more of the following features:

Difficulty initiating sleep

Difficulty maintaining sleep

Early morning awakenings

Diagnostic Considerations for the FNP

– The sleep dysfunction causes distress and interruptions in ADLs

– Sleep difficulty occurs for at least 3 times per week

– Sleep difficulty occurs for at least 3 months

– The insomnia can/cannot be attributed to substance abuse

– The insomnia can/cannot be attributed to another illness or sleep disorder

Things to Remember……..

• Older adults tend to go to bed earlier and wake up earlier.

• Life style changes can impact sleep

• Sleep disturbances in older person in most cases is related to medical or psychiatric disorder (Tusaie & Fitzpatrick, 2013)

• Comprehensive health history should be obtained, including but not limited to: physical health history and medication history

Non-Pharmalogical Treatments for Insomnia

• Cognitive behavior therapy

• Sleep hygiene instruction

• Avoidance of stimulating substances (alcohol and caffeine)

• Reduction of environmental and stimuli (Janicak, 2011)

• These treatments may work better than pharmacological options due decreased metabolic processes of the older adult (APA, 2005)

Pharmacological Treatments for Insomnia

• Benzodiazepines: doses should be low and length of treatment should be short. This is due to decreased drug clearance in older patients, Example: Triazolam

• Zolpidem, zaleplon, eszopiclone, ramelteon (prescribe in low doses)

• Older patients should be weaned from medication slowly

Substance Abuse in Older Adults

• -Alcohol abuse is a significant problem for older Americans• -17% of older adults misuse an abuse drugs and alcohol• Alcohol abuse can cause:

– Cirrhosis– Malnutrition– Osteomalacia– Cognitive decline

• -4.4 million older adults are foreseen to need substance abuse treatment in 2020 (Gfroerer et al., 2003)

• -“Polypharmacy” drug use• -Older adults may dependent on “pill taking” (Tusaie &

Fitzpatrick, 2013)

DSM-5 Substance Related Disorders

• Alcohol/Substance Abuse– Excessive use of alcohol leading to clinically significant

impairment or distress for 12 months– Excessive use of substances such as opioids, hallucinogens,

cannabis, tobacco, stimulants, etc., leading to clinically significant impairment or distress for 12 months

Symptoms and Diagnosing

-Symptoms: Slurred speech

Incoordination

Unsteady Gait

Nystagmus

Impairment in memory/attention

Stupor/Coma

-Diagnosing: • Severity:

• Mild, Moderate, Severe• Remission:

• Early or sustained• Environment:

• Controlled• Frequency of ingestion

-Alcohol/Substance Withdrawal:• Signs and symptoms:

• Nausea, vomiting insomnia, tachycardia, etc.

Diagnostic Considerations for the FNP

– Comprehensive physical exam with medication history

– Evaluate for underlying medical and psychological conditions

– Situational sensitivity (Tusaie & Fitzpatrick, 2013)

Non-Pharmcalogical Treatments for Alcohol and Substance Abuse

Cognitive Behavior Therapy

• Health care professionals can help older adults boost their motivation to stop drinking, identify circumstances that trigger substance abuse, and learn new methods to cope with high risk drinking situations (APA, 2005)

Pharmacological Treatments for Alcohol and Substance Abuse

– Precise history of drugs taken and pharmacies used by the older patient. This will help with identifying potential adverse drug reactions, and frequency of self-administration.

– If any medications are prescribed the provider should be cognizant of decreased drug metabolism in older adults.

– Antidepressants and anxiolytics are occasionally used in treatment• Dosing should be low• Treatment should be short (Tusaie & Fitzpatrick, 2013)

Chronic Illness, Mental Health, and the Older Adult

• 85% of older adults have chronic illness

• Chronic illness can be caused by alcohol and substance abuse, poor nutrition and inactivity (Speer, 2003)

• Healthcare providers can help their patients cope effectively with:

• Motivational interviewing

• Cognitive behavior therapy

Pharmacological Treatments for Alcohol and Substance Abuse

– Precise history of drugs taken and pharmacies used by the older patient. This will help with identifying potential adverse drug reactions, and frequency of self-administration.

– If any medications are prescribed the provider should be cognizant of decreased drug metabolism in older adults.

– Antidepressants and anxiolytics are occasionally used in treatment• Dosing should be low• Treatment should be short (Tusaie & Fitzpatrick, 2013)

Case Study

• 73 year old woman who presents with 2 month history of tearfulness, loss of energy, apathy, inability to get out of bed in the morning, and insomnia with early morning awakenings. 

• She describes increasing anxiety, an inability to cope, forgetfulness, problems reading or even watching TV, a 30 lb weight loss and feels very constipated.  

• She expresses a concern that something is wrong with her stomach.  Her lower back has also been bothering her more.

Case Study

• She lost her husband 8 months ago and one of her children a little over 1 year ago.

• She has a remote history of resected breast cancer and a more recent history of thyroid cancer which was resected 3 years ago.  She also has a history of atrial fibrillation.  

• She has no past psychiatric history and has always been able to cope with difficulties until recently.

• She is on Coumadin and a beta blocker.

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