Transcript Suicide Lethality Assessment: Best Practices

Assessment & Response to Mental
Health Problems of Older Adults:
How Can We Help?
Margaret E. Adamek, MSW, PhD
[email protected]
Indiana University
School of Social Work
Senior Service America, Inc.
SCSEP Conference
September 10, 2008
Session Objectives
1. To share key facts about common mental
health issues of older adults (depression &
anxiety, suicide, substance abuse, and dementia)
2. To consider barriers to identifying mental
health concerns among older adults
3. To present recommendations for
responding to mental health needs
4. To identify resources for meeting mental
health needs of older adults
KEY FACTS: DEPRESSION AND ANXIETY
Prevalence
Depression
□ 8-20% of community
older adults
□ 37% of geriatric primary
care patients
□ 50% of LTC residents
□ doubles after age 7085
□ affects twice as many
older women than men
Anxiety
□ 10-25% of older adults
□ affects more women
than men
As many as 1 in 5 older adults experience mental health
problems that are NOT associated with normal aging.
Severe Depressive Symptoms
Late Life Depression and Anxiety
Common Characteristics
•most common psychiatric condition in late life
•major public health problem
•often undetected
•can be pervasive and chronic in nature
•often viewed as a normal part of aging
•tendency to discount the disorder
•negative impact on quality of daily life
•commonly co-occurs with physical illness
Common Characteristics
(cont’d)
•More likely to be presented in primary care than
mental health settings
•An understanding of the impact of depression &
anxiety on older adults is lacking (e.g., older adults
emphasize somatic complaints)
•Most studies are based on younger adults
•Most often treated with medication
•Counseling approaches are underutilized and
under-studied
Symptoms
Depression
Anxiety
□ Depressed mood
□ Loss of interest
□ Weight or appetite
changes
□ Sleep disturbances
□ Psychomotor agitation
or slowing
□ Low energy
□ Feeling worthless
□ Difficulty concentrating
□ Excessive anxiety &
worry
□ Restlessness or feeling
on edge
□ Sleep disturbance
□ Easily fatigued
□ Irritability
□ Muscle tension
□ Difficulty concentrating
Consequences
□
□
□
□
Decreased quality of life
Increased morbidity
Shorter life span
Greater use of health
services
□ Greater functional
impairment
□ More expense
□ Becoming suicidal
KEY FACTS: ELDER SUICIDE
Elder Suicide
□ 12% of the population; 18% of suicides
□ 15 older adults, on average, kill
themselves each day
□ over 5,000 older adults per year
□ White males 85+ have the highest rates
□ Firearms most common method—73%
of older adult suicides
Firearm Suicide Rates, All Races:
Gender and Elderly Age Groups Comparisons
60
50
Rates
40
30
Males
Males
20
10
Females
0
1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Year: 1981-1998
65-74yrs
75-84yrs
85+
65-74yrs
75-84yrs
85+
Elder Suicide Risk Factors
□Gender
□Substance abuse history
□Mood disorders & mental illness
□Age
□Widowhood & bereavement
□Chronic disabling illness
□Access to lethal means
Protective Factors
□ Positive social support
□ Reasons for living/future plans
□ Positive coping skills
□ Psychological strengths
□ Absence of psychiatric illness, or
having an illness that is treatable
□ Desire for help/ positive therapeutic
relationship
□ Spirituality/ life satisfaction
Progression of Suicidal Behavior
□ Thoughts - having thoughts about killing oneself
□ Gestures - self-directed, potentially harmful
behaviors which do not result in injury
□ Parasuicides - self-inflicted harm in which a person's
intent was something other than suicide
□ Attempts - self-inflicted harm in which a person's
intent was to kill him/herself but was unsuccessful in
doing so.
□ Completions - a suicide attempt which results in
death
Lethality Assessment 101
Questions to ask:
□ Have you ever thought about suicide?
□ Do you have a plan?
□ Do you have access to the means?
□ Do you have a gun at home?
□ Is it loaded?
Always take suicidal statements seriously.
KEY FACTS:
SUBSTANCE ABUSE
Substance Abuse: 3 key areas
1. Use of illicit drugs
2. Alcohol abuse
3. Misuse of prescription drugs
Illicit Drug Use Among Older Adults
□ In 2000, an estimated 568,000 persons aged 55 or
older used illicit drugs in the past month
□ The number of illicit drug users among older adults is
likely to increase in the coming years due to the
aging of the "baby boom" generation
Aging and Alcohol
□ 2-4% of the elderly meet current criteria for
alcohol abuse or dependence.
□ Over 5 million are "binge" alcohol users,
including more than 1 million who are heavy
alcohol users
□ An additional 10-15% meet criteria for at-risk
drinking.
□ 2 patterns: early onset, late onset
Treatment of Older Adults for SA
□ 4 out of 5 older people who seek substance abuse
treatment do so because of alcohol problems
□ from 1995 to 2005, alcohol was the most frequently
reported primary substance of abuse for SA
treatment admissions aged 65 or older.
□ The # of SA treatment admissions among persons
aged 65 or older decreased by 7% from 12,100 to
11,300 admissions.
--SAMSHA data
Misuse of Prescription Drugs
□ “Prescription drug abuse and/or misuse
among the elderly are a unique and
dangerous trend that warrants national
attention.” (Bio and Medicine)
□ the incidence of adverse events
related to drug reactions is 2-3x higher
in older adults (National Institute on Drug Abuse)
□ Increased drug prescription
costs ↑ misuse (Patterson, 2004)
KEY FACTS: DEMENTIA
Severe Memory Impairment, 65+
Alzheimer’s Disease
□ An estimated 4 million Americans currently suffer
from AD or a related form of dementia.
□ Nearly 10% of those over age 65 and up to half of
those over age 85 are thought to have AD or
another form of dementia.
□ Over 19 million Americans have a family member
with Alzheimer's.
□ Approximately 360,000 new cases occur each year.
Should I be concerned?
If you’ve noticed memory changes that are
worrying you, call any time at:
1.866.ALZ.4199.
Warning Signs for AD
□ Memory loss
□ Difficulty with
familiar tasks
□ Language
problems
□ Disorientation to
time and place
□ Poor/ decreased
judgment
□ Problems with
abstract thinking
□ Misplacing things
□ Mood changes
□ Personality
changes
□ Loss of initiative
--Alzheimers Association
Someone with Alzheimer's
disease symptoms
Someone with normal agerelated memory changes
Forgets entire experiences
Forgets part of an experience
Rarely remembers later
Often remembers later
Is gradually unable to follow
written/spoken directions
Is usually able to follow
written/spoken directions
Is gradually unable to use
notes as reminders
Is usually able to use notes as
reminders
Is gradually unable to care for
Is usually able to care for self
self
Source: www.alz.org
O
BARRIERS To HELPING
Barriers to Intervening
□ Stigma & shame
□ Inadequate assessment/ Improper use of
instruments
□ Lack of awareness of cultural differences
□ Failing to ask about access to lethal
means
□ Not recognizing or dismissing depression
□ Decline in physical health (mobility issues)
Barrier #1: Medical Model
Pills as primary
Polypharmacy is a major
cause of mental health
symptoms in older adults
Little understanding of how
to safely reduce
polypharmacy
Barrier #2: Resistance
□ Older adults’
resistance to mental
health treatment
□ Provider resistance
to treating mental
health problems in
older adults
Barrier #3: Policy
□ Policy Impediments
20% co-pay
50% co-pay
medical interventions
psychosocial interventions
“Policy needs to catch up with science”
-Alexopoulos, 2005
Barrier# 4: AGEIST ATTITUDES
“therapeutic pessimism” – expecting decline;
problem-focused
Ageist behaviors□
□
□
□
□
□
□
□
patronizing
using condescending language
“protecting”
failing to consult the older adult
disempowering
ignoring
neglecting
stereotyping
Are we guilty of “professionalized ageism?”
BARRIER #5: NOT RECOGNIZING
OLDER ADULTS’NEED TO CONTRIBUTE
□ “dis-ease” (Marcel, 1950)
□ “forgetfulness of being” (Heidegger, 1962)
□ “existential-meaning vacuum” (Frankl, 1959)
Do I matter? Why do I exist? Who cares?
Without meaning,
what’s left?
RECOMMENDATIONS FOR
HELPING
How to Help
□ Listen
□ Ask questions
□ Speak in private
□ Trust your instincts
□ Express empathy and concern
□ Share your observations
□ Be prepared for anger or resistance
□ Find out if the person will accept help
More ways to help….
□ Involve family & friends
□ Don’t promise confidentiality
□ Share information about resources
□ Encourage treatment
□ Educate yourself
RESOURCES
Positive Aging Act Provisions included in the Older Americans
Act Reauthorization On Sept 30, 2006 Congress reauthorized
the Older Americans Act (H.R. 6197) with significant language from
the Positive Aging Act.
New provisions authorize:
o an officer at AoA to be responsible for mental health services under OAA
o competitive grants to states for developing mental health screening and
treatment services for older adults;
o grants to states to increase public awareness, reduce stigma, and reduce
age-related prejudice and discrimination regarding mental disorders in older
adults.
The Geriatric Mental Health Foundation
-
established by the American Association for Geriatric
Psychiatry to:
□ raise awareness of psychiatric and mental health
disorders affecting the elderly,
□ eliminate the stigma of mental illness and treatment,
promote healthy aging strategies, and
□ increase access to quality mental health care for the
elderly.
Available on the GMHF website….
“A Guide to Mental Wellness in Older
Age: Recognizing and Overcoming
Depression”
Mission Statement:
The mission of the Older Americans Substance Abuse and
Mental Health Technical Assistance Center is to enhance the
quality of life and promote the physical and mental well-being of
older Americans through the provision of technical assistance by
reducing the risk for and incidence of substance abuse and mental
health issues late in life. Through partnerships with state and federal
agencies and community health care providers, the Center will serve
as a national repository to disseminate information, training, and
direct assistance in the prevention and early intervention of
substance abuse and mental health problems.
TAC Priorities
□ Provide technical assistance for the
prevention and early intervention of:
□ Substance abuse
□ Medication misuse and abuse
□ Mental health disorders
□ Co-occurring disorders
□ Dissemination and implementation of
evidence-based and promising
practices
Coming soon….
□ Implementation Resource Kits for
Depression in Older Adults
□ “Guide to Implementing EvidenceBased Practices to Prevent Substance
Abuse and Mental Health Problems
among Older Adults”
□ PHQ-9 Patient Health Questionnaire
Congress Passes
Mental Health Parity—Aug 2008
□ In an historical move, Congress enacted mental
health parity in Medicare.
□ The law provides Medicare mental health equity, by
phasing in a reduction in the 50% mental health
copayment to the 20% required for all other
outpatient services.
□ Cost sharing will be phased in starting in 2010:
45% in 2010 & 2011
40% in 2012
35% in 2013
20% in 2014 and thereafter.
Web Resources
□ Alzheimer’s Association
www.alz.org
□ American Association of Suicidology
www.suicidology.org/
□ American Association for Geriatric Psychiatry
www.aagpgpa.org
□ Geriatric Mental Health Foundation
http://www.gmhfonline.org/gmhf/
More Web Resources
□ National Coalition on Mental Health & Aging
http://www.ncmha.org/
□ National Institute on Aging
http://www.nia.nih.gov
□ NIH Senior Health
www.nihseniorhealth.gov
□ Older Americans SA & MH Technical
Assistance Center
www.samhsa.gov/olderadultsTAC
“The progress of a nation may be
marked by its ability to allow
citizens of all ages and backgrounds
to contribute as well as receive
needed care.”