alessandra scalmati, md phd department of psychiatry and behavioral sciences montefiore medical...

Identification and Assessment of Mental Illness in Older Adults

Alessandra Scalmati, MD PhDDepartment of Psychiatry and Behavioral

SciencesMontefiore Medical Center

Bronx, NY

Goals 1. To increase the understanding of the impact of mental

illness on functional disability and overall health in older adults

2. To provide tools to improve the ability of the participants to identify the characteristic presentation of mental illness in the geriatric population.

IOM Report

IOM Report and Other StudiesEven sub-syndromal presentations are

associated with functional disability and poor outcome

Mental illness is associated with poor compliance with medical treatment

Mental illness is associated with functional disability increased morbidity and mortality

Mental illness is associated with increased health care utilization and expenditure (higher use of ED, higher incidence of hospital admission, longer length of stay, higher readmission rates)

Challenges in the Assessment of Older Adults

Medical comorbidityPsychosocial stressors (Losses, Isolation,

changed social status)Normative declineAgeism both in patients and in ourselvesComorbid cognitive declineCultural barriers (particularly for SA)

Mental Disorder in Older AdultsAging of Person with Lifelong H/O Mental Illness

New Onset of Mental Illness in Older Adults

Mood D/OAnxiety D/OPsychotic D/OSubstance use D/OPTSDPersonality D/OOther

Late onset depressionDementia and cognitive

impairmentPTSDSubstance use D/ODeliriumMood or Anxiety or

Psychotic D/O due to a medical condition

Different Presentations in Different SettingsSenior Center:

Senior lives in the community Mobile and independent enough to go to center

Home:Senior lives in the communityRequires home care

Doctors’ Office:Senior lives in the communityLevel of disability and comorbidity is variable

Mr. A.Mr. A. is a man in his mid 80s, who lives by

himself after he lost his wife about 10 y ago. He attends the local senior center daily, as he has done for years. He arrives in late morning, reads the newspaper, attends news and exercise groups, has lunch and then leaves.

Lately, there have been a couple of altercations, when he has become irritable over rather trivial matters. Also he seems to keep more to himself. He still reads the newspaper, and he still attends all the activities, he is just quieter.

Mrs. B.Mrs. B. has always been a little difficult to

get along with. She has been a regular at the senior center and she has her social group, but she is often at the center of controversies. However, lately, nothing seems to go right. She has accused several staff members of antisemitism, meanwhile she has been clearly heard using racial epithets to address several staff members and clients. When confronted she burst into tears and protests her innocence in a way that makes the offended party feel guilty and confused. For the rest she is her usual, impeccably dressed and fussy.

Senior CenterAll presentations are likely to be confusing

because they are probably not at the very advanced stage.

Most of the symptoms will affect interpersonal arena.

Irritability is a classic symptom of depression particularly in older men.

Erratic behavior, even in somebody with a h/o poor interpersonal skills, specially when associated with mood instability and poor impulse control, suggests cognitive impairment.

Senior CenterBe Mindful of:

Change in behavior (More or less talkative, more or less isolative)

Change in groomingChange in mood (irritable, tearful, elevated)Change in pattern of attendanceAny interpersonal problems (fighting,

accusations, etc)

Late Onset DepressionFirst episode of depression after the age of

65, no previous h/o mood disorderUsually no family h/o mood disorderMore frequent association with neurologic

problems (vascular abnormalities on MRI, executive disfunction, gait abnormality)

Prodromal syndrome of dementiaPoorer response to antidepressant treatment

Elements of Executive Function

PlanningInitiatin

g

Sequencing

Monitoring

Stopping complex behavior

Abstractthinking

Mrs. C.Mrs. C. is referred to home care after

discharge from the hospital were she was admitted following a fall. She suffers from Diabetes, HTN, OA, she is in her early 80s and lives with her husband. As a consequence of the fall she fractured a few ribs, and she needs help with ADL, and some IADL.

Mrs. C. c/o pain, difficulties sleeping, and overall trouble functioning. She is poorly cooperative with care, and after 5 days she falls again.

Mr. D.Mr. D. is referred to home care after surgical

repair of a hip fracture and short term rehab. He is in his late 80s and lives with his wife who claims that before the fall he was fully independent and functional. He used to attend the senior center and play chess. He read the newspaper, followed the news, and helped with shopping and cooking.

At intake he is disoriented, confused, uninterested in PT, apathetic, irritable.

HomePatients referred for Home Care are more

functionally impairedFirst problems that need to be ruled out are:

delirium, D/O due to medical conditions, Substance abuse

Mental illness is either preexistent or inevitably associated with cognitive impairment.

Delirium in older adults can take many weeks to fully clear

The most common substances of abuse are: Alcohol and prescription drugs

HomeRed Flags for both delirium and substance

abuse are:Sudden change in functioningInconsistent historyFluctuation in presentationFallsNon compliance with care and medical

reccomendations

Increase in cognitive impairment Tannebaum, et. Al. Drugs & Aging. 29(8):639-58,

2012 Aug 1.

Use of benzodiazepines in patients over age 65 associated with 50% increase in incidence of dementia compared with never users

Billioti de Gage, et al. BMJ. 345:e6231, 2012 Sept.

Higher incidence of falls in patients taking benzodiazepines, especially in combination with other CNS medicatons

J Gerontol A Biol Sci Med Sci (2009) 64A (4): 492-498.

Risks Associated with Use of Sedative Hypnotics

Mr. E. Mr. E. is in his mid 70s and he has been a

patient at the clinic for a few years. He comes irregularly, he does “not like doctors” and he is skeptical about health care. He suffers from HTN and diabetes, but he is erratic in his diet and medications management. He lives alone since his divorce and he is reticent about his social history.

Epidemiology Alcohol:

Substance Abuse and Mental Health Service Administration (SAMHSA 2004): 35.3% people> 65 reported alcohol intake in previous month. 6.5% reported binge drinking (more than 5 drinks) at last once in previous month. 1.8% reported > 5 drinks on > 5 days in previous month.

SAMHSA report 4/2012: number of adults > 50 in need of substance abuse treatment expected to double by 2020, from 2.8 to 5.7 millions.

Standard Drinking Guidelines: adults >65, no more than 1 drink per day, or 7 drinks per week.

Clinical PresentationFalls, Malnutrition, Dementia, DeliriumIncrease in morbidity and mortalityClinical instability of medical comorbid

conditions, or new acute medical problemsComorbid Psychiatric DisordersPatients are often reluctant to disclose, we

should ask EVERYBODY!!

Mrs. F.Mrs. F. has been a patient at the clinic for many years she is pleasant, compliant, regularly attends her follow ups. She comes in religiously for her flu shot, and all her blood test, she follows up on mammograms and all referrals to specialists. Everybody at the office like her. She is now in her late 80s, her gait is unsteady, she has had a couple of falls and she has been coming in with a walker. Her blood pressure has become harder to manage. The doctor has needed to add a second medication to help control it, and it is still high. After another fall she is admitted to the hospital where her BP is found to be too low.

The Doctor’s OfficeWe are busy, we only pay attention to the

patients who give us troubleBeware of the quiet ones!Substance abuse, paranoia, cognitive

impairment can be very silent and unobtrusive for a very long time, until significant complications arise

Depressed and anxious patients are more likely to reports subjective distress (not always), and they look more distressed

The Doctor’s OfficeKeep an eye on:

Quiet isolative patients with poor social support

Patients with symptoms that do not respond to appropriate treatment (are they forgetting to take their medications?)

Patients who do not give an historyPatients who are always vague

DementiaOne of the top ten disabilities in developed

countriesChronic in duration:

3-4 years in community setting10-12 years in clinical settings

Costly: Annual cost estimates of dementia care in US will be near $400 Billion by 2050

Murman DL, Von Eye A, Sherwood PR, et al: Evaluated need, costs of care and payer perspective in degenerative dementia patients cared for in the United States. Alzheimer Dis Assoc Disord 21:39-48, 2007

Dementia is:Highly prevalent, with prevalence increasing

exponentiallyPeople 65+ represented 13.3% of the

population in the year 2011 People 65+ are expected to be 21% of the

population by 2040. The 85+ population is projected to triple

from 5.7 million in 2011 to 14.1 million in 2040. Based on online data from the U.S. Census Bureau

Epidemiology

SUICIDE RISK PROFILE HISTORICAL Previous attempt Lethality of attempt: firearms, jumping Family history Low probability of rescue Recent visit to primary care physician or mental

health specialist Anniversary of loss

SUICIDE RISK PROFILE SOCIODEMOGRAPHIC

White male Age 85 years or older Firearms purchase, possession Divorced, widowed Recent life change event (hospitalization)

SUICIDE RISK PROFILE CLINICAL

Expressed intent Depression or other non-dementing mental disorder Alcohol use, moderate to heavy Cancer, heart disease, lung disease Chronic pain Poor self assessed health Smoking

Prevalence of Depression Depends on Definition and VenueMajor depressive disorder

Among physically healthy community residents: 1-2% In primary care: 9%

Minor DepressionAmong community residents: 15% In primary care: 30%

Depression with psychosisDepressive syndrome in dementiaAs an “unwanted companion” with somatic illness

Neighborhood Personal Factors Factors

Stressors(poor health, depression)

Access to facilitiesTransportSafetyCollective efficacyNeighborhood amenitiesSocial engagement

Suicidality

DemographicsHealth literacyPersonality traitsPhysical activityAlcoholSmoking

Proportion of Suicides by Method, 2001

Other6%

Fall2%

Poisoning17%

Suffocation20%

Firearms55%

73% FirearmsAmong Persons 65+

Path to SuicidePOPULATION CHARACTERISTICS

Targets for Universal & Selective Prevention

Non-modifiable Risk Factors age, gender family history/genetics

Social-Cultural Contexts

Modifiable Risk Factors poor medical care poverty social isolation violence access to lethal methods comorbid medical conditions* poorly managed pain * alcohol/substance misuse *

INDIVIDUAL CHARACTERISTICS Targets for Clinically Indicated Interventions

PsychopathologyPersonalitySocial Ecology

Attempted Suicide men & women

ENDPOINTS

Completed Suicide men & women

* individual as well as population attributes

ConclusionDetails are importantChange is importantDelirium and Substance Abuse should be

ruled out first Patients without a lifelong h/o mental illness

who become mentally ill in old age are either medically ill or demented

If something seems strange it probably is strange.

Beware of vagueness, even when it is dressed up well.

SAFETY FIRST!

THANK YOU

alessandra scalmati, md phd department of psychiatry and behavioral sciences montefiore medical...

Documents