physical illness and co-occurring mental disorders
DESCRIPTION
Physical Illness and Co-occurring Mental Disorders. Developed by DATA of Rhode Island through a special grant from the RI Department of Human Services. Training Goals. Discuss and identify behavioral health issues for adults with persisting health conditions - PowerPoint PPT PresentationTRANSCRIPT
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Physical Illness and Co-occurring Physical Illness and Co-occurring Mental DisordersMental Disorders
Developed by DATA of Rhode Island through a special grant from the RI Department of Human Services
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Training GoalsTraining Goals
Discuss and identify behavioral health Discuss and identify behavioral health issues for adults with persisting health issues for adults with persisting health conditionsconditions
Identify implications of the co-occurrence of Identify implications of the co-occurrence of physical and mental illnessphysical and mental illness
Identify the most common co-morbid health Identify the most common co-morbid health and mental health conditionsand mental health conditions
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Mental disorders and physical Mental disorders and physical illnessillness
Relationships are varied & include:Relationships are varied & include:
(1)(1) Mental disorder biologically due to physical illnessMental disorder biologically due to physical illness
(2)(2) Psychological reaction to physical illness/disabilityPsychological reaction to physical illness/disability
(3)(3) Mental disorder due to medicationsMental disorder due to medications
(4) Mental disorder causes physical disorder(4) Mental disorder causes physical disorder
(5)(5) The conditions are coincidentalThe conditions are coincidental
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Stress and Physical illnessStress and Physical illness
Major health problems are stressfulMajor health problems are stressful
Response to this stress dependent upon Response to this stress dependent upon individualindividual Perception / Beliefs of illnessPerception / Beliefs of illness VulnerabilityVulnerability Coping abilityCoping ability Response of othersResponse of others
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Individual VulnerabilityIndividual Vulnerability
Personality traits make a difference (e.g. Personality traits make a difference (e.g. tendency to worry about illness)tendency to worry about illness)
Prior experience of illness within a familyPrior experience of illness within a family
An individual’s psychological state at the An individual’s psychological state at the time of the illnesstime of the illness
Previous experience of trauma, or a Previous experience of trauma, or a neglected or abusive childhoodneglected or abusive childhood
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Selected Medical Conditions Selected Medical Conditions associated with Mental Disordersassociated with Mental Disorders
ConditionCondition Associated Mental DisordersAssociated Mental DisordersParkinson’s diseaseParkinson’s disease Depression, Psychosis, Dementia, Delirium Depression, Psychosis, Dementia, Delirium
StrokeStroke Depression, Psychosis, Dementia, Anxiety, Depression, Psychosis, Dementia, Anxiety, Delirium, ManiaDelirium, Mania
Thyroid disordersThyroid disorders Depression, Psychosis, Dementia, Anxiety, Depression, Psychosis, Dementia, Anxiety, Delirium, ManiaDelirium, Mania
Chronic Airways Chronic Airways DiseaseDisease
Depression, Anxiety, Delirium, Cognitive Depression, Anxiety, Delirium, Cognitive impairmentimpairment
CancerCancer Depression, Delirium, AnxietyDepression, Delirium, Anxiety
Vitamin deficienciesVitamin deficiencies Depression, Psychosis, Dementia, ManiaDepression, Psychosis, Dementia, Mania
Injury with PainInjury with Pain Depression, Substance DependenceDepression, Substance Dependence
Metabolic disordersMetabolic disorders Depression, Delirium, PsychosisDepression, Delirium, Psychosis
HIV @ HCVHIV @ HCV Depression, Psychosis, Delirium, Anxiety, Depression, Psychosis, Delirium, Anxiety, Substance DependenceSubstance Dependence
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Depression is most common in Depression is most common in medical illnessmedical illness
All depressive disorders 15-36% All depressive disorders 15-36%
Each problem alone may have major implications for Each problem alone may have major implications for
how an individual functionshow an individual functions
Issues together often are interactive and can have Issues together often are interactive and can have
overwhelming effects when they coexist.overwhelming effects when they coexist.
Managing co-occurring mental health problems not only Managing co-occurring mental health problems not only
improves mental status health status is improvedimproves mental status health status is improved
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Mental Health Issues and our Aging Mental Health Issues and our Aging PopulationPopulation
Significant continuous growth in near futureSignificant continuous growth in near future
By 2030, U.S. population >65 years old = 70 millionBy 2030, U.S. population >65 years old = 70 million
2030, >65 years old = 20% of U.S. population2030, >65 years old = 20% of U.S. population
Age bracket w/ most growth: >100 years oldAge bracket w/ most growth: >100 years old
Current healthcare system not able to support growthCurrent healthcare system not able to support growth
Increased need for specialized healthcare Increased need for specialized healthcare
professionals and housingprofessionals and housing
www.research.aarp.orgwww.research.aarp.org
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The Myths of AgingThe Myths of Aging
Adults over 70 do not have sex.Adults over 70 do not have sex.
Older persons can’t really learn or change.Older persons can’t really learn or change.
To be old is to be sick.To be old is to be sick.
Older people are unproductive in societyOlder people are unproductive in society
Older people are rigid and crankyOlder people are rigid and cranky
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Mental Health Issues and EldersMental Health Issues and EldersRelocation Stress SyndromeRelocation Stress Syndrome
Anxiety, restlessness, apprehensionAnxiety, restlessness, apprehension
Insecurity, vigilanceInsecurity, vigilance
ConfusionConfusion
Depression, withdrawal, lonelinessDepression, withdrawal, loneliness
Sleep disturbanceSleep disturbance
Change in eating habits, weight changeChange in eating habits, weight change
Unfavorable comparison of pre-transfer and Unfavorable comparison of pre-transfer and post-transfer staffpost-transfer staff
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Geriatric DepressionGeriatric Depression
Depression is not a normal part of agingDepression is not a normal part of aging
Approx. 6 million people 65+ women>menApprox. 6 million people 65+ women>men11
15% community; up to 25% in residents15% community; up to 25% in residents
Can be triggered by medical condition, drugs, losses, Can be triggered by medical condition, drugs, losses, nothing at allnothing at all
““I think I’m going crazy!”I think I’m going crazy!”
Reoccurrence rate is a concernReoccurrence rate is a concern
Can exacerbate other medical conditionsCan exacerbate other medical conditions
1 The Brown University Long-Term Care Quality Advisor, vol 9, no 13, p.5. July 14, 1997.
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Geriatric DepressionGeriatric DepressionSigns & SymptomsSigns & Symptoms
Mid-LifeMid-Lifedepressed mooddepressed mood diminished pleasure diminished pleasure weight, weight, appetite appetite insomniainsomnia negative attitude negative attitude guilt, worthlessness guilt, worthlessness concentration concentration suicidal ideationsuicidal ideation
Late-LifeLate-Lifeirritable, critical of othersirritable, critical of others
isolation, withdrawalisolation, withdrawal
weight, weight, taste, swallow taste, swallow
early A.M. awakeningearly A.M. awakening
hypersomatichypersomatic
““the end”, burden, anxietythe end”, burden, anxiety
confusion, crazyconfusion, crazy
not overtly expressednot overtly expressed
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Suicide in the Older AdultSuicide in the Older Adult
Greatest Risk: older white maleGreatest Risk: older white male
More lethal attempts, successful oftenMore lethal attempts, successful often
1:4 success rate1:4 success rate
May not discuss the desire to dieMay not discuss the desire to die
> 50% visited physician within 1 week of death> 50% visited physician within 1 week of death
Be direct when questioning Be direct when questioning
Fear of moving to supervised housing, pain, loss, incapacity, Fear of moving to supervised housing, pain, loss, incapacity,
financesfinances
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DementiaDementia
Approximately 4 million Americans have ADApproximately 4 million Americans have AD
In 2050 ~ 14 million Americans will have ADIn 2050 ~ 14 million Americans will have AD
Greatest risk: Advancing ageGreatest risk: Advancing age
10% >65 years old10% >65 years old 50% >85 years old50% >85 years old
Family history: ? GeneticsFamily history: ? Genetics
Duration range 3 - 20 years, avg. 8 yearsDuration range 3 - 20 years, avg. 8 years
Family disease: patient & family are = victimsFamily disease: patient & family are = victims
www.alz.org/AboutAD/Statistics.htmwww.alz.org/AboutAD/Statistics.htm
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DementiaDementia
Neuropathological syndrome with Neuropathological syndrome with progressive deterioration of intellectual progressive deterioration of intellectual functioning, problem solving, and learning functioning, problem solving, and learning new skillsnew skills
Irreversible and progressiveIrreversible and progressive
Secondary: A result of other processesSecondary: A result of other processes
65% - Alzheimer’s65% - Alzheimer’s
Higher occurrence in women, Down’s and Higher occurrence in women, Down’s and head injurieshead injuries
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DementiaDementiawith with Reversible CausesReversible Causes
DepressionDepressionMedicationsMedicationsThyroid disease Thyroid disease TumorTumorB-12 deficiencyB-12 deficiencyMalnutritionMalnutritionInfectionInfectionHypo/hyperglycemiaHypo/hyperglycemiaDehydrationDehydration
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DementiaDementiaSigns & SymptomsSigns & Symptoms
Memory Impairment Memory Impairment impaired ability to learn new infoimpaired ability to learn new info
Functional Impairments Functional Impairments (acts)(acts) ADL’s, ADL’s, social social significant decline from previous LOF significant decline from previous LOF (gradual onset)(gradual onset)
Cognitive Impairment Cognitive Impairment (thinks)(thinks) aphasia - aphasia - comprehension & speechcomprehension & speech apraxia - motor activities apraxia - motor activities (eating, brush teeth, comb hair)(eating, brush teeth, comb hair) agnosia - inability to recognize familiar objectsagnosia - inability to recognize familiar objects disturbance in executive functioning disturbance in executive functioning (organizing, planning, (organizing, planning,
sequencing, abstracting)sequencing, abstracting)
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Progression of DementiaProgression of Dementia
Decline in everyday life activitiesDecline in everyday life activities
Failure of memory and intellectFailure of memory and intellect
Disorganization of the personDisorganization of the person
Psychotic changesPsychotic changes
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Dementia: Process and CharacteristicsDementia: Process and Characteristics
CausesCausesInfectionsInfections
Degenerative Degenerative neurological neurological disordersdisorders
Vascular disordersVascular disorders
Structural disorders Structural disorders of brain tissueof brain tissue
BehaviorBehavior (gradual/insidious)(gradual/insidious)
Multiple cognitive deficitsMultiple cognitive deficitsMemory impairmentMemory impairmentAphasiaAphasiaApraxiaApraxiaAgnosiaAgnosiaDisturbed executive Disturbed executive functioningfunctioningCatastrophic reactionsCatastrophic reactionsPerceptual alterationsPerceptual alterationsWanderingWanderingDisinhibitionDisinhibition
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Progression of Alzheimer’sProgression of Alzheimer’s
Early StageEarly Stage::
Difficulty remembering names, Difficulty remembering names, appointments, where things are.appointments, where things are.
Emotionally unstable, new onset Emotionally unstable, new onset depressiondepression
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Progression of Alzheimer’sProgression of Alzheimer’s
Second StageSecond Stage (2 ½ years): (2 ½ years):
Recent memory deficitRecent memory deficitDecrease in orientationDecrease in orientationRestless nights, wanderingRestless nights, wanderingBeginning of catastrophic reactionsBeginning of catastrophic reactionsMisperceptions cause paranoiaMisperceptions cause paranoiaMay blame family/staff for stealing lost objects May blame family/staff for stealing lost objects
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Progression of Alzheimer’sProgression of Alzheimer’s
Final StageFinal Stage (months to 5 years)(months to 5 years)
Severe disorientationSevere disorientationPsychotic symptomsPsychotic symptomsSevere emotional disregulationSevere emotional disregulationBlunted emotionsBlunted emotionsInability for self-careInability for self-careDoes not recognize family/staffDoes not recognize family/staff
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BEHAVIORAL SUPPORTS IN BEHAVIORAL SUPPORTS IN DEMENTIADEMENTIA
Calm Calm consistentconsistent environment environment
Cuing and reminding or validationCuing and reminding or validation
Emphasize cognitive strengthsEmphasize cognitive strengths
Music, familiarityMusic, familiarity
Watch for changes in functioningWatch for changes in functioning
Provide safe environment Provide safe environment
Daytime exercise, minimize napsDaytime exercise, minimize naps
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DeliriumDelirium
Acute, reversible etiologiesAcute, reversible etiologies
Most of the time secondary to underlying medical Most of the time secondary to underlying medical condition, medication reactions or intoxicationcondition, medication reactions or intoxication
Most often seen in children and adults over age 65Most often seen in children and adults over age 65
If untreated may progress to dementia, coma or If untreated may progress to dementia, coma or deathdeath
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DeliriumDeliriumTriad of SymptomsTriad of Symptoms
OnsetOnset Acute, hours - daysAcute, hours - days Lasting hours - weeksLasting hours - weeks
Disturbance in ConsciousnessDisturbance in Consciousness ↓ ↓ awareness of environmentawareness of environment Lethargic orLethargic or hypervigilant (agitated) hypervigilant (agitated)
Changes in Cognition/Perceptual DisturbanceChanges in Cognition/Perceptual Disturbance Memory impairmentMemory impairment Sensory changesSensory changes
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CLINICAL FEATURES OF CLINICAL FEATURES OF DELIRIUM vs DementiaDELIRIUM vs Dementia
Cognitively impairedCognitively impairedMedically illMedically illAcute/sudden onsetAcute/sudden onsetDisorientationDisorientationHallucinationsHallucinationsDelusionsDelusionsVisuospatial deficitsVisuospatial deficits
ApraxiasApraxiasLethargyLethargyComprehension Comprehension deficitsdeficitsAltered level of Altered level of consciousnessconsciousnessAgitation, irritabilityAgitation, irritability
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Etiology & Risk Factors for Etiology & Risk Factors for DementiaDementia
General medical conditionGeneral medical conditionSubstance use/abuseSubstance use/abuseDrug intoxication, polypharmacyDrug intoxication, polypharmacySystemic infectionsSystemic infectionsDehydration, fluid & electrolyte imbalanceDehydration, fluid & electrolyte imbalanceHepatic or renal diseaseHepatic or renal diseaseHypoxiaHypoxiaMetabolic DisordersMetabolic DisordersNutrition deficienciesNutrition deficienciesLimited mobilityLimited mobility
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MANAGEMENT OF DELIRIUMMANAGEMENT OF DELIRIUM
Schedule appt w/ MD or 911Schedule appt w/ MD or 911
Re-orient patientRe-orient patient
Quiet, less stimulating environmentQuiet, less stimulating environment
Maintain resident and staff safetyMaintain resident and staff safety
1:1 observation if possible until managed by medical 1:1 observation if possible until managed by medical personnelpersonnel
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Geriatric Substance AbuseGeriatric Substance Abuse
~2-3% women, ~10% men >60yo~2-3% women, ~10% men >60yo
Early Onset (<60yo)Early Onset (<60yo)About 2/3 of geriatric alcohol use disorders have been abusing throughout adult lifeAbout 2/3 of geriatric alcohol use disorders have been abusing throughout adult life
Greater financial, legal and social problems than later onset Greater financial, legal and social problems than later onset
Heavier drinkers than later onset patientsHeavier drinkers than later onset patients
Late Onset (>60yo)Late Onset (>60yo)About 1/3 of geriatric alcohol use disorders begin after 60About 1/3 of geriatric alcohol use disorders begin after 60
Aging social drinkers more intoxicated with same doseAging social drinkers more intoxicated with same dose
Cognitive disorder in heavy drinkersCognitive disorder in heavy drinkers
Social drinkers who increase drinking after lossesSocial drinkers who increase drinking after losses
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Medical Complications of Substance UseMedical Complications of Substance Use
Worsening dementiaWorsening dementia
AnxietyAnxiety
PsychosisPsychosis
Alcohol-induced mood disorderAlcohol-induced mood disorder
Dementia-like symptoms from mood disorderDementia-like symptoms from mood disorder
SuicideSuicide
Exacerbation or worsening of existing medical Exacerbation or worsening of existing medical conditions, ie, diabetes, blood pressureconditions, ie, diabetes, blood pressure
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Possible Warning SignsPossible Warning Signs
Cognitive decline or self care neglectCognitive decline or self care neglect
Family estrangementFamily estrangement
Unexpected delirium after hospitalization (withdrawal)Unexpected delirium after hospitalization (withdrawal)
GI problemsGI problems
Frequent injuries, falls, “accidents”Frequent injuries, falls, “accidents”
Does not attend medical appointmentsDoes not attend medical appointments
Socially WithdrawnSocially Withdrawn
Poor appetitePoor appetite
DepressionDepression
Difficulty sleepingDifficulty sleeping
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Contributing FactorsContributing Factors
Loss of spouse/pet/loved oneLoss of spouse/pet/loved one
Financial problemsFinancial problems
RetirementRetirement
Sale of home, move to supervised housingSale of home, move to supervised housing
Loss on independence/controlLoss on independence/control
DepressionDepression
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ConclusionsConclusions
Adults with certain medical conditions are Adults with certain medical conditions are at greater risk of co-occurring mental at greater risk of co-occurring mental illness problemsillness problems
The mental illness is frequently under The mental illness is frequently under diagnoseddiagnosed
Identification and intervention with these Identification and intervention with these problems can help both the patients problems can help both the patients mental status and health statusmental status and health status
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QuestionsQuestions