Bridging Communities: Helping Older Adults in Crisis Linda K. Shumaker, RN-BC, MA Pennsylvania Behavioral Health and Aging Coalition
Aging of America… §Growth will be from 12% to 21% of the population by 2030 –estimated 70. 1 million. §Rapid growth is expected to occur among the oldest & frailest population groups. §More diverse racially and ethnically §Will live longer §Will have multiple complex health problems §Need for the inter-disciplinary team approach! 2
The Dilemma Mrs. Smith is an 86 year old widowed woman who lives with her son in his home. She has been receiving services through the county office of aging due to increasing cognitive problems and safety concerns. She has no previous mental health treatment history. The son noticed over several days that his mother was becoming increasingly suspicious in the early evening. He returned from work one evening and discovered her in the kitchen with a knife stating that the people next door were trying to take her money. He was unable to redirect her as she became increasingly agitated. He contacted the County Aging Protective Service Worker on call who directed him to take her to the nearest emergency room.
The Dilemma Upon arriving at the emergency room Mrs. Smith refused to get out of the car. The son proceeded into the ER and discussed with staff who stated there was nothing they could do. The son once again contacted the Aging Protective Service worker who suggested driving his mother around the block and to attempt to re-enter the emergency room. When the son went back to the car he had found his mother had a knife with her and had sliced the seats in the car.
Crisis Response? Criteria for 302?
Barriers to Care!
Patient and Family Barriers § § § § Isolation Ageism – belief that depression, confusion are normal conditions of aging Preference of primary care Focus on somatic complaints Stigma Reluctance to discuss psychological symptoms Lack of /misinformation
Provider Barriers § § § § Ageism – “normal aging” Training barriers Focus on “medical issues” Lack of awareness of “geriatric-specific” clinical symptoms Complexity of treatment issues Reluctance to inform patients of diagnosis Lack of access to psychiatric care Lack of /misinformation
System Barriers § § § Fragmentation Intersystem boundaries – including exclusion of dementia from many community mental health programs Time constraints Lack of access to geriatric specific services/ treatment Reimbursement issues – including a mismatch between covered services and a changing system of long-term and community based care Cultural diversity needs
Pennsylvania’s Approach to Collaboration Ø Memorandums of Understanding (MOU) between the Office of Mental Health and Substance Abuse Services (OMHSAS) and the Pennsylvania Department of Aging (PDA) – State and County agreements
PDA & OMHSAS Memorandum of Understanding (MOU) The 2006 Program Directive MOU required PDA Office of Community Services and Advocacy and the OMHSAS to collaborate and to develop MOUs between each county’s MH/MR program and the county’s Area Agency on Aging.
Pennsylvania’s Cross System Approach 2006 - Mental Health Bulletin was released from the Deputy Secretary of Mental Health on the rights of older adults, even those with dementia, to receive mental health treatment. “Service Priority – Older Adult Population. ” (Bulletin issued, February 2006. )
Pennsylvania’s Cross System Approach 2006 – Cross System development with the Pennsylvania Department of Aging and Office of Mental Health and Substance Abuse Services, of a Suicide Prevention Strategy for Pennsylvania that specifically addresses the needs of older adults.
Pennsylvania’s Cross System Approach Cross systems collaboration is necessary to serve the older adult population. MOUs between behavioral health and aging provide an agreed-upon roadmap to establish and build collaboration.
Psychiatric Issues of Aging § Depression/ Late Life Depression § Caregiving and Depression § Behavioral and Psychological or Neuropsychiatric symptoms of Dementia § “Anxiety-based” behaviors
The Dilemma Mr. Johnson is an 81 year old widowed gentleman who resides in a senior apartment building. On Friday afternoon at 4: 30 he wandered into the manager’s office, confused and distraught over not being able to find his wife. When the manager reminded him of his wife’s death 10 years ago, he became agitated, combative and threatened suicide.
The Dilemma The apartment manager contacted Mr. Johnson’s daughter regarding her father’s confusion and suicidal comment. Her concern was that her father collects guns and had numerous weapons in his apartment. Due to the daughter residing out of state, the manager also contacted the Office on Aging for assistance. She was told to call Crisis Intervention due to the suicidal comment. On doing so the manager was told that he had dementia and could not be psychiatrically hospitalized.
Crisis Response? Criteria for 302?
Late Life Depression
Depression and the Older Adult § 7 million adults aged 65 years and older are affected by depression (Steinman, 2007). § 15 – 20 % of adults older than 65 have experienced depression. (GMHF) § Affects approximately 15 out of every 100 older adults age 65 and older – higher percentage in hospitals and nursing homes. § Affects more older adults in medical settings, up to 37% older patients in primary care – approximately 30% of these patients have major depression the remainder have a variety of depressive syndromes that could also benefit from medical attention (Alexopoulos, Koenig ).
Depression and the Older Adult Chronically ill Medicare beneficiaries with depression have significantly higher health care costs than those with chronic disease alone (Unützer, 2009).
Depression in Older Adults ü Causes may be physical, social, or psychological in origin, including: § Specific events in a person's life, such as the death of a spouse, a change in circumstances, or a health problem that limits activities and mobility § Medical conditions - Parkinson's disease, hormonal disorders, heart disease, or thyroid problems § Chronic pain § Nutritional deficiencies § Genetic predisposition to the condition § Chemical imbalance in the brain
Depression and the Older Adult § Individuals who get depressed for the first time in later life have a depression that is related to medical illness § Untreated depression can lead to disability , worsening of other illnesses, institutionalization, premature death and suicide (GMHF) § Community surveys have found that depressive disorders and symptoms account for more disability than medical illness § With proper diagnosis and treatment more than 80% of individuals with depression recover and return to normal lives (GMHF)
Late Onset Depression § Depression occurring for the first time in late life – onset later than age 60 § Usually brought on by another “medical illness” § When someone is already physically ill, depression is both difficult to recognize and treat § Greater apathy/ anhedonia § Less lifetime personality dysfunction § Cognitive deficits more pronounced § May be a precursor to dementia
Depression ü Major Depressive Episode § Depressed mood § Loss of interest or pleasure § Appetite disturbance § Insomnia or hypersomnia § Psychomotor agitation or retardation
Depression ü Major Depressive Episode § Fatigue or loss of energy § Feelings of worthlessness or guilt § Decreased concentration indecisiveness § Thoughts of death or suicide § Impaired level of functioning
Older Adults at Risk for Depression Those with co-morbid disorders Frail elderly Older adults residing in care facilities Caregivers of older adults Isolated older adults
Depression and Dementia § Depressive symptoms of various intensity occur in approximately 50% of demented patients ü Symptoms can include: Abrupt loss of interest, increased irritability, refusal to eat, crying, and sudden deterioration in skills (Rovner)
Psychiatric Issues in Dementia - Depression ü Depression: Behavioral symptoms of depression includes: appetite changes, sleep disturbance, irritability/ agitation, refusal of “care”, inability to make a decision, social isolation, withdrawal, tearfulness, and sad mood.
Depression and Alzheimer’s Disease § Depression that can occur with AD may be different than other depressive disorders in that the neuropathology of AD plays a role in the development of depression Olin, Katz, Lebowitz, et al “Provisional Diagnostic Criteria for Depression of Alzheimer Disease: Rationale and Background, ” American Journal of Geriatric Psychiatry, 2002
Depression, Suicide and Older Adults § NIMH - Older adults with depression are at risk for suicide. In fact, white men age 85 and older have the highest suicide rate in the United States. § American Association of Suicidology - Suicide rates for elderly males are the highest risk at a rate of 29. 0 per 100, 000 (2010) § The Centers for Disease Control and Prevention 2012 statistics state 51 out of every 100, 000 white men over 85 (the old-old) were at the greatest risk of suicide. The national average for all ages was 12. 6.
Suicide in Older Adults § APA – 20% of Older Adults who committed suicide saw their physician within the prior 24 hours, 41% in the past week and 75% within the past month § The risk of depression in the elderly increases with other illnesses and when ability to function becomes limited. Hybels CF and Blazer DG. Epidemiology of late-life mental disorders. Clinics in Geriatric Medicine, 19(Nov. 2003): 663 -696. § Associated with late-onset depression
Assessing Suicide Risk (SAD PERSONS) S ex (Male) Age (Elderly or adolescent) Depression Previous. Suicide Ethanol Abuse Rational Thinking loss (psychosis) Social Support lacking Organized Plan commit suicide No Spouse (divorce>widowed>single) Sickness Physical illness
Older Adults who take their own lives are more likely to have suffered from a depressive illness than individuals who kill themselves at younger ages
Depression and the “Nursing Home” § Occurrence 10 times higher than those elderly residing in the community (Rovner) § NIMH – April 2002 – up to 50% of nursing home residents are affected by significant depressive symptoms § Associated with distress, disability and poor adjustment to the facility (Rovner) § Most common cause of weight loss in long term care (Katz)
The Dilemma Mr. Johnson is an 82 year old gentleman who resides on a dementia unit at a local nursing home. He was recently placed there due to his wife’s inability to care for him as her health concerns have worsened. One evening shortly after his admission Mr. Johnson became agitated as his wife was leaving the unit. He yelled that he needed to take care of her and go home with her. He threatened the staff verbally and became physically intimidating.
The Dilemma Cont. The staff attempted to redirect him, but Mr. Johnson became belligerent, stating they don’t know what they are talking about and his wife is sick. The staff were concerned about the other residents on the unit becoming upset or even getting injured. The medical director of the facility instructed the staff to contact crisis intervention or take the resident to the emergency room. EMS had difficulty upon arriving, as Mr. Johnson would not get on the stretcher to go in the ambulance. Crisis intervention was contacted to come to the facility.
Crisis Response? Criteria for 302?
Neuropsychiatric or Behavioral and Psychological Symptoms of Dementia
“Dementia” § Irreversible chronic brain failure. § Loss of mental abilities. § Can involve memory, reasoning, learning and judgment. § All patients with dementia have deficits, but how they are experienced depends on their personality, style of coping and their reaction to the environment.
Psychiatric Symptoms of Dementia ü Dementia is the greatest risk factor for the development of psychotic symptoms in the older adult population. § Dementia process itself and; § An increased vulnerability to delirium Brown, FW. “Late-life Psychosis: Making the Diagnosis and Controlling Symptoms. ” Geriatrics 1998.
Behavioral and Psychological or Neuropsychiatric Symptoms of Dementia • Affects up to 90% of all individuals with dementia over the course of their illness • Causes: psychological, social and biological factors? • Recent research has emphasized the role of neuropathological and genetic factors underlying the clinical manifestation.
Psychiatric Symptoms of Dementia ü More than half of individuals with dementia experience psychotic symptoms during the course of their illness. § Delusions are the most common (up to 70%) • House is not their house • Spouse not their spouse (Capgras syndrome) • Infidelity § Hallucinations (up to 50%) – usually visual • Lewy Body Dementia up to 80% experienced visual hallucinations, usually early on in the disease. Clinical Brendel, R. , and Stem, T. “Psychotic Symptoms in the Elderly, ” Primary Care Companion, Journal of Psychiatry, (2005); 7 (5): 238 -241.
Psychiatric Symptoms of Dementia ü Hallucinations and delusions are commonly associated with aggression, agitation and disruptive behaviors. ü Psychotic symptoms are associated with more caregiver distress. ü Associated with institutionalization. ü Psychotic symptoms disappear in the more advanced stages of the disease.
Behavioral and Psychological or Neuropsychiatric Symptoms of Dementia § Symptoms of disturbed perception, thought content, mood or behavior that frequently occur in persons with Dementia § BPSD are treatable! § BPSD can result in: üSuffering üPremature Institutionalization üIncreased Costs of Care üLoss of quality of life for the person and caregivers Finkel et al 1996
Behavioral and Psychological or Neuropsychiatric Symptoms of Dementia ü Hallucinations (Usually visual) ü Delusions • People are stealing things • Abandonment • This is not my house • You are not my spouse • Infidelity
Behavioral and Psychological or Neuropsychiatric Symptoms of Dementia ü Misidentifications • People are in the house • People are not who they are • Talk to self in the mirror as if another person • Events on television
Behavioral and Psychological or Neuropsychiatric Symptoms of Dementia ü Depressed Mood ü Anxiety ü Apathy • Decreased social Interaction • Decreased facial expression • Decreased initiative • Decreased emotional responsiveness
Behavioral and Psychological or Neuropsychiatric Symptoms of Dementia ü Wandering • Checking • Attempts to leave • Aimless walking • Night-time walking • Trailing • Excessive activity
Behavioral and Psychological or Neuropsychiatric Symptoms of Dementia ü Verbal Agitation • Negativism • Constant requests for attention • Verbal bossiness • Complaining • Relevant interruptions • Irrelevant interruptions • Repetitive sentences
Behavioral and Psychological or Neuropsychiatric Symptoms of Dementia ü Verbal Aggression • Screaming • Cursing • Temper Outbursts
Behavioral and Psychological or Neuropsychiatric Symptoms of Dementia ü Physical Agitation • General Restlessness • Repetitive Mannerisms • Pacing • Trying to Get to a Different Place • Handling Things Inappropriately • Hiding Things • Inappropriate Dressing or Undressing
Behavioral and Psychological or Neuropsychiatric Symptoms of Dementia ü Physical Aggression • Hitting • Pushing • Scratching • Grabbing Things • Grabbing People • Kicking and Biting
Behavioral and Psychological or Neuropsychiatric Symptoms of Dementia ü Disinhibition • Poor Insight and Judgment • Emotionally Labile • Euphoria • Impulsive • Intrusiveness • Sexual Disinhibition
The Dilemma Ms. Moore, 73, was admitted to the geriatricpsychiatry unit from a local personal care home for withdrawal, decline in personal hygiene, poor appetite and disorientation. Upon admission it was determined that her symptomatology was due to pneumonia. She quickly responded to treatment, was discharged back to the personal care home however shortly after readmission she fell and fractured her hip. She became suspicious of medical providers and refused to go in the ambulance.
The Dilemma Ms. Moore, who suffers from schizophrenia, retired from state government at 69 and resided at home with her mother until her death 3 years ago. After her mother’s death she was hospitalized, re-stabilized on medication and discharged to a small, local, personal care home. Ms. Moore functioned well until her recent medical illness and subsequent hip fracture. Discharge planning for rehabilitation also became difficult as long term care facilities were hesitant to take a patient with a psychiatric diagnosis.
Crisis Response? Criteria for 302?
Hoarding Behaviors
Characteristics of Compulsive Hoarding Behaviors o Excessive acquisition and retention of “apparently” useless things and animals. o Cluttered living spaces that limit activities for which these spaces were designed. o Significant distress or impairment is caused by the hoarding behaviors. Frost and Hartl (1996)
Hoarding Statistics § It is a hidden problem. § Estimates are that hoarding behaviors effects between 2 5% of the population! § Recent research states there is no gender differences. § Though it is thought to begin in adolescence, due to the progressive nature of hoarding behaviors there are increasing problems as individuals age.
Risk Factors for Hoarding § Age –begins in adolescence § Stressful life event often precedes behavior § Lower socioeconomic income § Tendency to be single or divorced § Hereditary issues – 50 – 80% of individuals who had hoarding behaviors had first degree relatives who were considered “pack rats” or hoarders.
Risk Factors for Hoarding o Stressful Life Events – • Some individuals develop hoarding behaviors after experiencing a stressful life event such as a motor vehicle accident, death of a love one, sexual abuse, rape or witness to a crime. § Behavioral Research Therapy 1996; 34: 341 -350. § Behavioral Research Therapy 2005; 43: 269 -276. § Journal of Anxiety Disorders January 2005; 675 -686. § Clinical Psychiatry News, June 2006.
Risk Factors for Hoarding o Stressful Life Events Cont. § Significant correlation of hoarding in females to a history of interpersonal violence; 76% compared to 32% in the general populations (Tolin and Meunier et al. , 2010). § Childhood adversities § Parent with psychiatric symptoms § Homebreak-ins § Excessive physical discipline (Samuels, Bienvenu, et al. , 2008)
Co-Morbidity ü Depression – 57% ü Anxiety - Generalized, Social, Posttraumatic Stress ü Obsessive Compulsive Disorder ü Attention Deficit Hyperactivity ü Dementia
Individuals Who Have “Hoarding Behaviors” ü Have significant emotional attachment to items. ü Feel the items they collect will be needed or will have value in the future. ü Feel safer when surrounded by the things they collect!
Hoarding Research § Functional imaging suggests the medial prefrontal area of the brain plays an important role. § PET Scans show lower than normal activity in the anterior cingulate gyrus. This area is associated with such tasks as focused attention and decision making.
Hoarding and the DSM 5 §Now considered a distinct disorder §Previously was a Subtype or symptom of Obsessive Compulsive Disorder §Hoarding behaviors may also seen in individuals with Generalized Anxiety Disorder, Social Phobias, Schizophrenia, Dementia, Eating disorders and Mental Retardation §Those with significant hoarding symptoms are more likely to suffer from co-morbid depression
DSM 5 Hoarding: ü Persistent difficulty discarding or parting with possessions, regardless of their actual value. ü This difficulty is due to a perceived need to save the items and distress associated with discarding them. ü The symptoms result in the accumulation of possessions that congest and clutter active living areas, and substantially compromise their intended uses. If living areas are uncluttered, it is only because of the interventions of third parties.
DSM 5 CONT. ü The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). ü The hoarding is not attributable to another medical condition (e. g. : brain injury, cerebrovascular disease, etc. ).
DSM 5 CONT. ü The hoarding is not better accounted for by the symptoms of another DSM 5 disorder (e. g. : hoarding due to obsessions in Obsessive Compulsive Disorder, decreased energy in Major Depressive Disorder, delusions in Schizophrenia, restricted interests in Autism Spectrum Disorder, etc. ).
Assessment ü Saving Inventory-Revised tool (Frost) ü Saving Cognition Inventory (Frost, Steketee) ü Hoarding Rating Scale Assessment Tool (Frost) ü Clutter Image Rating Scale (Frost) ü Activities of Daily Living (ADL)
Treatment ü Treatment is challenging and has “mixed success” ü Cross system collaboration helpful ü Medication ü Psychotherapy
Treatment -Therapy ü Behavioral Therapy ü Cognitive remediation ü Focus on building concrete skills
Cognitive Behavioral Therapy ü Cognitive Behavioral Therapy is the most commonly cited approach and has been shown to be effective up to 50% of individuals. § Muroff, J. , Steketee, G. , Bratiotis, C. , et al. “Group cognitive and behavioral treatment for compulsive hoarding: a preliminary trial, ” Depression and Anxiety, 2009; 26 (7): 634 -640. § Steketee, G. , Tolin, DF. , “Cognitive-behavioral therapy for hoarding in the context of contamination fears, ” Journal of Clinical Psychology 2011; 67 (5): 485 -496.
Treatment -Therapy üFrost and his colleagues found that 26 sessions of behavioral therapy, including home visits, over a 7 to 12 month period helped half of the 10 hoarders who completed a cognitive behavioral/ psychotherapeutic program become "much improved" or "very much improved. ” Randy Frost, Ph. D, Israel Professor of Psychology, Smith College, Northampton, Mass.
Community-Based Interventions ü Cross system collaborative approach § § Multiagency Hoarding Teams – (MAHT) – coordination of public sector approaches “Hoarding Task Forces”
Hoarding Task Forces Key Issues § § § A comprehensive, multi-agency approach best serves the interests of the owner/ occupant. Each agency must have an understanding of services and capabilities of other agencies. Hoarding behaviors can create unsafe living conditions; action must be taken to protect life, health, and safety. Fairfax County, Virginia Hoarding Task Force, Annual Report, 2009
Hoarding Task Forces Key Issues § Significant staff resources may be required. Enforcement, follow-up, remediation, and court action may require many hours and there is no guarantee that the behavior will not reoccur. § A compassionate, professional, and coordinated approach must be developed to provide a chance of recovery for the owner/ occupant and the community. Task 2009 Fairfax County, Virginia Hoarding Force, Annual Report,
Cross System Collaborative Approach § Area Agency on Aging § Mental Health Centers/ Providers § Crisis Intervention/ emergency services § Inpatient Psychiatric Services § Department of Health § Humane Society § Vector Control § Biohazard § Private consultants – “professional organizers”
Evidenced-based Practices for Older Adults with Behavioral Health Issues
Evidence-based Practices for Older Adults with Behavioral Health Issues Ø Psychosocial and pharmacological treatment for depression and dementia. Ø Integrated mental health services in primary care. Ø Mental health outreach services. Ø Brief alcohol interventions for at-risk use. Ø Family/ caregiver support interventions. Draper, 2000; Unutzer, it al. , 2001; Schulberg, et al. , 2001; Sorenson, et al. , 2002; Bartels, et al. , 2002, 2003
Collaborative Approaches for Older Adults with Behavioral Health Issues Healthy Aging Initiatives: ü “Building Healthy Communities for Active Aging” – EPA ü “The Healthy Brain Initiative” – CDC and the Alzheimer’s Association – National Public Health Road Map to Cognitive Health ü Chronic Disease Self-Management Program (CDSMP) – Physical, emotional and health-related quality of life, healthcare utilization and costs
Evidence-Based Practices for Older Adults with Behavioral Health Issues Depression in Older Adults § Healthy IDEAS - (Identifying Depression, Empowering Activities for Seniors) – Integrates depression awareness and management into existing case management services. § Screens, educates, links to services and utilizes behavioral approaches. § Evidenced based Disease Self Management for Depression – NCOA Model Health Program.
Evidence-Based Practices for Older Adults with Behavioral Health Issues Depression in Older Adults § PEARLS -(Program to Encourage Active Rewarding Lives for Seniors) – Utilizes existing community-based programs. § Problem solving treatment, social and physical activation, PEARL’s counselor offers visitation. § Gatekeeper Program – Trains non-traditional sources to identify and refer older community residing elders to services.
Collaborative Approaches for Older Adults with Behavioral Health Issues Outreach Programs ü Multidisciplinary outreach services takes services to where older adults reside – home and community based settings § Psycho geriatric Assessment and Treatment in City Housing (PATCH) Baltimore, MD – Gatekeeper program with “assertive community treatment”.
Evidence-Based Practices for Older Adults with Behavioral Health Issues Depression in Older Adults ØInterventions for Family Caregivers – (Mittelman) – combination of counseling sessions, support group, education and ongoing support. § Assists in delaying nursing home placement. § Improved caregiver depression and health outcomes.
Integrating Mental Health Services in Primary Care PRISM-E (SAMHSA) –(Primary Care Research in Substance Abuse and Mental Health for the Elderly) comparing two types of care models for delivery of mental health services to older adults. § 50 clinical settings – managed care, community health clinics, VA system and group practice settings. § Diverse ethnic/ minority and rural/ urban populations. § Largest study of depression and alcohol uses in older adults. § The firsts effectiveness study of integration in older adults.
Evidence-Based Practices for Older Adults with Behavioral Health Issues Suicide Prevention üSupportive interventions including screening, psychoeducation and group activities. üTelephone-based supportive interventions. üProtocol driven treatment delivered by a case manager (IMPACT; PROSPECT).
Integrating Mental Health Services in Primary Care IMPACT (Hartford Foundation) - (Improving Mood Promoting Access to Collaborative Treatment for Late Life Depression) ◦ ◦ ◦ Identification of older adults in need. 12 month access to depression care manager and support. PCP manages anti-depressant medications. Brief psychotherapy. Case supervision by a psychiatrist.
Integrating Mental Health Services in Primary Care PROSPECT (NIMH) - Prevention of Suicide in Primary Care Elderly: Collaborative Trial ◦ Sought to decrease risk factors including barriers to accessing health care and the presence of untreated mental illness. ◦ Identification of older adults in need. ◦ Case management links to appropriate service. ◦ Depression – care management and suicide prevention.
Collaborative Approaches for Older Adults with Behavioral Health Issues Colorado’s Senior Reach ü Community-involved identification of older adults who need emotional or physical support and connection to community services. ü 70 % of seniors previously had “fallen through the cracks”.
Collaborative Approaches for Older Adults with Behavioral Health Issues Colorado’s Senior Reach Cont. ü 90 % who were referred have accepted mental health services. ü Program enables individuals to access service before serious problems arise. ü Senior Reach has found that building strong collaborative community relationships that enhance ongoing services to older adults is the key to prevention of more serious problems.
Behavioral Health Needs of Older Adults • Multidisciplinary approach • Consumer input • Stakeholder-generated principles – CSP/CASSP • Culturally competent • All levels of interagency collaboration • Toward the aim of dispelling stigma • Integrated at the community level • Continuum of care from prevention to treatment SAMHSA Strategic plan Substance Abuse and Mental Health Issues facing Older Adults 2001 - 2006
Resources ü Alzheimer’s Association – www. alz. org ü ADEAR (NIA) – adear@alzheimers. org ü Family Caregiver Alliance – www. caregiver. org ü Geriatric Mental Health Foundation – www. gmhfonline. org ü PA Behavioral Health and Aging Coalition – www. olderpa. org
Resources ü Medline Plus (NIH) – www. medlineplus. gov ü American Federation of Suicide Prevention – http: //www. afsp. org/ ü Pennsylvania Behavioral Health and Aging Coalition www. olderpa. org
What makes the engine go? Desire, desire. The longing for the dance Stirs in the buried life. One season only, and it’s done. Stanley Kunitz
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