Bridging from Diagnosis to Advanced Direct Practice The

Bridging from Diagnosis to Advanced Direct Practice: The Case of Older Adults With Mental Illness Course: Health Care Adelphi University School of Social Work

Acknowledgement The development of this gerontology teaching module was made possible through a Gero Innovations Grant from the CSWE Gero-Ed Center's Master's Advanced Curriculum (MAC) Project and the John A. Hartford Foundation. Adelphi University Project Team: Judy Fenster (Principal Investigator), Philip Rozario, Patricia Joyce, and Bradley Zodikoff.

A Phone Call from Mr. Shea, a widowed 74 year old man of Irish. American background, phones to say he won’t be at your bereavement group this week. He won’t leave the house because the last two times he rode the bus, he felt like he was choking, got dizzy and felt like he was going crazy. He tells you that he would like to go to his doctor, but he rides the bus there, too. He hasn’t left the house for two weeks. These feelings on the bus started about six weeks ago, and for a month he “just dealt with it. ” His neighbors shop for him, but he feels embarrassed to tell them or his daughters about his “riding the bus problem. I don’t want to be one of those weird crazy people. ”

Why Focus on Understanding Mental Health Issues in Older Adults? § Growth in Elderly Population § 1900— 4% of U. S. population was age 65+ § 2006— 13% of U. S. population was age 65+ § 2030— 20% predicted § Also: by 2030, the number of elderly 85+ is expected to double

Bridging from Diagnosis: Older Adults § Co-morbid Medical & Psychiatric Conditions § ↑ Use of Prescription Drugs among elderly, combined with mental disorders § ↑ Dementia and other Cognitive Deficits, combined with mental disorders § ↑ Risk of Depression/Suicide among certain older adults (white males

Mental Illness Prevalence: Older Adults § Prevalence of mental illness in US population age 55+, from the Epidemiological Catchment Area Study: § Any Anxiety Disorder: 11. 4% § Simple Phobia: 7. 3% § Social Phobia: 1. 0% § Agoraphobia: 4. 1% § Panic Disorder: 0. 5% § Any Mood Disorder: 4. 4% Source: L. N. Robins & D. A. Regier (Eds. ). (1991). Psychiatric disorders in America: The Epidemiologic Catchment Area Study. New York: Free Press.

Older Adults and Mental Illness § Older adults are actually LESS likely to meet diagnostic criteria for a mental disorder than are young or middle aged adults § It may be that life experience protects against some forms of mental illness

Protective Factors and MI in Older Adults § For some older adults, research shows that integrity and hope serve as protective factors against late life depression § Think about these factors in connection with your foundation year HB courses on older adulthood

Older Adults’ Perceptions of MI § Like Mr. Shea did, many older adults perceive the mentally ill as being embarrassing and having poor social skills § Older adults don’t think that mental illness only occurs in younger adults, don’t see mental illness very differently than younger adults and don’t report that they will never seek help

Older Adults with MI in the Community § Much more research needs to be done on the treatment needs of older adults with mental illness who live in the community § For example, research shows that increasing numbers of older adults with schizophrenia live in the community rather than in institutions, but little is known about their service use

Effective Treatments with Older Adults § Many evidence based practices work with older adults § For example, research indicates that cognitive behavioral therapy can be adapted to effective use with older adults

Which Diagnoses Co-occur for Older Adults? § Research shows that late life generalized anxiety disorder is often seen along with a diagnosis of major depression in older adults

Putting Together the Pieces for Mr. Shea § First, you would want to address your own values and biases about aging § For example, you might want to examine your own thoughts and feelings about Mr. Shea’s life experiences, his widowhood, his expectations for the future § Does he have the right to be happy after his wife’s death? § Do you think he will benefit from treatment?

Using Self Awareness to Deepen Practice § Based on your examination of your own values and biases about aging, do you § Think that Mr. Shea may have internalized some of these about himself and his own situation? § Think that his family members, friends and neighbors may harbor similar values and biases about aging?

Applying Ethical Principles § Next, think about who makes decisions for older adults § Mr. Shea has full decision making capability, but what if he didn’t? § Would he still be offered treatment for his difficulties?

Comprehensive Biopsychosocial Geriatrics Assessment § Be aware that assessment is the first step § After a full assessment, the practitioner will need to know what kind of treatment Mr. Shea will benefit from, and be able to find resources for him, and discuss treatment options with him § A full assessment includes health status and physical functioning

Diagnosing Mr. Shea § You will need to assess his cognitive functioning (how he thinks) and § His mental health status § What are his symptoms? § Choking, dizziness, feeling of going crazy might be symptoms of a panic attack § The fear of another attack may what’s preventing him from leaving the house, which may indicate agoraphobia

Possible Diagnosis § So, based on your knowledge of the DSMIV criteria for Panic Attacks with Agoraphobia, Mr. Shea might meet criteria for this diagnosis § But, you need to think as well about…

Co-occurring Diagnoses with Anxiety Disorders in Older Adults § Frequently mood disorders are seen along with anxiety disorders throughout the lifespan, including older adulthood § So, you would want to assess whether Mr. Shea meets criteria for a mood disorder

Overdiagnosing and Misdiagnosing § But Mr. Shea lost his wife in the past year, so be aware that grief or mourning can often look much like one of the most common mood disorders, depression § But you will remember that there are time factors involved in making a differential diagnosis of depression vs. grief. Be sure to review these!

Your Assessment Isn’t Over Yet! § Remember to include Mr. Shea’s social functioning in your assessment § This will include his social skills, his social activity level and what kinds of social supports he has in his life

The Whole Picture § If Mr. Shea meets criteria for a DSM-IV diagnosis, what then? § Based on your working relationship with him, you can § Discuss treatment choices, which may include psychotherapy alone, or psychotherapy along with psychiatric medications or medications alone

Working Together with Mr. Shea § Together, you can help Mr. Shea make informed and thoughtful choices that will help him continue to grow and develop in a rich and meaningful way