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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