Special Orders: A Mental Health Perspective

1. Special Orders:A Mental Health Perspective Michael Loh LGPro Aged & Disability Service Seminar - 18 October 2012

2. Workshop Plan • Contexts: Ageing & Mental Health • Supporting Clients & Families/Carers • Active Service Model & Recovery • Personal Recovery; Engagement; Supporting Recovery • Supporting Staff

3. Activity What are the 3 top challenges you/your staff face in supporting older persons with mental health issues in the community?

4. 1. Contexts – Ageing & Mental Health Ageing Context Mental Health Context Ageing & Mental Health

5. Ageing context

6. Mental Health context • Prevalence: 1/5 • Types: mood disorders, anxiety, paranoid illness, substance abuse • Increased awareness but Stigma remains • Impact on Family • Affects all of life domains

7. Activity • How do mental health issues present in Younger Persons? • How do mental health issues present in Older Persons? 3 common themes & 3 different themes

9. Themes – Mental Health & Older Persons • Co-morbidity common • Mental health and substance use • Mental health and medical illness • Pre-mature ageing • Biopsychosocial model -> Social models of health • Fluctuating support needs • Atypical presentation – physical, cognitive, behavioural, activity signs (rather than feelings) • Trauma informed – applicable to ageing? videos\Depression and Older People Ad - Beyondblue.mp4

10. “Life expectancy of people with severe MI ~25 years less than general population” Key Strategies • Smoking cessation • Nutrition • Improving physical activity • Dental care

11. 2. Supporting the Client & Family/Carers Active Service Model (in HACC) Recovery (in Mental Health)

12. Case study: BRIAN Brian is 65 years old and lives alone in a high rise flat. The flat is dark; smells of cigarettes and the windows are covered by new-papers. He was diagnosed with schizophrenia since his 20s and had spent much of his earlier life living in psychiatric hospitals. He also has asthma and NIDDM. He smokes heavily. He has lived in the community for the last 5 years. He tends to spend most of his time in the flat lying on his bed or sitting on his chair. His only visitors are the people who deliver his MOWs and the mental health nurse who visits 2-3 weekly. His paranoia about his neighbours fluctuates. He gets angry that “the bastards can listen to his thoughts, has his flat key and come in when he’s not there”. He shows you the scratches on the door and items that has been moved as evidence. He struggles to make his pension last the fortnight – there’s not much left after the rent and smokes. He behind in paying his bills and there’s little food left.

13. Case Study: John John is 70 lives in a retirement village. He has bipolar depression, COPD and mild vision impairment. He’s on a CACP package to assist to him in organising his appointments to his GP, community health and planned activity group. He also has MOWs, home help and is on the MPTP to assist his to get around. Generally, he is independent in his self-care, simple meal preparation, shopping and finances. Every few months, John has periods where he becomes irritable, is reluctant to accept services and attend his normal activities. He tends not to attend his self-care and even becomes incontinent and at risk of falls. He complains that your staff are incompetent and wants them to be sacked or replaced! John’s son would like him to go into care.

14. Case Study: Nancy Nancy is a fit and active 82 year old woman. She has never married and lives with her 3 unmarried siblings (2 sisters and a brother). Most of the siblings have defined roles in the household – the brother looks after the garden and heavier chores; the eldest sister the finances; the second sister the meals; and Nancy makes the beds. The siblings have routines that they adhere to • Shopping at the local market/shops every Tuesday • Hair-dresser every Wednesday fortnight • Church every Sunday (20 minute walk) Nancy has always been an active church–goer and the parish appointed a new priest last year. He reports that Nancy started to visit the parish more regularly and this has now increased to 3-4 times a week. She’s also ringing the parish daily but would often not speak or was unable to explain her reasons for ringing. The local GP practice is also reporting that Nancy has been visiting 2-3 weekly for no medical reasons. She appears to be highly anxious.

15. What would you do? • How could your staff work with him/her?

16. Key Support themes • The staff-client relationship • Connection • World view (from other’s perspective) • Learning vs Helping • Mutual Exchange • Collaboration • Positive risk taking • Focus on Recovery / Active Support

17. Active Service Model Core Principles • people wish to remain autonomous • people have the potential to improve their capacity • people’s needs should be viewed in an holistic way • HACC services should be organised around the person and his or her carer, that is, the person should not be simply slotted into existing services, and • a person’s needs are best met where there are strong partnerships and collaborative working relationships between the person; their carers and family; support workers and between service providers.

18. Active Service Model Strategies eg. • strength based assessment • more timely access to physiotherapy • retraining in activities of daily living • timely provision of aids and equipment • greater utilisation of relationships with community care workers • encouragement to participate in local health promoting activities, and • strengthening social support.

19. Recovery (in mental health) Personal Recovery • Belongs to the person • Non linear • Hope is keystone of recovery • Individual/person’s journey • Expert by personal experiences Engagement / Relationship • Trusting & Reliable • 2 experts in the relationship (you are Expert by learning)

20. Support by Staff • Environment – for hope & for empowerment to occur • Strengths based • Support across all social health domains self care, physical health, spirituality, practical assistance, housing, meaningful activities • Collaboration with family/carers • Multiple partners/services videos\Families and Mental Illness.mp4 Education - LGPro Aged & Disability Seminar 18Oct2012\videos\Mental Health_0001.wmv.mp4

21. 3. Supporting Staff

22. Staff roles • Appropriate communication – attitudes, trusts • Knowledge – illness, severity • Assessment – of change • The issue of confidentiality • Establishing the limits of your role Duty of care vs Individual Rights • Support and resources for you, the Carer

23. Attitudes & stigma. Illness vs behaviour • Relationship is key - Trust & Reliable. Eg. Engagement/Getting in • Strengths based assessment • Supporting risks/self responsibility and duty of care • Self care • Reflection / Supervision / Debrief • Mental Health First Aid Education - LGPro Aged & Disability Seminar 18Oct2012\videos\Stories from Instructors and staff at 2012 Mental Health First Aid Australia Conference.mp4

24. Attitudes / Communication • Treat the person with respect and dignity • Do not blame the person for their illness • Offer consistent emotional support and understanding • Be a good listener • Give the person hope for recovery

25. Strengths based assessment • Normally recognised both + & - • When unwell often Negative self image / mindset • Yet most have endured significant life events & do not recognise resilience developed. • Person will not easily recognise these strengths. • So notice/look for/recover strengths that clients have. Reflect/reframe/remind clients about these strengths. • Older persons (& families) have skills/strategies – look for intervention points, look for road-tested skills

26. Assessment • Engagement / relationship • Assessment – observe for changes eg. doing, thinking, feeling • Communication • When to report • Risk taking and duty of care • Safety of client, others and self

27. Mental Health First Aid

28. 4. Resources

29. Aged Person Mental Health Services • http://www.health.vic.gov.au/mentalhealth/services/aged/index.htm Mind’s community service directory • Education - LGPro Aged & Disability Seminar 18Oct2012\References\Community-Information-Telephone-Directory---Vic.pdf

30. Summary • The individual • MH – common, not linear, co-morbidity • Engagement /relationship as key – trust, reliable, partnership, hope • A strengths base approach • All of life domains (social models of health) • Collaboration with family/carers • Working with multiple partners • Personal risk taking & duty of care • Looking after yourself

31. Other Content

32. Mental HealthHow common are mental health disorders in community in old age? • Depression 8-13% • Anxiety 5-15% • Schizophrenia 1% • Alcohol abuse 3-4% male, 1% female

33. Depression • Common • Higher with physical illness eg. hospital & residential care • Risk Factors • Physical: Medical illness, disability, chronic pain, alcohol & other drugs • Psychosocial: life events/losses, lack of significant others eg. Single older men

34. Depression • Protective Factors • Good physical health • Physical fitness • Adequate social support • Marriage • ?social activity • ?coping skills in early life • ?religion/spirituality

35. Depression • Outcomes if untreated • Reduced quality of life • Unnecessary suffering • Burden on family, social, economical • Suicide risk • Increased service use • Increased physical morbidity & mortality

36. Depression • Presentation • Atypical presentation eg. Somatic symptoms, cognitive symptoms, behavioural change, activity change • Less “psychologically minded” • Ageism “normal to be old & depressed”

37. Suicide Rates (2009)

38. Suicide Rates 15-19 (1989-2009)

39. Suicide in young people • Rates of suicide for young males (15-19 yrs) increased from around 1970 until the middle1990s. This caused a great deal of concern and publicity about youth suicide. Rates of suicide in school aged males reached their highest level ever in 1997. Thankfully they have declined since then and in 2009, the 15-19 year age group represented the lowest age-specific suicide rate for males. Rates of suicide for young women have been fairly stable throughout the same period. • While the numbers of deaths and the rates of suicide are low, suicide does represent the largest cause of death in this age group. Thus youth suicide is a very important public health issue. Working with young people to promote positive mental health is an important strategy to reduce suicidal behaviour throughout the lifespan.

40. Suicide Rates 75+ (1989-2009)

41. Suicide in older people • The rates of suicide for older men have always been high. In the early 1920s, rates were around 50 per 100,000 for men aged 70 or over. While rates of suicide have declined since then, the issue remains a priority in Australia. For example, rates of suicide among men aged 85 and over have declined over the last ten years but this group still had the highest rate of any age group among men (28.2 per 100,000). Suicide rates in older women do not appear to be significantly different from that of other age groups of women. • Note that the number of deaths in this age group is relatively small and suicide represents less than 0.2% of all male deaths and 0.1% of female deaths. • Research has shown that physicians and people in the general population are more tolerant of suicidal behaviour among older people compared to young or middle aged groups (Pearson, 2000). This finding potentially reflects both stigma related to mental health problems as well as ageism. Suicide in older people is often characterised by: less warning or explicit cues; higher lethality; less history of previous attempts; greater prevalence of depression and physical illness; high levels of hopelessness; and less likelihood of contacting mental health services to seek help

42. Anxiety Disorders • Generalised anxiety disorders • Phobias • Panic disorders • Obsessive- compulsive disorders • Post-traumatic stress disorders

43. Substance Use • Alcohol • Drugs • Prescribed medications

44. Schizophrenia & other delusional disorders • Schizophrenia mainly develop before age 40 • Late life presentation mainly female, often paranoid type, ~25% develop dementia within 3 years.