Iowa Coalition on Mental Health and Aging

1. Iowa Coalition on Mental Health and Aging Lila P.M. Starr Adult Mental Health Specialist Chairperson, NASMHPD Older Person Division Iowa Department of Human Services 1305 E. Walnut Hoover Building, 5th Floor Des Moines, IA 50319 515-281-7270 Lstarr@dhs.state.ia.us June 22, 2010

2. WELCOME To The… Nineteenth Meeting of the Iowa Coalition on MH and Aging, founded in 2004 by Iowa Department of Human Services, Division of MHDSand the University of Iowa, Center on Aging • Over 300 ICMHA members – welcome YOU!

3. ICMHA MissionThe ICMHA exists to expand and improve mental health care for older Iowans so that they can live, learn, recreate, engage in meaningful activities and access appropriate services in the communities of their choice.

4. Olmstead Anniversary, Today! • The language that you see in the ICMHA Mission, “live, learn, recreate, engage in meaningful activities and access appropriate services in the communities of their choice,” comes directly from the landmark Supreme Court Decision in Olmstead vs. EW and LC – which was rendered on this date, JUNE 22nd, 1999

5. Partners in today’s training • University of Iowa, Center on Aging, contractor to DHS since 2004 • Magellan Behavioral Health Services, contractor to DHS/IME for the Iowa Plan for Behavioral Health • Iowa Department on Aging • Iowa’s Aging Services Network – Area Agencies on Aging statewide

6. ICMHA Goals • Make mental wellness for older adults a priority • Promote mental wellness with emphasis on prevention, early intervention, evidence based treatment and recovery. • Increase the number of qualified providers of evidence based mental health services to older adults • Integrate health and mental health services for older Iowans • Increase the capacity and impact of the ICMHA and it’s efforts throughout the State of Iowa

7. Please Join the ICMHA • You have the opportunity to sign up to be a member, join a workgroup, and receive periodic e-mail updates, training announcements, and meeting notices • There is NO COST to join • Sign up and view the many excellent resources found on our website: www.icmha.org • National Coalition on Mental Health and Aging: www.ncmha.org

8. Ten Things You Need to Know about Mental Health for Older Adults • These Ten things come to you from NASMHPD Older Persons Division • The National Association of State Mental Health Program Directors: representatives from each State Mental Health Authority, who are the Commissioner designees to work on policy and practice issues around Mental Health for older citizens, make up the Older Persons Division

9. #1 Co-Occurring Medical Illness is the Rule, Not the Exception • Among older adults with depression, approximately: • 1 / 5 suffer from heart disease • 1 / 5 have diabetes • 2 / 5 have arthritis • 1 / 2 have hypertension •Outcome: The presence of these chronic medical conditions complicates identification and treatment of depression and other mental illnesses in older adults

10. Co-Occurring Medical Illness is the Rule, Not the Exception • An Older Adult may present to his/her physician with: • –Lower Energy • –Poor Appetite • –Impaired Functioning • –Fatigue • –Irritability • –Feelings of Hopelessness •Cancer, Congestive Heart Failure and Depression share these symptoms

11. #2 Older Adults Take Multiple Medications and their Bodies Handle the Medication Dosages & Substances Differently than Younger Bodies • Older adults regularly take an average of: • 2 to 6 Prescription Medications and • 1 to three Over The Counter Medications 2/3 of Older Adults with Depression take 5 or more medications 1/3 of Older Adults without Depression take 5 or more medications

12. Older Adults Take Multiple Medications… • Prescribing for Older Adults is a specialty: • Older Adults are vulnerable to medication interactions • Older Adult bodies process chemicals differently than younger bodies: • Changes in body fat composition • Changes in liver metabolism • Changes in brain chemical functioning Mantra: “Start Low and Go Slow”

13. #3 Mental & Physical Functioning Varies Widely Among Older Adults of the Same Age Young children are fairly homogeneous • Biological, Psychological, and Social developmental milestones include: • –Gross Motor • –Fine Motor • –Cognitive • –Language • –Social These are measured in months of age.

14. Mental & Physical Functioning Varies Widely Among Older Adults of the Same Age • Aging can be described as: –Chronological –Biological –Functional –Psychological –Sociological –Economical –Spiritual

15. #4 Importance of Coordination and Collaboration between Behavioral Health, Aging, & Medical Health Providers • It would not be uncommon for an older adult to receive: –Diabetes management from their primary care physician –Bi-weekly medical checks from a home health nurse –Daily home health assistance personal care attendant –Daily delivery of “meals on wheels,” –Regular visits from a home and community case manager, and –Quarterly visits with specialists in Neurology, Rheumatology, Ophthalmology, Orthopedics, etc.

16. Importance of Coordination and Collaboration • For older adults with mental illness, in may be unrealistic to add another complicated layer of self management by adding mental health care, psychotherapeutic medication management, the psychiatrist, and the mental health case manager • Older adults with mental illness often fail to receive appropriate and effective treatment within fragmented delivery systems.

17. Importance of Coordination and Collaboration • Treatment silos: • –Mental Health –Community Mental Health Center • –Social Services –DHS Office, Catholic Charities, Pharmacy Assistance Center • –Aging Services –Area Agency on Aging, Senior Nutrition Center • –Medical -Clinic and/or hospital •Evidence Based Models for integrating behavioral and medical health treatment exist and should be used to provide effective treatment to older adults

18. #5 Family Members & Other Social Supports are Critical to Successful Treatment • Many older adults receive informal caregiving services from family members • Daughters, Daughters-in-Law, Spouses, and Sons contribute to caring for older family members • Friends, neighbors, and other community members provide essential services and often act as an early warning system for vulnerable and isolated elders. • Family members may be important providers of Transportation, Activities of Daily Living, Medication Management, and Medical Care Scheduling • These family members should be included in treatment planning.

19. Family Members & Other Social Supports • The Gatekeeper Model • Recruits community service personnel who have frequent contact with older persons • –Meter readers • –Utility workers • –Bank clerks • –Pharmacy technicians • These community folks are trained to identify and refer at-risk older adults for assessment. Trained assessors are available to evaluate the physical, mental , and social needs of the older person and refer them to the appropriate agencies and providers.

20. #6 Maintaining Independence and Aging in Place is a Commonly Held Value • Older adults want to “age in place” to the extent that is possible. • Treatment of Depression should support the independent community functioning of the individual • This should include a discussion regarding the potential risks of continuing to live at home, both with and without services. • The desire to remain at home can be a real motivator for making needed changes.

21. Maintaining Independence and Aging in Place is a Commonly Held Value • An effective care plan may need to include steps for: • –In-home Health Care • –Homemaker Services • –Transportation • –Home Delivered Meals • –Medication distribution devices • –Emergency Assistance Responders • –Telemedicine • –Phone Checks • –Assistive Technology

22. #7 Prevention of Depression in Older Adults is Possible • Prevention should not be limited to the young. • Targeted strategies to identify and treat mental illness in older adults can be effective • Common triggers for depression • –Losing a relative or friend to death, divorce, or moving away • –Losing money or prestige • –Having to move to less desirable house or apartment • –Finding out about a medical illness • –Drinking too much

23. Prevention of Depression in Older Adults is Possible • Existing Programs can help prevent and/or treat the onset of a depressive disorder in older persons: • –Cognitive Behavioral Therapy • –Problem Solving Therapy • –Reminiscence Therapy • –Cognitive Bibliotherapy • –Brief Psychodynamic Therapy

24. #8 Ageism is Everywhere and Affects Treatment Expectations and Outcomes • “Depression is normal in Old Age” –FALSE • “If I had all those medical problems, I’d be depressed, too” –FALSE • The stigma of mental illness, combined with an Ageist culture, can discourage older adults from seeking treatment. • –They feel ashamed • –The feel it is their fault • –They feel they should be able to help themselves feel better (Pull up by your bootstraps)

25. Ageism is Everywhere and Affects Treatment Expectations and Outcomes • Only a minority of depressed older adults receive treatment for clinical depression. • Workers, families, and older adults must be educated and empowered about treatment for mental illness and the prospects for recovery at any age. • The public must be educated about mental health and aging issues. • The Iowa Coalition on Mental Health and Aging provides a voice for advocacy around this issue. • http://www.icmha.org/

26. #9 Older Adult Depression is Associated with the Highest Rate of Suicide • Older adults have the highest rates of dying by suicide of any age group. • Overall males die by suicide at rates 4:1 over females • The suicide rate for people age 85+ is twice the national rate • White males over the age of 85 have the highest rates of suicide

27. Older Adult Depression is Associated with the Highest Rate of Suicide • Older adults who die by suicide have often seen their primary care physician within one month • Community training to help identify warning signs and call for help are available • Mental Health First Aid training is available for community groups through the Iowa Department of Human Services, Division of MHDS • Karen Hyatt @ 515-281-3128 or khyatt@dhs.state.ia.us

28. # 10 Psychotherapy Can Be Just as Effective as Medications, but Needs to Be Individually Tailored for Older Adults • Psychotherapy Works • Adaptation and modifications are necessary when working with older adults who may have hearing impairment, cognitive impairment, or medication management issues • Simple modifications such as repetition, breaking tasks into smaller units, speaking clearly, reducing background noise, and using appropriate names (For example, Mr. or Mrs.) can overcome some of the barriers

29. Psychotherapy Can Be Just as Effective as Medications, but Needs to Be Individually Tailored for Older Adults • –Cognitive Behavioral Therapy • –Problem Solving Therapy • –Reminiscence Therapy • –Cognitive Bibliotherapy • –Brief Psychodynamic Therapy • All are effective treatment for depression • For older adults with recurrent depression, the combination of antidepressant medication and psychotherapy is shown to be more effective than either approach alone

30. RESOURCES FOR AGING AND COMMON MENTAL HEALTH AND CO-MORBID DISORDERS Websites: • Administration on Aging: http://www.aoa.gov • American Association for Geriatric Psychiatry: http://www.aagponline.org • American Geriatrics Society: http://www.americangeriatrics.org • American Society on Aging: http://www.asaging.org • Center for the Study and Prevention of Suicide: http://www.rochesterpreventsuicide.org • Geriatric Mental Health Foundation: http://www.gmhfonline.org • Gerontological Society of America: http://www.geron.org • National Association of Geriatric Education Centers: http://www.nagec.org • National Council on Aging: http://www.ncoa.org • Older American’s Substance Abuse and Mental Health Technical Assistance Center: http:// www.samhsa.gov/OlderAdultsTAC • Positive Aging Resource Center: http://www.positiveaging.org

31. ADDITIONAL RESOURCES FOR AGING AND COMMON MENTAL HEALTH AND MULTI-OCCURING DISORDERS • Older Adults: Depression and Suicide Facts: http://www.nimh.nih.gov/publicat/elderlydepsuicide.cfm • Facts about Depression in Older Adults: http://www.apa.org/ppo/issues/olderpressfact.html • Late-Life Depression: A Fact Sheet: http://www.gmhfonline.org/gmhf/consumer/factsheets/depression_factsheet.html • Depression and Older Americans: http://www.nmha.org/ccd/support/factsheet.older.cfm

32. PLEASE JOIN ICMHA! • Please remember to visit the website, www.icmha.org, and simply sign up! • Or, “check off” the YES available to you today, with your sign in sheet • You’ll receive regular e-mails about training opportunities, meeting notices, work groups, and policy issues at state and national level

33. IOWA COALITION ON MENTAL HEALTH AND AGING Lila P.M. Starr Adult Mental Health Specialist Chairperson, NASMHPD Older Person Division Iowa Department of Human Services 1305 E. Walnut Hoover Building, 5th Floor Des Moines, IA 50319 515-281-7270 Lstarr@dhs.state.ia.us