PART 2- What is Mental Illness? -Depression, Anxiety Disorders...DISORDERS? ANXIETY •Most common...

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ROAD TO WHOLENESS BEHAVIORAL HEALTH

HOME CARE TRAINING FOR

PARAPROFESSIONALS

All Rights Reserved C & V Senior Care Specialists 2019

PART 2- What is Mental Illness? -Depression,

Anxiety Disorders

PART 2- What is Mental Illness? -Depression, Anxiety Disorders

C&V Senior Care Specialists, Inc.

Katherine J. Vanderhorst, RN-BC,BSN,CCM

Dr. Amy Craven,PT,MS,DPT


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Webinar Objectives

• Discuss the occurrence of depression and anxiety in the elderly.

• Define depression and anxiety diagnoses.

• Identify the co-occurrence of depression and anxiety with the leading medical co-morbidities.

• Assess depression & anxiety in the homebound elderly.

• Describe behaviors that decrease depression and anxiety.

• State patient goals for an episode.


What is Mental Illness?


• A mental disorder, also called a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. ... Mental disorders are usually defined by a combination of how a person behaves, feels, perceives, or thinks.

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How Should We Respond?


• Patience, acceptance, understanding are essentials for working with mentally ill

• Goal to assist patient to be as independent as possible

• Need special interventions

Figure 26. Percentage of long-term care services users with a diagnosis of Alzheimer's disease or other dementias, depression, and diabetes, by sector: United States, 2013 and 2014

NOTES: Denominators used to calculate percentages for adult day services centers, nursing homes, and residential care communities were the number of current participants enrolled in adult day services centers, the number of current residents in nursing homes, and the number of current residents in residential care communities in 2014, respectively. Denominators used to calculate percentages for home health agencies and hospices were the number of patients who received care from Medicare-certified home health agencies at any time in 2013 and the number of patients who received care from Medicare-certified hospices at any time in 2013, respectively. See Technical Notes for more information on the data sources used for each sector. Percentages are based on the unrounded numbers.

SOURCES: CDC/NCHS, National Study of Long-Term Care Providers and Table 4 in Appendix B.


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HOW COMMON ARE THESE DISORDERS?

ANXIETY

• Most common mental illness (18.1%)

• Only 36.9% of those suffering receive treatment

• 3-5x more likely to go to doctor

• Associated with high ER use

• 6x more likely to be hospitalized for psych dx

LEADING ANXIETY DISORDERS

• Specific Phobias-8.7%, women 2x as likely, high in elderly

• Social Anxiety-6.8%, equal among sexes, high in elderly

• GAD-3.1%, women 2x as likely, high in elderly

• Panic-2.7%, women 2x as likely

• PTSD-3.5%, higher in women

• OCD-1%-equal among sexes


HOW COMMON ARE THESE DISORDERS?DEPRESSION

• 37.9% of home health users had Depression Dx

• 6.7% of the U.S. population age 18 and older in a given year.

• Median age at onset is 32.5 years old.

• More prevalent in women

• Leading cause of disability in U.S.

1/2 of those diagnosed with depression are also diagnosed with an anxiety disorder


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SYMPTOMSOVERLAP

HEALTH CARE PROFESSIONALS

MORE LIKELY LOOK FOR DEPRESSION

AND MISS ANXIETY


WHY ARE ADULTS MISDIAGNOSED?

1-Older Adults have difficulty

communicating their experience

2-Anxiety symptoms can mimic side

effects of medications

3- Anxiety symptoms can mimic disorders (Such as SOB can be sign of COPD,CHF, etc.)(trembling can

be anxiety or Parkinson’s)

4-Older Adults with Anxiety present with different symptoms then younger Adults

with Anxiety

5-Not screened for as commonly as Depression


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Depressive Disorder:Major Depression


Defined: when a person is sad with depressed mood or irritable much of each day for two weeks or more. There is a clear change from previous functioning.-Unchanged in DSM-5R.

• The symptoms cause significant impairment or distress in social, occupational, school, recreational, or relational functioning.

• The symptoms are not due to medical condition (hypothyroid), substance use or medication.

Symptoms of Major Depression

❖Anhedonia –lack of pleasure - almost ALWAYS present

❖ Appetite changes – usually weight loss

❖Sleep disturbances – Insomnia (more COMMON) or hypersomnia

❖ Restlessness or psychomotor

retardation

❖ Fatigue – decreased energy

❖ Feeling worthless, guilty, hopeless or helpless

❖ Inability to think clearly or maintain concentration

❖ Difficulty with making decisions

❖ Thoughts of death or suicide: suicide attempts


This Photo by Unknown Author is licensed under CC BY

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DEPRESSION MAY LOOK DIFFERENT BY THE SEXESMEN

•Often deny, don’t recognize symptoms

•Irritable, angry

•More likely to use alcohol and drugs

•Escaping-Turn to outlets-TV, gambling

•More likely to commit suicide

•Becoming controlling, violent or abusive

•Less likely to ask for help

WOMEN (2x as likely)

•More likely to ruminate(dwelling on negative self-talk)

•Crying

•May be triggered by stressful event

•May co-occur with an eating disorder

•Hormonal(post-partum, menopause)

•Feel helpless & hopeless

•More likely to ask for help


DEPRESSION IN THE ELDERLY IS A PERFECT STORM

• WHAT HAPPENS AS WE AGE?• SO MANY LOSSES-JOB,

SPOUSES, CAREER, LEVEL OF FUNCTION(DRIVING)

• DECREASED LEVELS OF SOCIAL INTERACTION

• MEMORY LOSS• MEDICAL ISSUES• SYMPTOMS OFTEN LOOK LIKE

MEDICAL DIAGNOSES• PAIN

• RISK FACTORS FOR DEPRESSION IN ELDERLY

• Being single, divorced, or widowed

• Social isolation

• Lacking a strong support system

• Experiencing numerous stressful life events

• Recent loss of a significant person in their life

• Previous history of depression

• Family history of depression

• Chronic disease or pain

• Alcohol abuse

• Medications-B/P, steroids, arthritis meds


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Anxiety Disorders:


ANXIETY DISORDERS-Generalized AnxietyDisorder***-Separation AnxietyDisorder -Specific Phobia-Social Phobia-Panic Disorder-Agoraphobia

General overview of ANXIETY


A FEELING OF………. UNEASE, APPREHENSION, WORRY, FEAR, NERVOUSNESS, DISCOMFORT, DREAD, DOOM.

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MAY BE ACCOMPANIED BY A VARIETY OF PHYSICAL SENSATIONS SUCH AS PALPATATIONS, SHORTNESS OF BREATH, DIZZINESS ETC…

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Pathological or Abnormal Anxiety vs Normal Anxiety

• Pathological Anxiety:

• Greater Intensity/Longer Duration

• Anxiety does not respond to conscious suppression

• Anxiety is unlinked and not seen as

caused by life events – “ Free floating”

• Anxiety is High and Maladaptive (not being appropriately managed by the individual)

• Symptoms are distressing and impact the normal functioning of the individual


(GAD) General Anxiety Disorders: Signs and Symptoms

➢ The presence of excessive anxiety and worry about a variety of topics, events, or activities. Worry occurs more often than not for at least 6 months and is clearly excessive. (DSM V)➢ The anxiety and worry is associated with at least 3 of the following physical or cognitive

symptoms:1-Edginess or restlessness.2-Tiring easily; more fatigued than usual3-Impaired concentration or feeling as though the mind goes blank.4-Irritability (which may or may not be observable to others)5-Increased muscle aches or soreness6-Difficulty sleeping (due to trouble falling asleep or staying asleep, restlessness at night, or unsatisfying sleep)

• Frequently associated with traumatic events such as a fall or acute illness.• Many individuals with GAD also experience symptoms such as sweating, nausea or diarrhea.• The anxiety, worry, or associated symptoms make it hard to carry out day-to-day activities and responsibilities. They may

cause problems in relationships, at work, or in other important areas.• These symptoms are unrelated to any other medical conditions and cannot be explained by the effect of substances including a

prescription medication, alcohol or recreational drugs.


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https://www.verywell.com/what-does-anxiety-feel-like-6-physical-symptoms-1393151

https://www.verywell.com/how-anxiety-can-cause-relationship-problems-1393090

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An "adult" anxiety

disorder

• Constant and often debilitating worry — usually “worry” about routine events

• Tend to experience more physical symptoms, and less intense emotional disruption.

• Drugs may not be the best choice for older patients because they are more prone to side effects.

• Cognitive behavioral therapy is a good first-line

• 90% of patients w/GAD also have symptoms of another mental health problem, such as depression, dysthymia, bipolar disorder, or substance abuse.

• Tends to be chronic, however, with symptoms that fluctuate in intensity over time.

• 2/3 are women

• May emerge or worsen in conjunction with other serious medical conditions, such as heart disease or chronic obstructive pulmonary disease

LEADING HOME CARE DIAGNOSES & OVERLAP WITH BH DIAGNOSES

• CHF/CARDIOVASCULAR

• Prevalence rates of depression in congestive heart failure patients range from 24%-42%.

• Rates of Anxiety 20-25% in cardiovascular disease

• Prevalence of anxiety 70-80% in pts who have experienced a cardiac event

• WOUNDS

• Persons living in the community with chronic wounds had more mental health problems than those without wounds, and they are less able to cope with stressful events Upton et al., 201

• Those with Depression two-fold increased risk of developing a diabetic foot ulcer

• DIABETES

• Depressive disorders are 3x higher among adults with diabetes than in the general population (Markowitz et al., 2011).

• Depression affects 20% to 40% of individuals with diabetes and is accompanied by an increased risk of myocardial infarction (Home Health NOW)

• COPD

• Prevalence of anxiety ranges between 10% and 19% in Stable COPD

• Prevalence of anxiety from 50 to 75% in severe COPD

• Anxiety in COPD patients is often associated with clinical depression

• In Pts who recently recovered from an acute exacerbation of COPD, the prevalence of depression is high and ranges between 19.4 to 50%.


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http://journals.lww.com/homehealthcarenurseonline/Fulltext/2016/02000/Comorbid_Depression_and_Diabetic_Foot_Ulcers.3.aspx#P97

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NORMALIZE

Depression and Anxiety

Mrs./Mr. Jones – you are dealing with a whole lot of things – you just got out of the hospital; you

are not feeling well, you are worried about……………(fill in the

blanks). I would be very surprised if you were not feeling

a little bit down and even worried or overwhelmed about

your own health. Does that sound right? Am I on target?

Communication Guidelines with Severely Depressed Persons

• 1-When a patient is mute, use the technique making observations: "There are many new pictures on the wall," or "You are wearing your new shoes.“

• 2-Use simple, concrete words

• 3-Allow time for the patient to respond.

• 4-Avoid platitudes, such as "Things will look up" or "Everyone gets down once in a while.“

• 5-Help patient identify one simple thing he/she can do.

• 6- BE PATIENT, BE KIND.


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Communication is so important• “I’m here for you”.

• “I care”.

• "Have You Told Your Doctor How You Are Feeling?“

• "Is There Anything I Can Do to Help?“

• "Do You Need Someone to Talk With?“

• “I understand”.

• “There is help”.

• “This is not your fault”.

• “How can I help”.


Communication is so important

• “You are not alone in this. I’m here for you.”

• “You may not believe it now, but the way you’re feeling will change.”

• “I may not be able to understand exactly how you feel, but I care about you and want to help.”

• “When you want to give up, tell yourself you will hold on for just one more day, hour, minute—whatever you can manage.”

• “You are important to me. Your life is important to me.”

• “Tell me what I can do now to help you.”


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WHAT CAN WE DO?1-Be aware of signs and symptoms of Depression and Anxiety and Report to Case Manager

• LOOK FOR TRIGGERS that need to be reported

2-DEVELOP A THERAPEUTIC RELATIONSHIP

3- Learn how to talk to patients-

• HOW TO “NORMALIZE”

• Don’t minimize how they feel

4-Remind to take medications as ordered

5-MAINTAIN SAFETY

6-FOLLOW THE CARE PLAN THAT INCLUDES DEPRESSION AND ANXIETY MANAGEMENT

7-DOCUMENT WHAT YOU OBSERVE


Symptom Management• 1-Not Eating/Lost Weight

• Offer small high-calorie and high-protein snacks frequently throughout the day and evening.

• When possible, encourage family or friends to remain with the patient during meals or you sit with the patient.

• Ask the patient which foods or drinks he or she likes. Offer choices.

• 2-Not sleeping well

• Provide periods of rest after activities.

• Encourage the patient to get up and dress and to stay out of bed during the day.

• Encourage the use of relaxation measures in the evening (e.g., tepid bath, warm milk).

• Reduce environmental and physical stimulants in the evening—provide decaffeinated coffee, soft lights, soft music, and quiet activities.


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Symptom Management• 3-Not dressing, bathing

• Encourage the use of toothbrush, washcloth, soap, make-up, shaving equipment, and so forth.

• When appropriate, give step-by-step reminders such as "Wash the right side of your face, now the left.“

• Ask when is the best time to “bathe”, “freshen up”

• Use events and appointments as reasons to dress and bathe.

• Offer to take out for a walk, shopping, to eat


Encourage Patients with Depression and Anxiety to

• Eat adequately, stay hydrated-Encourage adequate nutrition

• Sleep well, take naps, stay on a schedule

• Encourage positive coping strategies taught by the case manager

• Encourage relaxation techniques

• Exercise-walk or move with the patient

• Encourage family and friends to visit

• Talk-listen empathetically


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Behaviors that Reduce Depression-Depression Self Management (GOALS)


Safety-communicate any feelings/thoughts of self-harm

Medication management

Maintain adequate nutrition & sleep

Identify relationship(s) for support and reassurance

Identify positive coping strategies & and practice them

Journaling

Socialize with family and/or friends

Exercise routinely

Participate in home health visits

USE THE CAREGUIDE

❖ FOCUS ON TEACHING

o Illness

o Behaviors that reduce depression

o Medication

o Coping strategies

o Mood monitoring

o Telephone Care Management


❖ FOCUS ON REINFORCING POSITIVE STRATEGIES THAT REDUCE DEPRESSION AND ANXIETY

o Encourage client to do the followingo Eat Righto Get enough resto Get some exercise

o Take medicationo Use Positive Coping strategies-Relaxation strategies, breathingo Mood monitoringo Safety

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ENCOURAGE YOUR CLIENT TO ENGAGE IN AN ACTIVITY

-People who are involved in social activities at least two times each week have less depression than those who are not engaged in social activities.

-Engaging in physical activity for 20 minutes a day, 5 times a week, decreases depression and improves health.

WHAT IS AN ACTIVITY YOU CAN DO WITH YOUR CLIENT?


This Photo by Unknown Author is licensed under CC BY-SA

MAINTAIN SAFETY-SUICIDAL

• Immediate warning signs that someone may be thinking of suicide include:

• Talking about suicide or death in general

• Talking about feeling hopeless or having no reason to live

• Engaging in self-destructive behavior (drinking a lot of alcohol, taking drugs, driving too fast, or cutting, for example)

• Visiting or calling people to say goodbye

• Giving away possessions

• DO NOT LEAVE THE PATIENT ALONE

• TAKE ALL THREATS SERIOUSLY

• CALL THE OFFICE/CASE MANAGER


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RED FLAGS TO CALL CASE MANAGER, MD TO BE NOTIFIED❑Thoughts to hurt self or others

❑Hopeless or helpless feelings

❑Overwhelmed by anxious, irritable, angry or empty feelings

❑Unable to get out of bed

❑Not eating

❑Unable to sleep

❑Unable to take medications


CASE STUDY

• Helen is a 73-year-old woman who calls her doctor’s office often. She resides in an ALF and the staff has begun to ignore Helen because her complaints are constant, and no amount of encouragement seems to lessen her worries. Helen depends on her daughter to drive her to frequent medical appts – Helen is “too afraid”. She is frequently concerned about physical symptoms that come and go, and she has many questions about her medications.

• Helen has always been a worrier, but things got much worse after her husband of 40 years died 5 years ago. He had been a significant source of reassurance for her. Once she was alone, she had to find other people to check in with about her worries. Her daughter reports that Helen calls her too often with questions about her health, the grandchildren, and her finances. However, when asked about excessive anxiety or worry by her physician, Helen says, “Oh, no, I don’t worry. I just think too much.”

In addition, Helen does not sleep well; she wakes up often with worries on her mind and cannot get back to sleep. Chronic muscle tension has exacerbated her arthritis, and constant pain has developed in her back and neck. Helen’s daughter also reports that she has been irritable more frequently than in the past, and that her concentration and memory are not as good as they once were. She often looks very sad. Her daughter hired an Aide to be her 4 hours a day.

• You are now with Helen 4 hours a day. How would you help Helen? What should we focus on? How would we talk with her?


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Questions ?

Katherine Vanderhorst, RN-BC, BSN, CCM716-863-0743

Amy Craven, PT, MS, DPT, CCM716-491-2098

cvseniorcare.com

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PART 2- What is Mental Illness? -Depression, Anxiety Disorders...DISORDERS? ANXIETY •Most common...

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