ADDRESSING DISPARITIES IN BEHAVIORAL …...Nintendo Wii Sports in older adults with SSD (three 35...

Improving the lives of 10 million older adults by 2020 | © 2019 National Council on Aging

National Coalition on Mental Health and Aging

and

National Council on Aging

PRESENT

ADDRESSING DISPARITIES IN BEHAVIORAL HEALTH CARE FOR OLDER ADULTS

2019-2020

August 21, 2019

Improving the lives of 40 million older adults by 2030 | © 2019 National Council on Aging | ncoa.org | @NCOAging

Mission:

To provide opportunities for professional, consumer and government organizations to work together towards improving the availability and quality of mental health preventive and treatment strategies to older Americans and their families through education, research and increased public awareness.

Visit: www.ncmha.org


History, Membership and Activities:

•Formed in 1991 by a group of organizations from the aging and mental health fields

•Comprised of 100 national and state associations, state coalitions, and governmental agencies, e.g., SAMHSA and ACL.

•Co-sponsor events to highlight challenges of mental health and aging

• Identify new approaches to addressing problems.


NCOA: Who We AreWe believe every person deserves to age well

OUR VISION A just and caring society in which each of us, as we age, lives with dignity, purpose, and security

OUR MISSION Improve the lives of millions of older adults, especially those who are struggling


NCOA’s Center for Healthy Aging

• Goal: Increase the quality and years of healthy life for older adults and adults with disabilities

• Two national resource centers funded by the Administration for Community Living ❑ Chronic Disease Self-Management

Education (CDSME)❑ Falls Prevention

• Other key areas: Behavioral health, physical activity, immunizations, oral health


Webinar Series on “Addressing Disparities in Behavioral Health Care

for Older Adults”• Following the May 20th National Older Adult Mental Health Awareness

Day (OAMHD) events, NCMHA developed a plan to collaborate with interested government agencies, private sector groups, and experts to maintain the momentum and recommendations generated from OAMHD.

• A series of webinars during 2019/2020 that target specific topics with a practical focus and accompanying tools/resources to address the needs of older adults with mental health conditions, as well as state/local efforts/best practices.

• A special feature of the webinars will be that the sessions will coincide with monthly, weekly and daily national mental health or aging observances.


Key Objectives of the Webinar Series

• Identify specific approaches that address disparities in behavioral health care for older adults

• Ensure that older adults with mental health and addiction-related conditions are integrated within all MH awareness raising, policy, programmatic and research efforts going forward.

• Raise awareness among primary care, mental health, other health service providers and the aging network about the impact of suicide, opioid use, and interrelated problems, and impact provider practice patterns for older adults.

• Identify specific tools such as geriatric assessment, questions –suicide ideation, firearm presence, opioid use and other screening tools – and detailed guidance.


Webinar Series Roll Out – 2019-2020

July 23, 2019 (2:00 PM EDT) – National Minority Mental Health Month

“Integrating Culturally Relevant Mental Health Services in Primary Care Medicine for Older Adults (Co-sponsored by the Amer. Psychological Assoc.)

August 21 (12:00 PM EDT) – Senior Citizen’s Day

“Prevention and Health Promotion for Late-Life Mental Health Disorders”

September 18 (12 PM EDT) – Suicide and Healthy Aging Month

“Strategies for Reducing Suicide in Older Adults”

October 10 (2:00 PM EDT) – World Mental Health Day

“Home & Community-Based Mental Health Services: Meeting the Needs of Older Adults”


Webinar Series Roll Out – 2019-2020

November 13 – Family Caregivers and Alzheimer’s Awareness Month

“The Invisible Health Care Provider: Family Caregivers of Individuals with Dementia”

January 23, 2020 (12:00 PM EST) – Mental Health Wellness Month

“Solutions to Behavioral Health Workforce Shortages & Lack of Funding”

February 27 (2:00 PM EST) – Eating Disorders and Mental Health Month

“Bridging the Science-Practice Gap: Potential Opportunities for Geriatric Mental Health”

March 26 (3:00 PM EDT) – National Brain Injury Awareness Month

“Traumatic Brain Injury and Mental Illness Among Older Adults: The Problem and New Management Approaches”


Today’s Webinaron “Senior Citizen’s Day”

“Prevention and Health Promotion for Late-Life Mental Health Disorders”

Presenter: Amanda Leggett, Ph.D.

Dr. Leggett is a Research Assistant Professor in the Program for Positive Aging and Geriatric Psychiatry Section of the Psychiatry

Department, at the University of Michigan

Prevention and Health Promotion for

Late-Life mental Health Disorders

Amanda Leggett, PhD

Research Assistant Professor

Department of Psychiatry, Geriatric Psychiatry Section

1. Why prevention?

2. Prevention terminology

3. Risk and protective factors

4. Pharmacological prevention

5. Psychological prevention

6. Other forms of prevention

and intervention

7. Conclusions and future

directions

An ounce of prevention is worth a pound of cure

Benjamin Franklin

Why prevention?

PKU (Phenylketonuria)

• An intellectual and seizure disorder

• Early diagnosis and special diet can lead to normal lifespan and mental development

But what about mental disorders?

Depression is prevalent in older adults

6-10% in primary care

settings

30% in medical and

long-term care settings

(Hindi et al., 2011)

may be more reversible

Subsyndromalstates

Leading cause of years lived with disability worldwide

Mental and substance use

disorders(Whiteford et al., 2013)

Excess mortality after myocardial infarction, stroke and cancer

Depression results in (Hindi et al., 2011)

Major risk factor for suicide

Especially in older white

men(Van Orden & Conwell, 2011)

Shrinking number of specialty geriatric mental health providers

Importance of prevention:Reducing other downstream

negative outcomes

•Cognitive decline

•Better pain control

•Caregiver burden

•Cardiovascular and cerebrovascular health

•Healthcare costs

Whiteford, H. A., Degenhardt, L., Rehm, J., Baxter, A. J., Ferrari, A. J., Erskine, H. E., ... & Vos, T. (2013). Global burden of disease attributable to mental

and substance use disorders: Findings from the Global Burden of Disease Study 2010. Lancet, 382(9904), 1575–1586. (PubMed ID: 23993280)

http://www.ncbi.nlm.nih.gov/pubmed/23993280

Prevention terminology

Caplan’s (1964) public health framework:

Primary

Secondary

Tertiary

Gordon’s (1987) framework (adopted by the Institute of Medicine):

aimed at an entire populationUniversal

Selected

Indicatedfocus on individuals who already

show early signs or symptoms of a

disorder

target those at high risk

SAMHSA.Gov

Preventionconundrum

If individuals in the control group donot develop the clinical disorder at acertain rate, difficult to see effect inthe group without avery large sample size.

Statistical

significance

Risk and Protective Factors

Risk factors- associated with increased likelihood of a negative outcome

-Early childhood adverse events

-Low SES

-Insomnia

Protective factors-associated with lower likelihood of negative outcome

-Social support

-Self-efficacy

-Higher income

-Mature coping style

-Mastery

Individual, family, community level

-Stress

-Disability

-Isolation

-Bereavement

Livingston, G. et al. (2017). Dementia

prevention, intervention, and care, The Lancet,

390, 2673-2734.

Potential Brain Mechanisms for Preventative Strategies in Dementia

Livingston, G. et al. (2017). Dementia

prevention, intervention, and care, The Lancet,

390, 2673-2734.

Pharmacological prevention

For example…

Preventing relapse

•Reynolds et al. (2006): adults (age 70+) who recovered from MDD and then received two years of paroxetine (Paxil) were less likely to develop a new episode of MDD

Following medical crisis

•Robinson et al. (2008): Adults (age 50-90) who had suffered a stroke in the past 3 months; a 12-month trial

Escitalopram

(Lexapro)

8.5%

Problem-

solving

therapy (PST)

11.9%

Placebo

22.4%

NNT = 8

Limitations of Pharmacological Prevention

Results are mixed

Ethical concerns- prescribing without diagnosed disorder?

Less effective for mild symptoms

Side-effects (e.g. fall risk, cognitive impairment)

Older adults already take many medications

Non-pharmacological treatment preferred by older adults

Psychological intervention

Cognitive Behavioral Therapy Approach

targets dysfunctional thoughts

and levels of activity, aiming to

restructure one’s thoughts and

ultimately change behavior

“Coping with Stress” Course

in nursing home residents with SSD

(13 sessions over 7 weeks) (Konnert, Dobson and Stelmach, 2009)

Scores on the Geriatric Depression Scale

declined significantly and were significantly

better compared to the control group

No significant improvement on CES-D and DASMIE scales

Baseline to 6 months post-treatment

Problem Solving Therapy(Rovner & Casten, 2008)

6 hour-long sessions across 8 weeks that targeted non-depressed individuals with

macular degeneration

At 2 months the experimental group had half the incidence rate of depression

compared to the control group (11.6% vs. 23.2%).

No differences in incidence at 6 months; however, activities were better

maintained in the experimental group.

targeting inaccurate appraisals of problems and teaching skills to solve

these problems adaptively

Other forms of prevention and intervention

Stepped Care

•Van’tVeer-Tazelaar et al. (2009) older adults (75 yrsor older) in primary care over three 4-month periods

• Watchful waiting

• Bibliotherapy (Coping with Depression) with nurse visit and follow-up

• 7 session Problem Solving Therapy

• Primary care referral for antidepressant treatment

Reduced odds

of developing

an anxiety or

depressive

disorder by half

over a year

.12 vs .24

Care management & Suicide Prevention (Alexopoulos et al., 2009)

Primary care patients (age

60+) with minor or

major depression

Care Managers gave recommendations to physicians and helped patients

maintain treatment adherence

More likely to receive

antidepressant and/or

psychotherapy (85-89% vs 49-

62%)

2.2 times greater

decline in suicidal ideation

Internet based

• Spek et al. (2008) adults 50 and over with SSD;10 week Coping with Depression group Course vs. 8 session Internet-based CBT self-help vs. Wait list control

• 62% of internet based below threshold

• 45% of group CBT below threshold

• 38% of waitlist control below threshold

Light therapy

•Re-Timer (30 mins a day for 2 weeks older adults with SSD and poor sleep quality)

•Feasibility and acceptability

• 91% reported it very easy to use

• 93% adhered to the intervention

• 64% would continue to wear

•No adverse events

Depressive symptoms declined and self-reported

sleep improved significantly

Brief Behavioral Treatment of

Insomnia (BBTI): Education about

sleep regulation, what influences sleep,

behaviors that inhibit or promote sleep

•Germain et al. (2006) 60+ yrs with diagnosed insomnia✓Spend only the amount of time

in bed one expects to sleep

✓Wake up at the same time each day

✓Only go to bed when sleepy

✓Get out of bed if not sleeping

• Improved: nighttime awakenings, sleep latency, quality, and efficiency, anxiety and depressive symptoms

Reminiscence and Life Review

• Pot and colleagues (2010): 50 to 90yrs with SSD; 12 two-hour sessions vs. control group which watched a successful aging video

• Discuss life experiences, sensory recall, etc.

• Houses the individual lived in or smells from one’s past

• Significant improvement in depressive symptoms relative to control group

• Not anxiety- both groups improved

• Meta-analysis: reduced depressive symptoms in those with SSD (d-0.37) (Bohlmeijer et al., 2003)

“Exergame” Intervention

•Rosenberg et al. (2010): 12 week Nintendo Wii Sports in older adults with SSD (three 35 minute sessions a week; no control group).

•Depressive symptoms significantly declined

• Reduction maintained at 24-week follow-up

• 37% of participants’ symptom scores declined by 50% or more

•Anxiety scores declined across the intervention, but not significantly

The Silver Song ClubA health promotion example

• Coulton et al. (2015): 14-week 60+ yrs choral intervention (90-minute rehearsals) vs. a normal activity control group

• 6 months: had significantly improved mental-health related quality of life scores (Mean difference= 2.35)

• Cost effective

Social activities-easy to implement, high impact

(Forsman et al., 2011)

Mind-Body

Tai Chi

• Lavretsky et al. (2011): adults 60+ with MDD who only partially responded to escitalopram (Lexapro); 10 week tai chi intervention vs. 10 week health education group• Reduction and remission in depressive

symptoms• improved health-related quality of life• decreased inflammation (C-reactive

protein)

• Also associated with improved cognitive abilities like delayed recall (Lam et al., 2012)

Meditation

• Lavretsky et al. (2013) Dementia caregivers with mild depressive symptoms

• Kirtan Kriya vs. listening to relaxing music for 12 minutes a day for 8 weeks

• 65% showed 50% reduction in depressive sympomts (vs. 31%)

• 43% improvement in telomerase activity (vs. 3.7%)

Conclusions and Future Directions

Conclusions

Pharmacotherapy• efficacy in preventing

recurrence of

depression

• yet antidepressants

and benzodiazepines

are associated with a

number of negative

side-effects for older

adults

Psychotherapy• reduces the

incidence of

depressive and

anxiety disorders

• therapy sessions

are lengthy and

may require travel

to a therapist.

Psychosocial• promoting mental

health

• more indicated and

selective studies are

needed to show

whether psychosocial

prevention can

reduce incidence of

disorder

Limitations

Few studies consider prevention of new incidence over time

Studies need an adequate follow-up period

Very large samples required to detect differences when rate of conversion to disorder is low

Most studies have limited racial and socioeconomic diversity

Future Directions

•A better understanding of risk factors can enable us to target the most vulnerable

•Disabilities, mobility and cognitive capabilities & resiliencies, wisdom, and strength

•Patient centered outcomes research

•Making informed health care decisions, outcomes that matter to patients

•Values and preferences of older adults

Future Directions

•How to reach rural elderly?

• Innovations in technology

•Reach elders with mobility, transportation, or economic difficulties

•Allow individuals to work at own pace

•Shared globally

• Inexpensive

•Reusable

•Downside: crisis assistance and ethical concerns

Future Directions

•Can prevention use biomarkers to target etiology of mental disorder?

•Need for interventions that can be carried out by more than just mental health specialists!

•Work through primary care physicians or social services

•Lay counselor approach in low- and middle-income countries (Dias et al., 2019)

Negative Valence Systems

• Loss

• Fear

Positive Valence Systems

• Reward responsiveness

• Reward learning

Cognitive Systems

• Attention

• Working memory

Systems for Social Processes

• Attachment

• Social communication

Arousal/Regulatory Systems

• Arousal

• Circadian Rhythms

Sensorimotor Systems

• Motor actions

• Habit

Helpful Reviews & Reports

• Bohlmeijer, E., Smit, F., & Cuijpers, P. (2003). Effects of reminiscence and life review on late-life depression: a meta-analysis, 18, 1088-1094.

• Butler et al. (2018) Does Cognitive training prevent cognitive decline?: A systematic review. Annals of Internal Medicine, 168, 63-68.

• Fan & Wong (2019) Effect of cognitive training on daily function in older people without major neurocognitive disorder: a systematic review. Geriatrics, 4, 44.

• Forsman, A.K., Nordmyr, J., & Wahlbeck, K. (2011). Psychosocial interventions for the promotion of mental health and the prevention of depression among older adults. Health Promotion International, 26, 85-107.

• Fournier, J. C., et al. 2010. “Antidepressant Drug Effects and Depression Severity: A Patient-level Meta-analysis.” Journal of the American Medical Association (JAMA), 303(1): 47–53.

• Kim et al. (2017). Cognitive stimulation as a therapeutic modality for dementia: a meta-analysis. Psychiatry Investigation, 14, 626-639

• Lee, S.Y., Franchetti, M.K., Imanbayev, A., Gallo, J.J., Spira, A.P., & Lee, H.B. (2012). Non-pharmacological prevention of major depression among community-dwelling older adults: A systematic review of the efficacy of psychotherapy interventions. Archives of Gerontology and Geriatrics, 55, 522-529.

• McDaid, D., Park, A., & Wahlbeck, K. (2019). The economic case for the prevention of mental illness. Annual Review of Public Health, 40, 373-89.

• World Health Organization (2004). Prevention of Mental Disorders: Effective Interventions and Policy Options. Retrieved from: https://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf

https://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf

Thank you!

•Questions?

• [email protected]

mailto:[email protected]

References

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https://www.samhsa.gov/

What about cognition?

Cognition Focused

Cognitive Stimulation

Cognitive Rehabilitation

Cognitive Training

•COGNITIVE

STIMULATION

•Engagement in a range of activities and discussions

•Typically conducted in groups

•Goal – Improve general cognitive and social functioning

(Kim et al., 2017; Rai et al., 2018)

Evidence for cognitive stimulation therapy

Improvements in self-reported quality of life

Small improvement in general cognitive performance

Cost-effectiveness compared to medications

No improvement in mood or behavioral symptoms

(Kim et al., 2017; Rai et al., 2018; Spector, Orrell, &

Woods, 2010; Woods, Aguirre, Spector, & Orrell &, 2012)

Goal –Improve performancein a specific domain of cognitive function

COGNITIVE

TRAINING

Guided practice on a set of standardized tasks that aim to address specific aspects of cognition such as memory, language, or attention

(Belleville, 2008; Butler et al., 2018; Clare & Woods,

2003; Huckans et al., 2013; Papp et al., 2009)

•COGNITIVE

REHABILITATION

•A collaboration between client, family member (where appropriate) and professionals aimed at devising and carrying out an individually-planned intervention

Goal – Improve personally-relevant areas of cognitive functioning that impact everyday life

(Bahar-Fuchs et al., 2013; Hampstead et al.,

2013; Huckans et al., 2013; Kurz, Pohl,

Ramsenthaler, & Sorg, 2009; Thivierge, Simard,

Jean, & Grandmaison, 2008)

Evidence for cognitive rehabilitation and training

Small improvement in general cognitive performance

Can help change targeted behaviors, may improve instrumental activity of daily living function

Inconsistent results on specific cognitive domains

Studies have not considered conversion to dementia over time

(Butler et al., 2018; Fan & Wong, 2019; Hampstead et al., 2013;

Huckans et al., 2013)

Childhood Aggression

• Community level efforts work!

• Behavioral strategies

• Reducing TV and video game exposure

• Group public feedback with group rewards

• Cooperative games

(Institute of Medicine, 2009)

Current treatments aren’t preventing all disability

Whiteford, H. A., Degenhardt, L., Rehm, J., Baxter, A. J., Ferrari, A. J., Erskine, H. E., ... & Vos, T. (2013). Global burden of disease attributable to mental

and substance use disorders: Findings from the Global Burden of Disease Study 2010. Lancet, 382(9904), 1575–1586. (PubMed ID: 23993280)

http://www.ncbi.nlm.nih.gov/pubmed/23993280

Effort• Number Needed to Treat

• Number if individuals who would need to receive an intervention to avoid one new case of illness

Effect• Attributable fraction

• Cases that would be prevented if a risk factor was eliminated

0

25

50

75

100

No intervention Intervention

NNT

% of condition

that result in

death

25% survive regardless

of intervention

50% survive

because of

intervention

25% die regardless

of intervention

NNT= 100/50 = 2

Pharmacological Prevention

Antidepressants effective in the treatment of depression even among the oldest old (Trappler & Cohen, 1998)

Most older adults recover, but many relapse

Prophylactic antidepressant use as maintenance/relapse prevention

Exercise

• Baker et al. (2007): retirement community residents with no to mild depressive symptomatology

• 10-week exercise program vs. wait-list control

• Three 1-hour sessions a week of:

• high intensity resistance training

• moderate-intensity aerobic training

• balance training

• No differences were found

• Symptoms were low to begin with

• But participants with more symptoms at baseline improved most

Tai Chi

•Lam et al (2012): tai chi offered for 1 year for older adults at risk for cognitive decline vs. stretching/toning exercise group

•Greater preserved cognitive abilities, improvement in delayed recall, and depression scores

•But no change in global cognition test scores

Sleep as a Mechanism for Prevention

•Sleep disturbance and mood are strongly associated• Incidence of depression over time 13.1% in individuals with insomnia

symptoms vs. 4% among those without insomnia symptoms (Baglioni et al., 2011)

•Circadian rhythm disturbances- etiological role?

•Healthy older adults not exposed to enough daily light


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