AIGNA Conference 2016 Presentation by Prof Agnes Higgins

1. Higgins, A. 2016
AIGNA 8th Annual Conference 2016
Thursday 5th May Crowne Plaza Hotel, Dundalk
“Mental Health & Wellbeing for Older People"
Professor Agnes Higgins
School of Nursing and Midwifery
Trinity College Dublin
ahiggins@tcd.ie
Ageing and Mental Health:
beyond dementia
Depression

2. Ageing and Mental Health
• Most older people
face life challenges
with equanimity,
good humour and
courage and
manage transition
and stressors with
resilience,
resourcefulness and
hardiness
Higgins, A. 2016
Time of fulfilment

3. Why consider Mental health?
• Mental health is a
precondition to active ageing
and quality of life
• No health without mental
health
Higgins, A. 2016

4. Why Consider?
“It is not enough for a great nation
merely to have added new years to life--
our objective must also be to add new
life to those years.”
John F. Kennedy
Higgins, A. 2016

5. Why consider?
• Mental health problems
– Barrier to active and satisfying ageing/ negative impact
on quality of life
– 70% of all GP visits have a mental health component
– Prolongs stays in general hospital and increases
recovery time from physical health problems
– Negative impact on motivation and compliance with
rehabilitation ( eg diabetes: medication, diet)
– Increases risk of premature placement in nursing home
– Increase mortality from natural causes
– SUICIDE in older age a major concern
Higgins, A. 2016

6. Silver tsunami
Higgins, A. 2016

7. Mental health problems
Dementia
Bipolar
disorder
SchizophreniaAnxiety
Substance
misuse
Depression
Higgins, A. 2016

8. Depression
• A spectrum of mood disorders
characterized by a sustained
disturbance in
– emotional, cognitive, behavioral,
or somatic regulation
– associated with significant
functional impairment
– a reduction in the capacity for
pleasure and enjoyment
Higgins, A. 2016

9. Depression: Prevalence in older people
Older community
Over 65 years
Major depression
Clinically
significant
depression and
depression
symptoms
Residents in
nursing home
Cognitively intact
Residents in
nursing home
with cognitive
impairment
1-5% 10-15%
10% TILDA
10-20% 40-50%
Higgins, A. 2016
Regan et al 2013; Hassin et al 2005Copeland et al 2004; Beekman et al 1999;Parmelee et al 1989
HIGHER in FEMALES
Gender difference declines with age

10. Under identified
Person Clinician
Higgins, A. 2016
63-80%
Unidentified

11. Lack of identification: WHY?
Clinician
Lack of knowledge
about mental health
Ageist stereotypes part
of normal ageing
Prognostic pessimism
Diagnostic overshadowing
Challenging to
diagnosis
Reluctance to refer to
mental health team
Higgins, A. 2016

12. Lack of identification: WHY?
Person
Less likely to
recognise or
report
Fears of stigma,
institutionalised,
medicated,
Embarrassed to consult GP
Not acceptable to discuss
feelings
Pride of
independence
Stoic: put up with it
May attribute
symptoms to physical
health problems
Unaware of resources
or how to access or
worry about cost of
treatment
Higgins, A. 2016

13. What triggers?
Psychological Social Physical
Higgins, A. 2016

14. • Previous history of depression
• Loss of relationship: bereavement
/separation/divorced
• Loss of role: retirement
• Significant life event: financial
crisis, loss of home, negative
revelation regarding a family
member, loss of valuable or
meaningful object(s)
• Trauma: abuse/domestic violence
• Transfer to nursing home
• Diagnosis of significant physical
illness
• Chronic sources of stress
Psychological
Higgins, A. 2016

15. • Social isolation (living alone)
• Loss of independence
(physical mobility/driving)
• Loss of sensory ability
leading to loss of social
connection
• Loss of social networks and
supportive networks
Social
Higgins, A. 2016

16. • Chronic pain
• Urinary Incontinence (20%)
• Visual Impairment
• Secondary to neurological
disorders, endocrine, COPD,
Cancer, MI, Head trauma
• Secondarily to alcohol and
substance misuse
• Vascular depression
Physical
Higgins, A. 2016

17. Clinical Depression
S
I
G
E
C
A
P
S
DEPRESSED MOOD
PLUS
Sleep disturbance (insomnia or hypersomnia)
Interest diminished (loss of pleasure anhedonia)
Guilt excessive and inappropriate worthlessness
Energy diminished
Concentration impaired (indecisiveness or vacillation)
Appetite disturbance/weigh loss or gain
Psychomotor disturbance (agitation or retardation)
Suicidal ideation (recurring thoughts of suicide or death)
Higgins, A. 2016
2 weeks

18. Level of Emotional Pain
• “I have suffered from severe, recurrent depression
for 40 years. The psychological pain that I felt
during my depressed periods was horrible and
more severe than my current physical pain
associated with metastases in my bones from
cancer.”
• “I woke up in the middle of the night to use the
bathroom and forgot that my furniture had been re-
arranged. I accidentally tripped over my cocktail
table, breaking both of my legs. The pain that I
experience from depression is so much worse than
the pain associated with my breaking both of my
legs.”
Mee et al, J Psychiatric Res2006Higgins, A. 2016

19. Depression: does it look differently
in older person?
• May present with masked”
depression
–less often report
depressed mood,
sadness or guilt feelings
–more often report
physical concerns or
somatic symptoms
–Sudden onset of anxiety
Higgins, A. 2016

20. Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.
Depression – Primary Care
N = 1146 Primary care patients with major depression
Higgins, A. 2016

21. Depression: does it look
differently in older person?
• Psychosis more common: delusions
– Guilt, hypochondriasis, persecution, jealousy
• Hallucinations less frequent
• Psychotic depression accounts for
– 4% depressed elderly
– 20-40% of elderly with depression in inpatient psychiatric
services
• Frequent and severe anxiety and agitation more
common
Higgins, A. 2016

22. Bereavement versus depression
• Depression
•Guilt
•Suicidal thoughts
•Feelings of worthlessness
•Psychomotor retardation
•Prolonged and marked functional impairment
•Hallucinations (not just thinking they heard voice of loved
one, or transiently saw their image)
Higgins, A. 2016

23. Differentiate from Physical illness
• May mimic some
physical conditions
– Hypothyroidism;
– B12, Folate deficiency
– Anaemia;
– Electrolyte imbalance,
– Infections
Higgins, A. 2016

24. Side-effects of Medication ?
– Pain medications: codeine, opioids
– High blood pressure
– Steroids: prednisone
– Hormones: estrogen, progesterone
– Cardiac medications: digitalis, propranolol
– Anti anxiety: benzodiazapines
– Parkinson disease: Carbidopa/Levodopa
– Cancer medications
– Anticonvulsants
Higgins, A. 2016

25. Older adults and Suicide
• Suicide among the 10 leading causes of death
worldwide
• Older people have highest rates in Europe.
• One fourth of all suicides occur in persons  65
• Ireland demographics differ: higher in young
males; however still an issue in older people
• Male 19.1 per 100,000; Female 5.9 per 100,000
• Link between deliberate self harm and suicide
greater in older people
Higgins, A. 2016

26. Higgins, A. 2016
Suicide in the Older Person
• There is a greater lethality of self -destructive acts.
• Demonstrate greater planning and determination to
die. They give fewer warnings.
• Carry a higher burden of physical illness and
physical frailty which renders them less likely to
survive a suicide attempt.
• More likely to live alone and therefore less likely to
be discovered early.
• It has been argued that older people are more
accepting of death
– May view suicide as a less drastic option than younger
people.
– More likely to accept suicide as an option ‘I’ve lived a full
life and it is time’.

27. Recognition of depression
Higgins, A. 2016
ENGAGEMENT

28. Recognition: Engagement
KEY QUESTION TO ASK THE Person
• How is your mood? (use wording for example, “sad,” “low,”
“miserable”,)
• Have you lost interest in anything? (ask about withdrawal,
reduced ability and/or interest in housework, and lack of
interest in family or hobbies).
• Do you get less pleasure from things you usually enjoy?
• How long have you had symptoms?
• Have you been diagnosed before with a depressive disorder?
• Have there been any important health changes within the
past year?
• Have there been any major changes in your life in the
preceding 3 months?
• Have there been any symptoms to suggest underlying
physical illness (for example, weight loss)?
• Have you ever thought you would be better off dead?
(Asking about suicide does not provoke it. CopyrCopyright © 2012. World
Psychiatric Association
ight © 2012. World Psychiatric

29. Recognition: Engagement
QUESTIONS TO ASK SOMEONE WHO KNOWS
THE PERSON WELL
• What changes have you noticed in the
person?
• What is his/her personality normally like?
• Is there a history of depression in a blood
relative?
• Copyright © 2012. World Psychiatric Association
Higgins, A. 2016

30. Scales
• Geriatric Depression Scale (GDS)
– 30 items cut off score of 11 or above
– 15-item cut off score at 5 and above
» (Yesavage et al, 1982-1983)
• Patient Health Questionnaire 9 (PHQ- 9)
– PHQ-9 scores of 5, 10, 15, and 20 represent mild,
moderate, moderately severe, and severe depression
» (Kroenke et al. 2001).
• Cornell Scale for Depression in Dementia
– depressive disorder in dementia.
– This scale incorporates information from a caregiver
» Alexopoulos et al, 1988
Higgins, A. 2016

31. Suicide Assessment:
SAD PERSONS…….a mnemonic
• Sex (male)
• Age (older) – (beginning at age 60)
• Depression
• Previous suicide attempts
• Excessive alcohol or substance misuse
• Rational thinking loss (psychosis)
• Social supports lacking
• Organized plan to commit suicide or attempt
• No spouse or social supports (divorced > widowed >
single)
• Sickness (chronic physical illness)
Higgins, A. 2016

32. Intervention
• Multidisciplinary team
• Structured and meaningful social and
intellectual activities (age and gender appropriate)
• Spiritual and religious activities
• Structured physical activity
• Therapy Art/pet/ CBT therapy
• Promote autonomy and choice
• Problem solving skills
• Family involvement
Higgins, A. 2016

33. Intervention: Medication
• Medication: antidepressant or
antipsychotic
• Polypharmacy
• Choice should be based on
– comorbidities,
– side-effect profiles,
– patient sensitivity ( prior experience of drug
– potential drug interactions,
Higgins, A. 2016

34. Prevention of depression
• Individual level
– Life long learning
– Socialisation
– Physical activity
• Community level
– Strategies to overcome barriers to
community engagement
– Increased recognition and willingness to
access and accept support
Meaningful things to do and someone to talk to
Higgins, A. 2016

35. Depression is a
significant mental
health issue
Recognising
assessing and
referral is
critical
People can and
do recovery if
receive
appropriate and
early
intervention
Higgins, A. 2016

36. Higgins, A. 2016
Professor Agnes Higgins
School of Nursing and Midwifery
Trinity College Dublin
Ageing and Mental Health:
beyond dementia