Treating Co-Occurring Disorders in Geriatric Populations Jeremy King, LMSW, CASAC

Objectives Define co-occurring disorders and discuss how medical conditions should be included in this definition when discussing geriatric substance users Identifying risk factors for geriatric substance use disorders, mental health disorders and medical conditions Compare/Contrast rates of substance use, mental illness and medical comorbidities between geriatric and other populations Identify best practices for the treatment of geriatric consumers with co- occurring disorders

Large Group Brainstorm Name some of the risk factors for geriatric substance use and mental illness.

Definition of Co-Occurring Disorders Co-Occurring Disorders: The co-existence of both a mental health and a substance use disorder-SAMHSA, 2014 If a medical condition and a mental health disorder occur at the same time, are these considered co-occurring disorders? What about a medical condition and a substance use disorder? What is co-morbidity?

Common Substances Used

Frequency of Co-Occurring Disorders (Mental Health Disorders)

Most Common Co-Occurring Mental Health Disorders Current Program Population: Major Depression Mild Neurocognitive Disorder Anxiety Disorders Post Acute Withdrawal Associated Insomnia (not a diagnosis) Bi-Polar Type II

Frequency of Co-Occurring Disorders (Medical Conditions)

Most Common Co-Occurring Medical Conditions Current Program Population: Hypertension Diabetes Hyperlipidemia (Elevated Cholesterol) Benign Prosthetic Hyperplasia (Enlarged Prostate) Osteoarthritis COPD/Asthma Cardiovascular Disease Renal Disease

A Treatment Model for Geriatric Substance Abusers: Assessment Comprehensive evaluation includes battery of mental health inventories and a comprehensive physical exam: Beck Depression Scale Patient Health Questionnaire (PHQ-9) General Anxiety Disorder 7 Question Scale (GAD-7) Self Evaluation Questionnaire (Anxiety) Modified Mini Screen (Psychotic, anxiety, depression, bipolar, PTSD-symptoms) History and Physical with bloodwork (Collect collateral information from previous medical and psychiatric providers if possible; may become easier with EMR interoperability, RHIO’s, DSRIP Reforms, etc.)

A Treatment Model for Geriatric Substance Abusers With Co-Occurring Disorders: Diagnosis Important to note that not all DSM-V criteria for substance use disorders are perfect fits for geriatric substance users: Failure to fulfill role obligations (may already be reduced as nature part of life cycle changes) Recurrent use in situation that are physically hazardous (may no longer drive or travel independently) Social, occupational, recreational activities given up or reduced (See above) Other Factors can impact accurate diagnosis: Geriatric client’s inability to remember details of substance use Unwillingness to disclose information related to mental health disorder because of fear of stigma

Cohort Older Adult Substance Users A Treatment Model for Geriatric Substance Abusers With Co-Occurring Disorders: Treatment Cohort Older Adult Substance Users Take into consideration health problems and physical limitations Respect is extremely important Confrontational approaches are contra-indicated with geriatric populations and individuals with co-occurring disorders Provide safe, quiet, well-lit, and easily accessible environment for geriatric clients with co-occurring disorders Consider shorter treatment services including groups and individual counseling sessions

A Treatment Model for Geriatric Substance Abusers With Co-Occurring Disorders: Treatment Provide services that address various psychiatric and medical conditions Seeking Safety-PTSD Cognitive Behavioral Therapy-Depression, Anxiety, Insomnia, Substance Use Wellness Self Management Plus-Substance Use and Mental Health Disorders Psychiatric Social Work-Complex Case Management

Medication Management Medication management is an important issue for all geriatric individuals. Provide opportunities to teach and educate: While providing medication Brief treatment from RN Psycho-educational seminars Doctor’s Visits Counseling Sessions with clinician Medication Independence Protocol (Being developed, implemented later this year). All non-compliance should be discussed in case conference and documented in clinical chart.

Recreational Services Consider low intensity activities (walking, modified yoga)

Discharge Planning Consider client placement in: Long Term/Short Term Nursing Facility (At least one member of your nursing staff should be trained in administering the PRI) Skilled Nursing Facility/Assisted Living Facility Congregate Care/Transitional/Scattered Site Mental Health Housing Programs (Have one staff member A31 OP Mental Health Treatment Program Consider family members as appropriate

Discharge Planning and Recovery Support Does client belong to health home? Does client qualify for HCBS services? Does client have a PCP in the community? Does the client have a psychiatric provider in the community? Does 822 referral provide geriatric specific services? Does recovery support provider provide geriatric specific services?