A Clinical and Community Perspective in Treating Older

Adults

Dr. Stephen J. Bartels, MD, MS

Vicki Rodgers, MS, LPC

Why are Senior programs needed?• By 2020, the 60+ population will have more

than doubled.• As they age, some seniors have little or no

support from family and friends.• The average person is not aware of

resources in their community.• Seniors face specific age-related challenges.

• Connecting these seniors to resources may improve their lives.

• Depression is not a normal part of aging and research shows seniors are as responsive to treatment as young adults.

• High prevalence of

suicide.

Older Population by Age: 1900-2050Source: U.S. Bureau of the Census

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Nu

mb

er

(00

0s

)

65-74 75-84 85+

Mental Health Concerns

• Higher rates of “minor” depression.• 27% have depressive symptoms causing some

impairment.• 20% of elders have a debilitating level of

anxiety with even higher rates among the very old.

• 63% of those age 65+ presenting for Senior Reach services have an unmet need for mental health services.

• Alcohol/drug abuse is a growing problem among older adults.

Access Barriers Seniors Face• Ageism• Health or physical limitations• Loss of self (cognition, independence,

purpose)• Loss of family, friends, home• Fear of dependency and fear of death• Lack of money or knowledge of resources

Why some older adults don’t ask for assistance

• Stigma in seeking help• Concern over loss of independence or

control over their life• Fear of being placed in a nursing home• Don’t want to be a burden• Fear of dependency• Fear cost of services• Fear they may be exploited financially

Is Community-Based Mental Health Outreach for Older Adults an

Evidence-based Practice?

A Systematic Review of the Research Evidence

Steve Bartels MD, MS

Director, Dartmouth Centers for Health and Aging

Overview• Older Adults with Mental Disorders in the

Community and Unmet Need• Models : Case Identification and

Multidisciplinary Outreach Teams• Systematic Review of the Evidence• SAMHSA Implementation Initiatives and

Resource Kits

Unmet Need for Community Treatment

• Less than 3% of older adults receive outpatient mental health treatment by specialty mental health providers

– (Olfson et al, 1996).

• Only 1/3 of older persons who live in the community and who need mental health services receive them

– (Shapiro et al, 1986).

Falling Through the Cracks• Community Mental Health Services

• Under-serve older persons• Lack staff trained to address medical needs• Often lack age-appropriate services

• Principal Providers: Primary Care and Long-term

Care • Medicare

• No general outpatient prescription drug coverage & lack of mental health parity

Fragmentation of the Service Delivery System

•Primary care•Specialty mental health•Aging network services•Home care•Nursing Homes•Assisted Living•Family caregivers

“The advantages of a decisive shift away from mental hospitals and nursing homes to treatment in community-based settings today are in jeopardy of being undermined by fragmentation and insufficient availability of services.” (Admin. on Aging, 2000)

Outreach Models

• Case Identification: Identifying older persons in need and linking them to appropriate services

• Multidisciplinary Outreach Treatment Teams: Providing MH/SA services to older persons were they live or spend time in the community

Case Identification: Overview of Findings

• 2 studies – 1 controlled prospective study– 1 comparison group study

• Support for use of gatekeepers (non-traditional referral sources) in identifying socially isolated mentally ill older adults.

Outreach Case Identification Programs

• “Gatekeeper” Model– Trains community members to identify and refer

community-dwelling older adults who may need mental health services

– Identifies isolated elderly who are not receiving formal mental health services

Florio & Raschko, 1998

Case Identification: The Gatekeeper Program (Study Descriptions)

“Gatekeeper” Case Identification Evaluation of the Evidence-base

• An observational and pre-post study find differences between older persons identified by gatekeepers and those identified by conventional approaches

• However, studies do not use a randomized design and are conducted by the same research group

Multidisciplinary Outreach Teams: Overview of Findings

• 12 studies – 5 RCTs– 1 quasi-experimental study– 6 uncontrolled cohort studies

• Home and community-based treatment of psychiatric symptoms improved or maintained psychiatric status.

• All RCTs: Improved depressive symptoms • 1 RCT: Improved overall psychiatric

symptoms

Multidisciplinary Outreach Teams (RCT Study Descriptions)

Multidisciplinary Outreach Teams (RCT Study Descriptions-Cont)

Author,Yr

Model Setting

Diagnosis Age

Banerjee, 1996

Psychogeriatric team treatment for elderly receiving home care

Home Depression 80.7 (6.8)

Waterreus, 1994

Blanchard, 1995

Nurse case management implementation of a care plan created by a hospital-based psychogeriatric team

Senior Public Housing

58% Minor Dep23% Major Dep6% Dementia

73.0 (8.5)

Results of Outreach RCTs:% Recovered from Depression*

0%

10%

20%

30%

40%

50%

60%

70%

Waterreus Ciechanowski Banerjee Llewelyn-Jones

Intervention Control

* Greater than 50% reduction in symptoms or meeting syndromal criteria

Outreach Programs (Example)• Psychogeriatric Assessment and Treatment in City

Housing (PATCH) program. – Serving Older Persons in Baltimore Public Housing

• 3 elements– Train indigenous building workers (i.e.,managers,

janitors,) to identify those at risk – Identification and referral to a psychiatric nurse – Psychiatric evaluation/treatment in the residents home

• Effective in reducing psychiatric symptoms– Rabins, et al., 2000

Multi-disciplinary Outreach TeamsEvaluation of the Evidence-base

• Multiple RCTs by different research groups find better outcomes for depression compared to “care as usual” control groups

• Combined Case Identification and Outreach treatment also effective

• Evidence supports effectiveness for depression:Effectiveness for other disorders uncertain

Conclusions and Implications for Services

• We know that community outreach teams are effective in the treatment of depression for older persons

• The Gatekeeper model of case identification may be effective in identifying and referring at-risk isolated older persons

• The Challenge: Dissemination, Implementation, and Financing of Outreach Mental Health Services for Older Persons

SAMHSA Initiatives

• SAMHSA’s Older Americans Substance Abuse and Mental Health Technical Assistance Center

• SAMHSA’s Implementation Resource Kits for Depression in Older Adults

Older Americans Substance Abuse & Mental Health Technical Assistance Center

• Provide technical assistance with respect to the prevention and early intervention of:– Substance abuse– Medication misuse and abuse– Mental health disorders– Co-occurring disorders

• Dissemination and implementation of evidence-based and promising practices

Overview of Substance Abuse & Mental Health Problems in Older

AdultsBartels SJ, Blow FC, Brockmann LM, Van Citters AD. Substance Abuse and Mental Health Among Older Adults: The State of Knowledge and Future Directions. Older Americans Substance Abuse and Mental Health Technical Assistance Center. 2005.

Available at: http://www.samhsa.gov/OlderAdultsTAC/

Review of Prevention EBPs for Older Adults

Blow FC, Bartels SJ, Brockmann LM, Van Citters AD. Evidence-Based Practices for Preventing Substance Abuse and Mental Health Problems in Older Adults. Older Americans Substance Abuse and Mental Health Technical Assistance Center. 2005.

Available at: http://www.samhsa.gov/OlderAdultsTAC/

EBP Implementation GuideBartels SJ, Blow FC, Brockmann LM, Van Citters AD. A Guide for Implementing Evidence-Based Practices to Prevent Substance Abuse and Mental Health Problems among Older Adults: Older Americans Substance Abuse and Mental Health Technical Assistance Center; 2006.

Available at: http://www.samhsa.gov/OlderAdultsTAC/

SAMHSA Initiatives

• SAMHSA’s Older Americans Substance Abuse and Mental Health Technical Assistance Center

• SAMHSA’s Implementation Resource Kits for Depression in Older Adults

Target Audiences

• Consumers of Services• Mental Health System

– State Administrators, Provider Agency Administrators, Clinicians

• Area Aging Networks– State Administrators, Local Administrators

• Primary Care Offices Physicians and Care Managers

Components & Learning Objectives

User’s Guide• How to use the “toolkit” • What each target audience can expect to

learn and find in the “toolkit”

Key Issues• Understand the issues of treatment for older

adult depression

Components & Learning Objectives

What Services/Interventions are Available to Treat Older Adult Depression?

• What it means to be evidence-based• Identify available evidence-based and promising

practices• What training resources are available and where to find

themTool Kits for:

• Consumers• Direct Care Clinicians• State Local, and Regional Administrators

Summary• Two ongoing initiatives funded by SAMHSA to

provide resource materials aimed at facilitating implementation of evidence-based practices for settings and providers that care for older adults– Prevention and Early Intervention for substance

abuse, depression, anxiety, and suicide– Evidence-based Treatment Interventions for

Depression

A Community Involved Promising Practice

Vicki K. Rodgers, MS, LPCJefferson Center for Mental Health

What is Senior Reach?• A community based program that trains

volunteers to identify seniors needing help.

• A research project to advance this SAMHSA promising practice.

• A simple way for older adults to get help before a crisis develops.

• A strong partnership between professionals, businesses, and community members.

“Senior Reach has been fabulous! It’s been a lifesaver for us. They helped our families cope with many problems and they have helped our senior population with crisis intervention.”

Adrienne Franseen,

Director of In-Home Care Services

Seniors’ Resource Center

The Partners

TriWest Group

Focus• Identify and provide services to

seniors needing help who have not come to the attention of aging services or mental health systems.

• Develop and train persons in the local communities who can reach out to these seniors and contact Senior Reach on their behalf.

And to…• Offer support and mental health

treatment to identified older adults through a team of professionals.

• Build a strong collaborative partnership between agencies that enhance ongoing services to older adults.

• Make a positive impact on outcomes of isolation, depression, level of functioning, hope, and optimism.

Community Input and Advice• The Advisory Group consists of

members from the four agencies, members of the target population, and about 30 different organizations and agencies representing these counties or the state.

• We ask them to support/refer to the project, review reports, and provide honest feedback about our progress.

Involvement of Older Adults• Advisory Board • Senior Consultants• Focus groups were used at 3 agencies

during project start-up to review development and implementation plan

• Consumer Focus Groups• Consumers review marketing media• Consumers help with newsletter• Volunteers

How does the Senior Reach Program help older adults?

• Expands the resources available in the community for older adults.

• Trains professionals and community members in the needs of older adults.

• Expands community

coordination of services.

Senior Reach has met with overwhelming community response and has exceeded all expectations in training and outreach efforts.

Fidelity to the Model• Two previous programs have produced

research in a “Gatekeeper” model in Iowa and Washington.

• They provided information demonstrating that this model is a SAMHSA promising practice.

• We are hopeful that our research will inform so that this model can be considered an evidenced based practice.

New components to GatekeeperCollect data from the Geriatric Depression

Screen and Colorado Assessment outcomes to help define the positive impact this program has on depression.

Provide treatment and resources for mental health needs. – 50% of those referred in the previous

models could have benefited from mental health services.

– Senior Reach data indicates about 70% need and accept mental health services.

We have had significant (<.05) outcomes using this Senior Reach treatment model in:

*Degree of social isolation*Level of emotional disturbance*Risk for suicide*Geriatric Depression Scale outcomes*Positive activities with others*Overall level of functioning and*Optimism about future outcomes

Recruiting Community Partners• Building

relationships with area agencies and organizations

• Marketing materials

• Newspaper articles

• Cold calls to area businesses, professionals

working with older adults and non-traditional referral sources.

• Senior fairs, health care fairs

Partners are trained to:• Identify/refer older adults in need by

– personal appearance, – mental and emotional states, – personality and physical changes, – poor health, – social problems, social isolation,– substance abuse, – caregiver stress, – abuse or neglect, – financial hardship, and – risk factors of suicide.

Who are Senior Reach Partners?• Employees of

agencies, corporations (UPS) and businesses (the local diner)

• Older adult volunteers

• Utility workers• Landlords• Bankers• Staff at senior

centers

• Apartment managers• Postal carriers• Clergy/congregation

members• Pharmacists• Grocery clerks• Policy officers• Firemen• Civic club members• Senior peer counselors• Home health staff

Referral sources say…“I’m glad there is a program to turn to – that will

help with my mom.” Tom, Adult Son

“Intervention by Senior Reach has made a tremendous difference for my client.”

Veronica, Case Manager

“Our partnership really made the difference in

this person’s life.” Diane, Adult Protection

Clients say…“Senior Reach has been my life-line!”

Mike, age 62

“ One angel sent another angel at a time I most needed help.”

Betty, age 79

“I don’t know what I’d do without you during this crisis.”

Alma, age 62

How to implement a similar program in your community – Use a best practice model for change!

Step 1: The vision• Review what your

community offers for older adults.

• Look for gaps in community services.• Identify successful programs in similar

communities. • Bring together all the players.• Be willing to compromise, share and look for

resources.• Get a commitment from collaborators.

Step 2: Infrastructure activities to support services

– Refine needs assessment – Strategic planning for project

development and limit scope creep.– Review ways to increase case finding and

referrals from ethnic and racial minorities.– Determine what the community

understands about suicide, mental illness and older adults.

• Continue building consensus with other agencies and groups.

• Use realistic and older adult-friendly flow of services to provide linkage and coordinated service planning.

• Invite ongoing involvement from target populations, families, and advocates.

• Start community awareness projects to recruit and train.

Step 3: Install in your community

Thanks for letting us share

our thoughts about services to older adults

with you!