The Honest Aging Monthly Issue 6 Feature Article MENTAL HEALTH ISSUES AND SUBSTANCE ABUSE AMONG THE ELDERLY AS SEEN THROUGH THE EYES OF A SOCIAL WORKER The Honest Aging Monthly aims at discussing all topics related to aging: what happens to the body, the mind as we age, and also the societal framework during the advanced years. This issue contains the first article of a series dealing with professionals, who provide assistance to older individuals, specialists such as physicians, nurses, social workers, home care providers, and institutional caregivers. Social work for the elderly has become an area of high demand and further specialization. It is predicted that in the year 2030, 20% of all Americans will be older than 65 years. It is estimated that at least 70,000 social workers specialized on aging will be necessary already by 2020. To meet this increasing demand, several universities are offering dedicated programs in Geriatric Social Work 1. Recent discussions on health care in the media have made us aware that a large amount of money and provider time goes to the relatively small fraction of the people who are worst off. The same holds true for social work, where poverty, poor education, and illness can combine to extreme situations, which require a lot of attention. These individuals typically rely on television as the main source of information, and they are unlikely to be among the readers of the Honest Aging Monthly. Nevertheless, we hope that the descriptions of personal problems and 1
the general comments in this article find the interest of our readers. Specifically, the article discusses social work for elderly people with mental health or substance abuse issues. When asked to describe their work, social workers tend to start with descriptions of specific clients. An elderly man walks into in a mental health support center in a small Alaskan town. At first glance the man seems no different than anyone else there. Repeating discussions over time however show that hidden underneath the folksy, smoky appearance and odor there are dark aspects to this individual; he is at risk of being sent to prison, wanted for a small crime related to substance abuse that he committed in a different state. He thought he could outrun the past and not be punished. He fears the consequences for his new life, fears becoming an outcast here as well. He grudgingly states that, if necessary, he would tolerate being imprisoned in jail in another town, but not in this town. He is afraid to show his face and is tired of life. He is disconnected from those around him, and says I want to die and I came to Alaska to die. This is an extreme case but the man s basic problems and concerns reflect common issues for the aging population. A surprisingly large fraction of older individuals are given psychiatric diagnoses. Many have histories of substance abuse. Estimates indicate that in the U.S. approximately 20% of the elderly population is facing mental health or substance abuse issues 2. Many of these individuals are widowed, solesurvivors, or forsaken by the very people, their families, who should help them. Some don t understand their diagnoses or are in denial. Some of them, after struggling with a mental health issue their entire lives, have given up and wish to die. For those fortunate enough to have supportive families or other social networks, life in later years can be pleasant even if there are mental health issues. They tend to be surrounded by grandchildren, or greatgrandchildren, and have their own children as support. Even for these fortunate individuals, there is the question of family dynamics that needs to be looked at. Geriatric social workers know of families who do more harm than good to their elderly members with mental health or 2
substance abuse issues. For example, they may call or visit in excessive ways. They may make a big fuss about irrelevant little things (i.e. type of diet that is not medically or culturally appropriate or the type of clothes someone wears). In some families, children compete for attention of their elderly parents and maintain sibling conflicts into old age. Some elderly people with chronic mental health conditions push supporting family members away. They estrange their family on purpose, not wanting them to know or for fear of being labeled a bother. A geriatric social worker will ask upfront about surrounding family and social network and explore whether their might be detrimental influences. Such problems tend to be among the most difficult to resolve. The social worker will be guided by experience and intuition, and will use subtle questioning methods to get a picture. There appear to be no helpful statistics or formalized questionnaires for dealing with this specific issue. The available statistics show that a large percentage of older people live alone 2. People with mental health issues are more likely to be found in this group. Functional and positive family networks are particularly important for them. Elderly people with mental health issues or substance abuse problems make the most difficult cases. They often end up homeless, living of Social Security alone and fully dependent on Medicaid or Medicare. Often they have worn their families to the bone, so much so that they are burnt out and unable to help. Many of these individuals encounter the social worker after an initial admission through the emergency department followed by transfer to a geriatric unit, a general psychiatric ward, or a specialized geriatric psychiatry unit. Often they are escorted by the police or hospital security to meet the social workers. Sometimes the social worker needs to reconstruct the personal and family history from scratch because the clients do not remember or refuse to comply. These patients often spend many days in the hospital with little progress. They are given cognitive testing. They are regularly seen by a psychiatrist, who may prescribe new or different psycho- 3
pharmacological medication. A specialized treatment team, typically consisting of a psychiatrist, a nurse, a social worker and a milieu counselor, plans for their discharge. Where will they go from the hospital? They will be discharged with a list of medications, prescriptions and a few days to a week s supply. In addition, they will be given a list of appointments (psychiatrist, medical doctor, therapist), and a place to live. It is the social worker s charge to make these arrangements. The dynamics of the medical teams tend to work well during the residence time in the hospital and also during the discharge process. Nurses and milieu counselors are the ones who know the patients best, since they see them repeatedly and for prolonged periods of time. Psychiatrists control the treatment methodology and the discharge date. Social Workers see patients as often as necessary, and expand the horizon by meeting with family members and former outpatient providers. Despite these efforts, quite often, things fall apart again after discharge. The patients may refuse to take their medications, they may fall back into earlier habits of drug use, they have problems with housing, their social network becomes dysfunctional. Geriatric social workers in hospitals all tell stories of regulars, patients who come through the ward repeatedly and sometimes several times a year. Making arrangements for the time after discharge is relatively easy for patients with effective family support or a secure place in a nursing home. For the others a shelter needs to be found and medical care needs to be organized. The frustration from a social worker s perspective is that they have to rely on a scant list of known places. What can take days to find, and leads to a referral being made, may just be short-term beds, or walk-in shelters. Forced departures will then lead back to the vicious cycle of solitary life and hospitalization. This is either due to the patients not being welcome back as result of behavioral issues, or they are not sick enough or too sick for certain units, or their insurance has lapsed and they cannot afford care, or they are waiting for insurance policies to come through. Those with the 4
most hospitalizations are often the ones who have exhausted their resources, and there are fewer and fewer places for them to go. The ones with the most hospitalizations are not necessarily there by need. In is not uncommon in psychiatric units to find patients who enjoy being a patient. They have shelter, food, and are taken care of. Some of them may fake a physical problem in order to be admitted. Since the hospital cannot turn someone away who comes to an emergency room, there are few counter measures. Unfortunately, while such hospitalizations may seem advantageous at the time, in the long run they are not. The revolving door of a hospital does not help people to cope with life outside of a structured environment. Releasing regular patients from the hospital can be compared to the struggles of someone who is being released from prison and now needs to adjust to the outside world again. For both, the success rate seems to be rather low. It is not surprising that social workers in geriatric psychiatry units tend to question a system set up in such a way that people upon discharge are likely to fail. They point to the need for balance between medical and social work roles in the discharge planning. They emphasize the necessity of better outpatient providers, which are able to help those with chronic mental health and substance abuse issues, so that they do not continually return to inpatient units for stabilization. It is true that many people diagnosed with mental illness cannot be cured at this time and that those with substance abuse issues often know no other way to live, however, the continual revolving door begs for a better system that helps those who truly can and want to change to be more successful. Mental health issues and substance abuse in the elderly population are a most difficult and probably underestimated problem. This feature article has taken a first look at it through the eyes of a social worker specialized in geriatric psychiatry. Future articles will go deeper into the medical aspects. Reliable statistics on the magnitude of the issue seem hard to come by, but those available suggest that the numbers of older people with mental health issue may very well exceed the 20% 5
mentioned earlier. Depression accounts for a significant fraction. The rate of significant depression in older people has been estimated to be up to 5% in the general population and more than 10% in hospitalized elderly patients. Up to 10% of the elderly population has been reported to express feelings associated with anxiety disorders. Chronic substance abuse, alcohol abuse in particular, has been estimated to affect 15% of the elderly population 4. Mental health issues need be considered together with other diseases of the elderly. Chronic diseases of the aging body appear to often lead to mental health problems. It makes intuitive sense that disabling conditions or chronic pain may lead to depression. Alzheimer s disease and related degenerative diseases of the brain are often accompanied by anxiety or psychosis. The presence of depression worsens the prognosis of chronic diseases such as diabetes or bone loss and it may even be a predictor for some of the chronic diseases 5. Quite often, elderly people receive medications for the treatment of the primary disease as well as for accompanying mental health problems. Unfortunately, the current drugs available for the treatment of the mental health issues are not very effective. Drugs to treat anxiety tend to make people excessively drowsy and may lead to inactivity. Antidepressant drugs do not work in all patients and they have adverse effects, which may be exacerbated in older patients. Drugs to treat psychosis can impair cognitive function and may worsen memory loss in people suffering from Alzheimer s disease. Many elderly people use a multitude of different drugs, reflecting multiple medical advice and prescriptions received over many years and often from various providers. Fragmented medical care makes no provision for an integrative look at an elderly patient s drug cabinet. It is not uncommon to find older people who take 10-20 different drugs, some of which will not be compatible with each other and some of which will be largely ineffective. In absence of truly effective drugs, physicians have the tendency to prescribe the poorly effective ones, sometimes just to placate patients and family members who ask for something that might help. In addition, many people obtain additional 6
medication from the increasingly abundant stores of OTC (over the counter) drugs. Future articles of the Honest Aging Monthly will cover these complicated issues. Let s end the current one by going back to the core topic, the social workers as essential care providers for the elderly. Geriatric social work includes much more than mental health and substance abuse. Most hospital wards employ social workers to help with intake, discharge and adjustment issues. Outside of hospitals, geriatric social workers help their clients in assisted living situations and in nursing homes. Their tasks include providing access to resources on insurance, legal, and financial matters, acting as liaison between patient, family members and health care staff, and, counseling, as perhaps the most important activity. The social workers are an integral and vital part of care provision for older people. Very often, they are the only ones with an integral picture of their patients and clients. For this reason alone they tend to be quite influential. The Honest Aging Monthly 2011 References 1. Chicago Tribune, May 5, 2010. 2. Jeste D.V. Archives of General Psychiatry, 56:848, 1999. 3. A Profile of Older Americans: 2010. U.S. Department of Health and Human Services, Administration on Aging, 2010. 4. Hybels C.F. and Blazer D.G., Clinics in Geriatric Medicine, 19:663, 2003. 5. Cizza G. Dialogues in Clinical Neuroscience, 13:73, 2011. Previous feature articles in The Honest Aging Monthly Is Red Wine Making You Live Longer? Issue No. 1, July 2011. What Happens to the Taste of Food and Drink When We Get Older? Issue No. 2, August 2011. Publishing a Novel at 100? Writing Ability and Performance During Aging. Issue No. 3, September 2011. What Happened to the Growth Hormone Anti-Aging Clinics? Issue No. 4, October 2011. What Happens to Smell When We Get Older? Issue No. 5, November 2011. The previously published articles are accessible in Back Issues in the iphone/ipad apps. 7