PRE-TEST EVALUATION

SPEAKERS: Barbara Speedling, BS- Lee Hyer, Phd TITLE: Making a Difference Where It Matters

September 25, 2015 Oklahoma State University, Tulsa, OK

PARTICIPANT NAME: DIRECTIONS: Please circle the best response. Submit the completed post-test to the conference staff person at the break. Thank you!

1. A PASRR Level I Screen is required as a component of the admission application to an Article 28 nursing facility.

a. True b. False

2. A person must be rescreened following a significant change in mental health. a. True b. False

3. At later life the treatment of anxiety and depression differ:

a. Anxiety is best treated by only psychotherapy b. Depression is best treated by medication c. Anxiety can be best treated by medication and then psychotherapy d. Only cognition matters in these two problem areas

4. Perhaps the central feature of later life psychotherapy is

a. Cognitive Behavioral Therapy b. Problem Solving Therapy c. Interpersonal Therapy d. Careful Alliance and Validation

Hyer, L. (2014). Psychological Treatment of Older Adults: A Holistic Model. New York: Springer Press

9/8/2015

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Other Brain Stuff…Plus Lee Hyer, PhD, ABPP

Core Concept

• Millon: “Assessment is an eminent theoretical process which requires a weighting of this and a disqualifying of that across the idiosyncrasies and commonalities of methods and data sources through multiple iterations of hypothesis generation and testing. The ideal result is a “theory of the client,” a theory in which every loose end has been tied up in a logic so compelling that it seems to follow from a logic of the client’s own psyche, so convincing that one gets the feeling that things could not be otherwise.”

Graphic summary of the multi-factorial relationships between age, genetics, vascular risk factors, and Alzheimer’ s disease

that results in cerebral amyloid angiopathy (CAA) or cerebrovascular disease (CVD) that lead to cerebral microbleeds

(CMB), white matter hyperintensities (WMH), infarction and brain atrophy all of which contribute to reduced cognitive

ability (Lockhart, S., & DeCarli, C., 2014).

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Cognition

Measure Healthy Intact Mildly Problematic Problematic or Syndromic

Description

Normal memory and fully oriented, these patients will display good judgment and problem solving skills.

Memory loss that interferes with everyday activities, difficulty with time and/or place orientation, difficulties with abstraction and problem solving, but social judgments are intact.

Severe memory deficits, inability to retain new information, difficulty with orienting time and place, markedly impaired abstraction and social judgments.

MoCA 27-30 22-26 ≤21

MMSE 27-30 21-26 ≤20

Trails A ≤ 46s 47-70 ≥ 71

Trails B ≤ 115s 116-182 ≥ 183

Come Degrade with Me

Relationships Between Depression, Dementia, & MCI

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Kirton et. al, 2014

Kirton et. al, 2014

Prevalence of MRI infarction by decade of life among subjects of the Framingham Heart Study (Lockhart, S., & DeCarli, C., 2014).

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Oldest Old

• Biomarkers not assessed. AB42, tau, phospho tau not evaluated. PET fMRI not well assessed. Even vascular data are missing

• Do oldest old have atrophy rates like normal aging or do they look like pathological processes like MCI? WMH are prevalent.

• Sweden: 48% of residents 95 or > not demented still needed help with ADLs.

• Interesting: dementia prevalence > MCI rates.

Function

• Well-being is complex.

• Assimilation and accommodation: Older adults conserve resources and disengage from unattainable goals. The decline in function is progressive, starting out with more sophisticated IADLs (managing finances, driving, handling medications) and segues to the faltering of ADLs.

• Meta-analysis of 11,960 subjects showed a Q value of .88 for the use of function measures to diagnose dementia (Castilla-Rilo, et al., 2007).

• 40% of variance of cognition: Add function to cognition and get best results.

• Best markers for dementia is Trails B and FAQ

Depression Measure Healthy Intact Mildly Problematic Problematic or

Syndromic

Description

The patient is not depressed, mood is expressed in a healthy range and not consistently low.

The patient may have a subclinical depression or dysthymia. Mood is slightly depressed without significant distress or impairment.

The patient is likely experiencing depressed mood, anhedonia, and/or suicidal ideation. Many DSM-5 symptoms will be endorsed, some with great severity. Functioning is impaired

BDI-II ≤10 11-22 ≥23

PHQ-9 ≤6 7-11 ≥12

GDS-SF ≤5 6-10 ≥11

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123456789

10Problem

Moderate

Mild

Anxiety Measure Healthy Intact Mildly Problematic Problematic or

Syndromic

Description

Daily functioning is not impaired by worry or fear.

Some activities are impaired by worry or fear, but the person is still functional at work and interpersonally.

Some activities are impaired by worry or fear, but the person is still functional at work and interpersonally.

GAD-7 ≤6 7-14 ≥15

BAI ≤9 10-16 ≥17

STAI ≤29 30-44 ≥45

MBMD Anxiety ≤50 51-80 ≥81

SAST ≤21 22-29 ≥30

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10Problem

Moderate

Mild

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Health Measure Healthy Intact Mildly Problematic Problematic or

Syndromic

Description

Bodily function is normal. The patient has few or no complaints of pain and no chronic conditions which are likely to shorten life or reduce quality of life.

Minor health concerns which may include lesser chronic conditions. Quality of life is impacted, but not debilitating so. The patient’s ability to experience and engage in life is not compromised.

Basic ADL and IADLs are compromised by the patient’s health state. Ability to work and/or enjoy life is drastically impacted by health state. Chronic conditions which are likely to shorten life or contribute to dysfunction are present.

Number of Chronic Illnesses

≤1 2-3 ≥4

Epworth Sleep Scale ≤10 10-12 ≥12

Pain Visual Analogue Scale

≤44 mm 45-74 mm ≥75 mm

Cigarette Use Never smoked Smoked 100 or more but not a current smoker

Current smoker

Exercise >30 minutes everyday

30-60 minutes/ 4 days week

Housework, inactive

Alcohol Consumption ≤7 drinks per week if the patient is not on

medication

≥7 drinks per week if the patient is not on

medication

≥7 drinks per week if the patient is on medication known to interact with

alcohol

BMI 18.5 – 24.9 25-29.9 Under 18.5 or over 29.9

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10Problem

Moderate

Mild

Life Adjustment Measure Healthy Intact Mildly Problematic Problematic or

Syndromic

Description Overall lifestyle is positive, patient engages in the 7 core components of lifestyle. Little or no recreational drug use, including tobacco. Alcohol consumption is at or near the range recommended by the CDC.

Lifestyle choices are likely to contribute to disorder or have begun to do so. The patient consumes tobacco and/or higher than recommended amounts of alcohol. up to 3 components of the core components of lifestyle are not being fulfilled.

Lifestyle is compromising patient’s mental and/or physical health. Self-care is lacking or not present. Enjoyment of life is severely limited by lifestyle choices.

Modified Sheehan Disability Scale

≤9 10-19 ≥20

SF-12 ≤10 11-18 ≥19

Duke-UNC FSSQ ≥25 16-24 ≤15

Relationship Status Married/in a Relationship

Single/divorced Widowed in the last five years

Caregiving No needs Part time Full time or Part time with problems

Income by Poverty line

≥400% 2001%-399% ≤200%

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10Problem

Moderate

Mild

What are the Necessary Features for Psychosocial Therapy?

Good Psychotherapy

• Strupp: “Patients progress at their own pace.”

• All forms of therapy address two features at least: a new understanding and a new experience

• It originates from within and from without

• Techniques are placebo delivery devices

• Success depends on the extent that Rx matches shared social constructions about what it means to be remoralized or cured in a culture.

• This depends on the conviction by the patient that the therapist cares and is competent.

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Whole Person Dementia Assessment Approach

Watch and Wait Checklist

Watch and Wait Core Category Check

Validate Problem

Psychoeducation of Model

Assessment

Monitoring

Case Formulation

Alliance

Validation

• “The research shows an effective psychotherapist is one who employs specific methods, who offers strong relationships, and who customizes both discrete methods and relationship stances to the individual person and condition. This requires considerable training and experience; the antithesis of ‘anyone can do psychotherapy’.” John Norcross

• APA: EBP applies • All depression and anxiety behaviors make sense: “They are better than even more pain of…

failure, confusion, etc.”

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Alliance

• 1. Emotional bond between T and Pt

• 2. Confiding and healing setting

• 3. Therapist provides a psychologically derived and culturally embedded explanation

• 4. Explanation id adaptive (can work) and is accepted by the patient

• 5. Set of procedures or rituals engaged in by the patient and therapist that leads to the patient enacting something positive and adaptive.

Monitoring

• Monitoring techniques in depression

• Identifying goals – short and long term behavioral goals can be planned at home based on feedback.

• Reward planning – have patient list positive behaviors enjoyed and monitor these.

• Activity scheduling – have patients schedule rewarding activities, rating for pleasure and mastery. Self-monitor.

• Graded task assignment – have patient assign increasingly demanding tasks.

• Self-reward – have the patient increase use of positive self-statements and identify tangible reinforcers

• Decrease rumination – have patients develop distractions or active behaviors to replace passivity and rumination.

• Social skills training – Help patient develop positive behaviors toward others, e.g. complimenting and reinforcing other people.

• Assertiveness training – help patient deal in clear and assertive communication.

• Problem solving training – help patient in problem recognition, definition, identifying resources, and generating solutions

Psychoeducation

• Advocate therapeutic alliance

• Integrate care

• Strategic long term perspective The more treatment continues, the less nothing happens

• Assess brain/Health literacy/Compliance

• Watch out for pain, sleep, comorbidities

• Attitude counts

• Home care is a possibility

• Consider pre-therapy preparations

• Self-help helps

• Problems of old-old are more difficult. Therefore take more time and effort.

• Stressors have an impact: They are orthogonal to cerebral vascular risk factors (CVRF – which reduce treatment efficacy) in predicting depression

• Foster compassionate awareness (mindfulness)

• Be free to “therapize”: Our distinctions are not that clear

• Change is good: small change is also good: change comes from context.

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Recommended Treatment Factors Motivational interviewing

CBT/Behavioral Activation

Interpersonal Process Therapy

Problem Solving Therapy

Transdiagnostic application

Prevention

Case manager

Exercise

Modules

Cognitive Training

Booster sessions

Neuroscience input.

Mrs A

Questions???? Who is this?

Creating Meaningful, Satisfying Lives One Person at a Time

Page 1 of 2 Barbara Speedling, Quality of Life Specialist

213-37 39th

Avenue, Box 217, Bayside, NY 11361

Bspeedling@aol.com 917.754.6282 www.innovationsforqualityliving.com

WELLNESS: BUILDING THE CAPACITY OF TOMORROW’S OLDER ADULTS

SEPTEMBER 24, 2015

OKLAHOMA STATE UNIVERSITY, TULSA, OK

SPEAKER: Barbara Speedling TITLE: Interactive Panel - Making a Difference Where it Matters

Topic: PASRR Compliance in Long Term Care

Objective: Describe the status of PASRR compliance in long term care relative to the impact on special

needs populations and the remedies required to achieve and sustain quality care and quality of

life.

Summary: Review of recent changes in PASRR regulations concerning discharge planning and a significant

change in condition. Two case studies will be utilized to demonstrate the negative outcome of

PASRR noncompliance:

Case #1: A 36 year old man with a history of cocaine and opioid abuse, homelessness and long-

standing depression with suicidal ideation is admitted to a nursing facility without benefit of a

PASRR Level I Screen being completed. The admission application does not reference his

recent hospitalizations for severe depression or his attempted suicide that occurred the previous

year. The Admissions personnel do not understand the PASRR requirements and fail to ensure a

Level I Screen is obtained and reviewed as a necessary component of the admission application

(Ref. F285)

Outcome: The resident is admitted and placed on the facility’s unit for people with

dementia because he was agitated upon learning that he was being admitted to a nursing

facility and not being discharged to the community. He attempts to leave the facility that

first night saying the environment is making him think more about suicide than before.

He is then fitted with a wander alarm bracelet and identified as an elopement risk, but the

motivation for his behavior and his need for psychiatric intervention is not addressed. He

manages to remove the stop on the window in his room in the early morning hours and

leaps to his death.

Case #2: A 54 year old man with a diagnosis of paranoid schizophrenia has been living in a

nursing home for two years. A PASRR Level II Recommendation was appropriately developed

pre-admission and a plan of care developed incorporating those recommendations. Since his

initial admission, the resident has stopped seeing the psychologist and has refused his medication

on several occasions. He reports to a housekeeper he has developed a relationship with that he is

hearing voices and is suspicious of his roommate. He thinks his roommate is stealing money and

food from him. The housekeeper reports this information to the Charge Nurse who fails to note

Creating Meaningful, Satisfying Lives One Person at a Time

Page 2 of 2 Barbara Speedling, Quality of Life Specialist

213-37 39th

Avenue, Box 217, Bayside, NY 11361

Bspeedling@aol.com 917.754.6282 www.innovationsforqualityliving.com

the change in condition in the 24-hour report or to make the Nursing Supervisor aware. No

action is taken in response to his increasing hallucinations or his failure to follow the treatment

plan.

Outcome: Several days after reporting his thoughts to the housekeeper, he assaults his

roommate while he is sleeping, sending him to the hospital where he eventually dies from

his injuries. The resident is arrested and taken to the County jail where he continues to be

without proper intervention for his illness. Failure to recognize and act on the significant

change led to an avoidable incident that further delayed appropriate care and treatment to

the detriment of this resident.

Recommendations:

1. Ensure appropriate education and training for all involved staff in the PASRR requirements;

2. Develop quality monitoring systems to ensure compliance with F285 relative to admission applications;

and

3. Create systems to ensure that the requirements for rescreening following a significant change are met.

*I have no actual, potential or perceived conflict of interest.*

   

 

POST-TEST EVALUATION

SPEAKERS: Barbara Speedling, BS- Lee Hyer, Phd TITLE: Making a Difference Where It Matters

September 25, 2015 Oklahoma State University, Tulsa, OK

PARTICIPANT NAME: DIRECTIONS: Please circle the best response. Submit the completed post-test to the conference staff person at the break. Thank you!

1. A PASRR Level I Screen is required as a component of the admission application to an Article 28 nursing facility.

a. True b. False

2. A person must be rescreened following a significant change in mental health. a. True b. False

3. At later life the treatment of anxiety and depression differ:

e. Anxiety is best treated by only psychotherapy f. Depression is best treated by medication g. Anxiety can be best treated by medication and then psychotherapy h. Only cognition matters in these two problem areas

4. Perhaps the central feature of later life psychotherapy is

e. Cognitive Behavioral Therapy f. Problem Solving Therapy g. Interpersonal Therapy h. Careful Alliance and Validation

PARTICIPANT EVALUATION FORM

SEPTEMBER 24, 2015 WELLNESS: BUILDING THE CAPACITY OF TOMORROW’S OLDER ADULTS

SPEAKER: Barbara Speedling, BS, Lee Hyer, PhD, & Edward Kako, PhD, MSc TITLE: Making a Difference Where It Matters

Your evaluation of the program and faculty is very important. It will help us improve our program & serve you better. We review each evaluation, so please consider each question carefully. Please indicate if you are applying for CE credit. Thank you for your input.

Name: _________________________________________________ Date: _______________________

CE Credit: � Nursing � LADC � MSW � LPC � LMFT � CFLE � OT � PT � NAB

Please indicate how well the speaker met the following objectives:

1 Strongly Disagree

2 Disagree

3 Agree

4 Strongly

Agree NA

Learning Objective 1: Participants will be able to describe the significance of the most innovative and effective screening and evaluation tools needed to identify and serve individuals with a PASRR disability or mental health concern.

� � � � �

Learning Objective 2: Session participants also will describe the five core components of biopsychosocial care in outpatient settings, especially as applies to the mental health and older adults.

� � � � �

Please indicate your answers to the following statements:

1 Not Very

Likely

2 Probably

Not

3 Very

Probable

4 Definitely

NA

Presentation content enhanced my knowledge of Gerontology and Geriatrics. � � � � �

Presentation content will be used to alter my professional practice. � � � � �

Presentation information will be applied to my professional practices. � � � � �

What suggestion do you have for improving this course/session?

SEPTEMBER 24, 2015 - (continued) WELLNESS: BUILDING THE CAPACITY OF TOMORROW’S OLDER ADULTS

SPEAKER: Barbara Speedling, BS, Lee Hyer, PhD, Edward Kako, PhD, MSc

Please indicate your answers on presentation delivered

1 Poor

2 Satisfactory

4 Good

5 Excellent

Materials were useful. � � � � Speaker was prepared. � � � � Speaker was knowledgeable. � � � � Speaker was organized. � � � � Speaker’s presentation style was appropriate � � � � Speaker provided opportunities to ask questions. � � � �

What ideas do you have for improving the current session? What ideas have you taken away from the session? Please explain how session ideas will be used to alter your professional practice. Please explain how session ideas be applied your professional practice. List other topics of interests. General Comments: