Personality Disorders and Aging

Live event held Thursday, April 24, 2014, 1:30-2:30 pm Eastern Time
(First in the Mental Health and Aging Training Initiative, Series III*)
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SERIES BACKGROUND
This third installment in the series of webinars initiated by the Geriatric Mental Health Partnership (GMHP)--an informal, voluntary group of diverse stakeholders which focuses on geriatric mental/ behavioral health care in the Commonwealth--aims to improve communication and service coordination between the mental/behavioral health and long term care systems to facilitate timely care for older adults in the most appropriate setting. Lack of adequate training regarding the complex needs of an aging population with behavioral health issues has been identified as a major barrier to successfully providing community-based care for these individuals. Six previous webinars have attracted a continuously growing audience, which attests to the unmet need for this type of training. In fact, in 2012, our webinars reached 600 senior service providers and in 2013, more than 1,300 professionals benefitted from our online training.


As the aging population continues to grow, and use of State Hospitals as the site of extended behavioral health care continues to diminish, it is essential that community based staff and providers be prepared for the rapid growth of older adults with behavioral health and dementia-related issues. This is a key issue for workforce development as the Commonwealth prepares for the future. Effective training enables staff to more quickly identify and address behavioral health-related issues before the older adult’s condition declines further or situations escalate to possibly becoming dangerous to other frail elders (or caregivers) nearby. It also helps staff distinguish between behavioral issues which can be safely addressed at the facility (or at home) versus those which constitute a true psychiatric emergency and might require inpatient treatment.
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WEBINAR OBJECTIVE
Personality disorders can have a significant impact on how older adults interact with others, including those attempting to provide long term care or other services. Understanding personality disorders and how to effectively work with individuals affected by them can help staff achieve more productive/ lessstressful interactions with the individuals they are serving.
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INTENDED AUDIENCE
This presentation was intended for staff from many levels, disciplines and settings (both acute care and long term care).  Attendees included, behavioral health staff, nurse practitioners, nurses, CNAs, Nursing Home Administrators, Social Workers and Case Manages from both Acute and Long term care. 
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WEBINAR ACCESS
The live event was open to all and free for all. 

Attendees were required to have a computer with access to high speed internet (to view the slide presentation) and computer speakers OR access to a telephone.  Additional information was provided through the registration form.
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WEBINAR MATERIALS
The webinar was recorded.  

Download the slides as PDF.

 
© 2014 by Lindsey Slaughter. All rights reserved.

The recording of this webinar is at the bottom of this page.
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SUPPORTERS
This event was made possible through a grant from the Virginia Center on Aging's Geriatric Training Education Initiative and supported by the Riverside Center for Excellence in Aging and Lifelong Health, the Virginia Geriatric Mental Health Partnership* and the VCU's Department of Gerontology.




www.excellenceinaging.org/‎



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PRESENTER
Lindsey Slaughter, PsyD, is a licensed clinical psychologist and Psychology Director at Piedmont Geriatric Hospital in Burkeville, VA. Before assuming the director-ship, she served as a team psychologist on the admissions unit of this state psychiatric hospital solely servicing those 65 and older with severe mental illness and/or dementia.  Areas of passion include healthy and successful aging, assessment (such as decision-making, cognitive, personality), and cultural competency. She also enjoys facilitating trainings on various topics such as older adults and behavioral management and working with older adults diagnosed with personality disorders, and supervising graduate level trainees.

She completed her Doctorate of Psychology at Wright State University’s School of Professional Psychology and her internship at Howard University’s Counseling Center. Dr. Slaughter’s other clinical experiences included working in university counseling centers, in outpatient practice, and other inpatient psychiatric hospitals with civil and forensic patients.
MODERATOR
E. Ayn Welleford, PhDreceived her BA in Management/Psychology from Averett College, M.S. in Gerontology and PhD in Developmental Psychology from Virginia Commonwealth University. She has taught extensively in the areas of Lifespan Development, and Adult Development and Aging, Geropsychology, and Aging & Human Values. As an educator, researcher, and previously as a practitioner she has worked with a broad spectrum of individuals across the caregiving and long term care continuum.

As Associate Professor and Chair of VCU’s Department of Gerontology, she currently works to “Improve Elder Care through Education” through her Teaching, Scholarship, and Community Engagement. Outside of the classroom, Dr. Welleford provides community education and serves on several boards and committees.
Dr. Welleford is former Chair of the Governor’s Commonwealth of Virginia Alzheimer’s and Related Disorders Commission, as well as a recipient of the AGHE Distinguished Teacher Award. In 2011, Dr. Welleford was honored by the Alzheimer’s Association at their annual Recognition Reception for her statewide advocacy. Dr. Welleford is the author of numerous publications and presentations given at national, state and local conferences, community engagement and continuing education forums. In 2012, Dr. Welleford was appointed to the Advisory Board for VCU’s West Grace Village project.  She is also the recipient of the 2012 Mary Creath Payne Leadership Award from Senior Connections, the Capital Area Agency on Aging.
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RECORDING


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QUESTIONS POSED AND UNANSWERED DURING THE EVENT

We thank Dr. Slaughter for the additional time taken to respond to these audience-posed questions.

Q: What are you considering "Older Adults" here? 
LS: In this presentation, older adults are considered to be 65 years old and older.

Q: What approach would you take with OA that is depressed, combative, dependent on spouse but shows none of these signs when seeing physician?
LS: I think this would depend upon what role I am playing in this OA’s treatment/recovery, and the depressed OA’s willingness to accept help. If I were in my role as a psychologist (and in that situation, the spouse would likely present in therapy trying to get help for the depressed OA), I would try to help the spouse as the primary client. Then if the combative partner agrees, I would include he/she in marital/family therapy with the primary goal of creating a safe partnership with the two of them. Depending on the situation, that could include any of the following: 1) ruling out of any acute medical issues that could be altering his/her mental and/or behavioral status, 2) psycho-education on depression in older adulthood, 3) behavioral strategies to reduce dependency/maximize independence, and most importantly 4) conducting a risk assessment and creating a safety plan for aggression and suicide (including contingencies if/when aggression arose to level of involving police and/or mental health services like getting an Emergency Custody Order through the CSB). Treatment could also include a referral to psychiatrist for anti-depressant meds and to support groups for depression.

Q: What are the best current successful practices with schizophrenia?
LS: Typically, for all ages, schizophrenia is best treated with a combination of the following, depending on the individual: 1) psychotropic medication (i.e. usually anti-psychotic medications), 2) psycho-social skill building (e.g., establishing/maintaining family/friend support, employment, meaningful activity like volunteering), and 3) psychotherapy, usually cognitive-behavioral approaches focusing on relapse prevention, etc. It often depends upon what resources the individual has; frequently those with schizophrenia have lower socioeconomic status and may require more intensive case management services that include medication management/oversight, transportation to appointments, and Medicaid-sponsored day programming through local CSBs. Moreover, when relapse does occur, and the illness makes the individual unable to care for him/herself, or a danger to him/herself or others, then he/she may be considered for inpatient psychiatric hospitalization by being prescreened through the CSB. 

Q: We need a sequel to this training.
LS: That would be a lot of fun! I’d love to be a part of that.

Q: I would love to see a webinar on PD, Aging and determining capacity.
LS: Awesome idea! So often we emphasize how capacity issues arise with individuals with dementia and other organic cognitive impairments, but we don’t consider how a disorder like a PD could affect one’s capacity to make decisions.

Q: Should PRN psychoactive medication be prescribed for older adults [PRN psychotropic medications = medications given with the aim of changing the patient's mental state on an 'as needed' basis]
LS: Unfortunately I can’t answer that in a “yes” or “no” fashion. It depends on the situation. In general, psychotropics (PRN and scheduled) should be prescribed and titrated in a “start low, go slow” manner in OA. This is because OAs renal capacity (kidney functioning) decreases resulting in more rapid metabolizing of meds. This can lead to adverse side effects that may not otherwise be seen in YA. Also, OAs may be taking quite a few medical meds (sometimes up to 10-14 different prescriptions at a time); psychotropics on top of this leave an OA at risk for polypharmacy risk or toxic mixing of meds, most often “by accident,” but nonetheless dangerous to the OA. Lastly, depending upon the psychotropic, some can cause unintended impairment in function in OA… and this frequently includes those meds used PRN for anxiety, agitation, sleep disturbances, etc. I would not recommend benzodiazepines as a first line PRN (such as Ativan, Valium, Xanax); sometimes an SSRI with sedation side effects can work more safely like Trazodone for sleep, Celexa for agitated depression. This is because benzos can cause side effects like increased confusion, intense sedation leading to more falls, and addiction if one is prone to this. Nonetheless, some OA do very well on benzos as long as they are closely monitored and maintaining a high level of functioning. Keep in mind, I am not a medical doctor, and I would suggest asking a psychiatrist her/his opinion as well.

Q: Reference data was dated 15 years ago.  Any research that is more current?
LS: Yes! I have included a reference list of all sources used in this presentation; feel free to peruse at your leisure.

Q: Is medication effective for Dysthymia?
LS: I don’t know what current research says about this. However, I do know that Dysthymia can be potentially more challenging than major depressive disorder with just meds because Dysthymia is characterized by not only a type of depressed mood, but also a negativistic outlook on life in general. Some research shows that Dysthymia is more related to personality, or one’s way of interacting with the world around them, rather than having more of a biological basis of etiology like major depressive disorder. Regardless, SSRIs may work nicely with Dysthymia, if medication is deemed necessary. I’d ask a psychiatrist; I am not a medical doctor.

Q: How would you suggest differentiating OA paranoia in a personality disorder from psychotic paranoia? Generational knowledge gaps such as fear of technology and others?  But i could be lack of knowledge or miss information. "Cell phones will melt your brain if you use them."
LS: Paranoid PD is a maladaptive personality style in which the individual believes others intentions are bad or meaning them harm in some fashion; a basic suspiciousness about others’ motives and intentions. The individual is NOT psychotic, meaning he/she does not have delusions, hallucinations, or disorganized thinking that signals a break from reality. Paranoid psychosis is psychosis: a break from reality in which the person has delusions that others are out to harm them in some way. Anecdotally, in my treatment of patients, I have not seen too many OAs with paranoid psychosis be preoccupied with technology. More often, I have seen paranoid delusions characterized by false beliefs that others are trying to kill them (sometimes conspiracies), trying to monitor them, poison them, government targeting them, etc. Ironically, when I worked with YAs, I saw more inclusion of technology in delusions like microchips, etc. It would be a very interesting article!

Q: How can you motivate a client who is borderline, narcissistic, a pathological liar, medically unstable and unsafe at home and speaks although she speaks eloquently, is resistant to follow through and self care?
LS: Tough one! Motivation depends largely on the individual herself. What does she value? What does she find reinforcing? What are her goals in life? Once we know the answers to these questions, we can begin developing a plan of intervention. Motivational interviewing can be helpful: it is an approach based on meeting the individual where she is, getting her buy-in and her own goals, and exploring how she can meet her goals by highlighting how her current behaviors/thoughts are in conflict with her goals. For instance, if she is lying and refusing self-care, how are these behaviors preventing her from achieving her goal of maintaining independence in the community? By creating a sense of ambivalence about her behavior, she can begin to change for herself with your guidance. I would also use behavioral strategies that could include family or other people she considers to be supports in her life such as a structured reinforcement plan with consequences that she takes part in developing (e.g., “If I take my prescribed medications for 7 consecutive days, then I get to go to Shoney’s with my daughter.”)

Q: How can one relate to an OA who has cycles of behaviors unlike their usual self.
LS: That’s a tough question. It really depends. But assessment is the first thing to consider. With OAs, I always consider medical issues first, as well as the following: the frequency, onset and duration of symptoms in general. If there is an abrupt onset /change, then definitely explore medical issues that could be altering mental and /or behavioral status. Then it’s really a matter of what types of change are you seeing? What symptoms seem to be present? Then you can narrow things down to a diagnosis and get a treatment plan in place that helps others relate to that OA.

Q: How can CBT work for persons with dementia?
LS: Research shows that CBT can be effective with individuals with dementia, mainly those with mild cognitive impairment. Compensatory strategies can be used such as visual aids, written reminders, in order to help with reinforcement/rehearsal of material. Involving family can be very helpful too, particularly with behavioral planning and strategy development and implementation. CBT is also considered an evidence-based treatment for behavioral disturbances related to dementia, especially behavioral components of those interventions.

Q: Could it be possible the beginning research in the Webinar may be a bit different for the general population vs. the population some of us serve, APS, including more persons with Mental Health diagnosis, etc? Thanks.
LS: The research on successful and healthy aging was derived from large samples over time with OAs of all types (especially the Rowe and Kahn research). This research did not just target those with MH issues or low socioeconomic status, etc. I understand what you’re saying that when we work with “special” populations such as OA with MH issues and/or severe psychosocial problems (i.e., financial, social, etc)… these folks typically have myriad challenges in functioning often with comorbid medical problems and other stresses unique to this population. It is very difficult to “age healthily” when one is faced with a severe MH disorder that can leave them socially isolated, financially strained/without gainful employment, and medically compromised. This is especially pertinent for individuals with SMI or Severe Mental Illnesses like Schizophrenia, severe Bipolar Disorder, etc. It is important to note though, that just because an OA has a MH diagnosis does not mean they also have a disordered personality, bad medical issues, low functioning, etc. There are those who thrive despite the illness; we just don’t always get to see them in our workplace.

Q: Any other thoughts when persons refuse all efforts to offer Mental Health Services, may need Mental Health vs APS.
LS: It’s tough. APS is there in case of abuse and/or neglect, including neglect of self-care. If it crosses that line, then APS should get involved, period, often times in conjunction with MH services. Hopefully the individual has a good relationship with an agency in order to work with them when/if decompensation starts to occur.

Q: Can you speak to reporting requiring. When should APS be called?
LS: APS typically gets contacted in cases of abuse and/or neglect.

Q: tx team and family reinforcement of modeling positive behvaiors and validation of emotional responses seems to be very important in managaing the OA with PD
LS: YES. These interventions you mentioned are very important, especially for Cluster B pathology.

Q: Can one fit into more than one Cluster?
LS: An individual may have symptoms of PD that cross clusters. In cases such as this, a diagnosis of Personality Disorder Not Otherwise Specified is warranted. Anecdotally, however, I have seen more people with cross-over traits WITHIN a cluster such as an individual with Borderline and Narcissistic traits.

Q: At what point do you assign a diagnosis?
LS: Diagnosis is assigned when the individual’s symptoms meet criteria for the diagnosis whether that is in the ICD-10 or the DSM-V. Specific threshold criteria are found in both resources and used so clinicians can assign a diagnosis. Also, for PD via DSM-V, the symptoms must be NOT due to medical conditions, pervasive and existing since younger adulthood, and impairing functioning in the individual’s social and employment life via problems in their thinking, feeling, behaviors, etc. (see slide on DSM-V definition of general PD).

Q: What was the possible diagnosis for cluster A case vignette?
LS: Paranoid Personality Disorder.

Q: are people with PD more likely to develop combative behaviors and other issues of impaired impulse control with the onset of dementia?
LS: Great question. The research with which I am familiar purports that yes, if one has a PD prior to the onset of dementia or other cognitive impairment, his/her maladaptive personality traits and behaviors can be exacerbated and worsen. Much depends upon the type of dementia and its severity. For instance, one with Frontotemporal Dementia (or FTD), almost always exhibits some type of impulse control problems. I would think that if this individual already had a lifelong history of a PD (especially Cluster B pathology), this in conjunction with FTD could be pretty intense. But I think it all depends on the type and severity of dementia as well as the PD prior to the dementia onset.

Q: Are most older adults with personality disorde never formally diagnosed?
LS: GREAT question. Offhand, I’m not sure what the research specifically says about estimated rates of TRUE PD in OA, meaning not only those OAs diagnosed but also those who likely have a PD but remain undiagnosed. Let’s look it up! My immediate thought is that there are OAs who are not formally diagnosed due to various reasons such as: 1) the stigma that ironically clinicians have about PDs… clinicians can be reluctant to diagnosis a PD due to its stigma (which does NOT help!), 2) PD symptoms in OA can manifest differently as we saw in this presentation and may not reveal until later, 3) OA with PD are not likely to seek help with diagnosis. They are likely to have limited insight and not access services willingly. These are just some thoughts I have re: this question; I’d love to see predictive estimates in the literature of those presumed to be undiagnosed but to still have a PD in OA!

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BIBLIOGRAPHY and RESOURCES for the FUTURE

WHAT ARE PERSONALITY DISORDERS?

Jarrett, C. (2006). Understanding personality disorder. The Psychologist, 19, 7, 402-404.

Widiger, T. and Trull, T. (2007). Plate tectonics in the classification of personality disorder: Shifting to a dimensional model. American Psychologist, 62, 2, 71-83.


WHAT DO THEY LOOK LIKE IN OLDER ADULTS?

Abrams, R.C. & Bromberg, C.E. (2007). Personality disorders in the elderly. Psychiatric Annals, 37, 2, 123-127.

Balsis, S., Segal, D. L., Donahue, C. (2009). Revising the personality disorder diagnostic criteria for the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V): consider the later life context. American Journal of Orthopsychiatry, 79, 4, 452-460.

Greve, K., Curtis, K., Bianchini, K, and Collins, B. (2004). Personality disorder masquerading as dementia: a case of apparent Diogenes syndrome. International Journal of Geriatric Psychiatry, 19, 701-705.

Marley, J. & Fung, R. (2013). Debate: are we overlooking personality disorder in older people? Old Age Psychiatrist, 55, 1-8.

Mordekar, A. & Spence, S.A. (2008). Personality disorder in older people: how common is it and what can be done? Advances in Psychiatric Treatment, 14, 71-77.

O’Leary, D., Jyringi, D., and Sedler, M. (2005). Childhood conduct problems, stages of Alzheimer’s disease, and physical aggression against caretakers. International Journal of Geriatric Psychiatry, 20, 401-405.

Oltmanns, T. F. & Balsis, S. (2011). Personality disorders in later life: questions about the measurement, course, and impact of disorders. Annual Review Clinical Psychology, 27, 7, 1-29.

Segal, D., Coolidge, F., and Rosowsky, E. (2006). Personality Disorders and Older Adults: Diagnosis, Assessment, and Treatment. Hoboken, New Jersey: John Wiley & Sons, Inc.

Van Alphen, et al. (2006). The relevance of a geriatric sub-classification of personality disorders in the DSM-V. International Journal of Geriatric Psychiatry, 21, 205-209.


WHERE DO THEY COME FROM?

Bradley, R., Heim, A., and Westen, D. (2005). Personality constellations in patients with a history of childhood sexual abuse. Journal of Traumatic Stress, 18,6, 769-780.

Mitchell, S. & Black, M. (1995). Freud and beyond: A history of modern psychoanalytic thought. New York:  Basic Books.


HOW CAN WE BEST ASSESS PATIENTS WITH PDs?

Van Alphen, S., Engelen, G., Kuin, Y., Hojtink, A., and J., Derksen (2006). A preliminary study of the diagnostic accuracy of the Gerontological Personality Disorders Scale (GPS). International Journal of Geriatric Psychiatry, 21, 862-868.


HOW CAN WE BEST TREAT PATIENTS WITH PDs?

McCann, R. & Ball, E. (2001). Borderline personality disorder. In A.M. and J.L. Jacobson (Eds.) Psychiatric Secrets, Hanley and Belfus, Inc. Philadelphia, PA.

McCann, R. & Ball, E. (2001). Antisocial personality disorder. In A.M. and J.L. Jacobson (Eds.) Psychiatric Secrets, Hanley and Belfus, Inc. Philadelphia, PA. 
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