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Antipsychotic drugs have a long history of being used in older adults with dementia. They've mainly been used off-label to treat the behavioral and psychosocial symptoms of dementia, such as wandering and aggressive behaviors. However there's quite an extensive background history of these types of drugs increasing the risk of falls, excess sedation, and even early death among older adults with dementia. As such, there have been a number of successful campaigns across Canada and in the United States to reduce the use of these medications among people with dementia. so while it's important to highlight this this success, we also have to very carefully assess the type of care that takes place after people are taken off their antipsychotic drug. Living with dementia is challenging for folks living with the condition, their families, and their caregivers. And it might be challenging for homes to consistently implement or use non-pharmacological therapies for dementia which might then lead to the prioritization of other types of drug therapies. So there are two aims of this current work: the first is to identify whether or not antipsychotic drugs are indeed being switched with other types of drug therapies and the second aim will be to identify if that switching is associated with other types of downstream health outcomes such as increased risk of falls and trips to the emergency department. We're going to use de-identified data held at ICES to look at the records of people living in nursing homes with dementia to examine their patterns of medication use over time. I'd first like to thank the Alzheimer Society of Canada for awarding me this doctoral fellowship to pursue my doctoral research at the Dalla Lana School of Public Health. And also I'd like to thank ICES for providing rich data and methodological expertise to pursue this work. We want to make sure that nursing homes are on the right path for ensuring great quality of care for their residents with dementia.

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Welcome to module 10 of the ADRC Dementia Care Training series. This is the first of two modules that focus on supporting people with serious mental illness who have developed dementia. The development of this module was made possible through support from the ADRC of Oregon and the Older Adult Behavioral Health Initiative. This module follows 9 others in this series. The first eight modules focused on dementia in the general adult population, and the 9th focused on people with intellectual disabilities and dementia. If you have not yet viewed these previous modules you might find it helpful to do so before viewing Module 10 or 11. Serious mental illness refers to people 18 and older and is defined as having, at any time during the past year, a diagnosable mental, behavior, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities. Estimates of adults living with serious mental illness range from about 4-6%. The impact is disproportionate to their numbers. About a quarter of adults living in homeless shelters have a serious mental illness, and nearly half have a serious mental illness in combination with substance abuse. Billions of dollars are lost every year in potential earnings. People with serious mental illnesses have higher levels of health care costs, including hospitalizations, and medical visits. Yet, about 30% of those with a diagnosis of serious mental illness do not receive mental health treatment. Although the gap in mortality rates for those with and without serious mental illness is shrinking, those with a diagnosis live an average of 10-25 fewer years than those who do not. In part, this is due to comorbidities and higher rates of suicide. Many mental illnesses and disorders are included under the umbrella term of "Serious Mental Illness," including those listed here. In this module, we will focus on Bipolar disorder complicated by delirium or dementia. Schizophrenia and dementia is addressed in Module 11. These are two of the most common serious mental illnesses. Misdiagnosis of comorbidities or poorly treated symptoms cause significant distress to the individual with the mental illness and those who support them. These individuals are at high risk for poor quality of life and high rates of disability and mortality. We will tell the story of Carlos, who is 78 and widowed. His son lives across the country. Carlos has lived in his apartment for 10 years. His neighbor called aging services because Carlos has become increasingly agitated and very restless. He is up at all hours and seems disoriented. When asked about his son, he wrings his hands and says that his son is going to take him to the theater, but is late. Other times he is euphoric as he talks about his past with the theater, all the time pacing around the room. Is Carlos having a manic episode, or is something else going on? You will also meet Wilma. She is 89 and lives in a skilled care unit and is on hospice. She is quite a character, joking with staff and beaming when they are present. She's fairly confused and often does not know where she is, but she clearly enjoys spending time with others and participating in bingo, her favorite activity. She has a complicated relationship with her children. Only one of them is involved in her care. Wilma doesn't seem like the same person described by her family. They painted a picture of a woman whose life was chaotic. She spent most of her time either in bed weeping or being the life of the party, talking incessantly, and never listening. She had no social boundaries, telling all sorts of intimate details about her life and the lives of her children, much to their distress. In this module, we will use the stories of Carlos and Wilma to explore how people with Bipolar disorders experience aging, and how providers from aging services, behavioral health, and the health care system can work together to figure out how to provide needed support. Throughout this module, our guides to supporting Carlos and Wilma will be individuals with considerable professional and personal expertise in supporting individuals who are aging with a serious mental illness, including those who also have dementia. We will return to Carlos and Wilma in a moment. Bipolar disorder is a brain illness that causes extreme mood swings. These are more intense than the typical ups and downs that most people experience. Over time, those with a Bipolar disorder can damage relationships with family, friends, and colleagues. It can disrupt ability to work or maintain normal everyday activities. People with Bipolar disorders sometimes engage in dangerous behaviors and are at high risk for suicide. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, identifies several types of Bipolar and related disorders. For this module, we will highlight the two major types, Bipolar I and Bipolar II disorders. People with Bipolar disorder cycle between depression and mania. The DSM lists several criteria for a manic episode, which present as an abnormally and persistently elevated, expansive, or irritable mood. These episodes represent a major change in behavior for the person. The criteria for a manic episode include an inflated self-esteem or grandiosity, a decreased need for sleep, becoming more talkative than usual or seeming to feel pressure to keep talking, having a flight of ideas or feelings of racing thoughts, being distracted easily, such as being drawn to unimportant or irrelevant external stimuli, an increase in goal-directed activity or psychomotor agitation, and finally, excessive involvement in activities that have a high potential for painful consequences. The diagnostic criteria for both Bipolar I and II includes a manic episode which may precede or follow a major depressive episode. Three of the criteria for a manic episode must be present for at least one week, nearly every day of that week, and for most of the day. The same criteria used to diagnose Bipolar I are used to diagnose Bipolar II. The primary difference between the two levels has to do with the severity of mania. In Bipolar I, symptoms are more severe and result in marked impairment in functioning or relationships with others, or require hospitalization to prevent harm to self or others, or there are psychotic features. A manic episode in Bipolar II is referred to as hypomania. This episode is somewhat less severe and does not cause marked impairment in functioning, or require hospitalization, and there are no psychotic features. Hypomania is marked by a noticeable change in mood and can cause significant distress to individuals and those around them. Bipolar II is often paired with depression. Manic episodes may precede or follow a depressive episode. DSM-5 criteria for a depressive episode include depressed mood, reduced interest or pleasure, significant weight loss or weight gain, insomnia or sleeping excessively, restlessness or slowed behavior, fatigue or loss of energy, feelings of worthlessness or inappropriate guilt, decreased ability to think or concentrate, indecisiveness, and recurrent thoughts of death or suicide, or suicide planning or attempt. To be considered a major, or severe, depressive episode, five or more symptoms must be present over a two-week period, and one of these symptoms must include depressed mood or loss of interest or pleasure in life. The symptoms must be severe enough to be noticed and result in difficulties with daily life, including work, social activities, school, and with relationships. The symptoms are not due to any other factors such as substance misuse, medications, or medical condition. About 1 1/2% of the general population in the United States have diagnoses of Bipolar disorder I or II. This works out to an estimated 50,000 individuals in Oregon. You will notice that the prevalence in the older adult population is somewhat lower, between 1/2 and 1%, or approximately 2,000-4,000 older Oregonians. The lower prevalence among older adults is due in part to higher mortality rates associated with serious mental illness, and it may also be due to under reporting. Bipolar disorder typically appears in adolescence or in early adulthood. The average onset is 25 years. It is an expensive disorder for the individual, their family, and the health care system. Costs associated with Bipolar disorder are among the highest for any serious mental illness. Most older adults with Bipolar I or II disorder, had their first episode in young adulthood and have aged with the disorder. Although some people do experience a manic episode for the first time after 50 or 65 years of age, this condition is rare and is often related to a history of mood symptoms or other neurological conditions. Very little is known about older adults who live with the disorder, although they do have a shorter life expectancy of about 10 years. As they age, all older adults experience comorbidities, but those with Bipolar disorder have higher rates than other older adults. These include higher rates of cardiovascular disease, respiratory disorders, type II Diabetes, endocrine abnormalities, and obesity. As a result of these medical conditions, care and treatment of someone with a Bipolar disorder becomes more complicated. This is particularly true for medication management. Compared to younger adults with Bipolar disease, older adults have fewer psychiatric comorbidities. When they do occur, they are likely to reflect higher rates of substance abuse, which has likely been present throughout their adulthood. Anxiety disorders are also more common, although many older adults who do not have a Bipolar disorder experience anxiety. Cognitive dysfunction is a core feature of Bipolar disorder in all age groups. Up to 30% of older adults with Bipolar disorder have significant cognitive dysfunction. Research findings are limited and somewhat inconsistent, but areas of dysfunction reported most are executive functioning, verbal learning, memory, and emotion processing. Let's return to Carlos. He has symptoms that are consistent with symptoms associated with a manic episode. He's not sleeping, he's very talkative, and his conversation could be characterized as a flight of ideas. His constant talk of the theater and needing to get there may be thought of as an increase in goal-directed activity. His neighbor does not know whether Carlos has had a history of mental illness. Carlos also has some symptoms consistent with dementia, including poor memory, judgment, reasoning and changed mood. But, dementia is a slowly progressive disease. Are Carlos' symptoms new, or have they been progressing and are just now being noticed? I think people who work with the elderly, what they need to understand about Bipolar disorder is that often, patients are untreated for their lifetime. That many people have been diagnosed with Bipolar and manage that through use of other drugs such as alcohol or valium or whatever, or intermittently seek treatment, and often, don't want to have treatment because being hypomanic--not totally manic, but hypomanic--really makes them feel alive and more creative and more in control than their "normal" state. So it's difficult once you get to a certain age, just as anybody, that you want to feel like you're in control of your life. So I think Bipolar illness, just like any other aging person, you have to put that in perspective, that that's an extra, additional barrier for them. But a lot of them have coped somewhat successfully without treatment on and off. So I think one of the things is, as you age, things, just like any other thing, the illness flares up, and it has to be kind of dealt with in a different way. You just continue to have to work with the patient to the best of your ability, to get them to understand how it might benefit them to have treatment. NARRATOR: Understanding serious mental illness in older adults is complicated, particularly when behavioral changes occur. Health care, aging services, and behavioral health service providers all have a part in the detective work to figure out what is going on with a particular person. Well, I think we can't be jumping at manic episode absent some very good, clear history that he is, in fact, a person already diagnosed with Bipolar disorder. While the literature does include some stuff about late-onset Bipolar or mania, it's exceedingly rare. Carlos's case is interesting, of course, because it's common that a worker's going to get a referral like this from a neighbor or even a family member, that Carlos is exhibiting odd and strange behavior that isn't common to him. And so that's a key right there. If they say, "This is uncommon for Carlos. Something's going on. Something's different," what provoked this neighbor to call? How unusual is this? Or is it just kind of like him but just worse? So questioning his neighbor--the reporter--is very important. She probably has a lot of stuff that she knows and can offer but isn't aware that she should be telling us that stuff. And so she, of course, would be the first person to really be questioning. And in a way that kind of gets at etiology. Not just here's what he's doing today, but what was he yesterday or last month or even three years ago? In the case of Carlos, I'd want to know, well, I'd want to have a medical exam done immediately because something that comes on that suddenly does not sound like a manic episode to me. It sounds like there may be a medical cause. Many, many older people have UTIs often that cause symptoms like this or symptoms like schizophrenia when they don't really have it. So I would certainly want to check that first. If for some reason, he had a medical exam, and nothing came out of that, then I would want to consult with a psychiatrist. It would be really odd for him to have a mania at that age, that suddenly. And there could be other medical problems going on. So I would certainly want to check that. Well, as a member of the team assessing Carlos, what I'd want to know are what are some of the other underlying factors that might be associated with what's going on? So are there medical conditions, are there infections or painful episodes that he's experiencing, but most particularly, emphasis on infection. Then, we would also want to look at his medications. So what other medications is he taking right now that might be causing some of the issues that we're seeing. NARRATOR: It takes all of those involved in care to answer these fundamental questions: What are the symptoms, and what is the context in which they are occurring? That is, what else is happening in the environment? Finally, what are the underlying causes of these symptoms? You will have noticed that all of the experts emphasized the importance of a complete medical exam and identified delirium as a condition to rule in or out as a first step. You may recall from Module 7 that delirium is serious. It is a medical emergency. Does Carlos have a delirium? Delirium is characterized by disturbed consciousness, poor environmental awareness, decreased attention, changes in cognition, and perceptual disturbances. Delirium is marked by its sudden onset, over a period of hours or days. Symptoms often fluctuate in a 24-hour period and are often worse at night. Fluctuations occur in alertness, cognition, thinking, perceptions, and emotions. A person with delirium may be hyperactive and present with agitation, restlessness, and hallucinations. Others may be hypoactive and be very sleepy or difficult to arouse. There may also be a mix of these symptoms. Visual illusions, misperceptions or hallucinations are also common. Delirium is often reversible with treatment. However, identifying delirium early and starting treatment immediately is critical. As described by the experts, delirium can have many causes. The most frequent include infections, falls resulting in head injuries, and medications, although other conditions can be causes. Those with dementia are at high risk for delirium. Risk also increases with physical frailty and age-related changes such as changes in metabolizing medications. Let's return to Ann Wheeler's exploration of medications as a source of delirium. We would look at anticholinergics in particular. So what is his current anticholinergic burden? Even one anticholinergic can cause someone to experience delirium. We would want to look at concurrent medications. We would want to look at adverse effects of those medications and then streamline as much as possible. By streamlining, what I mean is we would want to take away any medications that aren't necessary. So if he's being treated with an anticholinergic medication for sleep, are there other things that we can do? So are there non-pharmacologic alternatives to help him sleep? Rather than, let's say he's taking diphenhydramine. So we would want to make sure that we have good sleep hygiene, rather than using an over-the-counter diphenhydramine product, which is an anticholinergic. NARRATOR: Anticholinergic medications are used frequently. They block the neurotransmitter acetylcholine. In the peripheral nervous system acetylcholine activates muscles. Within the central nervous system, it acts in areas of the brain that control motivation, arousal, and attention. Many medications have anticholinergic properties, including those listed here. The Companion Guide for this modules provides information about some of the common anticholinergic medications in use. With age, anticholinergics have many negative side effects, including delirium and increased risk for or worsening dementia. Aging services contacted the primary care provider who felt that Carlos needed to be seen immediately. Carlos did not have insight or judgment about what was happening to him. Dianne Wheeling provides advice for working with someone in this situation. I don't really want to try to explain in detail what I'm doing and why I'm doing that. I'm just going to redirect him in very simple language and tell him what he can do, rather than what he can't do. So for example, it's not good to say, "You can't sit here," or "Don't do that. Don't pull on that IV line," etc. What you want to say is, "Here, hold this," or "Here, sit over here," or "I want to talk to you here." NARRATOR: A friend of Carlos, with the guidance of the aging services staff and support from Carlos' son, matter-of-factly told Carlos to come with him and took him to the emergency department. The medical exam revealed that Carlos has a delirium. Carlos has been taking Valium, a benzodiazepine, for 12 years to help him sleep. He also has a high anticholinergic burden complicated by increasing frailty. He has lost weight, is less mobile, and his nutrition is marginal. All of these physical changes in combination with normal changes in metabolism led to the sudden onset of delirium. So one of the other things that we would want to look for in his medication record would be use of a benzodiazepine. It's very common for people who are older to be on a benzodiazepine, particularly for sleep. So we would want to make sure that we evaluate for that. Benzodiazepines can cause delirium. They can also lead to cognitive impairment. So we would want to make sure that if one of those is on board and is unnecessary at this time, that we find a way to taper and discontinue that medication. NARRATOR: Benzodiazepines are a class of medications that depress the central nervous system, particularly the brain. About 5% of the adult population fill prescriptions for benzodiazepines each year. They are frequently prescribed for psychological disorders, especially anxiety and panic and for mood disorders, including Bipolar disorders. They are also used to help people sleep and for seizure disorders. Benzodiazepines have multiple side effects and are considered high risk drugs. They are particularly dangerous for older adults. Use is linked to higher rates of dementia and other cognitive impairment, reduced mobility leading to falls, and impairment in driving. It appears that long-term use of benzodiazepines with Bipolar disorder may be associated poorer control of symptoms compared to alternative treatments. Benzodiazepines in combination with other prescriptions can reduce the effectiveness of those drugs or result in adverse drug affects. This is also true for combination of benzodiazepines with alcohol, over the counter medications, and other drugs. People who have used benzodiazepines for a long time develop a physical dependence on the drug. Deaths due to overdoses increased fourfold between 1996 and 2013, and continue to rise for those over 65. Some of the commonly used benzodiazepines are listed in the Companion Guide for this module. I would say in terms of which older adults would be more susceptible to the side effects associated with benzodiazepines, that would be all elderly patients over the age of 65 is when we want to start using as low a dose, for a shorter period of time, as possible. They're going to be considered unnecessary in a lot of older adults. So we would want to look at getting rid of them in most cases. But the other people that are particularly vulnerable would be those that already have an underlying dementia. And so this is only going to make the cognitive impairment worse. NARRATOR: Carlos has been admitted to the hospital for delirium. We now turn to ways to support Carlos as the delirium is treated. The longer you're in a delirium, the more opportunity you are to have adverse events: Falls, pulling out medical devices, interfering with medical care. Also, you can have post-traumatic stress or have trauma--psychological or physical trauma-- from being restrained. And there are studies that indicate you can have permanent cognitive changes if you're in a delirious state for a long period of time. The longer you're in a delirium, often you're not getting adequate sleep, you're not being aware of your own needs, such as food and fluids, and you can kind of run yourself to death, so to speak. NARRATOR: Before we move on from delirium as a cause for Carlos' symptoms, Glenise McKenzie emphasizes the importance of thinking delirium first. So one of the things I actually love about working with older adults is that this is really complex. And while that can be frustrating, it also can be very interesting. Part of the complexity of older adults is that their hearts aren't working as well, their lungs aren't working as well, they're not as good about getting rid of infection, all these changes that have happened over time make them really at risk for delirium. And then, delirium can look like dementia, it can look like a Bipolar, it can look like a bunch of other symptoms. So if you're not paying attention, you can miss it, which we miss a lot of them in the health care system. The doctors miss it, the nurses miss it, the social workers miss it, we miss it. So I think that taking the time, again, to look at the whole picture of the person, history of the person, history of the symptom, how long has this been happening, is critical. Because the critical part about delirium is that it's treatable. You need to treat whatever's happening because it is really seen, as we say, a medical emergency. There is something medically wrong with this person that needs to be treated. Number ones are infections and/or pharmacology. We're giving a new medicine, the medicine's interacting with something, but it is causing this person to then have that agitation and/or have a bunch of withdrawal. But they are suffering. If you talk to someone after they've been cleared of the delirium, they will really talk about how fearful and how scary it is because they can sense something's very wrong. But they can't, they need our help, especially when they've got a dementia or any kind of a cognitive disorder, to figure out what it is that's causing that. So I always tell my students, "Think delirium first. Rule out the delirium before you go off on a, 'Oh, maybe it's late-onset Bipolar or late-onset schizophrenia.' The most common is delirium. So figure that out first before you go on to something else with an older adult, especially when they already have that cognition and behavioral issues that you can kind of like, 'Oh, well it's probably just a bad day'." And so we really need to focus on what's really wrong with the person. NARRATOR: Now, suppose that Carlos did not have a delirium and was in fact having a manic episode. Suppose that his medical history revealed that he did have a history of Bipolar II and had managed it pretty well by himself most of his life. In fact, many of his acquaintances were not aware of the condition. How can Carlos be supported? If Carlos were having a manic episode, we would want to probably look at what we could do with mood stabilizer medications. We would start at low doses; we would choose medications that wouldn't interfere with other medications or medical conditions that he has. We could look at starting a low-dose lithium. We would want to make sure, however, that he has good renal function, that it wouldn't lead to further cognitive impairment. We could also consider some of the anti-convulsive medications that are commonly used for mood stabilization, such as a Valproate or Depakote. Again, we'd start at a lower dose and make sure that what we're doing is reasonable and with good outcome. If this were a manic episode and not a delirium, first of all, the treatment--from a pharmacological perspective-- would be very similar, would be an anti-psychotic. But one of the things that you would want to do is to try to build some trust with the patient, in terms of building on their strengths. And if you can, if he's able to redirect with you, is to really ask what helps: What has helped you in the past? How have you managed your mania? Kind of what has helped you in the past? A lot of times, in the acute episode, they're not wanting to talk about that or don't feel that they have a problem. But sometimes, they are able to really reach back into their memory and say, "This medicine," or "I just need to get some sleep," or "I need to rest" or whatever. And it's often good to align with something that they feel is helpful that you can kind of cling to and provide for them. So for example, I do believe sleep is really essential, actually, for both delirium and mania. But for mania, getting some sleep really helps have the brain rest and heal. And so it's promoting good sleep hygiene, providing a calm environment, clustering your care, and if a person does finally get to sleep, to really negotiate with the rest of the treatment team to not go in and wake them up, and provide them a time frame for which to just rest, knowing that they'll be safe in the environment there. So usually, a manic episode takes quite a bit of time to abate, and hopefully, the person is out of an emergency department and maybe into an acute psychiatric hospitalization or getting enough rest, being supported by others to keep taking their medications and getting extra rest. I think as a person becomes more organized and less manic, is to really kind of reduce the shame, and so really be non-judgmental about what got them to this situation. Sometimes it's not really anything they did or didn't do, but rather their body and their chronic illness flaring up, just as you would have flare ups for arthritis or other chronic illnesses. And so just slowly letting the patient regain trust in themselves to take care of themselves, and maybe do their own ADLs. Set up the patient to do that on their own, and really reinforce positive self-care. NARRATOR: We now return to Wilma. Wilma is an example of someone who suffered from Bipolar Disorder I, and although she was not diagnosed until her early 30s, had symptoms that indicated Bipolar disorder in her early 20s. She had multiple hospitalizations throughout her adult life, but had many periods of remission when she functioned quite well. When she remained on her medications, she did well, but said she missed the pleasures associated with mania. What is the association between Bipolar disorder and dementia? Evidence is mixed, but those with Bipolar disorder appear to be at higher risk for dementia. Combined with the cognitive deficits associated with Bipolar disorder, it appears that those with both conditions experience a more rapid decline than people with dementia alone. It is interesting to note, that continuous use of lithium, a common mood stabilizer, may reduce the risk for dementia. Recall from previous modules that dementia is a broad term that refers to a group of symptoms. It is a progressive condition that leads to deficits in memory, including impairment in short term memory, ability to learn new things, such as new medication or care routines, and an inability to retrieve information. Dementia also affects a person's ability to take care of her or himself. These deficits are seen first in instrumental activities of daily living, or IADLs, and eventually affect the very basic aspects of daily life. Other cognitive changes include impairment in judgment, thinking, reasoning, and problem-solving. Dementia can also lead to changes in mood and/or personality. Wilma is a survivor. She was able to live independently and maintain some social relationships throughout most of her middle age. As with many people with a life- long Bipolar disorder, however, her cognitive skills declined throughout her adulthood. She was diagnosed with dementia late in life. She was supported many years in an assisted living community. After a series of falls and complications from congestive heart failure, she was admitted to a nursing home on hospice. A lifetime of Bipolar disease is very difficult for the family and friends of those with the disorder. In this next segment we will hear from Marilyn, whose mother had a Bipolar I disorder that began in her early 20s. Wilma was modeled after Marilyn's mother. Marilyn will share what it was like to have a parent with Bipolar disorder and her role in caring for her mother throughout her life and through the end of her life. So as a child, of course I didn't know my mother was mentally ill, and she didn't know either. In fact, people didn't talk about mental illness. I grew up in the '50s, early '60s. People didn't talk about mental illness, and maybe we didn't know very much about it at that time. But what I did know was that my mother could be really fun. But oftentimes, when I came home from school, I found my mother in bed. And although she was good about taking care of us as far as having clean clothes and having meals... I don't know what that was like for her, but as a child, it seemed there was a lot of chaos. Let me just say that. There was a lot of chaos in our house as I grew up. I remember one time coming home from school, and my mother had baked a cake. I had a little brother, and she was in bed. I came home from school, and he had demolished the cake. So there wasn't a lot of supervision as we were growing up. And my mother had four children. We're three and four years apart. So the older children--I'm the second oldest--took care of the younger children. So I grew up really fast. My mother's first decomposition happened when my step-father left her. I was 10 years old. So my mother had four children with three different men. So that sexual promiscuity was a very real part of her Bipolar disorder. She was married to my older sister's father, divorced him, got pregnant with me, so I was born out of wedlock. And then she married the man that I call my father when I was six months old and had two children with him. They were married for 10 years. So at 10, he left her. Oh, the divorce was less than amicable. So I mean, it was a hard and fast decomposition. Happened over the course of about a year, and so in that time, my father went to court, filed for divorce. My father got temporary custody of these two younger children, and my older sister, who was a teenager, chose to go with him. I went to court and said I wanted to live with my father, I mean, with my mother. And then I went to court and said I wanted to live with my mother. At 10. I can't believe that's what happened, but it did. So she and I lived in a little house on the East side of town. She had a job, a minimum wage job working as a fry cook at the bowling alley, which was fine with me because I got free bowling. It wasn't all bad. But we were sharing a bed, and she wasn't able to sleep some nights. She would just ramble on about things that were-- It was delusional: delusional talking, conspiracies, conspiracies against her by my father. It just happened over time. And then again, I was a child, so I'm not sure how some of this happened, but she was committed to the Oregon State Hospital. At that point, I just went to live with him and his new wife and her daughter. After mom was released from the hospital, she moved back from Medford. She never had any visitation with us, no formal visitation at all. Her life was really hard after that, but the good thing about my mother's mental illness was that she responded really well to medications, very low doses of medications. Over the years, she was on all of them probably at one time or another: Thorazine, Lithium, Stelazine, Zyprexa. And as long as she stayed on them, she stayed well. But I do remember my mother saying that she missed the highs. Forget about the days in bed, but she missed the highs because my mother--good news also-- never self-medicated with drugs or alcohol. She didn't need to. She would be the life of a party because she was manic some of the time. NARRATOR: We now have a picture of Wilma through her adult years from the perspective of a daughter. In her 70s, Wilma moved into an assisted living community. She was willing to move because she had friends there. Her family was relieved because of her increasing inability to manage her medications, recurrence of symptoms, and increasing difficulties with other instrumental activities of daily living. As Wilma requires more care, what do health, social services, and long-term care staff need to know to provide optimal support? So for Wilma, some of the things that I would want the team to know and understand about her care would be what medications has she been on in the past, what has worked well for her, what medications is she on currently, does she have anything that could be potentially contributing to symptoms of dementia and cognitive decline? So are there medications that we might need to evaluate and get rid of and at least taper down on dose, if at all possible? We would also want to evaluate her current level of pain. Pain is going to contribute significantly to any sort of neuropsychiatric symptoms. So we're going to want to make sure that that's evaluated. And make sure that her environment is one that's going to care for her well. Mood stabilizers, psychotropic medications in general, can have significant impact on medical co-morbidity. So we always look at the impact that they can have on blood pressure, on heart rate, kidney and liver function, and drug interactions that might occur with the medications that are necessary in order to treat those conditions. Most notably, lithium can have an interaction with certain anti-hypertensives. So we would want to avoid those and start other ones. So it's just a matter of medication selection and making sure that there aren't drug interactions that are going to impact her overall medical well being. Well, the question of Wilma, is the impact of the Bipolar disease on her current life, but also her life throughout the life course is important because what, as I read the case study, what it tells me about Wilma is one, that she is lovable and has long periods of times where she's essentially normal. And I would think that sometimes that's even without meds, but certainly with. And there are four marriages, suggests that she's a person that you can like and be friends with and be with. The fact that her family has remained involved means that, indeed, that she's had long periods of time of seeming normalcy. And the family tries to help when she's depressed and/or manic and get burned out. So that suggests that probably those go on for a long time before some intervention changes her status, such as hospitalization. NARRATOR: As Marilyn describes, Wilma's Bipolar disorder was managed well living in assisted living. As we know, Wilma did have dementia. As in many families, it was difficult for Wilma's family and caregivers to identify a time when they first noticed. The challenges that my mother faced with her mental illness followed her throughout her life. The dementia, for me, would be hard for me to pinpoint when that actually happened because she didn't remember things, she didn't listen to me, she had just a non-stop monologue of what was important to her. If I would try to talk to her, she wasn't listening to what I was saying; she was thinking about the next thing that she wanted to say. So she would just ramble on. So the cognitive decline, it was hard to separate from her mental illness. She lived in assisted living for five years, and so at that point, she didn't have to remember to fill her prescriptions. She didn't have to remember to take her prescriptions, because over the years, if I said, "Mom, have you taken your medication?" Because I might pick up on "Oh, you've been in bed all week," or "Oh, you're talking really animatedly about something that happened. Have you taken your medication?" She would just lie to me: "Yes, I took them." But when I would go down to Medford to look through her prescriptions before I would bring her up to Portland to stay with me for a couple of weeks, I'd want to make sure she had all of her medications. And I'm looking at a bottle that should've been refilled two weeks ago, and she still had 10 tablets left. So she was spotty at best. So when she lived in assisted living, her prescriptions were filled, she took her medications on time, meals were provided, and they took good care of her. NARRATOR: The end of Wilma's life was similar to that of many older adults living with a chronic illness, although it was complicated by her mental illness and its treatment. Marilyn described what happened after the third serious fall in assisted living. They ended up admitting her and keeping her long enough so she could be discharged into skilled nursing. I don't know what the rules and regulations are, but that's what happened, which was good because assisted living was not able to care for her congestive heart failure adequately at this time. So she was discharged on hospice, and I wanted to move her up to Portland. My brother was done. He said he'd taken care of her 30 years. He couldn't do it anymore. And I really couldn't keep driving down to Medford to care for her adequately either. And I wanted to be with her at the end of her life. It was more important to me, maybe, than it was to her. I'll never know, but that's what happened. It wasn't easy to move her up here because you had to move her from county to county, so there's paperwork. I had to get a court order to let me move her out of the county and became her legal guardian at that point. I moved her into a skilled nursing home here in Portland where she got the very best care, and she was also in hospice. So there was that team coming in to see her as well. And it was at that time, around those three falls, where her personality really changed. She stopped talking all of the time. And I don't know that she was listening, but there was more quiet time for me to engage with my mother more and to just be at peace with my mother. So when I would go visit her, we could play cards, or we could play bingo, or we could just sit in the garden. We could go for walks. She was in a wheelchair at that point. But it was easier for me to be with my mother and to care for my mother. So that was a blessing for me. Her quality of life those last seven months was as good as it could get. NARRATOR: In this module, we have explored the experience of aging with Bipolar disorders, or with experiencing symptoms often associated with a Bipolar disorder, and how these experiences can be complicated by health status, cognitive decline, and a range of age-related changes. As suggested by Glenise McKenzie, it takes a lot of detective work to figure out what is happening with an individual, including a thorough medical exam, social and medical history, and environmental assessment. In sorting out the causes of symptoms and how to address them, it is important to keep in mind how those symptoms impact function and quality of life. So in my experience working with older adults who have dementia and psychiatric symptoms, and whether that's from a psychiatric disorder, or whether it's basically symptoms of the dementia, what I think that's really important as we're talking about thinking about what the behavioral issues are, and then what that means for the person's function. So from my perspective, regardless of what's causing the symptom or the behavior, the importance for thinking about the quality of life for that individual and for the caregivers is really to think about is this impacting function? Is there something we can do, should do? Then we start all the assessment about what can be potentially happening and what we can do. So that's why I really focus on what the functional level of the person is and then how to take care of that symptom that's impacting function. And again, I don't really care what's causing it, from the level of improving that person's function in the day, which then improves their quality of life. More people living with Bipolar disease are entering old age. They are likely to have more medical comorbidities and greater cognitive impairment than their age peers without a mental illness. Symptoms of manic episodes are often confused with delirium or dementia. Aging services providers need to be knowledgeable about symptoms of Bipolar disorder and understand how the disorder is treated and managed. They also need to understand how age-related change and comorbidities can complicate care and treatment of people with Bipolar disorders. Finally, aging services providers need not be afraid to serve older adults or people with disabilities who also have a diagnosis of Bipolar disorder. Help is available through Older Adult Behavioral Health Specialists located throughout Oregon. Contact information is in the Companion Guide for this module. As the population they serve ages, behavioral health providers also need to be knowledgeable about age-related changes, including the susceptibility of older adults to delirium, the impact on medication management, and the need for increased supports. Mental health providers, especially those in residential care, often can provide ADL support to help people age in place. Aging services can help, and resources can be found through the ADRC. In summary, aging services and behavioral health providers need to partner with each other and with health providers to understand the source of symptoms and work together to obtain needed resources and supports to enhance function and quality of life. When symptoms appear or change significantly, always advocate for a thorough medical evaluation to rule out medical or environmental causes of the symptoms. Finally, it is important to move from a system focused on eligibility to one that gives priority to maximizing function regardless of the source of symptoms. This concludes Module 10. Please copy this link and complete the short feedback form. We want to know your opinions about this module and how to improve programs in the future. Thank you again for your attention and your support for people with dementia and their families!

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so well led me to come to ATMC was I had just undergone a manic episode and about I would say two months prior to coming into ATMC I started my manic episode and I was first put into the mental hospital where they then put me on abilify and then after that mental hospital stay which was five for five days I went home and I thought I had conquered that part of the manic episode but I apparently I had not I've never been on medication for more than I don't know just my mental hospital stay so I did taper myself off cold turkey and that was not such a great idea so I got off the abilify immediately after I came out of the hospital and then I went right back into another manic episode and this time it was a lot heavier and I was in to the mental hospital again where they then put me on even higher doses and even on even more medication which was Thorazine and Haldol and lithium and I was on very high doses but then again I was this is when we found orthomolecular therapy after my second stay at the mental hospital I tapered self off cold turkey again by coming off of Haldol and Thorazine and lithium and that again was not a good idea but it was replaced by lithium orotate and then again I thought I had conquered that but the supplement that I'm so excited but it would I tapered myself off too quickly and I came back out I didn't know how to use the supplements correctly i and i again ended up in the hospital for another for a third time and there I was put on lithium depakote and Haldol and cogentin and I was again in the mental so I had been in the mental hospital now that was three times prior to coming to ATMC and I came on here I came on I was on deaf echo and Haldol and cogentin and I had switched lithium carbonate over to lithium so I didn't come over with that but that's what was going on in my life I was just undergoing this manic episode and I was on and off all these different kinds of meds and I was just kind of feeling helpless and like I needed medication to kind of control and stave off this manic episode and that's something that I knew I didn't want to live my life on because I've been I just knew that's just not the way for me and I was so grateful to hear that I was gonna come to ATMC to taper off correctly and just really undergo a spiritual journey so my overall experience at the Detox Shoppe was one that I will never forget I absolutely love the staff there including Katy Lotus and Michelle like I'll never forget Katy coming in the mornings to come get me and make sure that I was feeling all right and not for the detox shop and just always encouraging me till I keep going in the sauna I didn't think I was gonna get up to two hours and Katy just kept pushing me to go there and I absolutely adore Katy and Lotus oh my gosh I cannot say enough good things so hello it is like I connected with her so well she just she knew what to say she knew how to keep things going in a bubbly fun manner and she just she was so professional but so kind and so patient and just so empathetic that I've never met a human quite like Louis before and Michelle is just such a dear always just hanging there like providing the foot bath and just being so loving it was just at the deep talk shop I felt very loved and very taken care of and very blessed to be there even though at times there was moments I didn't want to be in the sauna for two hours but it was just like you know it was nice to just see Katy making the smoothies I was in the infrared sauna and I would just kind of pop Katy was like my entertainment when I was sure to make the smoothies and do the ice and she made her jobs everyone there made their jobs look so easy I was just so grateful that I could just sit back and walk and just detox so that's great it was an amazing experience it felt amazing to be there and the detox shock because the energy was phenomenal but the staffs energy was just amazing so at the Detox Shoppe shop and included the sauna for two hours and then it included ionic foot baths and magnesium lavender baths and when I was detoxing it was it was definitely a spiritual like detox as well under an emotional detox because there was times where it was just like I was I wasn't just sweating just a sweat I was sweating to get out all this negativity and all of this fear and anxiety and anger because when I'm in the sonnet all you can do is really like just sit there in 140 degrees and your mind starts to race and it starts to wonder and it can easily get anxious and it can easily get worried but there I was able to like the staff was able to just come together and just always keep me calm always keep me happy always just ensure that I was detoxing just getting ready for life you know I was just detoxing everything that was making me scared and making me worried and it was it did go beyond just sweating and I did go beyond just being in the sauna it went on to a deeper levels we had five evening groups and they were all extremely helpful so but the most helpful of the evening groups from me was Dustin's seven o'clock group on Tuesdays he was amazing he just was able to hold space in such a profound manner and this past Tuesday I actually are yeah before leaving I was really anxious and nervous about going into another manic episode but it was just we did this exercise and thing like what do what is it that we want to get rid of in our lives and I did want to get rid of the mania but it does seem needed a point like when we want to get rid of something that there's a void and what do we want to fill that void with and I was always afraid that whatever I feel that my manic void with would always just continue the cycle of mania but the way he was able to approach me and assuage my fears of getting manic again was it was unbelievable because I was just able to be just stand there with me and just allow me to realize that you know what it's okay to be in the moment and it's okay to go ahead to get manic but you're gonna have more tools to deal with it and the tools I learned at a TMC were crucial in my understanding that I'm ready to go home and ready to like I'm prepared for this man for this man manic episode if it should happen again as I've realized here that I've come to realize here that I'm stronger than any manic episode in my transition back home I feel completely supported like for that's what I was I would always talk about being here just talked about with my care manager my therapist it was trying to develop that plan of safety and that how can I create that a plan of security and safety for myself and I feel so blessed to have been able to come here and develop that security net because absolutely I have a family that loves me I have as the staff here immediately embraced me and I always felt supported here and I know most people aren't able to experience that because they're they feel alone in their plight and I was so blessed to just be cared for and loved and be supported so yes I completely feel support like support in my transition home and in my transition here the tools that I learned here were to like had a lot to do with self love and self regulation and it was just like coming back to a Center and being in the and being very mindful and being very trusting of like that I'm going to be able to I know myself well enough to identify the the symptoms of the manic episode and it was just a matter of being able to communicate that with my support system such as my family and especially my mom and my dad and what I've been taught here is that it's okay to ask for help and to reach out and to advocate for yourself and I've learned that not everything's going to be perfect and not everything's gonna be solved overnight in a manic episode isn't going to be solved by just isn't going to be solved overnight it's gonna take time and it's gonna feel like it's gonna never go away but what I've learned here is that by living in the present moment and by acknowledging what it is that you're going through that you will be able to get past even your darkest moment I absolutely loved everything about my stay at ATMC I love seeing the housekeeper's in the morning they always had such a cheerful and bright demeanor and I loved the my bed it was always made for me that was amazing I loved the grounds that the ground I would always see the groundskeeper maintaining the pool maintaining the the garden and it was just such an idyllic setting that there was nothing really here that I can beat that created anxiety and that created worry however it was quite interesting to me to see that people here still had that anxiety and still had that worry and I still had my fears but what ATMC does such a great job of doing is I'm meeting people where they were at and I enjoyed that I was able to always reach out for help when I needed to and I was able to always take here was a day where every day was a mental health day you were able to just meet yourself where you were at and do whatever it is that you needed to do to respect yourself and center yourself and relax yourself so there's not I absolutely loved it there was no one particular thing that I can say that really what I loved more that I loved more than another it was just the fact that I was able to do whatever it is I needed to do to heal myself in this an ATMC created an amazing environment and cultivated an amazing environment to do that if you're considering ATMC do not even consider just come here like you just it's a must if you're able to it is probably the best thing you could do for yourself it honestly the message that I would like to just say it's just keep keep the faith while I was here like there was moments where it always felt like I was in the right place but it was it got difficult at times to the point where I wasn't happy with certain things about myself I was just like I don't think I can do this I was losing faith in myself and I was not sure if I could go on like this because there was this journey was the more of a spiritual Odyssey and it's something that no one should take lightly but it's honestly one of the best experiences I've ever had and you shouldn't consider anything else other than a TMC if you're trying to get off your medication if you're trying to just get get yourself rebalance this is the place where you cultivate mindfulness cultivate self compassion and love and you just really learn to find yourself here and I really believed that a TMC would help a lot of people with their goals