Personality Disorders and AgingLive webinar held April 24, 2014
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.
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.
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.
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?
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!
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.