 Hello, and welcome to all who have joined us tonight. Tonight's webinar, primary care, older persons and mental health, as well as the viewers who will be watching the recording later on. I'd like to begin by acknowledging that we meet this evening on Aboriginal land, always was and always will be. I pay my respects to First Nations elders past, present and emerging. We have much to learn about respect for elders from Aboriginal culture that has thrived for over 65,000 years. I'd also like to acknowledge the elders of the many diverse cultures with whom we share this land and its water. I'm here on Gamoragel country in Northern Sydney, and for all of you out there around Australia, you might like to start practicing using the chat room to let others know where you are and where you're sitting around the fire tonight. In case you're still settling down with your refreshments, I'll read this slide out to you. I won't read other ones. This webinar is the result of a unique partnership between the 31 Australian Primary Health Network and the Mental Health Professionals Network. It's the first of three webinars exploring older persons and mental health produced under this partnership and to be broadcast over the next 12 months. Through a facilitated case-based panel discussion, each webinar will offer interdisciplinary insights into the complex interrelationship of aging-related health issues, as well as merits, challenges and opportunities in providing collaborative care to older people, correctly with age-related health issues. I'll be facilitating all three webinars, but the panel and case study will change each time. So again, welcome. My name is Stephen Ginsberg. You may have read my bio, but suffice it to say that I'm an old GP who's still passionate about compassionate care, and I also work in primary health policy. And to the issue of policy and the workforce in this area that we're in tonight, it might interest you to know that 3,195 people registered for tonight. And I thought just for your interest, I would tell you what the breakdown of that number is. Roughly, there are 770 out of that 3,000 psychologists, 520 social workers, 245 are nurses, 240 are mental health nurses and workers, 250 counsellors and psychotherapists, 200 occupational therapists, 160 GP, 130 students, psychology and social work, 30 psychiatrists and 2,3 geriatricians. Now your voice out there, all of you and the experience that you bring are important to fully bring this webinar alive because you're all muted. I want to know you're there. We all want to know you're there. And we will collate your comments to help plan this webinar. Sorry, to plan the next webinars and to feedback to the PHN. And you might like, as I say, to let us know what country you're on. Without further ado, on to our elder of the night, Virginia. And I know when I've been going on a webinar or lecture, sometimes I don't read the supporting documentation. But if you have all the better, so Virginia may be now a little familiar to you. Briefly, she's a 78-year-old woman who has a range of physical and mental health issues. And we created a story to give scope to the panelists to discuss the themes of this webinar. And I'm sure that many of you will have ideas of how you would help Virginia. So please don't hesitate to share these ideas in the chat box. And as I say, it will make this evening have more relevance when we put some of these ideas together. And here, how people are dealing with situations such as Virginia is offering us. That's the webinar platform of the chat box. And here are the learning outcomes, which I think you probably got sent around. So I'll leave them up just for a moment. I've marked those feedback comments and often, unfortunately, what we put as the learning outcomes aren't always achieved to everyone's satisfaction. But I hope tonight we'll go some way to meeting these learning outcomes. So without further ado, I'm going to hand you over to our panelists. They and I have already had a chat about Virginia. They'll each give us about a five-minute introduction to their approach to Virginia's care. And then we'll begin to the discussion section of the evening. So, first of all, hello, Sue. Hello, Sue Curl, who may be familiar to you all from her excellent ABC series, Old People's Home for Four-Year-Olds. And Sue will start us off with a geriatrician's viewpoint. Thanks, Sue. Thanks, Steven. I've got three slides. And I think they're kind of self-explanatory. I did want to make it clear what geriatricians do. And it's interesting, there's three who've registered. So obviously we're in a very tiny minority tonight. But generally, geriatricians are generalists in old age. I guess we're not organ specific. And while we see a lot of older people with diseases of aging, we also see younger people with diseases associated with aging such as dementia, Parkinson's disease and stroke. I would have to say, geriatricians tend to look very broadly at their patients. Obviously we're going to look at the medical side of things, the medications. But very much cognition and mood, although I will be leaving that, a lot of that to my colleagues, Rod and Chris tonight. We look very much at mobility and function because that impacts so importantly on how people manage day to day. So I will always make sure I get people doing sick to stand and a bit of balanced stuff to see can they actually manage steps. We also look at the social situation. You know, have they got family? Do they have children, grandchildren? Where do they live? Are they in their own home or are they in rented accommodation or is it a housing department? You know, what are their finances? That can be incredibly important in this day and age. Are they on the pension so they have a health care card or are they self funded retirees who are really doing it hard at the present time? And we also look very much at what I call legal issues. Also, maybe you'd call it advanced care planning. Have people done enduring guardianship and power of attorney? Are they still driving? Do they understand some of the obligations around continuing to drive? So, you know, I really have to say we're generalists, which is what makes geriatrics so interesting. We do what's called a comprehensive geriatric assessment, at least we hope it's comprehensive. We then try and work out a care plan with the patient and their family. And I would have to say that I usually see patients with their family members, sometimes a little while on their own, but I usually have three or four chairs in my clinic room and even in this day of social distancing, we manage to fit usually at least three family members in. So they hear what is being said and they feed into what we're doing. And it's very interesting to watch their body language when you are talking to the older person who is the patient and they tell you what they can do. And then you see the family's body language telling you very clearly that maybe they can't do it in the way that they're describing to you. So having the family involved is incredibly important, but we have to make sure that there's not an abuse situation going on and some of the other issues that can occur with older people. Once we've got that care plan, it's working on it with the GP. And as it's usually the GP that's made the referral, they're integral to what we're going to do from there and then we look at where referrals. What does that person need now in terms of assistance with more diagnoses, with management, with counselling, whatever? I think it's also really important to organize a follow-up appointment to see whether the patient has actually done anything at all. Have they actually accepted what we talked about? Do they even remember what we talked about? Have they started what we might have suggested, whether it's a change in medication or maybe an exercise program or getting out a little more? Whatever we've recommended, it's really important to see, have they actually accepted that and then are they doing it? And I just, this last point is, I work in the public hospital system, so I'm really lucky. I do have access to other specialties and to allied health, and I work relatively closely with the aged care assessment team, although that's got a bit harder recently with my aged care. But a number of my colleagues work privately, so there may be some costs associated with going to see them and they may use more private referrals. So again, finance, knowing the financial state of the patient is important. So just my first thoughts on Virginia, and I have to say after reading her two or three times and thinking about it, it really, she is a bit of a hard-sink patient for me with everything that has been tried by the GP. But my questions would be, what's the GP hoping to achieve with the referral? What is it being said in the referral letter? And I think that's always important. And if I know the GP or even if I don't know the GP, I will often give them a ring and say, what is it you think we might be able to do that you can't do? What can we add to your management? So that's a general thought, but particularly with Virginia, why has she changed from being a vivacious active woman at a younger age to an unoccupied, inactive older woman as she's described? What's happened in between? And I think we've got an amazing list of things that have. Clearly there's a lot of losses with, and I'm sure you all got the determination of pregnancy when she was at school and then all the other losses. And I think we'll learn more about that and how we manage them. For me, particularly, it's looking at her physical state. How can we motivate her with her being overweight, having arthritis there, obviously, linked? She may be frail if she may be overweight, but she can still be frail, which means she can't climb a flight of stairs easily. We know that from the notes. And I also wonder what her cognition is doing. She's almost at 18, one in four people have dementia. She certainly got multiple risk factors of dementia with her lack of exercise in a way of her early retirement, but her heart disease, her smoking. There are a number of things there we've got to think about. So that's my take on Virginia as a start. I think now I'll hand over to Rod. Thanks, Rod. Or back to Steven, maybe. Yep, you can serve it back to me. Thanks very much, Sue. It's nice to know I fit into your over 70s demographics, very reassuring, especially as you work locally. And I hope you can inspire more doctors to take up an interest in geriatric medicine because we know what is ahead of us in terms of the numbers of people who will need your skills. So hello out there, Rod. Rod McCoy, who will bring his wealth of experience and share his deep interest in old person's care from a psychiatrist's perspective. Thank you, Rod. Thank you very much. I would like to acknowledge the Dural speaking people of the lands where I'm presenting from and pay respects to the Elders past and present of the Dural Nation. I would then like to acknowledge that this is my perspective as an old age psychiatrist of how I would approach Virginia. And there's no doubt that psychiatrists can have different approaches, although at the centre hopefully there's some core things in common. So my perspective has been influenced by the fact that older people who I focus on, who I guess I love working with, and it was interesting when Sue said that Virginia would feel like a heart syncopation. In many ways, particularly when I do my rural work, Virginia is almost by bread and butter. And in many ways actually would look forward to working with Virginia. And the reason for that is because often the reason I'm being asked to see Virginia is because other people are really having difficulty with that engagement. And as Sue said, how do you motivate, how do you understand? And so that really is the start for each person I see is really how do you engage with the person, know them, how do you know their context, then assess if there is illness in terms of mental illness you're considering, or is it broader issues that need better conceptualisation of what's happening for Virginia. And then make a plan that is often for others to enact, rather than me having the largest part of that. We'll come briefly to that as I go through. And the way I think about the older person I guess is both influenced and been influenced by work we've done in New South Wales, thinking about actually what do older people want from mental health services, and in this case from public services. But I think the concepts apply across all settings. And I think the key thing there is, is older people have had a really rich life, as Virginia clearly has. And we need to understand that and understand that coming in as any one professional, we've only got a fairly small and focused role in trying to assist Virginia, but we do need to understand all those other domains of her life, what's important in them for her, who else is helping her, how does she want us to work with them or not work with them. So one person or one person in a team, but needing to work with others, and one thing I've been wanting to do in my very first contact with Virginia, and hopefully before I get to see Virginia, is get an idea of who else is involved. Because a variety of perspectives are useful, but perspectives that are pulling against each other are not going to help Virginia. So as I think I said, often the reason I'm asked to see some of my Virginia is actually because other people have had difficulty with that engagement. And so I would start the referral by actually thinking about what are the likely barriers and facilitators of engagement, and also what's missing or what doesn't fit in the story. Because often before you even see Virginia, you've got some hypotheses. And so for Virginia, I'm very interested before I even see her in knowing a bit more about what's happened earlier in her life, a bit more about her relationships, and then trying to understand how they're influencing where she's at now. I'm also interested with her interest in art and photography, and I know it's stereotypes, but I've been thinking about also how she had me interested in various substances during her life as well, or have she seen others modelling use of substances, maybe not in a positive way, and it's that part of what's missing in this picture for Virginia. So the barriers I'd be considering in thinking about Virginia is the stigma of mental health. And it's interesting to think about who's stigma that is. Often we think that and talk about older people who are not being psychologically minded. It's interesting from the more recent work suggests actually they may have less stigma about mental illness than younger people, and it may be actually the mental health professionals and health professionals who've got the stigma about mental illness and older people and therefore not referring for assistance. And that also has to be workative. How do you encourage people to actually consider there's something positive that can be done for Virginia if she has got mental health? I would be thinking about what trauma she may have had and how that may influence her, particularly in the way she trusts or doesn't trust people and the way that she relates to other people and try to understand what her personality has been. Outgoing vivacious can hide many, many things behind it in terms of whether that's a positive or not. And I would be really interested of knowing what experience Virginia's had with other people who've had similar problems or have tried to access services because once she's heard something that's going to influence a lot the way she engages with me. And I'd be looking for what Virginia's strengths have been because clearly she's got strengths there and what I'll be one sick to do is to identify how the team can engage with those strengths to help them move from the position she's in. And most psychiatrists and definitely most old age psychiatrists work from a biopsychosocial perspective. So trying to understand how each of these elements of Virginia actually come together to explain her current health status. And I really like this paper because it really emphasises that these are actually in a constantly changing. They don't stay in one place. And so that's a real opportunity as well because it really emphasises that if you can find one place to start you can actually start to influence positively the other aspects of life. So we're looking at where could I start with Virginia. And a psychiatrist will start with a classic assessment observing her before she even comes here, hopefully before she's aware I'm observing her. Often you see a lot which you lose once a person you actually start the formal interview. I would want to see Virginia by herself as well as with who she wants to be seen with even if it's a short time by herself at the start of the interview just to see if it's the same or different in terms of the way she presents. Obviously history particularly exploring her past episodes and just what they've been about, what's helped, what hasn't helped any adverse effects that she feels she's had from treatment of positive things. I would be thinking about alcohol and prescribed or non-prescribed medications that she might be using because she must be at risk and we often forget that with older people as well as mental state examination and who can give me that picture of Virginia and does it match her or not? And then how does Virginia conceptualize what's happening and how do those around her conceptualize that and how do they fit? Are they similar or different to each other? How are we going to use or work through with that and does it fit my idea what's happening with Virginia? And as I said really be using that just I think at what is the plan largely for others to enact and I would probably be going to see Virginia again I'd imagine because I can't imagine that I will really get to know her and really know what's happening on the first assessment but I'll be planning for what others can do and others may well be the GP it may be a psychologist it may be if I'm working with a team members of that team and the key thing is planning with Virginia not for her and my key focus would be using my encouragement so others can continue those next stages of the care and Virginia will be moving in with that and my differential at present will be very broad we're thinking about depression we're thinking about bereavement thinking about early cognitive impairment probably more than dementia but clearly dementia is possible or it may be medication or substance use so really what I would recommend would depend on very much from that history mental state examination and my best guess is I wouldn't be recommending medication as a first line unless I saw something strongly indicating that and I guess one thing there I'd also be very careful to think about is actually, yeah, is a missing piece here is Virginia actually not wanting to be around and part of the reason she's not engaging is that she has been having thoughts of suicide and we'd need to make sure we actually ask that question but really then I'd come back to a framework around recovery that's used in mental health that I find very useful when I see each person and the acronym there's CHIME and it's thinking about each time you see someone what can I do that would help Virginia in her connectedness to others in developing or regaining hope it actually maintaining her identity she's a little bit different to younger people whether we talk about the maxiformia Virginia knows who she is but she might have, through whatever is happening have lost that a bit how do we help her to regain that sense of being that vivacious and confident person how do we give meaning back to her life and importantly how do we actually empower her so she does feel we're working with her not taking control over it because unfortunately one thing is very clear that actually we can in protecting older people often we take away that control that is so important to all of us but thank you thanks very much Rob that was great if we GPs just held some of those parts of that framework in our mind it would be very helpful I think when we're seeing someone like Virginia so we certainly need more psychiatrists like you and maybe in the discussion we'll discuss how available your skills are in the different communities around Australia and now over to you Chris Chris Hall will bring us his psychologists insights into Virginia's life journey welcome Chris thank you Steven it's good to be with you and everybody else on the session we've heard already from other speakers about the kind of litany of losses that Virginia's experienced really from the age of 15 through to an accelerating range of losses which all in many ways threatened to undermine her identity, her self-esteem and I love this quote by the American family therapist Carlos Schluzky that says losses are the shadows of all materials material and immaterial so from my perspective it's not just about the the deaths of course this woman has experienced but of course the range and the multitude of losses I think the caption says Dr Bowen will see you now Mrs Stradley but he really doesn't want to and I think for me what this speaks to is the impact of perhaps working with clients or patients where there's perhaps a reluctance to engage with other services where we feel we're doing our best but there is a gap between if you like our offering and what's taken up so I think we're an important part of this equation in terms of working with a client and we might describe as resistant or defensively self-reliant but obviously we're impacted by this the assessment that we would do particularly as a bereavement practitioner is kind of multifaceted we certainly would do some formal assessments around social support we know that social support is a very strong indicator of bereavement needs particularly both instrumentally and emotionally and we also would look at things like an integration of stressful life events scale which we use routinely which is really a measure of meaning making to what extent have these experiences of grief and loss been integrated into a kind of a broader framework of meaning and also a measure like the prolonged grief disorder scale which is mapped very closely to the ICT so in addition to a very lengthy intake interview these would be tools that we find very important in terms of triaging the kind of support that we might provide similarly we know that complicated grief as it's more quickly termed these days prolonged grief disorder rarely exists in isolation only about 32% of people in this particular study had simply complicated grief and we often see an overlap with major depressive disorders and PTSD so it's certainly important in terms of our assessment that it's comprehensive and I think this is clearly where a team based approach is very valuable we know that targeted treatment of complicated grief has been associated with reductions in depression and anxiety but it's not been found to work the other way reductions in depression and PTSD tend not to impact upon the grief symptomatology so I think that's an important finding that and points to some distinctions between complicated grief and depression so what could be done I think first of all we can help clients by naming it and claiming it and providing opportunities for them to identify their experience of loss and to identify what's captured the attention of the client there's often something that has derailed a very normative process of accommodation for clients I wonder whether it's a sudden and unexpected death their partner was she there at the time was there some other event that has captured the attention of her that has not enabled this processing of the grief to take place and also finding ways of re-engagement in the world we also were looking at encouraging self-observation and reflection with self-compassion very often there's a critical voice we hear from people about they should be doing better than this or there's a failure to recognize positive emotions in their experience but ultimately we help trying to help reconnect people to their life to a sense of meaning and purpose in their life so I hope some of these have already been touched upon by our previous speakers but the ability to self-reflect self-determination particularly where life feels got out of control goal-setting, self-compassion self-awareness important part of good grief therapy is good grief education so again in many ways providing a framework for understanding these experiences from a loss in grief lens I was touched by her interest in photography and I wonder whether her language is more a language of imagery perhaps a language of words so looking at expressive ways of perhaps communicating her experience revisiting the story often focused on those things being least well attended or being avoided and also recognizing that death ends a life it doesn't end a relationship so what's her ongoing connection with both the partner and the other losses in her life and I'm sure there are many of these things that we'll consider in greater depth as we as we proceed thank you Thanks very much Chris we've got a few questions coming in from the audience they're interested to know what educational resources there are for themselves and those that they work with around grief and bereavement and I was thinking that they could they could do no better than going on to your website at the Australian Centre for Grief and Bereavement which I think is in our resources at the end We're a Victorian government funded clinical educational service and so grief.org.au has resources there both for clinicians, practitioners and also for bereaved people That's great so we're now on to the question and answer time where I invite you three to have a bit of a banter around the questions that have come in we've got obviously we've got about half an hour now to talk these questions through so we may not get through that many but we just view talk amongst yourselves around the issue so I'll kick things off with a question which I think you've all raised to some degree about the older generations appetite to share their mind as much as they might be used to sharing their bodies with healthcare professionals certainly in the medical area and I heard a quote on the ABC from a woman from the Mali country in Victoria talking about her hard life and she said I could say a lot so I will say nothing who'd like to start come on someone's got to jump in I might have to if nobody else does I think acknowledging what you don't know about the person and where they live is a really useful starting place so I know when I do my rural flying fly out to show a curiosity about where they live and often something that's not neutral and they're moving into the curiosity about them and be willing to listen and give time and I rarely find that approach doesn't then result in my main problem is that I then do have to actually bring that back around to actually some of the things which they might be so comfortable talking to but once they've got a bit of a comfort level they will have in their mind to you great great Chris or Sue I think that's very much along the lines of my thinking I think it's so important to cultivate a sense of curiosity a state of not knowing and inviting exploration rather than going in perhaps with too much of a predetermined sense of what may or may not be so I think you know cultivating curiosity I love the old Yiddish expression perhaps not a hackney phrase but God gave us two ways in one mouth and we should use them in those proportions and I think that applies particularly in the brief field it's really what people often lack is the ability for somebody to hear the story and to bear significance to it and to not move away from the but in a sense to lean in to that story and to hear it in all its complexity and ambiguity Sue here yeah I certainly wrote myself some notes and it's very much finding out what makes her tick clearly she had lots of things happening in her life earlier but it's particularly around where's her photography now I mean she retired at 62 and we're seeing her at 79 what's been keeping her interested other than downsizing in that 17 years so yeah it's that as Rod said it's the curiosity what what does interest her and particularly and I think Chris mentioned it what is she doing that she can control I think here's a lady whose life is probably out of control a bit and we've got to give her hope that came up several times and I think that's an incredibly important part of our job but what is it that we we can look at with Virginia that she can do and control and so getting getting into that I think it's important you know what she done since her since her retirement if she's a good photographer can we pull that out what she doing with it now does she have pets are there any grandchildren she was born during the war during World War 2 you know does she have memories of growing up that might be impacting on her other than what we already know so I think that that curiosity that both Chris and Rod mentioned are really important it's not just to get a link with her but it's also to find out you know what is what what makes a tick why has she suddenly gone or not suddenly but why has she changed into someone who seems to be passive and there's I think lots to look at there and look just while I've got the I've got the the chair so to speak I would also like to know about her health literacy I wonder what she actually does know about her heart disease what does she know about you know hip replacements they've changed a lot since her mother had them she's fairly nihilistic about all these things but maybe we could explain to her that there are some positives now that's me taking a very physical viewpoint I guess but in a way trying to give her hope that there are things we can do for her in the in the physical sphere that that may help her feel better that being said I think there's a much bigger role for my two collies in this area so I'll hand back to them could I just briefly come in I think one thing we can give control and I think that I've come to realise more in the last few years of my career is actually the control of where we see Virginia and who's with her when we see her traditionally the teaching around old age psychiatrists whenever you can see the person in their home see them in their home and whenever you can see them with family see them with family so each older person's got very strong views about what they would with each of those things and that is something that I think has been a change in my practice in the last few years is really trying to give that control from the very start around those things something you brought up when we were chatting beforehand because you know how do younger clinicians reach the age gap with Virginia because you know here we all are well fairly advanced in our careers but how do the younger clinicians reach that gap and it would be lovely to have a younger clinician on the panel as I was saying that because I'm struck by that there is no doubt some younger clinicians who do it so so well and yet others who have a challenge so we do you start I do think those who listen well is definitely one starting place but I think another thing is finding out a bit about history or having a willingness to listen to history is really important and I think that's because then when someone says something you know you can ask a question back about what that meant to them or you understand why they said that you can pick up on cues that you miss if you don't know something so I if I start working somewhere new I try and find out a bit about the social situation where it that you know in that place and what the history has been and that is maybe because I've got an interest in it but it also is incredibly useful to begin that conversation going and also for that sense of something's not fitting that's really what I think what a big part of what we do working with older people is getting a sense of something's not fitting what you normally expect then we are to explore that term. I wish I'd had you around when I was a younger clinician thank you I might just go on to a little group of questions that came up I read the other day about evidence of the Royal Commission from a Dr Alison Argo of Queensland psychologist and she gave evidence that there was a dearth of identification and assessment of mental health problems amongst the elderly in the public system and this raised questions have come up would Virginia be lucky to get mental health care at a price she could afford and how would regional care differ to the support she might get in the city those of you who are using the chatroom do feel free to put in your news about how you're finding access to older persons mental health care in your area so over to you, what do you think what's your experience some of you are in going to regional areas a bit you're all in policy so it's soo here I certainly work in effect I'm down at the moment on the country you and the people on the south coast of New South Wales we, yeah I do quite a lot of clinical work here and there certainly is less services than we have in the city but we do have we do have aged care psychiatry although it is a little bit difficult to access you've got to sort of go through quite a few people to see the aged care psychiatrist but I think the use by the GP's of some of the counsellors is really important what I think you're getting at Stephen is what's happening in residential care and certainly what Alison Argo said is so true I have approached one of my patients in residential care and offered her the opportunity of some counselling and she said what's the point I'm going to die soon and I just and you know it's hard because neither I nor the psychiatrist felt she was depressed she was just being realistic because she'd lost a number of her colleagues we actually did talk her into seeing someone who ended up being a volunteer and it was a wonderful experience for them both and it actually has worked really really well but it was a case of being persistent because she just didn't think you know I don't know if she didn't think it was worth it look the other thing to mention and I'm not getting into trouble here particularly in residential care but everywhere is the advantage we haven't mentioned animal assisted therapy yet and I do although I know I think Virginia lives in a block of flats so she may not be able to have an animal but that's one thing we often forget and I have seen so many times the absolutely wonderful change that having an animal can make for a purpose and whilst our ABC series you know older people terms four year old showed that if older people had a reason to get up in the morning and that involvement with the kids was absolutely magic we know that having animals and having a responsibility for animals is there as well so I just wanted to throw that in while I had the opportunity because I think we do get very negative about what we can do in residential aged care and I think there is a lot we can do and get more there is certainly funding for some counselling for some psychologists in aged care facilities and it's how we access them thanks Stephen I think there are also as tradition clinical therapeutic intervention we run a program called coffee and chat and so people meet together socially it strengthens the social connection it gives them a goal and great a great joy so we've got a group of men that meet in a pub and so I think we need to think about different kinds of settings and also I think some assumptions about the use of technology in older people the most rapidly growing cohort on Facebook are those over 60 years of age and so we'll often see clients on telephone or via telehealth and so I think technologies are not suited or appropriate I think there are also other organisations out there that offer free or very low cost ways of strengthening social connection and providing a social support certainly if anyone is having difficulty finding avenues of referral I put a link into the resources about health pathways 30 out of the 31 primary health networks are using health pathways which you can reach through their website and they open up many of the avenues of referral to a whole range of services that help you navigate the most appropriate services in your area and often guidance will be given by one of the specialists as to what would be most helpful in the information you can give them to start the assessment so that is in the resources at the end and certainly there are many people registered tonight from a whole range of I don't think we've got any volunteers registered but there's certainly a whole cohort of other health professionals out there 25 May I think it's also before mentioning that if you google find a psychiatrist there's actually quite a good search engine on the College of Psychiatrists website where you can actually put what location you're looking for and also what area of specialisation and that's the location is probably getting slightly more difficult to interpret as we're looking for more telehealth but definitely it's a useful search engine and I think this room for both hope and despair I'd say in terms of access to older persons, mental health specialists I was involved in the atlas of healthcare variation and variation is the key across all of Australia about access for older people but the rule is basically once you're over 65 your chances of seeing a psychologist in Australia is poor no matter where you live and we've got to get better at actually referring because we also know that one of the blocks there is actually using GP mental health care plans and referral but also in building up skill base and that's why I've moved largely into education is trying to build up skill base across all the disciplines in working with people with mental illness and particularly those who'd like to work with older people being my passion and we we've got to remember that broad range, I talk holistically I try to practise holistically but we also need to be prepared to actually when we think someone really has got mental illness to treat and to treat we are we're talking therapies and to treat appropriately with medication and I think sometimes we're more afraid to do that with older people and then they get hit with inappropriate ranges of medication because we haven't been prepared to intervene earlier and people get despair and if we despair what hope for the person in terms of the role of medication in older people so look forward to that no surprise that there are a few questions coming up about COVID how do you think this is affecting older people and I imagine people out there are thinking of the worsening of the social determinants of health such as loneliness that's affecting us Steven it's so oh yes go ahead first in okay was that me I've been amazed at how resilient a lot of older people have been and working down here on the south coast we had the bushfires late last year and early this year and we thought that was bad and now we've got COVID and of course Bateman's Bay was a hotspot over the weekend unfortunately there haven't been any more detected but it's been interesting quite a few older people are doing very well they've said they have met more in their community this is older people living at home obviously it's much harder for people in residential care particularly those who are in facility that have not been allowed to have visited and I see this very much in my own family my mother is in a facility she's in a high care dementia unit I'm allowed to visit her as often as I like as long as I'm temperature checked and ask for the questions and hand sanitise and only spend an hour with her my mother in law on the other hand only recently has been allowed to have any visitors at all and I think it is very very hard for those people in residential care often to understand why their husband or wife or child isn't visiting and while telephones are quite good it's not so good if you've got dementia or you're deaf we're doing quite a lot of telehealth I've certainly expanded that all I have been doing for some years anyway and it's still very difficult when someone's cognitively impaired to be able to see or hear adequately and understand what's actually going on so I think in response to the questions Steven I've just been a mix of reactions and I think we've got to work out what have we done that works really well and what can we take forward and I think the GP telehealth consultations are a real positive and certainly we've done a few of them where I work down the south coast and a lot more in Sydney but it's where do we go in the future and I'd love to hear my colleagues comments on their experiences certainly of COVID I actually did a presentation around what was learned from overseas about some pandemics and older business mental health and actually I put some of that in as a link if you were interested in viewing that but I think key messages there are in some places older people vulnerable and more risk of suicide probably about those issues of social disconnectedness and also not accessing services but in other places they've actually done very well and I think what that's about is actually the environment the person is in their social environment which is very personal is really crucial so I think in thinking about the older person this time of COVID actually understanding what their social environment is about have they got a source of access of support is to me the crucial thing that I focus on I'm encouraging others to focus on and I'd agree there have been some residential care facilities that have been outstanding and actually people have said their lives have improved during COVID other people obviously have been extremely fearful and it's been very negative and I suspect in the community it's been more arranged but as I said really I think that issue is about the environment and if it's something positive we can do it is making sure each older person has got someone they can connect to if they need to and that person is important I mean we certainly we know some weirdos and certainly the degree of resiliency we see in our population has been quite surprising for many of the other clinicians the issues I guess dealing more with are issues around end of life family access funerals particularly the involvement of older people in funerals and also some of the complications for people who have been bereaved where the bereavement may have kind of legal processes involved so I think in general we're seeing people coping really well and I think it's important to remember in the bereavement space 93% of people respond to bereavement with great resiliency and go through a kind of acute period of pain and distress but then adapt we're really talking about a very small proportion of people whose bereavement can derail them undo them and we then see this kind of prolonged complication of bereavement it's important to not only be strength focused but also to recognize the high level of resiliency out there in the community I think it's important to recognize that it's also time of economic recession coming and in general older people have actually coped better psychologically in that time than younger people so we do need to be aware that the older men do have a very high risk of suicide we can't ignore that but there's a lot of resilience in older people a lot of our volunteers are older people we need to respect that and try and work with that so thank you I think that's very positive and we have to remain positive it says a couple of questions come in from some of the registrants the demographic of our registrants is split between those who have had medical training and those who haven't had a strict medical training Virginia obviously I think one of you mentioned she's a bit of a heart sink because one wonders what can you do to help we've all offered many solutions but I think for those of us in the medical field especially GPs where we're trained to help and to do and when we're faced with someone like Virginia we're a bit up against it the question is about how do you motivate the unmotivatable well one is unmotivatable that's good and I think to me the issue there is and I'll go back to that issue about recovery orientation is that recovery orientation is pretty much like the more modern literature about person setting care it is about understanding the person their goals what their goals are now or they were because actually it may be that if Virginia is depressed or bereaved she can't remember the goals that she had and we need to help her to refine that goals which means we need to speak to those who knew those before or to try to work that out those are the bits we can get from Virginia and if we focus on her rather than her problems you'll find what are those things that will help motivate her and some of it does take time but when I said no one can not be motivated I can't think of the last person outside the context of some people's dementia where there might be a very physical thing causing that lack of motivations and different issue but outside of that I think everyone can find a motivation to focus on what is their motivation not ours I think the important thing is instilling or co-creating a sense of hope many bereaved people don't take up referrals because they feel it's too painful it's too painful to go there and so finding ways that developing a collaborative trusting relationship where that kind of pain is really important but it really does it does require a strong therapeutic relationship in order for that level of trust I think the other thing we find is that people often don't take up referrals to bereave me because they don't feel like a difference and so I think it's important to recognise that this field of Greek bereavement has moved on incredibly since the late 60s and Kubler-Ross's stage model that we now have good evidence informed interventions that can make a difference and can reactivate people's engagement in the world and for them to live alongside those experiences of loss so I think instilling a sense of hope and optimism I think the other thing we find also in bereavement is often the person who would resource them or assist them in seeking support and care isn't there they're the person who's died and so I think the resources of actually going to appointments and one of the things we've found is telehealth is actually increased access because people are able to do it often in their own time in their own place that's safe but I think this idea of instilling hope that is really important and also recognising that we can't do that completely and of course individuals have free agency we do all that we can but we hang in there and do whatever we can to develop an understanding of those referral resources too so we can speak about them with some degree of confidence I think there's a huge responsibility there for us to maintain our own hope I had an excellent presentation from the American Psychiatrist talking about our role is to help the person see a future they cannot imagine and to do that we have to maintain our hope and I think if we do that that in itself is a huge help for the Virginia and people like it that is exactly what I was going to say we've got to stay we have to stay positive and hopeful and it's not always easy you know and I was one that said heart sync patient but in a way saying that then makes you think okay what are we going to do about this how can we develop hope in them and also in ourselves and look just some comments that have come in through the chat box about usefulness and appropriateness of other disciplines and I think of some very successful work that I have seen done with occupational therapists and I know there are some on particularly mental health occupational therapists and I declare an interest here because my daughter in law is one and I really have learnt what they can offer and I think there will certainly be things in terms of Virginia it's just how we access those easily and they are in mental health services and I think in old people's mental health services but getting them it can be difficult but I did want to highlight that because that's certainly one one group of people that I think in some ways are underutilised and really do understand both the physical and if you like activities the functional the functional side and the cognitive and mental health side of well particularly older people in my case but I'm sure in all age groups and I think we really have to acknowledge their incredible usefulness and they often make they're often successful where we're not yeah I'm using therapists and art therapists to that list as well we certainly do a lot of work with those two professional groups and have a great result and community I mean there are so many resources for peer to peer in the community now the awareness of the culture I think is changing so we're at that point that liking Q&A we ask for a one sentence sum up from each of you and it's a bit of a bit of an ask I know but I'm sure you're up to it who would like to start just a brief summary of what you reckon about Virginia or mental health for older people in general well I'll go to since I started the I think it's particularly and we've said it already giving her hope finding out what it is that makes her tick so we can work out how we can motivate her and you know the I guess I was saying if she may be one of the unmotivatable if there is such a word certainly understanding that is I think really important what is the way into Virginia and certainly I'm sure we could do we could help with her her physical health and maybe I can convince her to do a little bit of exercise and lose some weight and that would help in some of the other areas but you know if we can just find the chink in her armour and get in there and maybe make a few small changes then she can see what she can do and I think that's quite important in terms of it but I really do like the idea of hope how we give her hope I guess that's what I'd really be keen to see with Virginia I like that I'm sure everyone does tonight that simple word Chris or Rod well I think we've touched upon a number of these things I think maintaining a sense of optimism of ourselves and the extent that we can within Virginia is important I think we really need to hear a story this is part of the tantalising frustrations of case studies there is such nuanced history and what her meaning is that she's made of her life of her experience and the importance of kind of sticking in there what we have is the relationship at the moment and to create opportunities for her to explore that and I'm still very interested in the way that photography and what's her kind of her language of image that might represent her experiences and so I think there's enormous creative potential but within Virginia and also within the way we might work with her rather than repeat what's just been said I would agree totally I'll take a slight tangent I think what Virginia needs and the Virginias of this world need is more people in aged care who want to build out their skills in working in mental health and more people in mental health who want to build up their skills in love of working with older people and I'd encourage people to be on Chris's site I'd encourage people to think about some of the work we do out of HETI where we've got some older person mental health courses and learn more because working with older people and their mental health and mental illness is just so rewarding and I think that's what Virginia needs she needs people who can see that, know how to do that love that and give her the hope and with the hope she'll get there and certainly someone taught me many years ago the role of the GP is to hang in there and stay with your patient because if they know that you're there through sickness in that's a very good anchor for everything else that happens still point in a turning world so thank you all would just come to that stage of I'll just move the slide along a little bit that there's all of the resources available that each of the speakers have contributed add to this a little bit MHPN supports the engagement and ongoing maintenance practitioner networks where clinicians from different disciplines meet regularly with other mental health practitioners to share and build local referral pathways and engage in CPD as you'll see we started one in North Sydney with the support of MHPN and our local PHN we have about four meetings a year we've had talks on substance abuse management of BPSD First Nations elders art and music therapy e-prescribing compassionate communities and even a showing of that great film alive inside if any of you get a chance to have a look at that it really is worthwhile so the supporting resources for the webinar are all posted in the supporting resources tab and you'll receive communication from MHPN with the recording of this activity now there will be two further webinars to be delivered by way of this partnership between the 31 PHNs and MHPN and after these I'm just putting out some of the ideas that I've had we might discuss the role that community can play to raise the issue of aged care facilities so I think it would be good to have a panelist to discuss health care in residential aged care facilities First Nations elders and their care multicultural issues and the role the wide range of the other health care professionals that we've talked about a little bit tonight could be expanded on and also the care of our socially marginalized and vulnerable older citizens so those are a few sort of topics that we might be able to weave into our future webinars but we really would appreciate in the exit survey that you put some of your ideas for the topics and then the PHN MHPN reference group will consider suggestions and that will help us plan the second and third webinars produced through this partnership so my sincere thanks to the Ceasings panel Sue, Rog and Chris thank you for your time and sharing your great wisdom I certainly find that one of the great pleasures of an event such as this is if we can allow it to live on in the busyness of the next day so it may inspire us to experience a consultation with slightly different eyes with some of your words of wisdoms ringing in our ears I hope as we see perhaps what we call an easy patient but also perhaps that heart-sync patient so I hope that happens for you all and please remember to use the exit survey and I think that's we actually have a couple of minutes left I've been probably over cautious about finishing on time my patients will tell you that's either a good or a bad habit of mine so if there was a last word apart from hope that any of you would like to add, please do so I might just say wrong one I might just say one thing we haven't discussed at all is the issue about the ongoing impact of trauma in the older person and it's a whole topic in itself but a really, really important one to let the person talk if they want to but also to not in any way force them to talk which I fear that some of the discussion around trauma-informed care sometimes encourages too much focus and aimed for Virginia the understanding of Virginia in her entirety the good and the bad is just so important I think it's one thing we haven't touched on almost the talking itself well yes there was a question came in and I saw trauma and I thought it really does deserve a whole section for itself so we'll certainly plan to do that in in the future webinars thank you for bringing that up Rod I think we'll say good night to you all and again thank you and thank you all of you out there it's a strange world isn't it that you're all muted but I look forward to reading all of your comments from the chat room and hope to see you at the next webinar have a good evening