 I'd just like to welcome everybody to our webinar tonight from MHPN. This is an interdisciplinary panel discussion. The title is Working Together, Working Better to Support Older People with Mental Health Issues. I'd like to welcome our audience who are now logged in from every state and territory in Australia. Our panel tonight are three, Ms. Julianne White, Dr. Nancy Pichana and Dr. Rod McKay. Julianne is kindly logging in tonight on this webinar from our hospital there. She's been on well recently but has gamely agreed to present tonight. Dr. Nancy Pichana and Rod McKay will follow on from Julianne. I'm here for the facilitator tonight, Dr. Michael Murray. This webinar is hosted by MHPN. MHPN is a Commonwealth Funded Project supporting the development of sustainable interdisciplinary collaboration in the local primary mental health sector across Australia. We currently support over 450 local interdisciplinary mental health networks. For more information or to join a local network, visit MHPN.org.au. The session outline. The webinar is comprised of two parts. The first part is a facilitated interdisciplinary panel discussion following a PowerPoint presentation. The second part are question and answers from you, the audience. We have already received many questions so far but you are welcome to pose any questions in that bottom right-hand corner. The ground rules for tonight, please ensure that your stand is on. That does not apply to panelists and the volume is turned up on your computer. If you are experiencing problems with sand, please dial toll-free 1-800-142-516 on your telephone number and enter the passcode 40151365. You will see that message appearing frequently in the bottom right-hand corner. You can minimize the text box if you are finding it distracting using the arrows above and beside the text box. If your specific question is not addressed or if you want to continue the discussion, feel free to participate in a post-webinar online forum on MHPN online. The learning objectives for tonight. At the end of the session, participants will be able to recognize the key issues in the assessment of older people experiencing possible mental illness. Recognize the key principles of intervention and the roles of different disciplines in treating, managing and supporting older people experiencing mental health issues as well as functional issues. And thirdly, to better understand the merits, challenges and opportunities in providing collaborative care to older people with mental health issues. We will now move on to our first panelist. It's Julianne White, a social worker from the Riverine. She has had experience as a nurse and a clinical mental health social worker across the Riverine. She is presently doing a doctorate. She is the founder of the Amaranth Foundation. Julianne, are you ready to go? Yes, I am. Thanks, Michael. Thank you very much. Thanks. I'll just go to the next slide. Slide 8. So just looking at... Hang on a minute. Are you disconnected from the server? What I'm presenting tonight is the view of a social worker in looking at the case study we had, which was Morris. And what I wanted to do first is actually say, you know, sort of to place social work into the context that we're doing here. Whereas social work is concerned with the way people interact with their environments. We're using a series of social systems, life-stage development and human behavior. But we also look at the fit that a person has with their environment across those three levels, the macro, the mezzo, and the micro level of a person's life and their capacity to function and live meaningful lives across all those sectors. But we're also concerned with the biopsychosocial issues. And you choose tools and ways of engaging with a person to build their trust and rapport. Initially with Morris, and to gain his trust and rapport quickly, which I believe is really important, you know, we have to engage with him with great regard and dignity and compassion. Sorry, I'm just getting some things on my page here. Sorry. It's also important to educate him about the role of a social worker because there's a lot of you know there that a lot of people don't know what we do in mental health or how social work, psychology and psychiatry and even the role of a GP, you know, works in collaboration together. So I think that's really, really important. The other things we're really concerned with Morris is the negotiating, looking at his presenting problems and how he's negotiating this really important stage of his life and the fears and issues that he might be having. And also concerned about his family and other significant caregivers interact with him and how they also perceive Morris's problems and strengths. But prior to any formal assessment, I'm getting some feedback here. Is everyone getting feedback? Is that causing a problem? It's not causing a problem, Juliana. Well, I'll keep talking. I'm just trying to move the slide across. Michael, can you help me here to the next slide? Do you want slide nine or ten? Nine. That one. It's on nine. Thank you. Prior to any formal assessment tools, what I've got up here is that from a social work's perspective, I think it's important to understand the context of Morris's life and the things that provide his life with meaning and purpose. And what I find from a social worker is a great way to start with a genogram, looking for his strengths and his weaknesses in his immediate circle, looking at his relationships, the losses, gaining an understanding of how he perceives and values these relationships. And then of course, moving on to the echogram, which is an important part of a social work intervention, which introduces us to Morris's broadest connections in his community and the supports and roles that play in his life. And also to gain an understanding of the value and importance Morris places on these connections, which is terribly important to get a context of Morris. We also look at his family and cultural sensitivities, because I think that's really, really important to understand how his family relate, how they communicate, how they cope with change, who are the key people in his family and how they relate. And I think when you get a sense of all of those things in that initial engagement with the person, that you can then move on to other questions and other assessments very, perhaps with more empathy and more compassion, and also have things to relate back to. But also to be checking in to Morris constantly so that he's really okay with the things that you've actually asked him about and your interpretation and the way you're hearing and seeing things is actually exactly what he meant. And what I've got up there on the slide, I think it's important to actually gain his perception of what his significant issue is, because if you've all read the case study, there's lots and lots of things that are really impacting on Morris and how he feels about where he is in his life, some of the presenting problems that are really very in your face. There's the evidence that he fell and all those things that we see. But those other intangible things that we don't see necessarily, which are the multiple losses, the fears that he's got and his reaction to the situation he's facing at the moment. I think it's really, really important to look at his goals that he might have all his hopes for the future. Because as we all know too, a sense of a loss of hope and meaning can actually cause an awful lot of fear and anxiety and problems and can be actually misinterpreted too as depression. So we need to really understand what his hopes and what gives his life meaning. We also need to know how he's coped with change and especially with all the things that have happened in his life and what strategies he's worked, that he's used in the past and what's worked for him or what hasn't. And I think that's an important consideration to ask him what he's done previously and whether these things are actually going to help him at this stage of his life. But I think we also, with all the losses too, to gently explore his reaction to his wife's death and that of his father, which is also very closely and related to how his feeling goes through now and how he had made sense of these deaths and the impact that they've had on him especially now. Michael, could you help me go to slide 12? Let's just sort of... Slide 12 now? Yep. So sorry about this, guys. After I read my slides today, I thought I needed to jump to the end of it. No, that's fine. That's fine, Julianne. It's lovely. It's very interesting. And what I've got on slide 12 though is... because what I thought is I actually had some other things about doing some case management collaborative care. So, Julianne, I'm just getting some feedback from the audience that because of the echo from the hospital phone, you can just speak a little bit more slowly and more clearly. Okay. I can see that over there. Thank you. I'll do that. Slide 12 up? Yeah, slide 12 is up. Oh, okay. I can't see it here, but that's okay. No, you're fine. What I think slide 12 is saying is that what we might look at because of where we've gone with all this discussion about trying to really get an understanding of who Morris is and some of the issues that have impacted on him is that maybe at this stage to actually look at some other assessment tools and the ones that I've used in my clinical practice with older people particularly and those facing hope and meaning in their life is the HADS, the Hospital Anxiety and Depression Scale which I think is really an excellent tool to use in this cohort but also the distress thermometer which I think has been well validated in the older population and also with people facing end-of-life issues and concerns. And so I was thinking after I looked back at my slides that maybe it's this tension and the rhythm of an assessment. Is it time now to jump in and do a formal assessment or depending on how well Morris is engaging with that conversation about his losses and his goals and his perceptions as to whether to continue with that conversation. And I think that's part of the intuition that goes with good clinical practice that says go with this, don't go into a formal assessment where you might actually sort of turn off that engagement which I'm always very conscious of especially with older people. And I think with someone like Morris, never to forget the concept that he's been a professional all his life and he's only been retired 10 years so he's been a professional, he's been well engaged controlling his life. He's been in charge, he's the expert of his life and so we have to show great respect for the expert status that he has on the things that impact on his life and how he feels. And I think constantly go back and check with him to say look, am I hearing you correct? Is this what you feel? Is this what you're seeing are the issues? And then on slide 13, I've got... Do you want to slide 13 now? Yeah, thank you, Michael. That'd be lovely. I can't see these slides, I'm guessing. No, that's fine. We have slide 13 up now, thank you. Lovely. On slide 13 I've just got a list of some of the interventions that from a social worker as a mental health social worker these are some of the interventions that we would feel most comfortable with in engaging with Morris perhaps in exploring some issues around especially acceptance and commitment which is a very values orientated approach to some goal definition and perhaps addressing some of his fears and anxieties. I'm not sure if I put dignity therapy up there as well but dignity therapy is also another really wonderful therapeutic intervention to do with people who might be facing end of life because it actually looks at their life, their expert status and looks at the values that they may have had that have guided their decision making over their years leading them to this point. So I've just got a bit of a list there. I'm not going to go into them, of course, but they just might be there so I wasn't sure what the audience consisted of but from a mental health social worker perspective these are the ones we would be most comfortable with. And then going back to slide 10, is that all right, Michael? Yes, I'm just going back to slide 10 now. Thank you. It's lovely to have a little helper. Slide 10 is off now. Oh, lovely. Now slide 10, I sort of talk. I'm hoping this is what's on the slide but that looks at some of that collaborative care that we would be looking at working with other healthcare professionals. I'll just go and grab my other notes. And what we would do would be using a strengths and a solutions approach to look at other possible areas of community-based supports, if required depending, and also any reviews by GP. So trying to engage with him in looking at from his genogram in the echogram and looking at the strengths that he's identified and some of the things that community supports, try and engage a conversation with Morris about how some of these could be used to actually support him based on how he perceives his problems to be. And I think also here, as I said before, constantly checking in, rechecking in with Morris constantly, is he okay with this? I find that if I forget to check in with people, I lose them. They just, you know, you can just see that they drop off from the conversation and I think rapport goes, but I'm not checking in constantly. They think you think you know what you're on about. You know, and I know that I would feel like that if someone was trying to engage with me, you know, a stranger into my life. So I'm really passionate too with doing an intervention with people to be conscious of the rhythm and the tone of the interview so that I'm very conscious listening to how the engagement is happening, you know, the rhythm of the questions and how Morris and the people, you know, that how that interaction is happening so that your intuition can come in. As much as we've got to have all that theory sitting there, you know, being able to draw upon, we've actually got to have the intuition that guides our responses and our response to this, you know, individual and this person in front of us. Also important, and I think I'm quite sure if it's this slide or the next slide, Michael, so if you're able to have a bit of a play with that one and slide 11. But to look at who are the other healthcare professionals who may be out there, I think it's absolutely key and critical that Morris knows that I know who's out there and that we're going to work together because I think if he's been engaged with healthcare in the past, maybe when his wife died or other things have happened to him, that maybe there was some disjointed interactions with healthcare professionals which, you know, this stage in his life where he's expressing fear and anxiety about his future, he doesn't quite know what's ahead of him. You know, he wonders, is this it for him? You know, what's the future hold that he needs to know that we as professionals are going to work well together and we're not going to double up? And so I think that my role is perhaps maybe not necessarily in this order, but maybe the first healthcare professional that might work with Morris post-discharge from hospital is that I need to know who else could help him and have a good understanding of other healthcare professions, roles and responsibilities and where we cross over and where we complement. And I think that's an important thing to check with Morris and let him know that this is all, you know, with his consent and permission that we'll work collaboratively together. I think that's all I've got to say on that one, I think. That was lovely, Gidley, and that was a lovely presentation. Thank you very much. Oh, thank you, Michael. Now, we're just going to move on to Nancy. Nancy Pichana from Queensland, a clinical psychologist and neuropsychologist attached to the University of Queensland as a professor. Nancy. Hi. I'm very good. I'll just move on to your first slide. I'm sorry. I've advanced it myself. Good on you. So I'm hopeful that that's up. I thank Julianne for that great intro into my own bit, which is the psychologist's perspective of this very interesting case of Morris. And I think that this case really illustrates very well the complexities of an older adult coming in for this sort of assessment, the complexities of their life history, their medical history, and their emotional history. So that's why this kind of a case really lends itself to an interdisciplinary approach. So I'm going to speak about the case both from a clinical psychology perspective as well as a neuropsychology or a cognitive assessment perspective. And in saying that, I'm going to echo what Julianne said about having a biopsychosocial approach to the assessment of the case in terms of instrument selection and sort of tailoring that to the gentleman's presentation even a little bit on the day. I'd always suggest with such cases to have, you know, if the person isn't quite up to some more complex assessment to have some backup assessment instruments. And then also formulation is key. So how are we putting together all of this information to make some hypotheses about what is underlying his current concerns and where we might want to go with both the assessment and the treatment? So my next point is that really the structure and emphasis of assessment varies according to the treating psychologist experience and training. And this is my little plug for getting some training like what people are doing tonight because the evidence suggests that for this age group the efficacy of assessment and treatment is directly related to whether the person has training. So I think that knowledge of normal developmental life stages as well as then being able to distinguish abnormal trajectories from that is really key. And finally you have to balance this assessment of cognitive and emotional functioning now compared to any kind of baseline assessments. Of course, I wish everyone had a baseline assessment when they were 20 and 30 so that neuropsychologists could have a true baseline. Sometimes that may be more difficult to ascertain. And again, it would be good to get collateral information to get that sort of assessment. I'd like to also emphasize here that Morris' wishes are really important. Here we have a case where you're going to do some neuropsychological assessment. And people may approach this kind of assessment with a lot of trepidation. They may be saying a lot of things to themselves. So for example, this gentleman has a potential issue driving and when they come in they may say, is this assessment going to result in the loss of my license? And so I think it's really important to ascertain what the person sees as what may be some potential outcomes to the assessment. And this is a new way of thinking in neuropsychology. It's called therapeutic neuropsychology and there's a lot of research about it and this kind of approach, if you look it up online, there's starting to be more and more articles about this, about really taking the person and their family's perspective into how the neuropsychological assessment is constructed. I'm going to move on and talk a little bit about the setting of the assessment. I think that you can obviously do assessments in the person's home and certainly this gives a great richness of the assessment. You can actually see how the person is coping in their home and it can give a lot of information and a lot of times that's how older adult assessments are conducted. I would say though that there is the possibility of the environment influencing standardized administration of instruments and so there has to be kind of a balance and negotiation if you're going to do some extended cognitive testing in the person's home setting just to make sure that you get the best data possible. I think that the interplay of the person's mood and their cognition and the environment is very important. So for example, when you test people cognitively in familiar settings, you will get better results than in say an unfamiliar setting like the hospital. Also obviously a person's mood affects their cognition and again, this makes it really important to have very good instruments with good normative data to base your assessment on. So I would say that if you're choosing instruments for older adults and by that I mean individuals over age 65, you choose instruments, for example, that were developed and normed on older adults if at all possible. So for example, geriatric depression scale, geriatric anxiety inventory. And just in case anybody's wondering how to assess such assessment tools, a really great resource is called assessment scales in old age psychiatry. It's a relatively inexpensive book that gives actual assessment tools in it. And so one of these tools I've mentioned on the slide, the IQ code, that's in the book. That's an informant questionnaire for cognitive decline in the elderly. But a lot of these tests, including various forms of many mental state tests are in that book, highly recommended text. Now some specific assessment issues in this case would be to determine premorbid functioning if you can triangulate that sort of as a baseline for your cognitive assessment. To compare also the patient's report of issues and concerns versus objective data. So for example, a key differential in terms of progressive neurocognitive decline like a dementia versus depression is this kind of mismatch between the person saying they have lots of issues with memory and can't do anything, and the testing is telling you a slightly different story. I think here we have the issue of alcohol and self-medication issues are important and that you'd want to get a detailed history. And there are some specific instruments looking at substance abuse in older adults. So I would suggest an instrument like that. Driving issues, again, paper and pencil tests are not great for driving issues. Obviously an OT in a driving assessment is kind of gold standard for this. But some useful tests include things like just simple trail making tests and also gauging some kind of insight into whether the person notices that they have any difficulty compared to family reports. Bereavement is a big issue in this case and again you'd want to do some assessment around that. And also a risk assessment obviously if there may be some suicidal ideation. And then finally, I think partly because it's a research interest of mine, capacity issues in terms of financial capacity and capacity to look at their own health issues would be key. And again looking at issues such as vulnerabilities to things like internet scams. Now in terms of management, I'll just try to be brief here because there's a lot going on. I think that the management by the psychologist will vary. I think that if the psychologists were to do some both either assessment or treatment that it's really important for older adults who may not have been exposed to a psychologist to socialize people into what is the purpose of the assessment, who has access to the results. If you're doing therapy, what sort of therapy are you doing? What will it entail? How long? How many sessions? Stressing a collaborative approach. These are really key in terms of making sure a rapport and the direction of the therapy go well. And you always want to be as Julian said checking in, making sure you're in touch with the patient's goals. And then of course there's collaborative case management with other healthcare professionals. And you really want to make sure that all of the parties short and long-term goals are clear to everyone else. And if anything changes, for example, in a acute medical incident, that everybody's just kept up to date. I think that that's really key. So from a neuropsychological perspective, really the battery should be tailored to suit the referral and the initial formulation. And it really whatever cognitive tests you give, it could be five minutes. It could be an hour. You know, it's really tailored and you're not over-testing, but you're sampling enough to make some sense of what's going on. I've already mentioned choosing appropriate instruments for older adults and really be clear with the person what you're doing with that data. And to give feedback. Unfortunately, data suggests that people don't get regular feedback when they're given assessment. And this may be particularly true for older adults. And it's so important to give that person feedback about what were the results of the testing. I mean, I think it's just absolutely essential. And then from a psychotherapy perspective, again, really tailoring the treatment to suit this presentation, Julian mentioned several sorts of therapy. And I think all of those could be appropriate. You know, CVT acts, you know, lots and lots of different approaches, you know, depending on the therapist's training and what the goals of the patient are. But again, very important to socialize into what can you expect from this therapy modality. What do you think are the number of sessions we'll be meeting, checking in with the person? You know, are you doing assessments? Does the person have homework? Is homework an issue? For example, for CVT, homework is a major component of ensuring the efficacy of the treatment. And again, with older adults, negotiation of homework, probably not calling it homework would be a good way to start. You know, ways that between sessions you can work on some of the skills that we are talking about in session. I mean, that's how I would frame it to a patient. But again, you want to negotiate homework and give the person a sense of success in completing it and you're on the same page with the patient. I just have to mention, you know, especially with younger therapists, sometimes there's transference issues and I think whatever treatment modality you should be alert to transference issues, does this patient remind you of an older adult in your life? An older adult sees something in you, especially for younger therapists, you're just like my granddaughter. I think therapists need to be alert to transference. And then finally, all of the literature suggests a more gradual termination of therapy with good supports in place and maybe checking in with the person say a month after the last face-to-face contact is a good idea. I think that's my last slide, so thank you. Thank you very much. That was a great presentation Nancy. And now we'll hear from Dr. Roderick McKay. Roderick, the psychiatrist working with older people based in South West Sydney. Rod. Okay, thank you all. And thank you, my two previous presenters. I think it's hard to know exactly how to present this because a lot of the issues that a psychiatrist would go through are very similar to have been presented from the social work and the psychologist's perspective. And the thing that's been striking me as they've been talking is the importance of prioritization. And I think that as a psychiatrist is assessing Morris, and definitely as I'll be assessing Morris, I'll be thinking very much what are the key issues, what are the key issues from the point of view of Morris, what are the key issues from the point of view of his family, and what are the key issues I need to know about before Morris leaves the room or I leave Morris' house because it's very easy to get lost in the complexity of an older person. And yet a lot of issues are actually quite simple if you can identify which ones you're going to focus on and be sure about who's going to focus on other things. And I think that comes down to that when a psychiatrist is assessing someone like Morris, there will be variation in the way they approach things, but they'll all have some sort of structure in the background to their assessment. And that structure will all have a respect for Morris' wishes and will be adapted for the setting of the assessment. And I think very much we're encouraged to take a semi-structured approach, and I think that's going back to a lot of the issues that have already been discussed, that it's really important to, for a poor and also to get a good history to actually let the patient lead you as much as possible in the assessment, but know the areas that you have to cover and then gently guide them to those areas if they don't go through them themselves. And it's interesting if you let someone talk with gentle prompting how often you can actually, how often they do tell you the things that you need to know. In terms of, you've heard the words, biopsychosocial a few times, you can see in the questioning, there's questions about spirituality in that. And I think there's a lot of different views amongst mental health professionals about whether to go or not go into the area of spirituality. We know spirituality is more important in older people. And if you're looking at understanding a person's fears or lack of fears, looking into the future, it can often be an important thing to approach, but making sure that you approach it in a way that if the person telling you about their views about the future and what is important to them in terms of spirituality, it's not coming with any assumptions about what their spirituality may be or a lack of spirituality if you like. If they don't have any certain beliefs, it can also be important. When there's a real lack of any beliefs, I think it's important to think about has that always been the case or is it something which is happening because something else is happening for them. And I'd be particularly worried in that case in terms of depression. Within a biopsychosocial assessment, really what we're looking for are what have been the factors that have led up to Morris being in this situation now, what are the things that may have predisposed him to where he is now, so looking at whether there's any biological factors. So is it that he's starting to have some cognitive impairment or not? Has he got a genetic predisposition for any problems? There's the talk of an accidental overdose by his father. So is there any other depression in the family? Is there family history of suicide or not? Maybe something we don't know or something we need to keep in mind. Then looking at what are the precipitating factors? What are the things that have been happening very recently? What do they mean for him? And importantly, thinking about what might be the factors that may perpetuate his current problems. I think the one that really jumps out here is both the social factors, and even though he has family, it's interesting as most of his communication is reported via email. So the issue about how isolated he does or doesn't feel and obviously the alcohol will be an important factor to assess and to be very cautious in interpreting the responses that you're given and that will come into the issue of collateral history. I think it's really important and something that definitely within a multidisciplinary team and I think though most sole psychiatrists would do as well is trying to get the patient's consent to talk with someone else as well as them. And I think it's a very interesting question about when you see an older person and they're a family present at the time, whether to see the person first, to see them with the family. I don't think there can be hard and fast rules. I think again you have to be led by the patient. It's very important to see the patient alone but in terms of whether that's first or after seeing them with family, I think it's very important to actually ask the person themselves what they think and be guided by that. And if I could go on to the next slide. Coming up now. The pause you mentioned already, really history is about 80% of your assessment. I think it's one thing where we know assessments go wrong is relying too much on the mental state examination. It's very important to go systematically through your mind about what you are seeing in front of you but it's important not to let that override the history you're receiving as well. And I think it's particularly important into the risk assessment and where we know risk assessment goes wrong. Obviously the history suggests there may be some cognitive impairment. It's really important not to assume there is cognitive impairment present and therefore you would do some degree of cognitive testing and whether that was informal or formal testing on the initial assessment would very much depend on whether the degree of rapport allows formal testing. I think the clock drawing test is one which often people will agree to do when they're reluctant to do more formal testing. Within NSW Health we've actually moved across to using the 3MS rather than the Minimental State Examination and I have to say I think that's a much better instrument. It's the instrument that was recommended in the dementia outcome measurement suite as a preferred instrument for cognitive, brief cognitive testing. It's a little bit longer than the Minimental State Examination but it covers particularly frontal domains as well and it's got greater cross-cultural validity than the Minimental State Examination and so if I did formal testing it's very likely that's the instrument I would use. I'll really be aiming at a problem formulation. Although diagnosis is important the big thing I'll be trying to identify really is what are the key problems? Why are they happening and then starting to think what are we doing about it? In terms of risk assessment I would be very cautious of this history about risk assessment. If you think about the factors that increase your risk of suicide even though we've got no reported suicide ideation Morris has a lot of those risk factors. He's over 75, he's male, he lives alone, he's in the rural area, he's been agitated, he may have a family history of depression or suicide and importantly he started drinking again. So in that situation it'd be very important both to do an assessment regarding suicide and initial assessment but also for it to be something that's in the back of your mind in future assessments as well. The other thing I'm very conscious of is the importance of not jumping to an early diagnosis unless it's clear it's there because a false diagnosis can be or a false positive can really be an issue in itself. I think it's important for all people to be able for all mental health practitioners to be aware that the new national driving guidelines actually state that a diagnosis of dementia is automatically associated with a restriction in driving license and diagnoses of depression or anxiety stick with people. To say there's a problem and to think about starting treating the problem is one issue to actually give a clear diagnosis is something I think should be done but I knew when you were clear about that. The other thing I think in assessment is really thinking about what are the gaps between Lawrence's needs and their available support and then what is going to be the role of each of the people who are involved. And if we go to the next slide. It's coming up now. So in terms of what the role of the psychiatrist will be in management it really will vary depending on what the requested role is what the resources are that are available and the patients use. My practice is mostly within the public sector where I have the luxury. Most of the time I've been accessing a multidisciplinary team and we negotiate that role within the team. I started working when I only had one nurse I was working with and often worked very similarly to being as a sole practitioner. And the role you take on is very different in that. The other thing is really important is actually the patient's views and you may have you about what you want your role to be but the patient may want to negotiate something quite different especially regards the role of the psychiatrist and the GP and how they want that balance to work. It will be always important to make sure that all three domains and needs are met both by the psychological and the social. So you want to be comfortable there is someone who is looking after Morris' physical health. A psychiatrist is a doctor and I would strongly encourage all my colleagues and I think the majority of psychiatrists do make a conscious effort to stay up to date with at least their knowledge about current medical issues and so whilst you may or may not be examining the patient physically you definitely would be taking observations of the patient and thinking about whether what you're seeing matches up with information you've given about their medical needs and medical state. You'd obviously be wanting to look at their psychological needs and how they're met and for Morris I think the key issue there is his alcohol and really getting a handle on whether it's a minor problem or a major problem and therefore whether you feel that the intervention should be focused on possible anxiety or depression or whether they should be focused upon his alcohol use initially whilst providing supportive measures around his mood problems. And from the psychiatrist's point of view it almost always consists of varying degrees of direct management, collaborative management with others and I think really the key issue is good communication and coordination with the patient and others and if we could just move on. So in the short term for Morris I think the key issue is psychoeducation for the patient and the family. There seems to be an assumption made by the family that Morris has got major problems. His son is going to put the word out to his brothers and sisters and it seems to me, it almost infers the word is that Dad's going downhill and so I think it'd be really important to actually feedback your assessment and I suspect actually that Morris's prognosis should be very good but you'd be looking out for the factors that might be so good. You'd want to make sure that risk factors are both identified and there's an agreed approach to either exploring them further or managing them and the ones that jump out are alcohol to me the suicide in the background and driving but also thinking very much that a 76 year old man who's drinking falls is actually the risk that may be most likely to cause an acute deterioration in his lifestyle. Making sure there is management of his medical conditions making sure there are adequate support and then safe commencement of effective treatment if it's indicated. I think it's important to make sure it is indicated and that may be just like education it may be starting some formal psychotherapy and psychiatrists are trained in a range of different therapies. In my practice I think I'd probably say I would use a cognitive behaviourally informed therapy without in any way being formal CBT with the most likely approach if I was doing something with Morris and then considering whether medication was indicated and if it was choosing one with the least side effects and starting at a low dose and monitoring the side effects and then in the longer term really looking at coming back to re-clarify the diagnosis we can get it wrong and I think it's very important to be quite willing to admit that both to yourself and to others. To term the duration of treatment if Morris really did have a major depression and he required any depressants he would require them for at least six months and it's very likely that he may require them for longer and if this is presenting as Morris's first presentation and he's representing you'd need to think about more than 12 months to two years in terms of duration and that's because there's good studies showing that if you stop the treatment early the chance of relapse increase quite markedly. I think we should move on to people's questions. Thank you very much. That was a great presentation. This part of the webinar now is where each panelist will ask each of the other panelists a question and I'll ask you Nancy to ask Juliana a question. I believe you had a question around about driving cessation. Yes. Sorry. Yes. So my question was what are the potential implications of looming driving cessation from a social work perspective? So I really appreciate that question Nancy. It's fantastic because I think that's as we've identified one of the big issues that's impacting on Morris at the moment but I think just I've just had someone enter the room. Hi. No I'm right thank you. Sorry about that. And I think what we have to look at with Morris is the concept of what is loosing capacity to be independent and especially in this life-changing event that's happening to him. I'm sorry I've just lost my concentration. They asked if I wanted a cup of tea. Isn't it lovely being in hospital? I think I've ever been asked. Sorry about that. I think so. Asking Morris about what does it mean for him to actually want to be to lose capacity. Finding out what it means to him to be able to drive. What are the other multiple losses that he might be experiencing? But I think in the discussions that we had with Morris earlier about his strengths and his community supports around him find out any other supports that might be there any other groups that are there other people that are supporting him already. Find out from him what would happen. Has he got plan B? Plan A is that his driving would be fine any issues that he's got his perspective of his problems and then what would happen if he perhaps potentially down the track or now would have to have his license suspended and what would that look like for him and perhaps get him to elucidate what some of those solutions might be to that. I think it's a really difficult one because losing the license is a bit like when people fall over and fracture their hips becomes a real life changing event for people because it is about independence and about caring for themselves and it often is the one thing that makes such a difference in people's lives, doesn't it? Yes indeed. Thank you very much. No worries. That was a really good answer. I believe that you had a question for Nancy about coordinating care where there were more than two professionals involved. I was just really interested in what ways Nancy's found have been the most effective strategies in coordinating care when there's more than two people involved. It's relatively easy if you suggest yourself and the GP but once there's a third person involved as well it seems to get quite complicated. Yes, I totally agree with that and in my own clinical practice I work a lot with patients in nursing homes and so it can get quite complex. I think that it's a good idea to have, if you can, a face-to-face meeting just to quickly discuss issues but then some kind of ongoing whatever seems to be the best strategy to keep some ongoing contact is good because some people are more reachable than others and it would be good if someone knows that they're not very reachable by phone. You might even agree to do some technologically advanced things like texting. Just something to keep communication lines open and I guess some sort of agreement ahead of time that if there's a major shift, so for example if the person is hospitalized that just a quick note to the other professionals involved would be appreciated and I think that goes a lot towards helping those kind of interdisciplinary efforts with the case. That's a really good answer. Thanks. One of the questions and one of the discussions in the text box, Rod, I'd just like to ask for your comments on this and you did refer to it briefly with spirituality and existentialism meaning for life. Would you like to comment on that? I think it's really interesting the range of views that people have about whether to explore spirituality or not within a mental health context and the range of views vary from I don't think it's just a discipline-specific issue but for a mental health professional to feel that there has been there's a severe risk of abuse of imposing your own views about spirituality even if you don't mean to or that somehow that all spirituality must be wrong in terms of in a way imposing their own views about atheism or agnostic views onto the patient and therefore a lot of people avoid the assessment but we know spirituality is more important in older people and I think it's really important to explore it even if and often I would start it with the perspective of looking at it as a social issue so I'd often start the discussion in the context of person support and I would ask them whether they attend any activities and I'd move on to whether they do have any beliefs and whether they are something it's an active part of their life or not and then if the person doesn't want to go further I wouldn't push it further that the question be opened up That sounds very sensible Julianne do you have any comments on spirituality? Thanks Michael I really do because I love what Rodry said about that I just think it's really excellent we've got to start these conversations a lot of the work I do is with people at the end of life and so we often start with exploring the difference between religion and spirituality and let people know that their social practices of their faith are about how they publicly express their spirituality or their faith spirituality is key to each person so we often, well my practice often start with exploring around how people find hope and meaning and I ask people what are the things in their life that give their life meaning what is it for them, what do they hope for and often those conversations are elicited, the things that people do find that give them meaning are the things of the spiritual all their fears about what might happen when they die or fears about things that have happened to people that have died previously and you can ask people then about what are your most fears about dying and that allows you to explore what might be an afterlife be like what do you think just explore those conversations and I've found in most conversations with people that they're very keen especially older people to have these conversations and for us to be the ones to open them up for them and to give them an opportunity to give them permission to have these conversations so I think it's really really important Nancy I can feel itching to say something there Well I just wanted to say that someone in the comment stream mentioned the Men's Shed and I think Men's Shed that's an excellent suggestion like we're talking about it from a mental health professionals perspective but there's lots of resources in the community more and more for older adults and I'm myself a big fan of Men's Shed so I think that it's very important to keep those sorts of resources in mind Yes and I noticed somebody in the text box mentioned bush walking as well so the old CBT goes a long way and there's very good evidence for exercise in lifting mild depression as well as doing a whole lot of other good things Now Nancy you had a really good question for Julianne if she just had one session to work with Morris what would be the main priority Julianne would you like to comment on that Yes One session I think if I just had one session with Morris and knew that I had one I think it would be just so important to engage with Morris and allow him to build the trust and to build the rapport and to show that this must be a really scary time for him because he's been identified he's been in hospital and he's not terribly well engaged at a very emotional level with family this thing about his dad is my time come I think there's a lot of psychological issues here and I think he'd be suspicious was it Nancy who was saying about the driving cessation is this assessment going to mean I'll lose my license I think he'd be quite in trepidation of who are these people and what are they asking I believe we have to put them in a home so I think it's getting his trust and getting his sense of engagement with him so you could see what we were doing it's really trying to get a sense of who he is what his life has meant for him and looking at the way we're not trying to put him away we find solutions for some of his problems this is where I like Rod was saying too about not jumping to a conclusion about diagnosis and assuming there's cognitive decline the other issues. So I think my role would be definitely building rapport and doing some of those things like the genogram and talking about his family and his values. I'd probably go straight into a two discussion around hope and meaning and what are the things he hopes for, what are his goals and what is his perception of the issues. And depending on how long I'd have with him, you know often you've only got an hour and a half tops with a family with an individual and generally by then you're they're exhausted anyway, is just to try and get some permission to either refer on to the next most appropriate healthcare professional or refer back to his GP or a psychogereetric team if possible or to try and get him to engage so that you know that there was some flow on to somewhere else that you weren't the only clinician, you know that only opportunity to make some change. Does that answer your question, Nick? Yeah, that's a really good answer I think. Nancy, what do you reckon? I reckon. Too lovely. Okay, now, Rod, you had asked this question but I'm going to put it back on to you. Did you just comment about access for people to live in rural areas? Many of our clinicians live in quite rural areas and unfortunately your videos dropped out because you're still on audio. How does being in a rural area affect access to and collaboration with other clinicians just from your experience as possibly as a registrar in a previous life? My experience in terms of rural areas is a bit twofold. One is direct and one is indirect. I regularly have meetings with rural professionals and they talk both with the challenges of travel time and being able to access people as frequently as they like but then actually when they discuss that with their colleagues in the city they find that actually getting through PQA traffic or just getting access to a car actually makes those problems quite similar between rural and urban in many ways and I think that the main strength they bring out is because services are smaller, people often know each other much better and so the informal collaborative networks actually seem stronger often in rural areas so I think there's real pros and cons of in rural areas and in many ways I actually think that for someone like Morris his supports may actually be stronger in some rural areas definitely been in how to Metro. Yes because he may have been a member of a club or something and he may in a small town and the club may rally around but familiarity is very important. That's what you're saying. Yeah that's good. Nancy do you have any comments on that? Well I think that I'd agree with that there's a different kind of support network in rural areas that may actually have more of a safety net and that even extends to driving in terms of people having better access to where they need to go sometimes in a rural setting sometimes it's worse I think it really depends on how long the person's been in that setting, do they have family, you know is this a sea or a tree change and they haven't been there that long because that sometimes happens. I mean I think you really have to see how that person fits into the context of their environment but I also agree that rural doesn't necessarily equal less support. Yep. Julian can I ask you a question? Yes of course Michael. How do you handle, I'm a GP, how do you handle difficult GPs? Everybody's itching to our success. You want my real answer or my polite. And we've had it texted in as well. Have you? Look I think it's, I think we're all faced with those issues and pressures and you know we've all found a few care professionals whether they're GP or whether they're social workers or others. Look I find the best things and it's that old adage you know keep your enemies close you know I don't know whether that works but I think it's about engaging well. Sometimes a difficult GP is just one who's extremely busy or doesn't like the paperwork or finds you know the previous engagement with healthcare professionals especially mental health professionals this hasn't been necessarily positive. I often see it as a bit of a challenge to actually to try and engage well by writing letters by you know dropping notes or you know ensuring that there's you know documentation for him and I just think it's just that constant persistence of respectful practice. Sometimes you can't win him over and I think that's just one of those things that you have to accept that you know or even advocate you know for the patient to find a better GP perhaps that might be more engaging or more willing to work collaboratively. And my quiet answer is in the back of my mind I have a piece of 4B2 and I just go. But I didn't say that in public did I? That's good. Would anybody like to comment on who should lead the multidisciplinary team or should it have a leader? Should a leader just a marriage? It's right. I actually do have some strong views here. I think in the Australian system and I think it's to do with the system of working it's really important that the GP remain at the core and so even if we have a case manager the GP is still very clearly from our perspective we tell the GP and the family the GP is the core person and so that would be my perspective. Nancy? I mean I'd have to agree. I mean I you know I think that there really has to be someone who's the nominated you know someone who's coordinating things and I do think in the Australian system it is the GP. I mean I will just comment that you know sometimes there is a difficult GP it's not really you know it's difficult that that the person may not have a lot of experience with older adults and that's really the main thing that I strike and and there I think that you know oftentimes if there's just a good collaboration you can actually get people on board and working together quite well even in that circumstance. Would anybody like to comment just last day we only have a few minutes left unfortunately indigenous and multicultural issues? Would you like to? Julianne? From what perspective Michael? Well just you know does it make a difference are we you know should we be conscious of different spiritual? Absolutely. Look I think it does make a difference but I think you know if we're working authentically and I feel quite passionate about this if we're working authentically with all peoples then we should be very conscious of all cultural sensitivities across all population groups whether they appear to be first you know like first Australians or fourth generation Australians you know everybody has some cultural sensitivities that I think we need to be very conscious of and you know and I just think just concentrating our cultural competence and sensitivity just to indigenous or vividly you know evidence you know first Australians and ignoring the cultural sensitivities of third and fourth generation Australians perhaps is ignoring the full gamut of cultural sensitivity that should be we should be a put I'm getting tongue-tied applying in our professional practice so I think we do need to be very sensitive to the nuances of indigenous people and multicultural groups and you know how to relate to them and what I need to know in order to effectively develop rapport with certain groups of people because there are rules of engagement and rules about behavior and who you can and can't talk to I think that's critically important but I think we must as authentic professionals use that cultural sensitivity across all groups. Okay that's good Nancy do you have any comments? Well I just think you know just switching into assessment mode I really think you know the tests you choose for people from Cald or linguistically diverse or culturally diverse backgrounds is key you know if possible to choose assessments that are tailored to that group and I will just make a plug there is an Aboriginal indigenous assessment tool the Kika that was developed out in the Kimberley that is a sort of a version of the mini-mental or a mental status exam for indigenous Australians so I think there's a lot of interesting things happening in instrument development for this group and and taking some care here is time well spent. Rod do you have any comments on that? I would agree with both comments although my views have changed a little recently because with my state role we actually had quite extensive consultations between a senior policy person who was Aboriginal and Aboriginal elders about their views about what it meant in terms of connection and that has changed my views to a degree I think there are particular issues about recognition of the status of Aboriginal people and the role of elders and their expectation that there will be an Aboriginal person involved in some way in the care that I think we need to respect and so my views have changed slightly so I would mostly agree I think we should be culturally sensitive to everyone and I think it's where we often fall down as mental health professionals she's imposing our values but my views are changing a bit and that report actually either either will shortly be available from the New South Wales Health website. Wonderful thanks for that. Now unfortunately it the time just goes too quickly on these webinars unfortunately and it's now time to spend two minutes each summing up and I will put you off after two minutes to Leanne. Oh you can sum up you can talk. Look I just think I just want to thank everyone for this opportunity I have learned so much listening to Nancy and Rod and Phil because I haven't had a lot of exposure to psychologists and psychiatrists I'm a rural social worker in private practice and even when I was working in the health sector you know we were very rarely had access to psychologists and psychiatrists in our region especially you know at that interface and I just feel listening to you and getting an understanding of how you would work and the the roles that you would take the assessments that you would do the more formal summation of issues and concerns you know I can see that by having exposed to this and thinking you know about having a case that we've actually used as a focus allows me as a social worker to think you know where do we fit into this you know to get the rhythm right you know to where do we fit you know where would we start what would we do how would we complement each other and I think this is perhaps what we need a lot more of is this understanding of the nuances of each professional's role and their interpretation of presenting issues and problems and I just think I can't thank the panel enough for your generosity and you know this respectful professional practice I just think it's it's been a great opportunity for me so thank you thanks very much to Dion Nancy you've got two minutes two minutes well I'd also like to extend my thanks I've learned a lot from Julianne and Rod but I've also learned quite a bit I'm loving you know hearing everyone's comments on the message board especially about things like spirituality and existential sense because that certainly was what drew me into the case you know we often especially in nursing homes we talk about person-centered care I find it hard sometimes to conceptualize not having that person in the center of care when I'm working with older adults and and so many things in this case that we've talked about you know the premature death of his father him feeling his time is up this really sad story he's told himself about his wife and this this not making things right with her before she died you know these are the kinds of stories that draw you into cases with older adults I love working with older adults and I'm so pleased that so many people have chosen to tune into this webinar to discuss an interesting case and I'm very pleased thank you very much Nancy that was lovely Rod I'll take a totally different tact I think it's been a great experience I think it's a learning experience all around and I think one of the great things with older people is they teach us so much and it would be really interesting if we actually had Morris here to actually hear his views about what was going on whether he really had a problem or not but the other thing the other thing I think the most important thing is is to emphasize that most older people are well healthy and enjoying life and one thing as health professionals we can really do is we get the perception that being old is about being sad and is about having lots of problems and actually at 76 Morris is still young stuff most of people I mean our average age I think of people we see is now about 76 and that's because we have quite a few unfortunately of quite young people becoming with age related problems at 76 a lot of people are very active very healthy enjoying life and that's why it's so important to be worried if someone is older and they're not enjoying life and the other side is they've still got a lot of resilience and as I said earlier I suspect that Morris actually could do very well with some simple interventions and I think everyone can really contribute to that and that's what I'd encourage people to do is to realize I can make a difference. Thanks very much Rod that was that was very total statement you actually stole my thunder because I was going to say that Morris is a silent witness to all this because as Anne Marie S said in the textbooks we will all be older one day so it is interesting that we are looking from inside the cube out and outside the fishbowl in so I am speechless it's been such a great evening and I'm very privileged to be able to sit here and just listen to these month after month and this has been an excellent webinar probably one of the best I've attended and Julianne speaking from a hospital bed and took us through how social workers approach approach a case like this the genogram the echogram negotiating with with health care professionals and respecting the respecting the person using your intuition and being conscious of the rhythm and the tone of the consultation I think that's really important the consultation is one of my one of my pet hobbies. We then moved on to Nancy's presentation she stressed again the biopsycho social approach which everybody has talked about tonight and including in the text box she discussed the many assessment and tools that are available and she will I'm sure post those up on MHPN because many of our audience just wouldn't ever pick up on all the assessment tools but that would be great if you could Nancy. I was particularly interested in the discussion about about giving feedback and also the transference issues that are going to occur and I think it's really really important that we give feedback if we do an assessment on somebody we give we give the person the feedback and also you did stress as you regarded building rapport and then Rod's presentation just the key issues being Morris his family and also the parapet the effect that that's that managing a patient like Morris and his family has and I think Rod quite rightly stressed that we should have a respect for Morris's wishes and he also said stress that we should always approach these interviews in a semi structured way and letting the patient lead you will often get more information as Rod stressed by gently leading the patient and the effects of alcohol and medication and illness on the person were stressed by Rod and also the importance of of psycho education not only of Morris but also of his family. I've only touched on a few of the key messages but I think we can all take from this presentation tonight that we all need to work collaboratively as psychiatrists, psychologists, social workers, mental health nurses, occupational therapists, GP's, anybody involved with older people. So I am going to have to bring this to an end I would like to thank our panelist Julia Nancy and Rod and I would also like to thank those audience members who logged in tonight and I trust that we will see you all again at another MHPN webinar. Thank you everybody and good night. Thanks so much it was really wonderful. Good night. Thank you. Come out Nancy. Good night everybody. Sleep well. Sleep well. Good night. Thank you.