 Hello everybody, I would like to welcome you all back again to MHPN's webinar. Tonight's topic is supporting the mental health of older people living in the community. I would first of all like to welcome 493 participants so far. We've had 1,400 people registered, so that number will climb during the evening. It is also important to say that MHPN wishes to acknowledge the traditional custodians of the land across Australia upon which our webinar presenters and participants are located. We wish to pay respect to the elders past, present and future, for the memories, the traditions, the culture and hopes of Indigenous Australia, particularly on this day-to-day, sorry day. My name is Michael Murray and I'm a GP from Tanswell. I have a special interest in mental health and I'm also a medical educator. We have a very talented panel here tonight and I shall go through their names. The first person I'd like to introduce is Sharon Lee Hazel, who is from the ACT. Sharon, can I just ask you how did you first become interested in being an advocate for carers and for the elderly? Well, Michael, I was actually a carer for my mother who had bipolar disorder and my husband's mother has Alzheimer's. Since my mother's death, which was about six years ago, you have more time when you're not in a caring role and I've been able to take some of the issues that I came across to various tables, particularly in the ACT. So I'm a carer's rep for a carer's ACT. I'm on advisory boards and such and I'm also now doing a PhD at the ANU on older people and chronic mental illness and their carers and looking at services and support that can be needed. Great. And do you find that you've been listened to and being respected for your opinions? Yes, it does. I think that the culture is changing. I think sometimes there was room made at the table for consumers and carers and I think now people are very used to having them at the table and so the conversations can be very, very good. Great. Thank you very much for attending and agreeing to be on the panel tonight. Next, I would just like to introduce Associate Professor Morton Rowland. Morton, you're very welcome here tonight. Thanks Michael. Can you just give us a brief overview of your expertise in this area please? I'm a GP currently working in Melbourne. I have been a rural GP previously and I'm currently the chair of the General Practice Mental Health Standards Collaborative and on the MHPN Board. I have particular interest in mental health and particularly around keeping people within their communities and working within the community for their mental health. I have an interest in aged care. I visit six different aged care facilities around my local area and provide that sort of service also. That's great Morton. Thank you very much. You sound like a very well-rounded GP and educator. Thank you very much. Next I'd like to introduce Julie Bajik. Julie is a psychologist who joins us from New South Wales. Julie, can you give us an overview of your expertise in this area please? Good evening Michael, yes. My name is Julie. I'm a psychologist in private practice in Sydney. I am also completing a PhD looking at the impact of mental health in older people on the aged care workforce. I visit 48 facilities in Sydney, Central Coast and Newcastle and I work particularly with people who are transitioning from independent living moving into supported accommodation. I also chair the New South Wales Psychology and Aging Interest Group of Australian Psychological Society. Could you explain the organisation-wise care to us please? Oh yes. So I have a team of psychologists who support me in delivering treatment to older people who move into care. So what we do is we run wellness programs as part of the admission into residential care. In my experience I found that it's not just about treating the individual and their transition, it is also about supporting the families, educating staff and supporting the wider community. So taking the health, the healthy home model rather than the illness model. That's right, that's right. That's really good. Thanks very much Julie. And last but certainly not least I'd like to welcome Henry Brody as a psychiatrist in New South Wales. Hello Henry, you're very welcome. Can you tell us how you first became interested in aged psychiatry? I became involved in setting up what's now Alzheimer's Australia first in New South Wales and then internationally. And I moved full time into Psychiatry in 1990. Currently I work at the Prince of Wales Hospital in Sydney as a Psychiatrician and I head up at Memory Disorders Clinic. And I spend probably a bit more than half my time at the University of New South Wales where I'm a Professor of Aging and Mental Health and also Director of the Dementia Club of Research Centre and Co-Director of the Centre for Healthy Brain Aging. I'm also involved with the International Psychiatric Association where I'm the current President. I see patients, doubt patients. I go to people's homes and I go to nursing homes and I used to look after inpatients as well but I've stopped doing that lately. That's great Henry. You sound like a very, very, very well-rounded psychiatrist. Thank you. What do you prefer doing the most? I quite like the home visits. I mean I like to research a lot and that's where I've really put my energies in. I used to be Director of our department at the hospital but I stood down from that about two or three years ago and had my full-time in university with a conjoint hospital appointment. I love the research but I would not like to give up seeing patients and since I gave up being the Director of the department I've had time to go and do home visits which I think really leads to a whole new dimension of seeing what happens with people. You get quite different views from having them come into your consulting room. Yes, there is, isn't it? Thank you very much. Now we have a poll that's running this evening. Now we have 622 participants on board out of 1400. We expect the other 800 to catch up. I did notice that somebody had written that if MHPN had been in the Eurovision Song Concert we would have gotten 12 votes. So can you all quickly vote and just show us where you are coming from? It will be interesting to see if we have anybody internationally. If there's one. So that gives us a fair breakdown so far. Right. Okay, so we're running about 2 to 1 between Metro and Regional and probably the rule would make up and make that even Steven really with that one international person still hanging in there. We might just close that poll now and move on with tonight's presentation and we will just move firstly to Sharon and first I'll just go over the ground rules. Just remember that when you are posting all attendees be respectful of other participants and panellists and behave as if this were a face-to-face activity. Post your comments and questions for panellists in the general chat box. If you get into trouble and you need to help for technical issues go into the technical help chat box and please keep all the comments on topic if you can. If you'd like to hybrid chat remember you can click the small down arrow at the top of the chat box. Your feedback is extremely important to MHPN and at the end of the session I will remind you of that again and there is a short exit survey which will appear as a pop-up when you exit the webinar. And now as we head towards our first speaker we have 640 people online but any outcomes for tonight are three and through an exploration of Eddie's experience you will have had Eddie's story. The webinar will provide participants with the opportunity to firstly recognize the key principles of the teacher-discipline approach and screening and assessing the mental health of older people living in the community. Secondly understand how different practitioners can intervene to support older people living in the community thereby improving mental health outcomes. And lastly to identify challenges too and opportunities for collaboration that may emerge as practitioners from different disciplines working together. To achieve the first learning outcome we'll move to the first part of our presentation and we will now hear from Sharon. Thanks Michael. The first thing that I really picked up from the scenario was that Tom wasn't aware I think that he was a carer for quite some time. So early in the story you could see that in the scenario that Eddie had been a manager before his retirement he had been active in the community after his retirement with his wife Mary and it wasn't until around Mary's illness and death that he started to show some signs but this might not have been picked up by his immediate family straight away. And so at the same time his son and daughters and our other family would also be grieving the loss of Mary as well and so they'd be also going through their own issues around that time. So that brings me to the carers don't always know they are carers and also changes in the older person they are undetected by the family and it isn't until sometimes the matters have become quite serious that the family really starts to understand what's going on and this is mainly because the person has been independent potentially for quite some time they are the parents in this case and they've got that parent-child relationship and it takes a while for older adult children to take on their parents like a responsibility to ask them what's going on and so you can see in this scenario too that Tom was fearful of ridicule or making his father angry or upset by posing some probably useful questions to his dad and so there's a potential for conflict then between the older person and the carer but there's also that potential there for conflict between in this case Tom and his sisters because the sisters aren't living not that this has come up much in the scenario but the sisters are living away from that area don't see their father regularly and so sometimes the older person can put on quite a different persona on the phone to their other children and so there is that potential for conflict and also between the carer and the medical team and I'll talk a bit more about this soon so what does the older person with the mental health condition need and from my experience they really need that sense of dignity and control over the situation they are feeling confused anyway if they are having maybe they're depressed or anxious or maybe they do have early signs of dementia but they still want to keep their independence for quite some time so access to services and support is really essential that they have the right physical and mental health services that they need home and personal care disability aids that they still have some social outlets and that their housing is adequate for their needs as well but sometimes I found that older persons risk making their needs for their family because they either don't want to be a burden or they want to retain their independence I think we can all understand that too that they have been their own person for a long time maybe 70, 80 years and so it is a difficult time for them but there is also a burden for the carer first of all as we can see in the scenario with Tom he would have had also his own stresses certainly emotional as he saw his father deteriorate but perhaps also financial and this can happen if the carer has to spend more time looking after the older person maybe skipping work or they need to go to work so they are worried about not being with the person they are caring with and so their mental health can also suffer as a result and the other thing that is apparent in this scenario is carers don't always know what questions to ask either of the person that they are caring for or of the medical profession so sometimes it takes them a while to really get around to the questions they want to ask and it's great when the health professionals can step in and anticipate what they need to know if it's the wrong thing so what does the carer need? They need to be aware of the right responsibilities and they also need to have a sense of control and understanding of the situation. This can come about with some education and discussions with teams and support groups and there has to be appropriate and open communication between the older person that they are caring for the rest of the family and also with the health professionals and it would be great if the health professionals can also assess the care and need. Work out who the carer is and this might be that the consumer will tell the health professional who they think their carer is or it might be just quite apparent from the situation. They possibly need financial support and they need to know at times they don't know if they haven't been a carer before but there are organisations that consult them that can provide counselling. Some final things I got from this scenario too that I consider a real issue around discharge planning. This can be a very stressful time for the person and the older person and the family if it's not done correctly and I think it should start from when a person is first admitted to hospital and in this case too this is being submitted of physical versus mental health here because Eddie was actually admitted for a physical illness he was only in there for three days but it doesn't look like there's a discharge planning or during his hospital stay perhaps he didn't have the mental health assessment that he needed and I often found that with my own mother if she went into hospital with a physical ailment that's her and Mum had clear mental health issues with her bipolar disorder that they were treated rather separately and this often always helpful on discharge. The other thing too is the impact of change on the older person and so there might be the changes in medication they might have to experience that they might have injuries like Eddie did, illness, grief, loss this all seems to really affect my mother and other older people that I've known and sometimes very hard I found for the family or the health professionals that we talk with to really know what was the cause for some of what were quite depressive signs or anxiety and so it's quite a tangled web that has to be worked out so I think I'll leave it there because there's a lot more to be said and for Michael back to you. Thank you very much Sharon I'm very much looking forward to your PhD and I'm sure you'll be coming back to MHPN as a proper doctor rather than as a bachelor doctor and now we'll move on to Morton's presentation from the general practice perspective. Thanks Michael and thanks Sharon that was a really good summary and start off. I guess the main things that I wanted to bring up was what the GP can bring to this process. Essentially the GP should be in the position to be the coordinator of the information and the primary point of contact both for the patients primarily but also for the family as well. The number of times that I get information from family members and relatives and friends for that matter about individuals and their concerns the difficulty is what can you actually do with that and we might touch on that a bit later. It is important for somebody to be able to try to facilitate the discussion between the patient and the family. The patient may not know how to start that conversation the family may not know how to start that conversation. They may still be grieving over their mother's loss and now all these other things are being brought up after the admission to hospital. All of these things make life difficult for the family and also the patient. It's really important for the GPs to also remember that we are actually dealing with a family and that's not always easy. At the bottom of it we as GPs need to try and exclude and classify the various medical issues that might be going on with this patient. Not everybody who is confused is depressed. Not everybody who is confused has a brain tumor or things like that. We need to sort out what is happening. The number of people who I have seen who have had long-term battles with being depressed and turn out to have things like hypothyroidism and things like that which come on very slowly and are easily missed if you don't keep them in mind and keep looking for them. In terms of the medical issues and often with the mental health issues as well the GP is often the person who needs to commence the treatment of various types and that may be with counseling or it may be medication and that may be in association with other services whether that be in the mental health arena or in the more physical arena. Sometimes we actually end up being the advocate for those patients into the health system. Again, the number of times that you have to ring to facilitate an appointment particularly in the situation of older people because it is very hard for them to sometimes negotiate through the switchboards of public hospitals then the outpatient department then trying to speak to the admitting people and then trying to speak to the list goes on and sometimes they do need somebody to cut through the red tape and most GPs will do that if at all possible. If, and this is another big if, patients tell them that they're having difficulty. We aren't mind readers so you can sometimes assure but it's better to work with the person and to help them come to terms with what needs to happen and also what can happen for them. On occasions the other part of our advocacy role is to try and break down some of the barriers. One side of the family is not talking to the other side or a friendship has broken down over the back fence or something like that and we sometimes have to get involved in that as well. Similarly it does take a bit to work through what might in fact be going on with this person. It is not only some of the big things but in my experience it can also be big things to them which may seem small to us. The fact that their cat is thick or they are no longer able to afford going to the club or something like that all of these things are matters that we have to look at and keep in mind. All of this is on the basis of a legal background and there are obviously some definite legalities that you need to keep in mind. There are privacy issues, confidentiality issues and amongst all of that is trying to weigh up the line between what is safe for the patient to stay at home when they wish to and when is the time when it is no longer safe and they are putting themselves at risk and that is a very hard conversation that we sometimes have to have. We can't force them to leave their homes and we have to try and assist them but you actually almost have to be the voice of reason in some times like this and it is also important that we appropriately discuss matters with the other carers the other professionals who are involved as well as the individual. I'll stop at that point there's lots more to be said but that's pretty much more than we'll have the panel discussion shortly and we'll be able to get into all those flags that you've mentioned. Thanks very much that was a really good presentation. We'll now move on to Julie Bajik's presentation Julie, our psychologist. Thank you, thanks Michael. Firstly what I'd like to do is define older people. What we know is that depression presents in four different types of symptoms. We've got feeling symptoms, physical, behavioural and thinking. With older people they tend to present with more physical symptoms as opposed to younger people. With the feeling symptoms they might become irritable which Eddie appears to be. Overwhelmed, lacking confidence and reports of anxiety. In terms of physical symptoms it could be changes which we've noted through his decreased appetite, weight loss, reports of pain and multiple physical symptoms. So in my experience I've seen a number of people who are depressed who are more comfortable saying that they have pain rather than they feel depressed. Behaviourally they're not usually doing, they're usually enjoyable activities. They're slowing down in resonance and they're thinking, they tend to have memory problems, patterns which can lead to suicidal ideation. It is important to note that depression is essentially the same disorder across the lifespan. It's not just that with older people it tends to present differently than in younger people. Overall older people tend to describe sadness a lot less than younger people and it can be difficult for older people to accept the diagnosis of depression. When we look at the risk factors it is important to note that age itself is not a risk factor. However, risk increase with social isolation and isolation is a big, big issue not only for people who live rurally but also in metropolitan areas. A number of clients I see particularly who receive home and care packages. The home care worker might be the only person to speak with that day or that week. It is important to note that there are a lot of risk factors that can lead to grief and loss so accumulation of losses so I know Eddie is grieving the loss of his wife. Also loss of identity and loss of purpose. Changes in living arrangements. Chronic illness, chronic pain as well as looking at the possibility of dementia. What we touched on briefly before with the barriers and risks that have appeared to tolerate at this time for their loved one certainly the risk of malnutrition the risk of safety and various treatments becoming an issue. In relation to looking at from a psychological perspective it is really important to note that depression in older people in the community is estimated to be between 10 and 30 percent as opposed to the general population which is about 15 percent older people are twice as likely than general population to develop depressive symptoms. In residential care it tends to go up to 50 percent. In relation to screening for dementia which Henry will touch on after me it is really important to get the baseline and baseline means to assess what was Eddie like before his wife's death. What was he like before he had a fall? What was his life like when he was bird watching and engaging in activities? It can be particularly difficult in identifying depression in dementia and we know that people who have early signs of Alzheimer's disease and vascular dementia are at greatest risk and have the most disabled in depression and that is particularly if they have insight into the illness and they know what is ahead for them. All the men age 85 plus have the highest rates of suicide in the population and that's really surprising for a lot of people because they anticipate that would be in younger age groups so we're not talking about the numbers we're talking about the rates so men aged 85 plus are the highest risk followed by men aged 8 to 84. This was published by Australian Bureau of Justice last year. In this stage it makes sense to look at what is happening, why are older people not accessing mental health support and why do we have such a high prevalence of suicide and the answer comes down to the fact that less than 25% of all the people accessing mental health support at some stage in their life which is alarming given that in general population it's more than 50%. What tends to happen in particular in my private practice is that I would get a referral for a person and I would see on the referral that they have depression and that would be identified by the GP and the family but the older person might feel depressed or they might feel stigma-sociated with a label of mental illness. So there are a number of barriers to treatment. It could be the client, it could be the family. The family might say we do not wish for our loved one to receive mental health support. They might not see that as a barrier. It could be a GP as well. The GP might not see that psychological support is required for the person as well as the access to service so there aren't many psychologists who work with older population or specialise in working with older population. So what I'm doing at my ministry is providing a group of students who are in Macquarie University and training them to work with older people particularly in aged care. Here are a number of screening tools used for depression in older people. These are often administered by GPs or also by psychologists as well as aged care facilities. In my experience I have been administered by home care service providers and certainly through my PhD research I have learnt that mental health is not routinely screened in clients receiving home and community services. I'm not saying that it is a role of home and community service providers to treat mental health but I think it's important for them to note any changes and to escalate it with the GP appropriately. So we've got a number of tools here specifically designed for older people which include the Geriatric Depression Scale which is self-administered 30 Ivan Scale, Geriatric Anxiety Inventory which was developed in Australia in 2007. The Cornell Scale for Depression and Dementia which is used predominantly in residential care as well as the brief assessment schedule depression cards. So based on these tools based on the clinical presentation the client might discuss with the GP or the family that is usually when my services would become involved. In terms of treatment we know that older people respond well to psychotherapy I certainly would expect Eddie would respond well to it and we found that research shows that the best treatment is combination of physical activity and cognitive behavioral therapy. We also know that interpersonal therapy is another type of intervention for older people and that psychosocial interventions can improve wellbeing and can be effective for depression in older people. That's all I had to say at this stage I am conscious of time and I'll be quite happy to pass it on to Henry. Thank you very much Judy. That was a very succinct but very very complete overview of Eddie's case and I have been asked by the Webinar High Honchos just to ask you to stop moving around so much you are so much into your presentation that with the small screen you do bob around a little bit but please don't let that cramp your style. Thanks very much and now we'll just move on to Henry. Professor Henry brought this in. Thanks very much Michael and thanks to you for that summary that's really good. If we just review Eddie's symptoms of depression these fit into the categories that we just heard about he's irritable, he's complaining he's lost interest he's withdrawn socially he's not eating his meals he's restless at night agitated. When I'm seeing someone with depression the first thing I want to know is is this the first onset or is this a late onset because if it's early onset and we find that out by looking at past psychiatric history if there's a family history of psychiatric illness it's more likely to come on early and I particularly always ask about alcohol and drug history if you've had a lot of depression before then I think well could this be an organic cause? Could there be something physically going on with him? As Julie's explained neurological disorders have very high rates of depression associated with it so Alzheimer's, Parkinson's vascular dementia stroke anyone who's got any neurological condition affecting the brain is at a high risk for depression maybe up to 50% say in Parkinson's but there are other things with some of which are treatable and some of which the depression won't get better unless the physical cause is addressed first. Things like having a tumour could be a tumour in the brain but it can be a non-metastatic manifestation of tumour somewhere else in the body. A classic example in textbooks is cancer of the head of the pancreas so that people may have the depression a year before the tumour is recognised I had a patient who had hypocalcemia due to a parathyroid tumour and he'd had a year or two of treatment before we found his calcium was high, found it was caused by the parathyroid, removed the parathyroid calcium came down and he responded then to treatment for his depression. Less commonly low B12 levels or some infection can be an occult infection hypothyroidism and you can get depression as a side effect of drugs. Moving on so when I'm seeing a patient with depression I use this framework I use it to derive an etiological map what is the cause of this person's depression now and so I think what's happening in the biological sphere and I've gone through that, the psychological interpersonal and the social environmental so if you look at Eddie you start from the inside out as it were the biological things, he's got pain he's had a fall and he's questioned head injury but the scans have been negative but still there may be a late sequelae of that is this the medication he's taking is this an early dimension that hasn't been diagnosed could it be secondary to one of the physical causes I mentioned I guess most prominent and most obvious in Eddie's case is his grief I mean he's angry and maybe even feel guilty about his wife having gone into hospital he's loneliness the interpersonal domain he's lost support he hasn't got his partner his daughter's in Adelaide, Tom's there but he doesn't have much in the way of support particularly as he's withdrawn and in the social environmental he doesn't seem to have a role in life he's withdrawn socially, he doesn't have any purpose so what I would do would be to get a history, I get it from the daughters and I've said ah there should be death I'd like to know more about his relationship with his wife because we know if relationships were conflicted before death the grief is always more complicated was he dependent on her what was going on beforehand he clearly needs to have a physical examination and a cognitive examination remembering the midi mental states that's the reasonable test but it doesn't do well for frontal lobe functions and so as a minimum I do a clock drawing test as well ask them to put in their hands sorry the hours, the numbers for the hours and then put in their hands for something like 10 past 11 or 20 past 5 I check his weight looks like he might be losing weight I do some basic investigations that's listed on that slide and importantly this man is at risk of suicide has just been highlighted older men with depression we really worry has he had thoughts of death is he drinking more has he thought about how to end it all religious practice can sometimes be a saviour can be some sort of safety against it it's certainly not an absolute safety but we should ask about that if I'm the new person coming into his treatment I need to build a relationship with Eddie, explore his feelings and of course deal with the pain which has been spoken about one of the common conundrums is this depression or is this dementia I only allowed one slide for this because I could have had three slides so just looking at the two the left is depression and the right is dementia so the course of the symptom in depression it's usually weeks really months or less commonly months in dementia it's mostly years sometimes months unless it's sudden onset like after a stroke the memory problems in depression are more patchy and may be linked to emotional content whereas in dementia it's more short term memory concentration can be down in both but more so in depression past history of psychiatric illness is a really good clue and the mood in someone with depression is pretty pervasive and it doesn't it may have an early morning awakening maybe a sort of a diurnal mood variation worse in the morning more variable in dementia there are vegetative features of depression early morning awakening diurnal mood variation loss of weight loss of appetite and in dementia or any organic brain syndrome people tend to get more confused in the evening we should do cognitive testing and the person with depression will give up easily I can't do it I'm losing my thoughts in my brain the person with dementia often delights if they get tests right so crap people can have both depression and dementia about 20% of people with Alzheimer's also have a depression so let's go to management this has to be a partnership it has to be the GP the community services the family and at the centre of it all of course is the patient timing is important now I don't think we can do much with Eddie unless he's had time to ventilate and deal with his grief he's not going to re-engage with his birdwatches or his friends or doing his activities until we do that the easiest thing is to reach for the antidepressant but this is not the first line of treatment and that should be kept in reserve if other things aren't happening so let's look at this etiological map and now put a management map so we start with the biological we're leaving the pain correct anything that's abnormal doesn't worry about his nutrition keep the antidepressant on our back pocket ready for use grief counselling as I said is really the main stage at the beginning I think and more support for him perhaps link him up with we should link him up with some more support than he's in the personal life I've changed that there sorry and in the social environmental sphere more community support making sure he's eating somebody coming around to check on him community nurse collaborating with a sister-in-law not the aunt sorry really looking at a stepwise re-engagement perhaps even organising a pleasurable event schedule this sort of thing really would do you start off with a very simple activity that you know you'd like and perhaps maybe half a dozen activities that he agrees that he used to like when he was well and then start at the easiest and build up gradually and that's the end of my session thank you very much Henry that was as many of the attendees have said that they just love going to listening to your talks and that's the first talk I've heard of yours it was absolutely excellent I learnt so much from it and I'm amazed that you got through it in seven or eight minutes thank you very much now we come to the second part of our presentation where we this was collaboration as a panel and we do have some questions that we want to ask each other on the panel and Morton I'll ask you to direct that question we discussed earlier used for Sharon in relation to family dynamics would you be able to discuss that with Sharon there? Sure Sharon it's clear that families are really important in this process how can we best approach families who is the best person to take the lead in that when the patient is clearly in trouble and not sure where to turn is there any rules that are needed in here? I think it's really useful to ask the older person who they think their carer is or if they have anybody that supports them because I speak to a lot of carers and they'll say the person I care for they don't think I'm their carer so it's very useful to hear what they have to say if they don't think they have a carer and again carers are silly for the word when it comes to families it might be just have you got anybody that supports you, have you got anyone that you see every week and that way you can find out from them I then see if you can say to the older person if you can actually talk to the carer and this starts that communication that's really very, very useful in the family sometimes it's thrown at you if they're in hospital with the carer and family it's usually the person who the health professional sees so that becomes you're the carer but it's not necessarily always the case sometimes the person as the main supports of the person might just not be at the hospital not be available at that time so it's really very, very useful to start the conversation I think with the older person if they're confused or in my mother's case at one point she was quite psychotic so it's really about then being able to talk to the people that are there and some of the information that was mentioned last night particularly Henry was superb to be able to actually work out what is wrong with the person and perhaps ask what their history is a bit about what religion they had resonated with me because there were some assumptions made for example with my mother that she was a fundamentalist Christian and she wasn't able to get that information from the family it can actually help with I think the health professionals being able to better diagnose what's going on thank you very much both of you we did have a number of questions that came up but one in particular caught my eye earlier on from Edward Reid and he was I just liked the panel's opinion on this patient autonomy what we as health professionals feel the patient needs could I address that to Henry first and then the panel can then jump in after that this is a really tough one autonomy versus beneficence beneficence doing what's beneficial for the patient so and I work a lot in the field of dementia so we're always considering this sometimes has the patient lost the capacity to make decisions for themselves they're irrational in their thinking so they're a danger to themselves this can be really tough and there's no clear line here it's a matter of clinical judgment and also talking to the patient and the family sometimes it is black and white if they're suicidal, if they stop eating and drinking if they're not able to care for themselves and the house is squalid then you have more more authority there's always a legal framework we can't take a person's rights away from them without going through a legal framework during the mental health arena we go through in New South Wales the mental health tribunal or if the person is mentally impaired with dementia say then we go through the guardianship tribunal so there's always a legal framework unless there's an urgency about the thing then you have a duty of care to take over thank you Henry can you now on this yeah sure look I agree with Henry it comes up to individual preference you can't force an individual to engage in services clearly they don't want to and therefore that's why interdisciplinary approach is so important so I think for case of Eddie looking at other ways that he could connect with people and keep his isolation to a minimum to get him obviously first of all engaged and make sure that he eats properly and that he's taking dog for a walk and doing things before we look at any behavioural or therapeutic interventions thank you very much Morton yeah look I would say that it's a really good framework that's been discussed I think one of the other challenges is and from Eddie's perspective he's actually got quite a supportive family that's involved with him on the other side of the coin and I see this from time to time there are some older people who are very much on their own with very little in the way of social support even though they have relatives close by and one of the difficulties that I've found in the past is how do you engage the family who for one reason or another don't want to engage in the process of helping their elderly relatives even if that elderly relative actually wants help so that's another side of the coin that we need to deal with sometimes and it's not easy thanks Morton I'm sure you would have some opinions on this yeah so it can be really hard for the family and the older consumer it can be a very confusing time for everybody that when the older consumer might need to be for example discharge from hospital and you can get very advice from different health professionals which is the best pathway for the person to return home and maybe that's something like a rehabilitation or something that they might need to so that their physical health can actually improve enough might not be available and so returning home is unsafe living with the relatives might be because of family history and because of family dynamics may be impossible to actually be able to live with the family and so with an age care can be an option it's a difficult time to be able to resolve what is best for the older consumer and for the family thanks very much Sharon one of the things that impressed me about his story was his anger and Elena the Yakimo one of our participants brought up in her comments brought up the anger towards the treating staff I mean how do we deal with that anger apart from interrogating what's causing it how do we actually deal with it Julie starting off with you do you have any thoughts on that sorry can you repeat the question Michael when a patient or a client like Eddie is extremely angry towards medical staff towards carers towards people who are trying to help him apart from diagnosing him in general how does one deal with that anger when he's angry towards medical people he may see more than an enemy as much as the hospital yes okay that is very common I think it needs to be acknowledged and it is the accumulation of loss that they've had so it would not be normal to say you should like all your doctors and you should like everyone and appreciate the big thing that comes up a lot for what I hear is that you should be appreciate that I'm doing this for you that I'm helping you and making you fresh meals so anger is a normal part of grieving and I think it really needs to be acknowledged and grief could you expand on that a little bit okay and his grief the accumulation of his grief obviously we don't look at grief as a newness straight away a person you know it's a normal part of the process it's for six months for persons grief before they would be classified as having complex grief so it is about looking at ways to get engaged and to get involved in activities so with grief it does take time and obviously it is something that you know waking up next to his wife for 60 years and her not being there you can't say well that's normal you shouldn't feel you shouldn't feel if you shouldn't miss her it is more about trying to build on new activities and new routines that would help him through the process well could I throw open the questions of grief and anger and depression to the rest of the panel now and again once they've spoken back to you Julie please so any of the panel have any thoughts on that Henry speaking I agree with Julie grief is a normal part of dealing with death and it's an important process to go through we shouldn't medicalise it it's only when it becomes incapacitating or when it prolongs beyond what it normally is for some people it's a few months some people it's a year but when it's getting beyond that then maybe more interventions are required generally what we do is we get the person to talk about the person that has died and about their feelings and I don't do grief counselling but there are people who are specialised didn't they yeah look I think to me the main thing is actually to acknowledge that they've had a rough time and that it is okay to feel let down and not to understand what went on if if I was the practitioner who actually was involved in the difficulties with his wife and the complications that went on acknowledging that some of the things might have been done differently may be appropriate but essentially if you are one step removed from that and that is in fact the core part of what's keeping him in that space actually starting to try and work with him about well let's look to make sure that the best possible care has got for you and that you're able to move forward and help you as a person to make sure that we get the most out of it to you generally is fairly successful in moving them a little bit further down the track and involving people in terms of a psychologist or another appropriate counsellor often somebody with OT skills or social work skills depending on what's available in your local area can be a real big bonus Thanks very much Morton. Now rather than asking you to comment on that Sharon unfortunately we're coming again towards the end of this webinar they seem to go by so quickly so I'm going to start off with you Sharon two minutes to sum up on whatever on your presentation or on the evening or on just your thoughts in general for two minutes and then we'll go through each one of the panels for two minutes after that each. Thanks Michael look I've really enjoyed this is my first webinar I've been involved with and so I've been really impressed I've been watching some of the chats so even though I haven't really been able to respond to anything there had my eye and everything but I've found that Henry's presentation is really great for me because I've had my mother-in-law with Alzheimer's my mother had bipolar disorder and that differentiation between the depression and dementia was really very very good one thing I would throw in the mix would be around delirium and when is and psychosis so when is a delirium a delirium and when's the psychosis just that and how that's treated that might be for another time big issue with older people too I think Thanks very much Sharon and thank you very much for your contributions tonight I will move on to Morton just two minutes thanks Morton alright Michael very succinctly I think that the big issue for GPs is information and certainly we want to be contacted in terms of if there are concerns if there are things that other councillors other people involved with our patients think we should know let us know so that we can help we do see ourselves as the linchpin as the coordinating activator in this so that's the key thing communication and letting us know where we can help Thanks very much Morton of course MHPN is all about collaboration and I think all of the speakers this evening have stressed that it's just I feel quite humbled to be here tonight now we'll move on to Julie two minutes Thanks Michael what I haven't had a chance to touch on yet is limited input that psychologists really have in gerontology due to partially funding and I've noted a number of comments on the discussion would about engaging other types of therapy including care and innocence therapy and including narrative therapy so it really depends what setting the psychologist works in in private practice if we receive referral through better access to mental health it has to be evidence based psychotherapy it's looking at CBT having maximum of 10 sessions in a calendar year even though it's increasing it up to 12 as the 1st of July so you really need to prioritize what are you assisting a client with and grief and loss is a major part of what it is going through so part of that is providing psychoeducation normalizing, allowing space for grief hope and reassurance but also working towards establishing some goals at this stage reminiscent therapy could be beneficial but I think that there are other priorities that he needs to address at this point of time. Thanks Michael That's fine Chidi, I just got you to expand on that because I did notice that there were a lot of questions a lot of comments around that Could you just expand on that on the therapies available for this age group with mental health? So the main ones well as I said they are governed by Medicare so when you receive a referral from a doctor if it is through Medicare it needs to be evidence based like a therapy and at this stage it is predominantly cognitive behavioural therapy because all the people respond to it quite well there is a growing trend of looking at reminiscent therapy there is some work certainly done down in Melbourne by Sunil Bail in terms of reminiscence and engaging so with reminiscence therapy there is two times there is a life review and reminiscence therapy doesn't necessarily need to look at all stages of life but engaging the person with what are the happy memories or even if they have had some challenges how they have overcome them in their life Unfortunately that doesn't fall under Medicare referral so you would not be able to engage in that therapy under a scheme that allows a rebate for a client Reminiscence therapy has been found to be effective with people with dementia then again if people do enter residential care a number of them are not eligible to better access to mental health rebates so a psychologist really does have a number of barriers to treating this population and it really depends what setting they work in in my experience there is only one or two residential aged care facilities which employ psychologists which are being able to look at alternative therapies but certainly for me as a psychologist visiting people in their homes I am quite limited in terms of what intervention I can provide under the type of referral that I receive Thanks very much Julie Henry you looked at some of our one of the things I didn't mention in the grief counselling Eddie is angry and he is angry at the doctors it's something that needs to be explored as well losing his wife unexpectedly and I think we have touched on that I would emphasise it one of the issues I haven't discussed is when should you refer, what's the threshold for referral most of this will be dealt with by in primary care it won't go to specialist practice so the issues after referral is severity if it's at the point where the person as I said is not eating or drinking it's probably suicidal chronicity so it's not getting better despite everything you're throwing at or risk if the person is at an acute risk then you can't wait so they're the usual indications for referral or sometimes you as a GP or as a nurse in the community or the social worker has been doing the counselling just throw up your arms and you say look I've really worked very hard with Eddie but I'm not getting anywhere so that's the main thing I want to say the other thing is that Michael you told us that there's a little clue in the text here that I'll leave to you that he'll let people know about I think that's an interesting one I missed it Yes, if everybody goes back to Eddie's case I've had the misfortune to do a writing workshop recently I've been practicing my skills on MHPN and I just want to ask you all why you think Eddie goes to the dump once a week and what he's bringing to the dump that nobody else knows he's bringing to the dump and somebody did mention earlier that it was bodies but I don't think it was bodies so we have come to the end of another session with MHPN and I always learn lots and lots of things from facilitating for MHPN and certainly tonight has been one of those nights and I would encourage participants who know each other to put up your own special interest networks or to join an existing one in your area remember that all of the PowerPoints and all of the Eddie's story if you have mislated they will all be available on the website from tomorrow and I'm pleased I would encourage collaboration between all the disciplines and not just the disciplines who were present tonight but we must remember our social work colleagues, our mental health nurses our occupational therapists, as Julie stressed continuously physical health is a major cause of psychological and mental deterioration in elderly people or sorry lack of physical health the things that came through to me tonight were the you know the normality and abnormality of grief and perhaps this grief is quite abnormal at the moment at wood funding and who pays for these services and how do we get a guy like Eddie to access the proper services the element of risk is certainly there with Eddie and he certainly stands as if he's becoming quite depressed with his abnormal grief and the aspect of his carers and possible care of fatigue and possibly lack of support of carers is important I wasn't aware of reminiscence therapy and I will be accessing Dr. Google at the end of this session to read up about reminiscence therapy thank you Julie and also I was very interested in the responses to how to deal with his anger and I don't think there is really a good any one good way and I think just being empathic also the issues that arise in relation to autonomy and beneficence as Henry so eloquently expanded on the Georgetown principles of ethical management of patients and clients are quite important and lastly when to refer to each other when does Henry refer to a GP when does the GP refer to a psychologist and perhaps in the future we will have care advocates with the expertise of Sharon and we can access with de-identified data to get their opinions as to what we should do so before I finish I would like to invite all participants to I think at the height we have something like 721 people on board tonight I would like to ask all the participants to join future MHPN webinars and particularly the next one which is supporting the well-being of people experiencing a trauma response which is on the 2nd of June and of course details that are available on the MHPN website before I close I would like to acknowledge the consumers and carers who lived with mental illness in the past and those who continue to live with mental illness in the present and I would like to sincerely thank you everyone our very talented panel and our very committed participants for your participation this evening and I trust I will see you all again some evening in the future goodnight everybody thank you goodnight panel goodnight