Providing Integrated Behavioral Health Care to Older Women in a Military Internal Medicine Clinic

Anne C. Dobmeyer, Ph.D., ABPPChief of Psychology

Wright-Patterson Medical Center

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session #C4 - TapasOctober 29, 201110:30 AM

Faculty Disclosure

I have not had any relevant financial relationships during the past 12 months.

Need/Practice Gap & Supporting Resources

Limited literature on age and gender variables as they affect integrated primary care services for older women

Supporting resources:Hunter, C.L., Goodie, J.L., Oordt, M.S., & Dobmeyer, A.C. (2009).

Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention. Washington, D.C.: APA.

Poleshuck, E.L. (2005). Women’s health and the role of primary care psychology. In L.C. James & R.A. Folen (Eds.), The primary care consultant: The next frontier for psychologists in hospitals and clinics. Washington, D.C.: APA.

Objective

The participant will be able to describe at least one challenge and potential solution in working with an older female population in a consultative model of integrated care

Expected Outcome

Increased awareness of gender and age as variables impacting the behavioral health care of women in

integrated primary care settings

Improved ability to implement effective interventions with older women in integrated primary care settings

Learning Assessment

A learning assessment is required for CE credit.

Question/Answer period will be included.

Gender, Age, and Health

• Older women experience increased health problems– Living longer, with chronic medical problems– Over 80% of women over age 65 have at least one chronic illness

• Some health problems are unique to women• Some health problems are more common in women

– Depression– Incontinence– Alzheimer’s Disease

• Some health problems present with different symptoms in women

Blumenthal et al (1994); Poleshuck (2005); Musicco (2009)

Gender, Age, and Health

• Life cycle transitions– Retirement (of self and/or partner)– Caregiver responsibilities– Loss of partner/friends– Decreasing independence/Problems of daily living– End-of-life concerns

Benefits of Integrated Care with Older Adults

• Address spectrum of severity (including prevention)– Three-fourths of older adults describe health has “good” or

“excellent” (Nat’l Health Survey Interview, 2009)

• Assist healthcare team in addressing biopsychosocial needs– Medical care often complex– Psychosocial needs are changing; may be more complex

• Provide older adults with needed behavioral health services– Older adults may be less likely to follow through on referrals for

specialty care

Collaborative Care Approach

• Behavioral health provider (BHP) integrated into primary care• Consultative model

– Primary Care Behavioral Health Model (PCBH)– Robinson & Reiter (2007)

• Internal medicine clinic – Internal medicine residency program– Psychology internship program

Referral Patterns - Gender

Referral Patterns - Age

Referral Patterns – Problem Area

Depression

• Depression more common in older women than men– Rates of depression in women decrease after menopause– Depression in older women usually occurs in those with prior hx

• Older adults may present with different symptom profile– Minimization of depressed mood– Greater cognitive symptoms (confusion/forgetfulness)– Increased somatic complaints

• Depression underdiagnosed/undertreated in older adults• Implement active screening program for depression

– Consider: GDS-5/15

• Assist in differentiation: bereavement , organic causes

Bebbington et al. (2003); Krishnan et al. (2004); NIMH Pub 09-4779 (2009)

Depression

• Interventions to consider– Behavioral activation/Increasing rewarding experiences– Cognitive disputation – Problem-solving– Medication adherence– ACT/Values clarification; committed action

• Tailor for age/gender– Consider health, cognitive status, functional limitations, social

support/relationships

Role Changes

• Shifting caregiver responsibilities– From children to parents to partners

• Shifting work roles– From employee to retiree

• Shifting social roles– Smaller social support networks– Those remaining in network gain importance

Role Changes

• Caregiver Stress Interventions:– Educate pt (caregiver) about family member’s condition & needs– Link to practical sources of help with caregiving– Encourage (and link to) respite care– Introduce methods for managing problem behaviors– Teach stress management strategies

Parks and Novelli (2000); Hunter et al. (2009)

Incontinence

• Affects nearly 40% of older, community-dwelling females– Over twice as common in F than M

• May impact quality of life– Recreation, sexual behavior, daily activities– Common precipitant to move to nursing home

• Interventions:– Implement Pelvic Floor Muscle Training (PFMT)– Decrease caffeine use (< 100 mg/day)– Address excessive fluid intake– Assist with weight loss

Anger et al., 2006; Hunter et al., 2009; National Institute for Health and Clinical Excellence, 2006

Other Considerations

• Size of room– Seating for patient, family, caregivers– Room for wheelchair

• Font size on handouts• Reading level of written materials• Rate and complexity of speech• Memory aids for plan/recommendations

Hunter et al., 2009

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!