1. Providing Integrated Behavioral Health Care to Older Women in a Military Internal Medicine Clinic Anne C. Dobmeyer, Ph.D., ABPP Chief of Psychology Wright-Patterson Medical Center Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Session #C4 - Tapas October 29, 2011 10:30 AM

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

3. 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.

4. 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

5. 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

6. Learning Assessment A learning assessment is required for CE credit. Question/Answer period will be included.

7. 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)

8. 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

9. 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

10. 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

11. Referral Patterns - Gender

12. Referral Patterns - Age

13. Referral Patterns – Problem Area

14. 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)

15. 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

16. 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

17. 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)

18. 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

19. 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

20. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!