>> Good morning.
Thank you very much.
So I'm Jin Hui Joo, and I'm a geriatric psychiatrist.
So I see patients in the clinic,
which is a really great complement to
the health services research that I do.
So I focus on late life depression,
and we try to develop interventions
that engage older adults in depression care.
Believe it or not, that's a very difficult thing,
because older adults have a lot of difficulty.
So I start with a little bit of a downer.
So when you're a geriatric psychiatrist
and you see older adults in your clinic,
change, or dare I say decline, is unavoidable.
And yet, really, some of them have
a great deal of difficulty accepting it.
And I'm sure, you know,
we all have older adults in our lives,
and we may have experience with that.
And one of the important things that I often
kind of gently, although with some resistance,
emphasize is that change is inevitable.
And occasionally, they'll give me an ironic smile,
but they resist a great deal.
And sometimes not being able to accept,
in the clinical situation, could contribute to depression.
So sometimes when we think about decline,
usually physical decline, cognitive decline,
and studies show, of course, that we're not quite as sharp,
driving may be a bit more difficult.
Studies compare 70 year old or older adults
with younger adults, and they find that multitasking
becomes more difficult.
So when you're driving a car
and you have to see multiple lanes,
monitor your speed, pay attention to pedestrians,
trying to pay attention to the multiple sources
becomes very difficult, and so you make mistakes.
But moving onto some positive news,
so some things remain intact, so the brain remains plastic,
and we're still able to learn.
So what Dr. Welson said, learn a new language,
learn a new instrument.
And so I can
show off a little bit of
some of the older people in my life.
So my parents are at 85, and my father who learned
how to use a computer in the 70s,
and now he's totally inseparable, watching the news,
watching Korean drama, and it's his kind of,
that's what he enjoys doing.
And my mom, similarly about 80,
learning new recipes,
watching cable news to cook new things.
So there are evidence of additional gains as well.
This is a common quote, youth is the gift of nature,
but age is a work of art.
So youth may be brilliant and it may be energetic,
but it could also be shallow and maybe impulsive.
But in age there may be depth of experience,
and breadth of experience, which may be wisdom.
And so, there's interest and some research on that.
So in terms of emotional regulation,
it appears that as we age,
we are able to manage our emotions a little better
in order to kind of reach our goals.
So in particular negative emotions, like anger or fear,
able to overcome those things
so that you're able to proceed without too much distress.
Also, there are other gains.
A lifetime of experience enables you to
interpret relationships a bit more efficiently,
better judgment.
There's also with experience, better coping skills
that may help you navigate difficult relationships.
And so there are some good things.
So illness is also not the rule.
And if you look at prevalence rates of depression,
depressive symptoms among elderly,
in the community of all older dwelling adults,
about five to 10%.
I mean still, in absolute terms, a pretty big number.
But it's not the rule.
And despite the decline,
most older adults feel they're aging well.
So interesting study that came out in 2016,
Dilip Jeste, who is a geriatric psychiatrist in San Diego.
He surveyed about a thousand older adults
who were 50 and older,
and what he wanted to understand was
the relationship between aging, depression,
resilience, and physical and cognitive decline.
And what he found was interesting.
It went against what he thought would be true.
First, his older adults that he surveyed
said this is cognitive decline and physical decline
associated with older age.
But they said that in older age,
the older adults that he surveyed seemed to say
that they experienced better mental health.
So again, depression can be damaging,
there's no doubt about it.
It's embodied, meaning that it has
physiological consequences,
and perhaps even produce structural brain changes.
And it's associated with mortality.
So in older adults, major depression,
as minor depression, which may be lesser in severity
but still pretty damaging.
And then a host of other outcomes.
So there's a difference between the blues
and clinical depression.
I think colloquially we use depression a lot.
So people will use it to say they're down.
But clinical depression is a different beast.
Its persistent disfunction causes impairment,
unable to do the things that you, household keeping,
self care, and there are psychological aspects of it,
like negative thinking as well as mood, irritability.
But there are also things like sleep, weight loss,
and aches and pains.
So the mind and body are intimately connected,
and so when you have depression,
you may experience physical symptoms
which don't necessarily have a medical cause,
or at least not a diagnosed medical cause, and yet persist.
So those can be telltale signs of something being wrong.
So even if you have the blues,
it's important to address because the blues
are a mild depression that doesn't,
isn't addressed or treated, can always get worse.
So another quote,
so in spite of illness,
sorry I'm a little old and I can't ready that,
it's very small.
(audience laughing)
So in spite of illness,
in spite of even the arch enemy, sorrow,
one can remain alive long past the usual days
of disintegration if one is unafraid of change,
insatiable and intellectual curiosity,
interested in big things, happy in small ways.
So I think she brings in this quote together,
the importance of both physical and cognitive illness.
And the importance of psychological factors
in attitude, in aging and remaining well.
So what was mentioned before me,
also very important for mental health,
as well as physical health, attitude and resilience.
So these are some of the factors
that are defined as resilience:
positive emotions like joy and gratitude,
adapting to challenges, having meaning and purpose,
it may be helping your daughter with your grandkids,
there may be some painful aspects to it,
but it may give you a purpose, which can maintain health.
Self efficacy, so believing that you can do something,
and not avoiding problems,
but actually trying to address them.
And all of that, in the context of a sense of belonging,
in a sense that there's a community
of which you are part, and who cares about you.
So the kind of research I do is Health Services
and Its Intervention Development.
And although one imagines that if
either the older adult identifies themselves as depressed,
or if the family member does,
then the next logical thing is they get care.
Whether it's seeing a counselor, either informal or formal,
or whether they're going to see
their primary care physician, or maybe a specialist,
a geriatric psychiatrist, who aren't very common,
and who older adults try to avoid.
But believe it or not,
in a majority of cases that doesn't happen.
So among white older adults, about 50%,
minority older adults, even higher, 70%,
who have indicated need, meaning they have a mood disorder,
don't get any sort of treatment.
And what I'm interested in trying to figure out
is how do you engage them?
So there are treatments that work,
psychotherapy we all know, medications.
But they're very hard to access.
Both psychologically for the adults,
because they may not see that they're depressed,
they may not want to see a specialist,
they may feel a stigma, you know,
which we all probably understand,
or they may not be able to afford it.
And so, what I'm interested in doing,
kind of using non traditional methods,
like peer support, as a way of engaging them in care.
Whether it's directly providing something,
like social support, decreasing loneliness,
which they can do, or increasing his coping skills,
to as a bridge to professional care,
a psychiatrist or a therapist,
as well as helping them navigate a very complicated
mental health system.
And so we're in the process of developing that further,
so that it can really decrease the barriers
to getting mental health care.
Thank you.
(audience applauding)
>> Once again, please use the center of the floor mics,
and identify yourselves and your affiliations.
We have time for a couple of questions.
>> Bonnie: Hi, Bonnie, (mumbles).
I'm interested in how access to care
might influence that, because Medicare doesn't provide
mental health services.
Medicaid does, but in a lot of states,
we don't have the expanded Medicaid.
Have you seen the effect that has had
on some of these populations?
Getting the care they need?
>> Right, so it's so true.
Medicare is very, very difficult.
It's a little bit easier with Medicaid.
So what's really interesting is
I'm involved in integrated care,
I'm Medical Director of Integrated Care
in the (mumbles) Caring Organization at Hopkins.
And as part of that, what we're trying to do
is make it, integrating care into primary care settings.
So putting a social worker who does counseling,
and putting a psychiatrist also,
to support the primary care physicians,
and to make mental health care accessible
for Medicare patients.
So that experience has been really wonderful
in terms of the patients' perspective.
They enjoy going to the primary care clinic
that they know so well, and they trust their
primary care doctor, who's giving them a warm handoff.
And they, and it's free right now,
and so they don't have to pay.
And so this has really led to a lot of older adults
engaging, probably in a way that might not have
if they had to search for a provider themselves,
you know, get transportation to go there,
and probably pay something.
Which Medicare, you know, patients on a fixed income
is really difficult.
So those things are kind of happening
as population health and healthcare reform is coming on.
So hopefully, we're hoping that integrated care
will become kind of more pervasive.
So I think that's one promising development
in the policy area.
>> Shannon: Hi, I'm Shannon.
I'm with MedPage Today.
I had a question just about change,
and this idea of accepting
what you can and can't do as you get older.
What, I guess, what advice do you have
for your older patients who aren't able
to do those things that they used to do,
like who, say, aren't allowed to drive anymore, for example?
>> Yeah, that's an incredibly difficult thing.
Driving has so much value,
you really feel trapped and stuck.
So one of the things that's really, really difficult
is trying to figure out who says you can't drive.
And sometimes an older adult will find it more acceptable
if they take a test and some agency says you can't do it
because it's not safe,
rather than the family restricting that.
But it's a process, and it's really,
depending on the adult, their perception of themselves
and their identity in terms of aging.
But it's a process, and it's a matter of kind of
being gentle about the limitations that are occurring,
but I don't try to diminish the fact that it is unsafe,
and they are changing, their bodies and their minds
are changing, and it just may not be possible
as you move forward.
But I try to encourage families to
slowly kind of help them accept it, not to deny
or kind of sugar coat things.
Because often,
kind of perpetuating the non acceptance
can be more damaging in the end.
>> Shannon: Can I ask one more question?
Just in terms of interventions,
you had mentioned like learning a language,
or maybe
learning computer skills.
If someone is older and they don't have the
ability to focus as well because perhaps they're depressed,
or have other dementia or something like that,
what, do you have any examples of interventions you used
to help, basically I guess, bring back joy, or agency,
or interest in life?
>> So, it's always kind of keeping it within
the boundaries, the capabilities of the person.
So often, families are very,
you know, they're so eager to help their loved one,
that sometimes they don't take into account the limitations.
And so, that could be self defeating.
'Cause if a person doesn't feel like they can do
what their, let's say, children or spouse
is asking them to do for their own good,
then they may feel demoralized.
So a lot of it is about tailoring what they enjoy.
And it could be as simple as kind of taking daily walks,
or sometimes we talk about doing puzzles with them,
or listening to the music that they like.
But it's not about performance,
and it's not about longevity.
It's more about, kind of, quality of life,
and improving their mood,
and not dampening their sense of self efficacy,
you know, given the fact that they do have limitations.
>> Shannon: Thank you.
>> Carol: My name's Carol and I'm a freelance writer.
I was just curious, I saw you had bipolar disorder listed.
It's one, often, things of, you know, as you get older,
maybe you'll get more depressed,
or you'll acquire some sort of clinical depression.
I hadn't really thought about other mental illnesses
appearing late in life,
and I was wondering how common that is.
>> Yeah, so it's not that common.
So when you think about late life mental, mood disorders
in older adults, it's not that uncommon.
And you think about neurodegenerative disease at that point.
So is it related to dementia, for example.
So if somebody who has never had depression in their lives,
or any sort of mood disorder,
but are showing signs of it, let's say,
in their 70s for example,
and they may have just some mild cognitive problems,
then you know, there is suspicion for
maybe something neurodegenerative going on.
>> Thank you so much.