Post on 01-May-2023
Differentiating Between Mental
Illness, Aberrant Behaviors and Neurological
Diseases in Aging Inmates
Kori Novak,MBA, PhD (knovak@mellivoragroup.com) and Jason King, PhD (jking@mellivoragroup.com)The Mellivora Group (www.mellivoragroup.com)
Roadmap
Examination of aging while incarcerated by the numbers Understanding age related disease Differences from disease and aberrant behaviors Best Practices
By The Numbers Deinstitutionalization in the 1980’s essentially turned
corrections facilities into in-patient mental facilities Currently sentencing laws are turning corrections
facilities into nursing homes 10% of the 1.6M inmates in state & fed facilities are
serving life In 2010 – 9,560 admissions were 55+ Age related disease such as Dementia, Alzheimer’s disease
and Parkinson’s occur 10-15 years earlier in the incarcerated population
By The Numbers
In 2010 41,470 inmates were affected with some form of Dementia- These were only the documented cases
These numbers are estimated to rise in 127,130 by 2050
Age Related Diseases “Dementia” is like saying “Kleenex” when you mean tissues. Different forms of Dementia: Lewy Body-
Earlier onset (45-65) Manifests in insomnia, hallucinations, movement disorders, difficulty
regulating body functions, confusion, disorganized speech Senile Dementia-
“old age” Manifests primarily after 75 years old Gradual onset Decline in special or temporal orientation Decline of basic skills
Age Related Diseases
Korsakoffs Syndrome “Alcohol Dementia” Can manifest at any age Displays same symptoms as various Dementias Irreversible brain damage due to alcohol killing brain cells
Vascular or multi infarct Dementia Can manifest at any age but tends to manifest in older years Small strokes – tissue dies Often caused by high blood pressure
Age Related Diseases
Other Aging Diseases Parkinson’s Disease
Speech impediment Tremors Stiffness in joints Leads to loss of fine and ultimately all motor control
Alzheimer’s Disease Manifests as loss of short term memory and ultimately all memory This include muscle memory, which leads to death Plaque in brain creates tangles which interfere with receptors
Age Related Diseases
Forgetfulness Confusion Indecisiveness Loss of judgment Disorientation to time and
place Wandering Loss of initiative
Handwriting problems Mood/personality changes Difficulty completing
tasks Difficulty with finances Difficulty with ADLs Sundowners**
For many of these neurological diseases the only way to truly diagnose them is through autopsy.
General signs of neurological distress/disease
How are these signs different than aberrant behaviors?
Knowing your offender population Patience= Flexibility & Good judgment Listen to your security staff
Means of Identification: Specific Traits (backwards shoes) Ask time- look at a clock Ask other inmates
Interdisciplinary committee critical Share the smallest things
Positive Responses
Units with good lighting Access to outdoors Purposeful programming with memory skills
Listen Remember behaviors are based in fear Don’t belittle, just take mental notes Patience
Best Practices Institutional examples: Fishkill State Prison-NY
1700 b med security facility 1st program for cognitively impaired inmates
30 b Unit- opened 2007All staff completed 40 hr training on interacting with cognitively impaired individuals
California Men's Colony in San Luis Obispo Utilizes peer assistance Training by Alzheimer’s Association
Definition of a Mental Disorder DSM-5
A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.
Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.
Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.
Major and Mild Neurocognitive Disorders Major Neurocognitive Disorder
Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:
Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and
A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.
The cognitive deficits interfere with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications).
The cognitive deficits do not occur exclusively in the context of a delirium.
The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).
Mild Neurocognitive Disorder Evidence of modest cognitive decline from a
previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:
Concern of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in cognitive function; and
A modest impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.
The cognitive deficits do not interfere with capacity for independence in everyday activities (i.e., complex instrumental activities of daily living such as paying bills or managing medications are preserved, but greater effort, compensatory strategies, or accommodation may be required).
The cognitive deficits do not occur exclusively in the context of a delirium.
The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).
Aberrant Behaviors
Without behavioral disturbance: If the cognitive disturbance
is not accompanied by any clinically significant behavioral disturbance.
With behavioral disturbance (specify disturbance): If the cognitive disturbance
is accompanied by a clinically significant behavioral disturbance (e.g., psychotic symptoms, mood disturbance, agitation, apathy, or other behavioral symptoms).
Individuals with NCD can present with a wide variety of behavioral symptoms that are the focus of treatment. Sleep disturbance is a common
symptom that can create a need for clinical attention and may include symptoms of insomnia, hypersomnia, and circadian rhythm disturbances.
Other important behavioral symptoms include wandering, disinhibition, hyperphagia, and hoarding.
Mental Illness
Mood disturbances, including depression, anxiety, and elation, may occur.
Depression is common early in the course (including at the mild NCD level) of NCD due to Alzheimer’s disease and Parkinson’s disease, while elation may occur more commonly in frontotemporal lobar degeneration.
Agitation is common in a wide variety of NCDs, particularly in major NCD of moderate to severe severity, and often occurs in the setting of confusion or frustration. It may arise as combative
behaviors, particularly in the context of resisting caregiving duties such as bathing and dressing.
Agitation is characterized as disruptive motor or vocal activity and tends to occur with advanced stages of cognitive impairment across all of the NCDs.
Mental Illness
Psychotic features are common in many NCDs, particularly at the mild-to-moderate stage of major NCDs due to Alzheimer’s disease, Lewy body disease, and frontotemporal lobar degeneration. Paranoia and other delusions are
common features, and often a persecutory theme may be a prominent aspect of delusional ideation.
In contrast to psychotic disorders with onset in earlier life (e.g., schizophrenia), disorganized speech and disorganized behavior are not characteristic of psychosis in NCDs.
Hallucinations may occur in any modality, although visual hallucinations are more common in NCDs than in depressive, bipolar, or psychotic disorders.