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.