Hello and welcome. I'm Tareen Khan, Senior Director of Workforce and Organizational Development at Thresholds, Illinois' oldest and largest provider of community mental health services, and also social work expert for SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar, Diversity Among Persons Living with SMI, a Focus on Older Adults. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patient. Next slide. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians, one Continuing Education Credit for Psychologists, one Social Work Continuing Education Credit, and one Nursing Continuing Professional Development Contact Hour. Credit for participating in today's webinar will be available until August 29th, 2021. Next slide. Slides from the presentation today are available in the handouts area, which is found in the lower portion of your control panel. Select the link to download the PDF. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We will be reserving 10 to 15 minutes at the end of the presentation for your questions. Next slide. Now, I would like to introduce you to the faculty for today's webinar, Dr. Crystal Glover. Crystal M. Glover is a social psychologist, mixed methodologist, and health equity and aging researcher at the Rush Alzheimer's Disease Center. She also leads the center's outreach recruitment and engagement core and serves as an assistant professor in the Department of Psychiatry and Behavioral Sciences at Rush Medical College. Her areas of interest include health equity and health disparities, structural and psychosocial determinants of health, including education, employment, housing, and purpose in life, intersectionality as a conceptual framework and methodology, and social cognitive processes such as attitudes, beliefs, and perceptions. She focuses on cognition and healthy aging in underrepresented and understudied communities, including Blacks and Latinos, and employs mixed method research designs to address related research questions. Dr. Glover, welcome, and thank you so much for leading today's webinar. Thank you so much for the lovely introduction, Shereen, and thank you, audience members out there for joining us today. Before I formally begin, I would like to note one disclosure. I am a member of the board for Threshold Psychiatric Rehabilitation Centers. Outside of that role, I have no other financial or conflicts of interest to report. So today, we have three primary learning objectives. First, we will identify factors, those that represent biological, psychological, and social aspects associated with aging and simultaneous SMI. Second, we will discuss potential cognitive changes during aging, as we all will do as long as we are alive. Lastly, we will develop strategies to provide care that is both culturally compatible and aging-friendly. So with that, we will have or hit upon four highline points. First, we will lay the foundation about the shifting demographics of persons living with SMI. With those shifts come changes and challenges with aging, and all of this culminates in diversity in aging with SMI. So we will talk about strategies to best serve aging persons with SMI. So to build this foundation, there are two main takeaway points from this slide. First, really, is that in the United States, we are an aging nation, and we estimate that more than 20% of the population will be 65 years or older in 2050. So in our field, older adults are defined as persons who are 65 years of age and older. So that means that one in five people will be 65 plus by the year 2050, and about 20% of people will be 65 years or older by 2034. So that's not that far away. So not only are we aging, there's more demographic diversity among us. So when I say demographic diversity, I mean racial, ethnic, gender, sexual orientation, sexual and gender minorities living in rural areas, and even more. It is not that these demographic groups have just popped up. People have always belonged to these groups or represented these groups. But along with plain and simple growth, more people are feeling more confident and comfortable to identify with particular groups, say sexual or gender minority groups. But we are now actually measuring membership more. So we're actually asking people, are they members of these communities? How do they identify themselves? So we're having a breadth of identities, but this breadth of identities is being documented. Simultaneously, we are seeing other converging patterns, especially for persons living with SMI. Traditionally, persons with SMI experience premature mortality, or more plainly put, these individuals do not live to be 65 years or older, or do not live to be an older age. And this is largely due to cardiovascular comorbidities. With these unfortunate stats and really lived experiences, because we're talking about people here in shortened mortality and higher morbidity, research and related interventions have focused on how can we decrease comorbidities and extend mortality. But something that's not on the slide is not only extending mortality, but quality of life while we are here, especially as we have approximately 5% of all older adults now living with SMI, and that 20% of all suicides are carried out by persons who are 65 years of age and older. So no matter, persons who are aging, especially those who belong to priority populations. So join me to the right side of the slide. So these are groups that are highly racial and ethnic minoritized communities, groups with low socioeconomic status, so think lower income, lower levels of education, and the hybrid that we see between the two, rural populations, persons with disabilities, including those with severe mental illnesses, and sexual and gender minorities. They face four big categories of determinants of their health during aging. These categories are broadly environmental, so think geographic as well as socioeconomic, socioculture, so think how particular groups of people, the foods that they eat, where they like to live, what they like to do, as well as psychological factors, including loneliness and stigma, which are huge, which I'll talk about a little bit more later, behavioral, so how people cope with everything that's going on in their environment and their cultures, as well as biological. So under this are physiological indicators, including cognition. All of these things are shifting and changing while aging, from cognition to finances to geographic location, and they can really have a intersectional mix as different groups grow older, especially those groups with SMI. So some of the lived experiences or experiential changes that people have, and that with those with SMI and even the broader aging community, here are some of the highlines. Things that really jar individuals are changes in income and financial status, especially if people are working, so they may go into retirement, you have a fixed income. This may lead to modification in living arrangements. Even if you're not seeing changes in your income and financial status, you may need to move in with a family member or an assistant living facility. Those things are very big challenges for individuals, and then we also see, just naturally with aging, decreased health and financial decision making. So when should I call the doctor? How often do I go? How do I manage my medications and the finances that I do have, leaving me very vulnerable to scams, as well as fraud, and really taking away from the loss of physical, social, and cognitive resources. So more plainly put, being able to get out and be physically active, communicating with others in my family, my friends, and also just engaging in mentally stimulating activities. Those things are likely diminished as people age. And one of the big things that I focus on in my research, both in terms of SMI, as well as just aging overall, because I focus on cognitive and healthy aging, is how these things change, cognition that is, while we age. So this is what we see, whether a person has SMI or not, but very much so, and I'll talk a little bit later, a few minutes, about what this looks like for persons with SMI, is what is cognition? And this is a person's ability to process information, not just observe it, but be able to integrate what they perceive, what they believe or think about it, how do they acquire or drop out that knowledge, and how does it jive with their lived experiences regarding a particular situation or set of situations? So this information, this cognition, goes into how we act, how we think, and how we ultimately behave. And so a lot of times people think, well, we just have diminished cognition in terms of memory, but this is also in terms of visual learning, what do we see, paying attention to things, how do we remember, how may we articulate what we are seeing, making decisions, and so forth. So cognition, of course, is important as we age, because it's a normal or natural part of aging to have decrease, and we'll talk about that, but those decreases may not signal disease. Indeed, cognition oftentimes declines or rather slows down as we age. And this has big implications for how do we plan for end of life? And this is a little bit misleading, because it's not necessarily end of life, but how do we live after we are 65 years of age and older, meaning how are we making financial decisions? How are we even planning for retirement even well before 65 years of age? Where are working, volunteering, employment plans? How do we interact with our family, our colleagues, loved ones, people in our communities, such as banking, cashiers, grocery stores, driving, the providers of our healthcare? How do we articulate our needs? And so really what we're seeing, the sooner, the better in understanding your plans, not only for end of life, but living in older age, that's really what I mean here, but also how do we live high quality lives? So as we see here, aging will occur, but there are three big phases of cognitive decline. So remember with normal aging, everyone experiences some slowing down, but what we're seeing with people with SMI who are aging are more likely to go through these phases earlier and more quickly. So those phases are first preclinical. So really how I speak about it here with colleagues and in my research, this is the stage where a person knows that there are issues or they're seeing differences, but their provider doesn't, and a family member, especially if they live with them, may or may not notice, but you can always tell usually with speech, not necessarily remembering things, but the quality of speech and the quality of articulating what people are thinking. So here they're experiencing changes, but they're not perceptible on any sort of measurement tests as such as the mini mental state examination. But as we move into MCI or mild cognitive impairment, family members and others notice, but their activities of daily living, so say getting up, getting dressed, cooking for themselves, maybe going to volunteer or work, those things are not diminished. But by the time we hit dementia, there are four stages there. Cognitive impairment increasingly goes from mild, moderate, moderately severe to severe, where you have increasingly diminishment in daily activities and abilities, meaning someone can go from not being able to tell you what they ate, not remembering to eat, not being able to drive, having more accidents and falls, and just not being able to process every day. So here from some of my work with the National Institute on Aging, we put together, especially for families and providers who are not in neurology, of how individuals can focus on persons with SMI, what is normal aging and what is Alzheimer's disease or what may be signals of that. So I include this here so you can always come back to it to say, what are things that may ping me as a provider or what can I tell family members versus, hey, we need to start having tests, maybe even pharmacologic interventions and other ways that we may be able to address cognitive impairment and potentially cognitive aging such as Alzheimer's disease. So one thing that is lurking behind all of this, aging with SMI, cognition, cognitive health is health disparities. So a disparity, simply put, say with the dictionary, is an imbalance. So it just means something is out of whack. But what I refer to and what the field refers to as health disparities are largely preventable differences in the burden of disease, injury, violence, or really what I focus on, opportunities to achieve optimal health or quality of life. And this is really experienced by, we call it here the CDC with socially disadvantaged groups, but I prefer what I described earlier is priority populations because everyone is dealing with some sort of issue, some sort of disease or a demographic group of really what we're referring to is people that belong to those priority groups that are historically and currently disadvantaged. That doesn't mean everybody in that group will experience this, but being more likely. So think of it statistically. So there are four big categories of health disparities. The first is what we're used to, there are differences between groups of people regarding a health status or a disease. So think Alzheimer's disease, epidemiologic work indicates that blacks and Latinos are two to three times more likely to have Alzheimer's disease compared to non-Latino whites. But really what I also focus on is the difference between attention given to a disease or health issue versus others at equal magnitude. Something that crops up in my work is how people speak about cognitive aging, so Alzheimer's disease and maybe mental illness, but also something more physical such as type two diabetes or cardiovascular issues. We tend to not devote as much time, funding, research or attendance to issues that may be cognitive, so brain and also psychiatric and also related to brain versus things that we can measure purely physically. But then we also have differences between groups regarding quality, accessibility and outcomes of healthcare and also what leads to that. So think structural and social determinants and the big four, employment, education, housing and healthcare. So when we see those determinants related to those, we're looking at a complicated mix of potential health disparities. So the big takeaway is health disparities are preventable, preventable differences in not only diagnosis, progression and burden of disease, even having it, but also treatment and response to treatment, caregiving, which is huge, especially for family members or loved ones of persons with SMI, especially those who are aging and really the overall opportunity to have quality of life and to achieve optimal health. So these disparities really rear their ugly head in dementia. So we notice here that as you can see on the slide, blacks, Latinos, women, and members of LGBTQIA communities are at higher risk of developing and being impacted by dementia compared to non-Latino heterosexual white men. What do I mean by being impacted? So we see that women are more likely to live longer, especially those with SMI than men. So they are more likely to develop dementia just by getting older, but also more likely to care for others. So being caregivers, being that high burden of stress that may lead to them having cardiovascular and other physical health issues. So it's really a confluence here of creating an imbalance in aging and diseases, chronic diseases of aging for these groups. What does this mean in particular for persons with SMI? So this is very novel, as you can see here, just recently, May 2021. As folks with SMI are living longer, people are turning their research, the interventions to understanding what does cognition look like in aging? Because a lot of work is not really focused on persons with SMI because simply they did not live past 53 years of age on average. But now we're seeing with interventions, with being more active, with supported employment, with other pharmacologic interventions that people are living longer. But we're also seeing that research indicate that mental illness, so SMI in early life is related to faster or accelerated aging and worse health in later life. So that means that we're seeing markers of cognitive impairment in the 40 years of age, 30 years of age for these individuals that were likely to have dementia in later life. So a recent study indicates that being diagnosed with dementia by age 66 was 25 times higher for persons with schizophrenia in their 30s and 40s. So folks with SMI are aging faster physically and cognitively, and by the time they reach the official or since this older age of 65 years, their dementia risk is quite high. So individuals are already impaired by the time they reach older age. So they may not be having those cognitive tests. People may not be looking for changes in their attention, memory, verbal, or eating habits here. And this is even worse for black people with SMI. So a key thing here is that by midlife for persons with SMI, we're already seeing markers, traditional markers of cognitive aging. So here, I would like to draw your attention. I'm going to show kind of mirror images of factors of mental health and SMI and how they are linked to the previous framework by the National Institute of Aging. There are four key components here that I would like to draw your attention to. Those that contribute to poor health overall, but also exacerbate the experience of living with mental illness. So that means not being employed. And really here, I've been toggling with this in my own research of not necessarily strict employment as we're seeing more gains in volunteering or being able to at least have a purpose in life. So it's a way that you can meaningfully spend your time, but that's linked to employment. Education is highly important in early and midlife. This is for persons, especially with mental illness and also for those who belong to racial and ethnic minoritized communities. Stable housing and of course affordable, accessible, and quality health care. These things are what we call the social determinants of mental health. But as I've moved on in my career and thinking about how to work with providers and other health care purveyors, is what can we really do? How can we distill it down? So here's another view of the same issue, but creating equity, not equality, not giving everyone the same thing or looking to have everyone look the same. But how can we meet people where they are? Priority populations, persons who are aging with SMI, how can we create equity? Because every group is different. Every person is different. So there's some need overall for stability and income or at least forecasting changes in income, especially as people grow older. Employment or purposeful way of spending their time. Education, so I understand that people may be done with schooling, of course, by that time, but continue ways of learning. So think cognitive activity, mentally stimulating activities such as reading, puzzles, such a cliche, but the research really backs this up that reading, doing puzzles, visiting museums, just being out and about really contributes to health in aging with SMI and that stable housing and also wraparound services with health care. Not necessarily just psychiatric, but now that the person is aging, we have neurological, social work, cardiovascular, and others. That way we can minimize discrimination and other stressors that are really important to priority populations, including those with SMI. So something that you've kind of heard as a thread throughout my work, explicitly hinted at, is the role of work or employment. So I created this maybe a year or so ago as it's being the great equalizer. I shy away from that now because we know there's so many persons with SMI are not only belonging to racial and ethnic minoritized groups, but also belonging to sexual and gender minoritized groups, religious groups. So not necessarily an equalizer, but focus on the second and third points, providing purpose in life and quality of life. So more research in the psychiatric world that converges with the cognitive aging world is people who have a purpose in life, meaning a way to spend their time meaningfully, are more likely to age with more quality of life, less chronic disease, and also more management of the diseases that they do have. So that may mean working, of course. People work longer and longer now, you know, I think as we all know, but also being able to meaningfully contribute to their communities. That could be volunteering, that could be taking care of loved ones, that could be part-time work, not necessarily full-time. Things that go into being integrated into communities, which is a key component of recovery, but also promoting that financial self-sufficiency that is oh-so-key, especially as people age. But here I've also been thinking of employment education in terms of activity. So really thinking about what I term as the three acts in my work. Cognitive or mentally stimulating activities, physical, so it doesn't mean you have to be lifting weights or running every day, but physical activities such as gardening, a yoga class, a walking group, just simply around, and socializing with others. I provide a working definition that I use in my CDC work that we're pumping up to develop multidimensional interventions for persons who are aging and persons who are aging with disabilities such as SMI. So it's really all about meaningful and sustained activity, so mentally stimulating, socially beneficial, and physically exertive, so something that would take them outside of the realm of what they do every day, so at least getting up and walking, maybe gardening, with at least one other person. Something that's valuable, not necessarily being paid for, but that's intrinsically valuable. The key thing here is that a lot of these things, cognitive, social, physical, activity overlap. So as you're doing one, you're also doing others. So if you're in a yoga class, you're not only simply moving your body, but you're thinking through the steps. If you're with a walking group, you're using your body physically, but you also may be talking to others, so having that social engagement. But the key piece is the social activity and social engagement. The Lancet Commission has set forth that this is one of potentially nine modifiable factors, protective factors for cognitive impairment for those with SMI and people who are aging, things that we should not wait until we are 65 years of age to start doing, but things that are beneficial, especially for persons with SMI starting in midlife. So I'm talking about my age, 40, you know, moving forward with really amping up those three acts, because it's a key component of healthy or successful aging, and taken together, they might address or prevent up to 40% of Alzheimer's and other dementia cases. But a lot of people think of, especially belonging to racial and minoritized communities, and this is a tricky subject as the role of family. Sometimes people do not have good relationships with their families, so I'm talking here about extended family that can be people they live with, others they socialize with in communities, or even now increasingly virtual. But these folks are seminal in the role of the three acts, and they're not just caregivers, but they're advocates, supporters, confidants, and purveyors of really getting people active, and hence the inclusion of these individuals, family, and the lives of persons with SMI, especially as they go from middle age to older age, especially important if they are not triggering. So, all of these things that I have discussed, understanding disparities, understanding the role of family, and the three activities, really empower people to reject internalized and societal stigma. There's a confluence here between SMI and aging. Our society values youthfulness, and also values being disability-free. So, here, being able to engage in those three activities and understanding what may work for each person helps people to improve their self-esteem that allows them to face the challenges with their mental health, physical health, aging, and medical treatment, and being able to say, yes, I want to engage in different activities, employment, and beyond. So, here, I'm really focused on thinking about, I see, providing aging-friendly care, but really, it's starting in midlife for persons with SMI, especially as we're seeing people in their 40s with psychiatric illnesses having cognitive decline that's synonymous about 65 years of age, or really 70, for people who are, quote-unquote, normal, and the loss of motor coordination, so standing up, balance, gait, and more falls. So, by midlife, we should be looking for people with SMI that are aging faster. What we really are looking at for cognitive impairment are three big areas. It's being able to balance, and walking speed, or gait speed, as we will call it, being able to see things visually, of course, so diminished eye function, and processing, so what do you see? Can you describe that? Can you verbally let me know what you're seeing and how quickly, and also your hearing and audio processing? So, we know hearing impairment is large, related to cognitive impairment, but also the processing of it, so everything is around processing and perceptions here, okay? So, what we're looking at in midlife, if not earlier, so when we think of midlife for, quote-unquote, normal populations, is about mid-40s to late 50s, but what I'm referring to here for persons with SMI is 30s and early 40s. It's the integration of physical and mental health that's focused on screening, monitoring, and having continuity of care, wraparound care, that really directly address cognitive aging for these individuals, so a dearth of research addresses social and service-based needs. I remember going back and forth with reviewers of this presentation with, how can we anticipate needs, and unfortunately, as people were not living past roughly 53, 55 years of age with SMI, we weren't thinking of what it would look like to have that intersexual aging or being an older adult with SMI, but there has been some promising work, and it's largely community-based. It's largely people who are social workers and folks who are clinician scientists that are saying, what are the actual ways that we can assist persons who are older with SMI who are dealing with cognitive changes? So they're really focusing on the managing of medications, not just saying, hey, are you taking them?, but also we're seeing cardiovascular, cognitive, as well as psychiatric side effects coming into play here, how to manage those, and then obtaining accurate information. As people go to more doctors or neurologists or even a psychiatrist that is in cognitive aging, what is that diagnosis here? How may that impact medication? What are your other comorbidities? How can you maintain or improve your quality of life while you're experiencing physical changes, cognitive changes, and financial? More or less, how can you afford to get shoes that you can walk around with? Is it safe to walk in your area? Can you go to a grocery store and, say, do an additional lap around Walmart or Target or Juul? Really thinking practically is what is needed. But also, identifying services that are at that intersection, meaning for aging persons with SMI, those are few and far between because many services are singular, meaning they're only focused on aging or they're only focused on SMI. But those things are coming more to fore with the great work being done by Thresholds, Eldercare Society, and one group that I'm going to highlight a little bit later to cue you in to some of those resources. So, people will really need assistance with communicating with their loved ones and providers. Think about what I said earlier about end-of-life planning or aging planning with people who are aging with SMI and speaking to their loved ones and providers about their financial, housing, health care, and other wishes, making sure their financial and transportation needs are met. And something we don't talk about enough is sexual and intimate health and hygiene. So, this is especially key for women who are aging with SMI and potential cognitive impairment or aging, making sure they're still getting their gynecologic exams. How does that work hormonally with both cognitive and psychiatric changes and making sure they take care of themselves hygiene-wise? So, this is a group that I work with, a group of physicians and other providers that provide care to older adults, but really older adults that are experiencing psychiatric comorbidities as well as countless others. So, please take note of them as they're doing great work called Catch On. And something I always include in my work with providers is just how to have culturally competent or culturally compatible care. What does that mean? So, it's not, I always shy away from, some people do cultural matching, which I just frown upon, not only in my own work, but the research supports that simply being a Latino psychiatrist, helping with or treating a patient or a person who is Latino, is not necessarily a one-to-one match. I'm talking about something beyond that, is where we develop cultural competence, where it's four stages that are additive, but they are a continuous developmental process, meaning you'll never just be top-of-the-pops, culturally competent, because it first requires you to be, to take two things into consideration. It's first being me-centered, who am I, meaning what are the demographic groups, the cultural groups that I identify with, what are our beliefs, norms, customs, stereotypes even, really doing the hard work with saying, how do I view myself and how do others view me, and then taking that to, when I say other-centered, I mean people that you are working with and also just broadly in your communities, but for here, people that you work with around their health, what are their values? How do they identify themselves? Not just how we perceive them, but how does a person, say, identify themselves geographically or racially, ethnically, or sexual orientation-wise, and what does that mean for their values, beliefs, their biases, their stereotypes, and behaviors, and how do they view you? Then you can move into that knowledge analysis, say, how are these things similar, so me compared to them or the other? How are we overlapping? How are we dissimilar? And really being honest with and aware of what more information do I need, and am I open to having similarities with various groups of people, and am I open to having differences, and what are they? And really moving to accepting and respecting those similarities and differences and not assigning judgments, and this is something that I work on constantly, because isn't everyone? We're in a society where implicit biases are in someone no matter whatever their racial, ethnic, geographic, psychiatric diagnosis. It's in us. We're all in the same pot, but challenging those, understanding how we describe ourselves, how others describe themselves, cultural accuracy here, reading up on these things, getting to know other people, and not passing judgment. That's how we move forward, cultural sensitivity, and then being able to say, I am ready to adjust how I think and behave toward myself as well as for others, especially in the context of providing health care. So this is something I put together. I just call it a thermometer, so I keep it on my own office wall. I give it to others who are part of my research team, and it's like a continuum of sorts, a handy-dandy of how do I know when I'm doing pretty okay, purple, blue, but when I'm in code orange, code red, which means bad, similar to, say, travel or the COVID-19 pandemic, is what do I need to do? So what am I exhibiting here, and then how can I go back to this model, and where am I? Do I need to read more, get more introspective with myself? Do I need to have more contact with others? What do I need in order to get back into having acceptance and respect for not only differences, but I find that people have a real hard time with accepting how much similarities there are between various demographic groups of people and holding all of this in high self-esteem. So really, as I see engagement for persons who are aging with mental illness is the seven principles, and I keep it very simple because people with cognitive aging, especially with comorbidities psychiatric, it's best to keep it simple. So you want to start with how can you help them map the pathway to help them make the best decisions, and this really goes also hand-in-hand with point five. These individuals are most likely to not be alone. They're having family members, loved ones, social social workers, and other people around them that are their supporters. How can you help strengthen their network of care to help the person make the best decisions? And then how can you place little triggers? Some people get overwhelmed, especially with cognitive aging, not being able to remember, to process, auditory, visual, other cues. How can you help them create those habits? To then build upon taking a few extra steps each day, reading a book, getting out and about with community, engaging in those three acts, and then specifying the smallest task that matters most that can really have maximum success. So a lot of folks with cognitive aging will have stigma around that, not wanting to talk about having a dementia diagnosis or not wanting to speak about any of their comorbidities, but saying, okay, well, can you join a group of, a support group of people who are going through the same thing as you and just talk once a month? That can may help with your physical activities, social, cognitive, as well as your emotional and mental health, and then going on to communicate in the patient's language to build rapport. And I'm not speaking about expressed language there in terms of a different language, but meaning, how do they describe what they're going through? How do they speak about their diagnoses? And that's where that cultural competency comes in, because some individuals, different groups, may not refer to it as dementia. They may not talk about memory loss. It may be in another way, but how can you then, of course, work with number five, that ever-present thing, family, caregivers, loved ones, and other providers, such as social workers, to really deliver the right information at the right time, because folks are overwhelmed, and we want to teach and not shut people out so we can acknowledge and build upon what folks are doing right, and encourage and nurture them moving forward. So, really, these are four big charges to you of everything that I spoke about, especially for people with SMI who are experiencing a cognitive impairment, cognitive decline, and potentially chronic diseases of aging, such as dementia, is that realizing that just because we say priority groups doesn't mean that just because I am a Black woman from the rural South that I identify with just simply being a woman, but it's all coming together. It's intersectional to create these complex realities that people are living through, and that we may have a disconnect between how we see people and how people see themselves, so identify, and the related meanings that people may have assigned to not only demographic characteristics, but also the meaning of psychiatric diseases, aging. Some groups may shutter aside folks who are aging. Some people revere their elders, and what does this mean in terms of isolation and aging with SMI? So, really continuous cultural competency is key. Something that's rooted in awareness and active assessment of not only your own identity and healthcare beliefs, but also those of the people that you serve. So really what I'm ultimately talking about is moving from simply describing these disparities. So people with SMI having more likely to experience cognitive impairment in midlife, and especially those who belong to racial ethnic groups, LGBTQIA communities and rural, that's a description. But really, how can we provide this culturally competent care, aging friendly care for these individuals who are growing older with SMI to create equity that is all encompassing, interconnected, and really addresses the structural and social determinants of health we talked about. Think about the big four, healthcare, education, employment, and housing. And that way we can build solutions at the individual level, the family level, community, and the macro broader level. So here we're moving to fixing the system that creates these imbalances. So this is something I always, always encourage. And I would like to point you to these resources here that are provided in various languages for people with various disabilities, including SMI, particularly focused on people who are older adults and their family members. Here's the sources that I used. And I was really keen on time and I hope I did okay. I'll take a quick look up. Oh, perfect timing, I think. And I welcome questions. Please follow me on Twitter and you can email me for all the future work. And thank you for joining me today and listening. I hope I didn't go too fast and I'm open for questions. Thank you. Thank you so much, Dr. Glover, for that presentation. And you're just perfect on time. I was just about to message you and say you have a few minutes to wrap up. So before we do shift into that Q&A, which please, if you do have questions, we have received some, but if you would like to get another one in, go ahead and enter that into that questions box in your dropdown there. So I wanna take a moment and let you know that SMI Advisor is accessible from your mobile device. So use the SMI Advisor app to access resources, education, and upcoming events. Complete mental health rating scales and even submit questions directly to our team of SMI experts. You can download the app now at smiadvisor.org slash app. Okay, so the first question that we have is that basically it's about how to differentiate between some symptoms of SMI and cognitive decline. So as we know, there's some patients with SMI have some cognitive impairments such as memory, disorganization. So how are we able to differentiate between that and cognitive aging? That is a very good question because some of the markers of cognitive impairment mimic other diseases. And this is very true in terms of with type two diabetes. So I would say first is to understand what are other comorbidity profiles that the person may have. And then speaking with a very highly specialized individual about neuropsychiatry. So how can we suss out where we may have the mini mental state examination, we may have different balance or gate sort of testing, auditory and other processing to whittle it down to see what exactly is contributing to those different cognitive changes that a person may be experiencing not just because of SMI or cognitive aging, but another comorbidity, cardiovascular, metabolic, et cetera or simply a change in lifestyle at that point. It could be a medication change, it could be different activity levels. But the key thing that I always stress is comparing the person to their previous activities or their previous behaviors. So we can go all day with testing and understanding, but really saying what is different? Are they just making a bad decision every once in a while? Is that similar to how people have already been behaving? Or are they simply say forgetting a word to use or losing something? Or is this increasing? Is this a marker of cognitive impairment? That's where you will see a further specialist. And big, big, big ticket is if you can single out, say it's not something cardiovascular, metabolic, or another activity of daily living that they may have changed, is the trouble in having a conversation. These things or markers are auditory, visual, perceptual, and memory. So you're kind of riding high with the five cognitive domains, four of those. If you're seeing big changes in those, it's likely that the person is experiencing cognitive impairment. Okay, great. I have a couple follow up to that too. So is the treatment different from a provider standpoint for SMI, cognition issues, or if it is related to something like Alzheimer's or dementia? I'm not sure I understand. Are you saying that is a treatment available, are the treatments available for cognitive impairment different than those that are for dementia? Is that what I'm understanding? Yes, so for cognitive impairment and SMI, would that treatment be different than it would be for Alzheimer's or dementia? Yeah, so right now, I don't know if you've heard about the big kerfuffle with some of the treatments, the pharmacologic treatments that are available, is that there are very little. And once a person is experiencing impairment, and once they have received a diagnosis of Alzheimer's disease or related dementias, because remember, it may not just be Alzheimer's, there are other dementias such as cardiovascular or vascular, Lewy body, frontal temporal. So there are highly nuanced ways that all present as dementia. So those big five cognitive domains, there are only a few pharmacologic options. So it is likely that they will not differ. And unfortunately, once a person has seen cognitive impairment that is not due to say medication or cardiovascular or metabolic issues, it's almost like a boulder just going downhill. At this point, we do not have a way to stop or decrease dementia once it is here. So the medications will likely be the same. Yes, nothing, it can slow it down a little bit having quality of life, but it is a highly progressive disease that is not responsive to the pharmacologic options that we currently have. I would be remiss even with all the controversy that's around aducanumab. So that means the industry name of aduline set forth by Biogen. People have seen some success. The clinical trial data are mixed. And when I say success, meaning that it will decrease the amyloid or the tangles in the brain. So what is linking the biomarkers of dementia, but that's highly controversial. And I don't know, given pricing, more clinical trials needed, will that be firmly on the market anytime soon? But long story short, yes, it will likely be the same treatment, but it is a chronically progressive issue. Okay, so somebody had specifically asked about antipsychotic long-acting injectables. I'm not sure if you have any information or if there is even any research on there on the treatment of Alzheimer's or dementia with long-acting antipsychotic injectables, but I thought I would ask since it was very related to what you were just talking about. Indeed, I do not have a pointed answer at this time, but there are highly, highly involved studies that are going on as we speak at the NIH level about not only psychiatric, but also Down syndrome and other developmental disorders that people may have earlier in life. And what can we learn? People traditionally have kept these things separate, but with seeing that we're more likely to see comorbid psychiatric illness and cognitive impairment, especially as people are aging. And also now as people with Down syndrome are aging, are living longer, we're seeing more trials with that. So I would suspect, and we know the nature of trials, within the next five years or so, this is going to explode because there's no way that we cannot understand the long-term impact of that exact question for persons who are aging. So I do not have a firm answer for you now, but knowing that research is being put forth going on right now. That's great, thank you. Somebody, a little shift, but somebody was asking about, is Alzheimer's and dementia considered a mental health condition or mental illness? So no, it is not. So clinically, or in the research circles, it is not. So dementia is an umbrella term. And so that includes not only Alzheimer's, but frontal temporal dementia, Lewy body dementia, and vascular dementia. And then what we're seeing more and more for persons who are either identifying as African-American slash black, or Latino slash Hispanic, is that they're experiencing mixed dementia. So that means that they're having Alzheimer's plus vascular dementia. And we know with the high prevalence of persons living with SMI, and especially those who belong to minoritized communities, having higher incidence of CVD and other metabolic issues. So that's just one part. We do not see it that way. But in my research with diverse communities, is that patients, participants, consumers, persons in the community, very much so see it as a mental health issue, dementia that is. And that's where the stigma that I spoke about comes into play. So that may have not been clear. I'm sorry, was I muted? Did go, just for a quick second. We heard up until, I might've not been clear. You're not for very long. Okay, sorry, good. I was saying that us as researchers and clinicians do not see dementia as a mental health or psychiatric issue. With dementia's umbrella, the different types, and I can reiterate that if needed, but in the community, so consumers, patients, participants, family members, they do view it as a mental health issue. That's where some of the stigma comes into play that I was hearkening to earlier in how people may describe it or view it. Henceforth in preclinical dementia, people don't seek care because they don't want to deal with what does it mean to be experiencing these changes? What does it mean for medication, insurance, finances? And also they may not want to deal with what it means in their families and communities. So it very much so is viewed in that way in diverse, demographically diverse communities. But for researchers and clinicians, no, we don't view it that way. Great, thank you. The next question is about screening. Do you recommend that providers do routine screening for cognitive screening such as the mental status exam or mini mental status exam so people have a baseline? Is that something that you would recommend for people who treat people with serious mental illness? You read my mind because not only do I recommend that for persons living with SMI, I've made this recommendation for overall populations that are more likely to experience CBD and other metabolic diseases because we are seeing if we wait until so, and this is just a big criticism that I have overall, is if we wait until 65 to start assessing people, the markers of cognitive impairment for individuals with SMI are presenting in their early 40s, late 30s, early 40s. So that means that the preclinical or the impetus, the shadow work is already occurring. And then we know for people without SMI, if we wait until they're 65, different things are occurring in midlife and early life, I would argue. So I would say, yes, starting to get the baseline earlier so you can know, is this something that is indeed impairment? Does this coincide with a CBD diagnosis or type two diabetes mellitus or a fall that they've had? You can triangulate your data better to understand, is it true cognitive impairment related to dementia or a type of dementia, or is it something else? So I agree, yes, I would start doing that earlier. And that's highly controversial, but that is something that I have been pushing for. And my colleagues, quite frankly, at the Rush Alzheimer's Disease Center, especially the last year or two, as we learn more and more about midlife. Great, thank you. So there's a lot of questions too, and this is probably going to be pretty specific to where people are located, what the resources in the community are, also, even the person's medical coverage, but it seems to be a lot around, people are not sure where a good level of care is for people who have serious mental illness and then begin to experience this cognitive decline. So do you have any type of recommendations on that? It seems to be, people end up going into nursing facilities at that point. But we know that, as we know, when people enter nursing facilities, it can kind of speed up that decline. So do you have any recommendations around level of care for people who have serious mental illness and then experience cognitive decline? Yes, that is huge. We see that all the time with, where can I get any help? Where can you understand that I'm aging with SMI and not only get help, but good help or quality? I will start with the group that I put up called Catch On, as well as, one group is global, but we have now in the United States, and Illinois is one of the leaders. It's called Dementia Friendly Illinois. So Dementia Friendly, as it was like DFI and Dementia Friendly Communities, huge. That means you can put someone in contact or help triage care for say, how can we get you linked up with the community-based resources that fit your needs? Is it financial? Is it social support? Is it physical activity? Is it medication adherence? Is it getting you a stable, safe place to stay? We have used that quite a bit. Dementia Friends, Illinois, as well as Catch On, it is very new, meaning within the last five to eight years. It just really realizing that we need, not only this is beyond just persons with SMI, but we see it so critically that it's almost like we forget about people once they hit 65 or experiencing these things like where are the services? Where are they centralized? Is there any way to get that? University of Chicago has huge resources and it's called Shared Resources with Lynn Dowers, Stacy Lynn Dower, a researcher there has put that together called NOWPOW, N-O-W-P-O-W. Also Catch On, as well as Dementia Friendly, Illinois. Those will be some good resources where people are working around the clock to develop that sort of level of care, that nuanced level of care, might I add. That's great, thank you so much. Those resources also have interventions. So we're running out of time, so I don't think we'll have time, but I was wondering if people are asking about specific interventions. Somebody brought up the three acts and some other resources for interventions for providers to do with people who are experiencing this. Yeah, right now, what we call multi-domain interventions, so those are the three acts plus others. People are, when I say people, I mean researchers are actively working on those now. But what does that look like? It's really understanding the level of activity that your person has now, or your patients that you serve, where are they at now, and how you can, as I highlighted, maintain or improve. Because it's going to include a calibration of those things. Some people need a little bit more physical activity, whereas other people are good with socializing as well as cognitive activity. But it's really assessing baseline, where folks are, and there are measures out there to do so. And then you can calibrate from there. It's almost like a soft prescription. So where you calibrate, say, blood pressure medication or Metformin. It's a similar method, but people are working now on researchers of what is the threshold? What is enough to have a clinically relevant threshold that will be meaningful for people with cognitive impairment, in addition to people with SMI and other comorbidities? So that work is out there, but I would say practically thinking of it as a calibration. First, assessing where people are, where can you improve, folks? How can you maintain? Because you know that could be overwhelming. I'm just focused on time. With the changes, you can go from there. Thank you so much. Just to end a Q&A, somebody said this has been one of the best presentations they've ever seen, and they've seen many. I believe you gave them your Twitter. They want to know where they can find more of you. That would be a good place? Yes, that'll be great. And then you can DM me there, and then we could take it to emails or however you would like to do it. Going from there, yeah. But Twitter is great. That's my professional Twitter account. So no spam. Excellent. And you can also, so we can move to the, I'm just going to conclude things now, but thank you so much for that presentation. So if you do have follow-up questions about this or any topic related to evidence-based care for SMI, our clinical experts are now available for online consultations. So any mental health clinician can submit a question and receive a response from one of our SMI experts. So for those that we did not get to, because we didn't get a lot of questions at the end, please feel free to submit through this, and we will respond to you there. Consultations are free and confidential. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select Next to advance and complete the program evaluation before claiming your credit. Please join us in two weeks on August 13th, 2021, as Dr. Rae-Ann Moore with the University of California, San Diego presents Advances in Smartphones and Digital Health for Schizophrenia and Bipolar Disorder Research. Again, this free webinar will be on August 13th, 2021 from 12 to 1 p.m. Eastern Standard Time. Thank you so much for joining us and until next time, take care. Take care, bye.

diversity

serious mental illness

older adults

aging

cognitive changes

culturally compatible care

family support

healthcare disparities

cognitive impairment

quality of life