Understanding Nuances in Geriatric Depression Treatment

What many presume to be typical “senior moments,” may actually be symptoms of more serious mental health issues, including depression.

In our latest installment of GeneSight Cares panel discussions, we took a closer look at some of the issues around geriatric mental health, and the challenges in treating senior patients.

The panel featured:

Parikshit Deshmukh, MD – CEO and medical director of Balanced Wellbeing LLC in Oxford, Fla.

Fay Bembry, FNP, PMHNP – Psychiatric mental health nurse practitioner, Team Health in Johnson City, Tenn.

Lesa Caffee, nurse practitioner, Senior Wellness Group in Royal Oak, Mich.

Charlynne Gervais – social services director, Majestic Care in Fort Wayne, Ind.

Ben Inventor, PhD, APN/CNP – director, adult-gerontology primary care nurse practitioner program and assistant professor, Department of Adult Health and Gerontological Nursing at Rush University College of Nursing, in Chicago, Ill.

What are the Challenges Diagnosing Depression in Senior Patients?

Identifying depression in senior patients was difficult, even before the pandemic, according to the panel.

“It’s very challenging to diagnose depression in older folks to begin with,” said Dr. Inventor. “And then, you add on top of that the COVID pandemic. It magnifies the challenges.”

Older patients don’t experience depression in the same way that younger patients do, according to Fay Bembry. Caregivers and providers may address the physical symptoms of their patients, not realizing those symptoms could indicate depression.

The panel agreed that in long-term care settings, more attention needs to be paid to depression symptoms for all patients. Lesa Caffee explained that patients with cognitive impairment may struggle verbalizing their depression symptoms. Quieter and more solitary patients may not be assessed for depression as often as those who show more outward behaviors.

How has COVID Affected Geriatric Care?

The most significant impact of the pandemic has been the limitation of family visits, according to Bembry. In the facilities she’s visited, she

has observed a faster deterioration among dementia patients and a significant amount of depression among the general patient population. To prevent the mental decline, her team has encouraged social activities, such as FaceTime visits with family members or Bingo where patients are masked and can participate from their doorways.

In relation to seniors during the COVID pandemic, Dr. Deshmukh stated “their uncertainties about their health and about their loved ones have gone up. Fear of dying has gone up.” Additionally, he noted “restricted visitations from family, restricted visitations from doctors is another factor…They’re isolated, sitting in their room, watching the TV. And what is on the TV? It’s all negative news about COVID.”

Dr. Inventor added that he has become much more reliant on facility staff since the start of the pandemic because the nursing home is not allowing outside visitors and clinicians.

“We used to diagnose people by ourselves, right? We come in, we see, we interview patients, we interview families, we interview staff. But now it becomes a partnership with the people in the nursing home. We are not allowed to go in and talk to the patient. So now we are in partnership with staff in looking at, diagnosing, assessing: what are the symptoms that these patients exhibit?… Staff are the ones with the patients 24 hours a day, and so we rely on them,” said Dr. Inventor.

Telehealth may be an Imperfect, Temporary Solution for Treating Senior Patients

Limited or no access to patients has increased the use of telehealth. While virtual visits have been a part of many efforts to return patients to a sense of normalcy, it has many limitations.  Dr. Deshmukh noted that senior patients may not be technologically savvy, or they may have a hard time with their hearing. And many doctors and patients alike feel a virtual visit is simply not as comforting as a face-to-face visit.

One of the challenges for clinicians is that they were thrust into telehealth without much training. Over time, the facility staff that Dr. Inventor works with have learned that having a strong audio/visual and Wi-Fi connection, having staff preface the conversation, and avoiding distracting backgrounds or clothing can help with telehealth visits. Additionally, it is important for clinicians to understand proper etiquette for Telehealth, including looking directly into the camera to help to make better a connection with the patient during a visit.

Returning to more in-person interactions with patients, as soon as it is safe to do so, will be most beneficial for patient care.

Using Gradual Dose Reduction

While the panel agreed that Gradual Dose Reductions (GDRs) can be good, increased pandemic stress may potentially reduce the effectiveness of a medication that had worked prior to the pandemic. The pressure for providers to follow GDRs has not decreased, and the panel discussed if providers should consider doing GDRs at this time.

“In long-term care facilities we are kind of programmed to do GDRs,” said Dr. Inventor. “This is not the time, actually, to do GDRs. I think that residents have the highest risk for relapse with isolation and stress and everything that’s going on with them, their support system is down.”

Using objective tools can help guide therapeutic dosing and serve as justification for not performing a GDR.

“I find in these times that I rely on some of our objective data like our PHQ9, our Geriatric Depression Scale, our Cornell Scale for Depression and Dementia. And do that testing before treatment, and then after treatment, to make sure that we’re getting response,” said Bembry.

Further, capturing as much data as possible from scales and ensuring staff is recording detailed notes, helps the clinical team make a determination on whether or not a GDR is appropriate for a patient.

“As we say, if you didn’t document it, it didn’t happen,” said Gervais.

The Ripple Effect of Treating Geriatric Depression

Treating a patient’s underlying depression will likely improve that patient’s quality of life, their physiological health, and the mental health of the people around them. Family caregivers, healthcare providers and staff who care for these patients are often more stressed and prone to depression and anxiety.

In fact, addressing one person’s depression could have benefits for other patients in the facility, their families, and even the people who treat them. Bembry described scenarios where treating and improving one patient’s depression may help that person’s roommate as well.

“If we treat depression aggressively, I have seen that it not only helps with their physical improvement, but their participation in physical therapy, participation in occupational therapy. And also research has been clear that people who are more depressed, they visit the emergency room more often, they go to hospitals more often for psychosomatic reasons,” said Dr. Deshmukh.

Ageism in Mental Healthcare

It is never acceptable for depression to be considered a normal part of aging.

“The thought that because of aging, you deserve to be in pain, or you are prone to pain, or you are prone be depressed or that it’s just a way of life – that’s ageism,” said Dr. Inventor. He says that ageism extends to stereotypes about “grumpy old man” and “irritable ladies” which can negatively affect treatment options.

Dr. Deshmukh recalled a patient’s child who asked, “What did you do to my mother? She has always been a mean lady throughout her life, and now she’s not.” He responded, “I just treated the underlying psychiatry condition which has been untreated for so many years!”

Tips for Better Geriatric Care During the Pandemic – and Avoiding Burnout

With limited face-to-face access to patients and staff on location, panelists noted that, in many situations, it can be beneficial to hold regular interdisciplinary team meetings that include doctors, pharmacists, nurses, unit directors and other staff who interact daily with patients.

This kind of collaboration raises the staff’s comfort level, saves time, and increases capacity to provide more robust care. Empowering Certified Nursing Assistants (CNA) to observe and report symptoms of depression is increasingly important because they interact directly with patients.

That teamwork is vital as the stresses of the pandemic can affect clinicians as well.

Long-term care facilities were already short-staffed before COVID. Now, when staff become ill and must quarantine, it puts more pressure on the remaining staff. Caffee says it’s important to be open with management about coping with stress, to take breaks, to ask for help when needed and to delegate tasks wherever possible.

Dr. Inventor recommended continuing safe and healthy activities, such as running and other physical exercise, getting enough sleep, or meditating, to help maintain a sense of normalcy and wellbeing. Bembry suggested taking breaks from digital screens, especially as use of telehealth options increase.

Ultimately, clinicians must take care of themselves and reach out to family, friends, colleagues, or a doctor if they feel overwhelmed.

“Healthcare providers are human beings, and sometimes the stress can be too much,” Dr, Deshmukh said. “It is okay to not be okay.”

To watch the full versions of both panel discussions, and view more topics presented by GeneSight Cares visit our YouTube page at: https://www.youtube.com/watch?v=8l_Vu6avL9M&list=PLUD2t4Qlp8d0Fp2a3MO4TAphBo-gRo_y1