HomeBlogHealthcare ProviderUnderstanding Nuances in Geriatric Depression Treatment Understanding Nuances in Geriatric Depression Treatment November 4, 2020Healthcare Provider 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 Our articles are for informational purposes only and are reviewed by our Medical Information team, which includes PharmDs, MDs, and PhDs. Do not make any changes to your current medications or dosing without consulting your healthcare provider. The GeneSight test must be ordered by and used only in consultation with a healthcare provider who can prescribe medications. As with all genetic tests, the GeneSight test results have limitations and do not constitute medical advice. The test results are designed to be just one part of a larger, complete patient assessment, which would include proper diagnosis and consideration of your medical history, other medications you may be taking, your family history, and other factors. If you are a healthcare provider and interested in learning more about the GeneSight test, please contact us at 855.891.9415. If you are a patient, please talk with your doctor to see if the GeneSight test may be helpful. Published: November 4, 2020 Healthcare Provider Overcoming Side Effect Concerns: Leveraging Pharmacogenomic Insights to Inform Depression and Anxiety Medication Selection Whitnee Brown, a lifelong resident now practicing in Birmingham, Alabama has nearly an entire alphabet following her name, abbreviations for degrees and certifi... 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Healthcare Provider Overcoming Side Effect Concerns: Leveraging Pharmacogenomic Insights to Inform Depression and Anxiety Medication Selection Whitnee Brown, a lifelong resident now practicing in Birmingham, Alabama has nearly an entire alphabet following her name, abbreviations for degrees and certifi... Read more
Patient Concerns about Mental Health Medication Side Effects Remain a Barrier to Getting Help for Those Diagnosed with Depression and Anxiety Lisa Roberts has raised a family, reached an impressively high level in her career, and was an anchor for her mother and other family members. When, within ... Read more
Patient Common Antidepressant Side Effects Taking an antidepressant can be an effective way to help treat a mental health condition like depression or anxiety. However, these medications can also cre... Read more
Patient MTHFR Mutations: Clinical Implications and Management Strategies MTHFR mutations—changes in the methylenetetrahydrofolate reductase (MTHFR) gene—have gained increased attention in the medical community due to their potent... Read more
Patient Can an App Help Me Manage My Anxiety? Health and wellness smartphone apps have become so common that if you can name a health goal, desire or condition, you can probably find an app for it. N... Read more
Patient Black Trailblazers of Psychiatry and Mental Health: A Legacy of Healing and Advocacy As we celebrate Black History Month, we want to recognize a few individuals who have made extraordinary contributions to the field of psychiatry and mental heal... Read more
Patient Mindful Moments: Tips for Anxiety If a well-meaning friend or family member has ever told you to “just breathe” when you’re feeling worked up or stressed out, you’d be forgiven if you felt l... Read more
Patient Hints To Help You Have A Better New Year The holidays have ended, and a new year has begun—a time when many embrace a fresh start by setting New Year’s resolutions. This year, why not consider s... Read more
Patient Movement as Medicine: Solutions for Anxiety Moving forward. It sounds like a nice idea, especially when you’re feeling stuck deep in the throes of an anxiety spiral. But it turns out that physically m... Read more
Patient Weight-Loss Drugs and Mental Health: What You Need to Know New medications for weight loss seem to be flying off pharmacy shelves these days. But could they be linked to mental health conditions? Researchers are ... Read more