May 1st, 2013

Treating mental illness in the elderly: achieving stability through inpatient care

PHOTO BY Tom Croke
Don Davidoff, Ph.D., chief of neuropsychology at McLean Hospital, notes that three-quarters of patients on the regular geriatric unit are treated for depression.

The Institute of Medicine (IOM) reports that approximately 5.6 to 8 million Americans 65 and older have mental health or substance use disorders; those figures are expected to double in the next 15 years, precipitating a tremendous burden on an already overburdened health care system. Although community-based care is preferred, inpatient care still remains important as a line of defense in stabilizing individuals and creating long-term solutions.

McLean Hospital in Belmont, Mass. has two separate geriatric psychiatry units, one serving individuals with dementia and Alzheimer’s disease and the other for patients with non-dementia related psychiatric diagnoses, according to Don Davidoff, Ph.D., chief of neuropsychology.

“Patients on the dementia unit are referred because their behaviors have become unmanageable in the assisted living facility or nursing home,” he says, noting only about 15 percent come from the community. A typical length of stay on the dementia unit is 12 days, although there are some outliers because of placement issues; the non-dementia unit average length of stay is 9.7 days, Davidoff reports.

Patients on the non-dementia unit present with a variety of diagnoses, including mood and bipolar disorder, psychotic episodes and affective disorder, the largest single diagnosis on admission. “Three quarters of the patients on the regular geriatric unit are also treated for depression,” Davidoff says.

Treatment options vary in each unit. For instance, individuals in the dementia unit engage in simple physical activities and life reminiscing. Validation therapy is also a key component of their treatment, according to Davidoff. “Say someone is looking for a long-dead spouse. You can’t tell them that he is dead. Instead you respond, ‘You must be feeling very lonely’,” he says.

Effectively treating depression for those in the non-dementia unit can be difficult, Davidoff says. “There could be sensitivity to psychoactive medications and additional complex factors. The feelings of isolation might be real. The kids are gone, the spouse is dead, and the person is retired and has no social circle. Isolation can feed into depression,” he says.

Medical co morbidity, which is common in seniors, complicates effective treatment as well. Davidoff points out that the average number of medications a person 65-years-old takes is nine. “Keep in mind that as people age, every bodily system becomes more dependent on the integrity of other bodily systems,” he says. “For instance, if you get a urinary tract infection at age 20, you have a little discomfort. But at age 80, it can precipitate delirium, anxiety, depression and make a person upset and disoriented.” In this type of situation, the medical condition would be treated and resolved and then the psychological issue would be addressed.

Regardless of diagnosis, a multidisciplinary approach to treatment yields optimal results, notes James Beauregard, Ph.D., geriatric neuropsychologist at Elliot Hospital in Manchester, N.H.. From pre-admission to post-discharge, a social worker, nurse, nurse practitioner, psychologist, psychiatrist, occupational therapist and geriatrician collaborate to evaluate and treat the patient. “We look for the cause that brought the person in. We also look at the environment, whether it’s the home, nursing home, day care facility,” he says. “After we evaluate the system, we try to get them to higher functioning. With a focus on early diagnosis now, there are better outcomes.”

For those patients who present with co morbid illnesses, whether addiction or medical, the same protocol brings maximum results. “We look at the body chemistry and how it’s affected and then help them clear. Patients get cognitive screening at the get-go,” he says, which includes blood work, a CAT scan and consultation with the family. “The complexity of what’s going on is the biggest challenge. They may have a long psychiatric history or may be recently diagnosed. There may be psychosocial losses, the loss of independence. You have to deal with a whole complex of social systems.”

Patricia D. Rizzi, Psy.D., director of psychiatry at Bridgeport Hospital in Conn. which has a 19-bed geriatric unit, reports that including the entire family in the treatment plan is critical, particularly for families experiencing the loss of their loved one’s mental capabilities for the first time. She notes that family members often find it difficult to accept the changes, especially behavioral and psychological, in a person who previously had been active, healthy and independent. “It’s a huge change in terms of memory and overall dementia. The person may now be angry and aggressive,” she says. “The family also has to deal with guilt issues so it’s really important to work with them.”

While hospitalized, patients receive multi-pronged treatment that might include recreational, physical, occupational, art and music therapy, as well as medication management and treatment related to the activities of daily living.

Bridgeport Hospital also features Snoezelen, a controlled multisensory environment used to calm agitation. Rizzi reports that a dimly lit room with soft colors, music and other soothing sounds and pleasing scents helps to reorient the patient and bring them back into balance.

In addition to open communication with family during the senior’s inpatient stay, staff should include them in post-discharge planning, according to Rizzi. The older person typically resists nursing home placement, but is often incapable of returning to the community. “We can’t just let the patient go home. An elderly sibling or spouse may not be able to handle the person. So when they go home, they have to call in a visiting nurse and home health aide,” says Rizzi, adding that a social worker meets with the family to assess safety issues and logistics of returning to the home.

Statistics show that dementia diagnoses will continue to rise, precipitating a need for better care, including hospitalization, geriatrician Dennis McCullough, M.D., lecturer and consultant at Dartmouth Medical School, says. “One quarter of individuals 85 and above will have subtle cognitive losses that will lead to dementia,” he says. “At age 90, 50 percent will have brain disease, cognition deficits classified as dementia.”

According to Davidoff, the biggest challenge in treating this population is “recognizing their humanity.” He says, “We’re all going to be in that position and need good understanding. There’s a lot of counter-transference in geriatric [care]. It confronts the practitioner with a keen sense of his or her own mortality. It pushes some awareness and some are not ready for it. We need to understand ourselves.”

By Phyllis Hanlon

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