Category: Depression/Mental illness/Substance Abuse
Posted by Dr. El - April 18, 2011 - Books/media of note, Depression/Mental illness/Substance Abuse, Resident care
I once heard a family member complain at the nursing station about a parent being on antidepressants.
“She can’t remember a thing. How can she be depressed?”
The nurse replied, “I know.”
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| Marc E. Agronin, MD |
We tend to associate Alzheimer’s disease (AD) and other forms of dementia primarily with memory problems, but as a geriatric psychiatrist who specializes in dementia, most of my consults are for mood and behavioral problems. In fact, rates of depression approach 40% in AD sufferers over the course of their illness. Depression may look differently, however, in the context of dementia. Irritability, agitation, and resistance to care might be seen as prominently as a sad mood. Loss of appetite and poor sleep are common manifestations of both dementia and depression, and can make it difficult to tease them apart. In clinical practice, we look primarily for a rapid decline from one’s baseline when depression strikes.
The cause of depression in AD likely has less to do with a psychological reaction to cognitive and functional loss and more to the damage the disease causes to brain nuclei that regulate moods and produce key neurotransmitters. As a result, antidepressants that we use to treat depression in younger and nondemented individuals can be used with similar efficacy and safety. In early stages of illness, talk therapy can also play a key role, and in all stages there may be benefit to therapeutic programming involving music, pets, and exercise.
As I make clear in my book “How We Age: A Doctor’s Journey into the Heart of Growing Old
,” we cannot adopt a fatalistic attitude or even give up when depression or other mental illnesses afflict AD patients. Not only is there much we can do to treat these symptoms, but there are always underlying strengths that can be tapped, including humor, creativity, sensory enjoyment, and the ability to interact in socially meaningful ways.
Posted by Dr. El - December 15, 2010 - Boomers, Depression/Mental illness/Substance Abuse, Resident education/Support groups, Technology, Younger residents
The saying in 12-Step programs such as Alcoholics Anonymous (AA) is that alcoholism is a three-fold disease: physical, mental, and spiritual. The only-half-kidding joke is that alcoholism is a three-fold disease: Thanksgiving, Christmas, and New Year’s. The holidays can be a particularly stressful time for nursing home residents as their celebrations have often changed significantly from those in the past. The loss of family members, the inability to get around independently, and the lack of opportunity and funds to shop for gifts can take their toll on residents who may have had trouble with the holidays even before they entered the nursing home.
In case you haven’t been persuaded by my previous arguments for holding AA meetings in nursing homes (or in case you’ve been persuaded but your administration hasn’t) there are also telephone meetings available to residents for the cost of a phone call. Callers can listen in, or share their story if they wish, in an anonymous environment. Below are links to the telephone meeting lists of several 12-Step programs.
Alcoholics Anonymous
Al-Anon (for family and friends of alcoholics)
Overeaters Anonymous
Nicotine Anonymous
Posted by Dr. El - October 22, 2010 - Depression/Mental illness/Substance Abuse, Younger residents
I’m on the front cover of the October 2010 issue of Caring for the Ages, published by the American Medical Directors Association. The lead article, quoting me, focuses on the need for substance abuse treatment within nursing homes.
Posted by Dr. El - August 30, 2010 - Depression/Mental illness/Substance Abuse, Resident care, Role of psychologists, Stress/Crisis management
In 1967, psychiatrists Holmes and Rahe created a scale that measures the stress levels of various life events, and found that people with stress levels over 300 are at high risk of illness. I’ve always considered a nursing home stay to be a very stressful experience, but applying the scale was illuminating.
I took the
Holmes and Rahe Stress Scale and modified it based on working with nursing home residents. For example, the Social Readjustment Rating Scale (SRRS) allots 65 points for a marital separation, but since moving away from one’s spouse to enter a facility isn’t a typical marital separation, I gave it 50 points. Nursing home residents aren’t technically imprisoned (63 points), but it is extremely confining, so I reduced that item to 50 points.
In my view, residents are not retired, but have started their jobs of working with the staff 24/7 in order to attend to the business of taking care of themselves, so I included many work-related items not usually considered the province of residents. This left me with the following items on the 43-item scale:
Marital Separation (50)
Imprisonment (50)
Personal Injury or Illness (53)
Business Readjustment (39)
Change in Financial State (38)
Change to a Different Line of Work (36)
Change in Responsibilities at Work (29)
Change in Living Conditions (25)
Revision of Personal Habits (24)
Change in Working Hours or Conditions (20)
Change in Residence (20)
Change in Recreation (19)
Change in Church Activities (19)
Change in Social Activities (18)
Change in Sleeping Habits (16)
Change in Eating Habits (15)
Grand Total: 471 points
471 points, on a scale that finds a high risk of illness at stress levels over 300 points. On the
updated SRRS, the total comes out much higher, with the person considered in a life crisis.
Upon admission to the nursing home, residents are required to see the dietician, dentist, social worker, and recreation therapist. A life crisis, and we have yet to require a psychological evaluation of the residents. Referrals are currently haphazard, and based on the psychological-mindedness of the nursing home staff.
Readers who feel they, their residents, or their loved ones might benefit from the assistance of a psychologist in coping with the magnitude of these life changes can suggest a referral for evaluation for a particular individual (until regulations catch up with the need).
Posted by Dr. El - July 13, 2010 - Business Strategies, Depression/Mental illness/Substance Abuse, Resident care
I refer my residents to therapeutic activities every day. I consider them a vital adjunct to my work as a psychologist. Here’s why:
- Therapeutic recreation reverses the downward spiral of depression. There’s a theory that when we’re depressed, we stop doing the things we enjoy, thus leading to more depression. In order to become less depressed, we need to engage in activities we used to find pleasurable, even if we don’t feel like it. Once we do something fun, it energizes us enough to take the next pleasant action, thus leading to an upward spiral out of depression.
- Structured days are happier days. I suppose there are people who flourish with nothing much to do, but in my experience, most people feel better when they have plans. Residents who sit in their rooms all day tend to ruminate on the negative. As the saying goes, “When I’m in my head, I’m in a bad neighborhood.” I encourage residents to find at least two activities each week to attend on a regular basis.
- Activities are more vital when all time is leisure time. Nursing home residents don’t have to go to work. They don’t have to cook, clean, pay bills, or take care of other chores. When life tasks no longer take up the bulk of the day, it’s essential to fill the time with something else constructive.
- Therapeutic recreation allows residents to continue or create new identities. Our identities as individuals tend to be based on the things we do or have accomplished. Who are we when we are no longer able to accomplish what we used to? Therapeutic recreation provides the opportunity for new experiences and helps residents find creative ways to continue old interests that might be challenging due to disabilities.
- Activities foster socialization with peers. Residents often believe there’s no one in the nursing home they can talk to. This myth is dispelled through recreational activities, especially those that encourage the residents to speak up, such as trivia or group reminiscence.
- Life needs purpose. Activities that allow residents the opportunity to contribute to society give purpose to life. Residents can raise money for a world-wide cause, join the resident council to improve their nursing home, or create a gift for a family member in their art class. Purpose can also be found in personal satisfaction such as besting a Wii bowling record or appreciating a musical performance.
- Apart from medical care, therapeutic recreation is the best reason to be in a nursing home. Residents receive essential healthcare in nursing homes, but it’s the recreation department that gives them the opportunity to create a new life.
Posted by Dr. El - June 4, 2010 - Business Strategies, Depression/Mental illness/Substance Abuse, McKnight's Long-Term Care News, Role of psychologists
I wrote a guest post for McKnight’s Long Term Care News addressing how psychologists can help nursing home residents and when a referral for treatment might be appropriate.
“The recent Illinois legal decision to move mentally ill nursing home residents into smaller mental health settings is likely to prompt an industry-wide examination of the practice of accepting mentally ill residents into long-term care. If nursing home residents are lucky, it will also trigger an evaluation of how we treat mental health issues in nursing homes in general.”
Posted by Dr. El - March 2, 2010 - Books/media of note, Depression/Mental illness/Substance Abuse, Medication issues
I saw an article yesterday in the Health section of the New York Times describing the difficulty of younger people to imagine what life might be like in later years, particularly in nursing homes. I thought readers would appreciate it.
The old woman had drawn down the shade in her room — hoping, I imagined, to stop the midday Miami sun from penetrating her grief. But the sun still hit the window full force and illuminated the shade like a Chinese lantern.
She sat silently in a wheelchair, her 93-year-old silhouette stooped in the bathing light. I entered, held her hand for a moment and introduced myself. “Sit down, doctor,” she said politely.
Click
HERE to read the entire article.
Posted by Dr. El - January 26, 2010 - Common Nursing Home Problems and How Psychologists Can Solve Them, Communication, Customer service, Depression/Mental illness/Substance Abuse, Resident care
An iatrogenic illness is one which results from health care treatment, and iatrogenic depression is typically a side effect of medication. I take a broader view of “treatment” and think of iatrogenic depression as a customer service failure. I see nursing home residents who have become depressed as a result of interactions with staff that left them feeling unimportant, and with nursing home systems that resulted in feelings of powerlessness. The good news is that this type of iatrogenic depression can be cured by training staff and adjusting systems to be accountable to the residents.
Resident/Staff Interactions
Without Accountability
Staff: “I’ll be right back.” (Never returns.)
Resident: feels neglected, invisible, possibly paranoid (why are they doing this to me?), angry, anger turns inward to depression
With Accountability
Staff: “I’ll be back in about ten minutes, after I finish up with someone down the hall.” Returns in about ten minutes.
Resident: knows how much of a wait to expect, which reduces anxiety; feels cared for and respected
Or, Staff: “I’m sorry about yesterday. I meant to come right back to you, but I had an emergency and didn’t remember until I was halfway home. Please accept my apology.”
Resident: will probably take some time to forgive and begin to trust again, but feels better having the situation acknowledged
Nursing Home System
Without Accountability
Resident Council Staff Representative/Leader: “Great suggestion. I’ll bring it up with the administration.” (The last the group hears about it.)
Residents: feel bringing up concerns is pointless, the resident council meaningless, and that their experiences aren’t valued
With Accountability
Resident Council Staff Representative/Leader: “The administration and I discussed the suggestion raised by the group at the last meeting, and we’re going to begin the project by taking this first small action.”
Residents: feel their recommendations and experiences are valued and that they’ll get their needs/wants met by a responsive organization; feel energized as a group
Or, Staff Rep: “The administration and I discussed last month’s suggestion, but there were some obstacles in the way. Let’s work as a group to think of ways in which we might overcome them and move forward with the project.”
Residents: feel respected and included in decision-making even though they might be disappointed their suggestion wasn’t immediately implemented.
Posted by Dr. El - August 19, 2009 - Depression/Mental illness/Substance Abuse, End of life, Role of psychologists
The two most important moments in a person’s life are coming into this world and leaving it. I might not be able to help someone have a good life, but I can help them make the most of their last months or years and to have a good death. That’s well worth my time and energy. More on that in a future post. Here’s a link to an article on the topic that was posted on Yahoo today.
Link to Yahoo story
Study finds end-of-life counseling improves mood
By CARLA K. JOHNSON, AP Medical Writer – Tue Aug 18, 4:00 pm ET
CHICAGO – As a political uproar rages over end-of-life counseling, a new study finds offering such care to dying cancer patients improves their mood and quality of life.
The study of 322 patients in rural New Hampshire and Vermont also suggests the counseling didn’t discourage people from going to the hospital. The research didn’t look at costs.
The study’s publication in Wednesday’s Journal of the American Medical Association coincides with the fight over health care overhaul proposals in Congress.
Some conservatives have called end-of-life counseling included in one version of the bill “death panels” and a step toward euthanasia. A House proposal allows Medicare to pay doctors to chat with patients, if they desire it, about living wills, hospice and appointing a trusted person to make decisions when the patient is incapacitated.
President Barack Obama called the euthanasia charge “simply dishonest.” Health and Human Services Secretary Kathleen Sebelius has said the end-of-life proposal is likely to be dropped from the final bill.
In the new study, trained nurses did the end-of-life counseling, mostly by phone, with patients and family caregivers using a model based on national guidelines.
All the patients in the study had been diagnosed with terminal cancer. Half were assigned to receive usual care. The other half received usual care plus counseling about managing symptoms, communicating with health care providers and finding hospice care.
Patients and their caregivers also could attend monthly 90-minute group meetings with a doctor and a nurse to ask questions and discuss problems in what’s called a “shared medical appointment.”
Patients who got the counseling scored higher on quality of life and mood measures than patients who did not.
On the quality of life scale, patients could score up to 184 points. The groups were about 10 points apart in the last assessment before they died. On the mood scale, patients could score up to 60 points and the groups were about 5 points apart.
The patients who got the counseling also lived longer, by more than five months on average, but that finding didn’t reach a statistical level of significance.
Patients getting such counseling often thank the nurses helping them, said lead author Marie Bakitas, a researcher and nurse practitioner at Dartmouth Hitchcock Medical Center in Lebanon, N.H.
“They seem to feel a whole lot better knowing there’s someone who’s looking at the rest of them and not just the tumor,” Bakitas said.
In both groups, hospital stays were rare: six to seven days on average during the patients’ last year of life. Betty Ferrell of City of Hope Medical Center in Duarte, Calif., who has done similar research but wasn’t involved in the new study, said that’s not surprising.
“It’s patients and families in their own living rooms who are dealing with end-of-life care,” Ferrell said. “They’re not in the hospital. They’re at home.”
Ferrell, who leads a guidelines panel on end-of-life care, praised the study, which was funded by the National Cancer Institute, and said she hoped it would clear up misconceptions.
“This is about helping people live with the diagnosis the doctor has given,” Ferrell said. “This study reflects on what kind of support do people deserve when they’re dying.”
Posted by Dr. El - August 18, 2009 - Depression/Mental illness/Substance Abuse, Resident education/Support groups
Alcoholism is not just a problem of youth. According to an 8/17/09 report in the American Journal of Psychiatry, 14% of men and 3% of women age 65 and older admitted to binge drinking (5 drinks or more on one occasion within the last month). I frequently see residents with lifelong addiction problems in the nursing home, and often their sobriety began with their admission to the facility. Early sobriety, particularly when dictated by outside forces, can be very difficult, leaving residents vulnerable to the underlying depression they were self-medicating with alcohol. Many residents with long-term sobriety but no AA recovery have behavior problems that could be successfully addressed in the meetings, as do mentally ill residents with a dual diagnosis of substance abuse.
Hospitals, churches, and community centers around the country regularly host AA and other 12 Step meetings, but I’ve yet to hear of a nursing home that does. I think they all should, for the following reasons:
- AA meetings establish a positive peer group for potentially difficult residents.
- Residents take responsibility for their own behavior, reducing the need for staff monitoring.
- Residents have an additional source of support from the group and from each other.
- Residents have a way to connect with the outside world, reducing their sense of confinement.
- For residents expected to be discharged, a connection to AA meetings and community members in the nursing home facilitates their transition back to the community.
- Staff members have a resource to which they can direct their residents in need.
- Staff members, some of whom may suffer from alcoholism themselves or in their families, become aware of a source of support, even if they don’t attend meetings in the facility.
- The nursing home increases its visibility and potential referral base in the community.
- There is no charge for AA meetings; in fact, the meetings often pay a small rent for the meeting space.
- AA meetings are easy to establish. Just contact AA, let them know you have a meeting space to offer, and they will do the rest.
