Depression and Anxiety in Geriatric Patients

Art by Misha Venzura, M.D.

On this week’s episode of the podcast, I am joined by Dr. Carolina Osorio, a geriatric psychiatrist (and one of my favorite people). After she finished her psychiatry residency, she also went on to finish a fellowship in geriatric psychiatry to take care of her favorite people. Dr. Osorio runs a special program that treats elderly people with depression and anxiety.

Mental health in the elderly

Sylvia Yu (MS3), David Puder, M.D.

As many people age, their health declines, and their needs increase. At the same time, we can experience loss of spouses because of aging, loss of friends and fear of death. We can lose eyesight, hearing, and subsequently, our drivers licenses and autonomy. It can be an incredibly stressful and lonely time.

At this time in history, like no other time before, we are experiencing a wave of baby boomers that will put a new strain on our already waning mental health facilities. Baby boomers are also more likely to stigmatize using mental health services.

Dr. Osario noticed these problems and she took steps to create a program that is helping her local aging population in a way that makes them feel comfortable.

If you are a primary care physician, psychiatrist, or a family member that is a caretaker for the elderly, this article will have takeaways from Dr. Osorio’s program that can help clarify how we can best help the aging population.  

When Dr. Osorio was a resident, she noticed that in mixed-age groups, older adults didn’t get the treatment that they needed. A general outpatient partial program wasn’t benefiting them, and sometimes it would make them worse because older adults tend to become parents to their younger peers in their group. She noticed that the older adults ended up taking care of their younger counterparts and not getting the individualized help they needed.

She started building a program to help the elderly in the way that they needed to be helped—through diet, exercise, therapy, medication management and stress reduction.

Medically, older adults have comorbidities, or more than one medical issue that needs to be treated. Because of this, having a geriatric therapist, group therapy session, or a geriatric mental health program can keep them happier, healthier and independent for longer.

If you run an outpatient group for the elderly, if you’re suggesting one for your patient, or if you are looking for one for an elderly friend or relative, here are a few things to consider:

Small groups - It takes longer to express their stories, to receive feedback, and to cognitively process information. Because of this, there should be no more than 8 participants in any one session.

Medication support/management/consultation - Often, elderly people are on too many medications, and this could be slowing them down physically, causing mental decline, and speeding up the aging process. We will make suggestions below on how medications can be managed.

Evidence-based therapies - A good outpatient elderly care program will also include evidence-based therapies (Bartels, 2003) to help the patients cope with their depression and anxiety, such as cognitive behavioral therapy (CBT), problem solving (Malhouff, 2007), reminiscence therapy (Elias, 2015), nutrition education, and medication education. Below, we will go into these therapies and why they are helpful.

Medications for aging adultsBenzodiazepines

Unfortunately, many elderly patients are prescribed benzodiazepines—drugs used to treat anxiety. Many primary care doctors have busy schedules with short appointment times. When the patient has hypertension, diabetes and osteoporosis, mental health can take a back seat to managing the more urgent health issues. The primary care doctor will usually just prescribe a benzodiazepine to deal with the anxiety issues.

There are several problems with giving benzodiazepines to the elderly. With time, the body gets used to the benzodiazepine, and the doctor starts to increase the dose. Then, the patient typically becomes even more depressed, more lethargic. This, in turn, increases other health issues.

That is why special consideration should be given when prescribing “benzos” to the elderly. It is also why Dr. Osorio’s goal in her outpatient program is to taper them off of their benzodiazepine medications. She says many of the patients she sees have been on them for 20-30 years.

Tapering a patient off of a benzo should be done very, very slowly in order to avoid delirium or worsening of anxiety.  

For example, if the patient is on 4mg of Xanax a day, Dr. Osario will convert them to Klonopin. Because of the half-life of the medication, the patient will have fewer symptoms of withdrawal when they start coming off of it. Then, she would reduce the dosage to 3mg of Klonopin over the next six months to a year.

Anticholinergic medications

As we age, our brain changes and there are parts of the brain that are going to have synapses that decrease. Acetylcholine actually decreases with age. But, if you add a medication that is anticholinergic, you are putting a bigger burden into that normal process. Then, there can be bad side effects such as confusion and dementia.

Because of that, Dr. Osorio says she will typically taper off or replace any medication with an anticholinergic burden. For example, the antidepressant Paroxetine is a no-go drug in the elderly population because it is very anticholinergic. The tricyclic antidepressants are also very anticholinergic. Nortriptyline, however, is one that Dr. Osorio would prescribe because it has much less of the anticholinergic burden at lower doses.

(I will put a list up on my website in my resource library of the different medications that are anticholinergic. Along with “Beers list,” medications that are contraindicated in older adults.)

Lithium

Physicians don't often think about lithium. Lithium is brain-protective (Forlenza, 2014). It has many functions that are very healthy and it actually produces neurogenesis in some patients. Consider, if you have a patient on an SSRI that isn’t responding how you’d like, adding a tiny dose of lithium (usually about 150-300mg).

Medication management for the elderly

Psychiatrists must work very closely with the patient’s primary care doctors. There are primary care doctors who also have a fellowship in geriatrics, but most do not have the specialized training needed to maximize mental health and minimize side effects. Sometimes it is helpful to have a conversation on behalf of the patient and guide them in certain medications. Every doctor should think about the whole body in general, and working with a primary care doctor can help psychiatrists do that.

A lot of older adults start feeling better when you start decreasing their meds. This indicates they were just depressed and did not have Major Depressive Disorder that required a heavy load of medications to manage it. It also shows that the depression was a side effect of medications. That, really, is the first thing you want to think about when you have a new patient and you see a very large list of medications that they are taking—are the symptoms because of the medication or is the medication helping alleviate symptoms? Should they be taking every single medication on the list?

There are a couple of studies that have talked about serotonin in older, depressed patients and how that can delay the progression of mild cognitive impairment of Alzheimer’s (Smith, 2017). One study showed that SSRIs are the best medications for it—Wellbutrin, SNRIs, tricyclics. There is actually another study done with older adults who had mild cognitive impairment and a history of depression (Bartels, 2018). Those who were taking SSRIs delayed progression of mild cognitive impairment by three years. But, in those patients who were put on another type of antidepressant, the progression was faster.

However, it is important to note that putting an elderly patient on an SSRI does not deal with the root of the issue. Therapy in conjunction with medication has been shown to be more powerful and sometimes eliminate the need for medication. If the patient is lonely, eating poorly, and has no life activities to look forward to, changing those factors can decrease the need for medication. Always consider therapy in addition to any psychiatric medication.

No matter what you prescribe, the patients have to take the medication for it to be helpful. Make sure to write down the medication, dosage, and times in clear language. Help the elderly patient understand what to take and when. When necessary, get helpful family members involved to remind the patient as well.

Therapy for the elderly

Another component of aging healthfully is receiving therapy. The cognitive load of aging alone, including the sum total of traumatic experiences, is often enough to require therapy to help with life transitions.

There are many forms of therapy available that can help the elderly experience a fuller life, deal with trauma safely, manage their depression and anxiety, and even stay mentally sharper for longer.

Problem solving therapy for the elderly

Problem-solving therapy is a way of teaching the elderly how to find ways to solve the particular problems that are unique to them. These problems cause anxiety and depression, so teaching them how to think about them, how to solve problems themselves, can give them a sense of autonomy and control. Sometimes, in therapy, you cannot solve the actual problem, per se, but the process of working through it together gives them different options that they can utilize if their anxiety starts to spike when they are alone.

For example, one elderly lady Dr. Osorio works with struggles with terrible anxiety. She recently broke her arm. She couldn’t clean her home, and her family would come over to help. She felt like a burden to them and was very anxious about this. During problem solving therapy, they  made a list of all of the things that needed to be done around the house, and then they marked the three things she could do, even with her broken arm, to help. She felt better knowing she could help her family while they were helping her. Even though we couldn’t fix the problem, we made it manageable, and gave her some autonomy back.

Reminiscence therapy for the elderly

In reminiscence therapy, you focus on reminiscing about good things. For example, Dr. Osorio will bring her elderly patients a picture of a turkey. She will ask them what it reminds them of. Everyone starts talking about Thanksgiving with their families. They discuss memories, smells, and they walk through the senses of what it was like for them at a happy time. This alone starts to fire up positive emotions in their brains and can change their moods instantly.

The cool thing about reminiscence therapy is that it even works with patients who have dementia, because their long-term memory is pretty solid. They can dip into their past and they immediately start brightening up. Their whole countenance changes.

It is a simple therapy to use, and it can be very helpful when dealing with depressed patients. They often feel alone, but when they begin to talk about the good times and share memories, it connects them to others in their group, and helps them make positive social connections.

Cognitive behavioral therapy for the elderly

There are also behavioral activations we can implement to help the elderly. The elderly patient typically has a hard time with scheduling routines. As their therapist, it can be helpful to get them to schedule a solid routine they can stick with because we have to break the cycle of depression and anxiety. For example, if you're depressed, you want to be in bed, you stay in bed, you get more depressed. This is damaging to an elderly person because it is much harder to get them to start scheduling and moving around again once they slow down. Activating their schedule can be a first step in keeping them independent for longer.

For elderly cognitive behavioral therapy, first, we do education on this process and then start helping them find ways in which they can break that lethargic routine. We want to help them choose an activity that they want to do so that it’s easier to break that cycle. Maybe that is going every Sunday to visit their grandkids. Maybe they can join a card game club, join a church, a quilting group, a storytelling group or take a community educational class. That one simple thing can break their cycle of depression, ease loneliness, and keep them engaged for longer.  

Aging and brain health

The evidence for maintaining brain health while aging says there are several things we can do to stay healthy: physical activity, socialization, nutrition and stress management.

Physical exercise

Dr. Osorio’s favorite exercise to recommend for the elderly is tai chi. Tai chi decreases the risks of falls in older adults (Lomas-Vega, 2017). There are even insurances that are starting to pay for tai chi for older adults because it is cheaper than fixing a broken hip. It’s a very easy, very smooth exercise.

For the wheelchair-bound, she recommends chair exercises. A physical therapist can help the patient move their arms, their torso, their necks. Maybe some of them can lift their legs from the knee up. Even if they can’t, they can still get a good exercise in and get some positive movement going.

When the elderly patient is doing really well in exercise they can start to add weights. Weights are very important because when they use weights their muscles are contracting and they’re positively impacting those bones. This is a good way to decrease osteoporosis. Even with the elderly, muscles can get stronger and their strength can increase. Studies even show that exercise in the elderly pretty much halts the dementia progression.

Socialization

Socialization is also very important. One study showed that the higher risk factor for morbidity and mortality was related to isolation (Holt-Lunstad, 2015). Isolation is actually toxic for our brains. If someone is home alone, they will usually die faster.

Being with friends and family and maintaining a social life helps the brain because it uses visuospatial skills, social skills and cognition. A simple conversation, a regular visit with a loved one or a new person can help an elderly person maintain positive brain health.

Human connection is necessary throughout all of life, and to have close, connected friends makes a huge difference. As part of her program, Dr. Osorio notices if they're having issues making friends, and she helps them create some behavioral activation to get them to places where there is a potential of making friends.

Nutrition

As far as nutrition goes, we have to take into account that the elderly population is pretty diverse. There are 60 year olds who are very fragile because of many health problems and there are 90 year olds who are pretty healthy.

Dr. Osorio personally recommends the Mediterranean diet. The Mediterranean diet is a diet that consists of grains, fish, olive oil, avocado, fruits and vegetables. The Mediterranean diet offers omega-3 fatty acids in the fish, high poly and monounsaturated fats in the olive oil and in the nuts.  There is also a lower amount of sugar then the average American diet. If elderly patients are struggling with making the big change in their diets, it’s best to merely suggest they don’t consume processed foods.

The Mediterranean diet has been associated with a reduced risk of developing mild cognitive impairment (MCI) or progressing to Alzheimer disease from MCI (Scarmeas, 2009). This year it was the number one diet recommended by the medical field.

Stress management

Stress reduction also adds to positive brain health. Mindfulness and visualization are both helpful practices to reduce stress. Stress reduction is not a one-time fix all. It is something that has to be practiced every single day in order to work.

Ask the patient to download a meditation app if they are technologically savvy, or even join a meditation group for seniors to increase their socialization. If neither of those works, getting them to quietly rest and close their eyes for even five minutes with the intention of relaxing, not just to nap or sleep, can have positive benefits.

Conclusion

If you work with the elderly, or know someone who is elderly, if they struggle with mental health issues such as anxiety and depression, or have comorbidity with other health issues, consider suggesting an outpatient group therapy for the elderly. It can be extremely helpful when paired with nutrition, exercise, and a cohesive plan with their primary care physician.

Other episodes I HIGHLY recommend if you are interested in treating elderly people:

Sensorium: Total Brain Function Optimization Part 1

Psychiatric Approach to Delirium with Dr. Timothy Lee

Questions, comments, thoughts? Please comment on the picture that corresponds to this post on my instagram: @Dr.DavidPuder