Mental Health and Aging: An Introduction for Heathcare Professionals

Editor’s Note: This text is a transcript of the course, Mental Health and Aging: An Introduction for Heathcare Professionals, presented by Jennifer Loehr, MA, CCC-SLP and Megan Malone, MA, CCC-SLP.

Learning Outcomes

After this course, participants will be able to:

1. Participants will identify three mental health diagnoses common in the elderly population
2. Participants will identify common symptoms and risk factors of mental health disorders
3. Participants will identify the common symptoms of caregiver burnout
4. Participants will identify resources and action steps in working with patients/caregivers who are suffering from mental health disorder

Introduction

Thanks to SpeechPathology.com for having us. We always appreciate the opportunity to share information with our colleagues. There is a lot of information in this course and we're just touching the surface on mental health and aging. We won't be reading our slides word for word but we will be giving an overview and some additional information that will, hopefully, be helpful for you to move forward in your practice, and Megan and I are certainly really happy to share this information with all of you. 

This is a very important topic for speech-language pathologists, particularly those who work with older adults. We know that mental health issues arise with our elderly patients. But I don't think that we, as a profession, are very good at focusing on them, in that, they are a barrier to our patients reaching their goals quite frequently.

Here are a few facts gathered from a number of different sources that are listed in this course:

• About 20% of adults 55 or older suffer from a mental health diagnosis.
• Mental health issues are the number one reason for suicide among our elderly population.
• Older men have a higher suicide rate than women in the United States.
• Anxiety, like depression, is among the most prevalent mental health problems among older adults.
• Half of older adults who are diagnosed with major depression also suffer from some anxiety.

So we are going to be seeing these issues come about in the majority of the patients that we see in our practice.

Why Is This Information Important for the SLP?

Why is this important? According to the American Speech-Language and Hearing Association, SLPs assist in differentiating between normal aging and disordered communication or swallowing functions. We provide vital services to those individuals who have communication, cognitive or swallowing impairments following illness, trauma, or disease.

The Centers for Disease Control and Prevention piggybacks on that statement from ASHA, and states that “understanding the prevalence of mental distress among adults with disabilities could help healthcare providers, public health professionals, and policy makers target interventions and inform programs and policies to ensure receipt of mental health screening, care, and support services to reduce mental distress among adults with disabilities.” Both of these items are very pertinent to what we do.

What Are Your Elderly Clients Experiencing

As a whole, the main concern I have come across in working with the older population for 35 years is fear of losing independence. There is also the inability to cope with the effects of aging. As much as we are an educated culture, there's nothing that can prepare us for what happens as we get older - mentally, cognitively, and physically. Older adults may be coping with the loss of an ability (e.g., post-stroke depression, hearing loss, mobility issues). There may be a financial impact of aging as well as increased social isolation from friends and family. In this last year, working in home health and hospice, I've seen a real uptick of our elderly folks who have become shut-in and increasingly isolated.  As a result, we have seen a lot more depression and anxiety among these older folks who have had limited ability to deal with the pandemic and the isolation that came about because of that.

Additionally, there is difficulty accessing healthcare, medications, and food as our older patients become sicker and possibly less mobile. As a result, they need to rely on other people for these very necessary items.   Finally, common risk factors for the elderly for mental health disorders include pre-existing conditions and significant life changes, which we see quite frequently.

Cognitive Disorders versus Dementia

Depression can often mirror signs of dementia. The literature suggests that dementia can compromise cognitive reserve and allow symptoms of dementia to be manifested earlier than they would have otherwise.  This could create a false impression that the cognitive impairment is “caused” (rather than unmasked) by the depression. Once the depression is properly treated, the cognitive impairment can effectively be reversed.

It's one of those issues, when you're talking about dementia, if you're able to help identify that there is some depression in those patients that have cognitive impairment and get them to where they can get treatment for that, sometimes we see the fog lift and we see the cognitive impairments start to lift as slightly as well.  I'm not saying it's a complete cure for dementia, but it can be a factor that makes it worse.

And, of course, speech-language pathologists are not diagnosing these individuals with their mental health issues (i.e., their depression or their anxiety). But, we're able to use our clinical judgment, our observation skills, and this information on symptoms and risk factors, so that we can help these individuals get the assistance that they need and perhaps the medication that might help them cognitively as well.

Common Mental Health Disorders in the Elderly

The most common mental health disorders in the elderly, according to the Centers for Disease Control and Prevention (2017), are depression, anxiety, and substance abuse or alcohol addiction. There are a number of different sites and a lot of research collecting data on mental health disorders. But most of the research compliments what the CDC states about these being the top three mental health disorders among our elderly patients.

Depression

Depression is the most common mental health problem among our older population. Nearly a quarter of the 600,000 people who experience stroke in a given year will experience clinical depression. This is an important statistic because it goes back to the fact that mental health issues, mainly depression, are a huge barrier to helping our patients meet their goals.  We need to utilize tools for developing our plan of care that help us identify all of the barriers. For example, the International Classification of Functioning Disability and Health is a tool used to develop care plans that takes into account not only barriers but positive factors that we consider for the plan of care.

But depression is a barrier.  If it was just a matter of treating aphasia or treating a swallowing disorder, without any other factors, our jobs would be much easier.  But they're not easy because of the depression that exists among our patients. It affects their motivation, their ability to focus and attend, and their ability to concentrate and meet their goals.

People aged 85 and older have the highest suicide rate of any age group, which is kind of startling. Additionally, two-thirds of seniors with mental health problems do not get the treatment that they need, which makes our jobs even more important in helping to identify these issues.

Depression Types

There are three different depression types: major depression, persistent depressive disorder, and minor depression.  The most significant difference between these has to do with time. Major depression is identified by the symptoms that most of us are familiar with: trouble sleeping, eating, enjoying life, et cetera. But the time factor is what is taken into account with diagnosing major depression. These are severe episodes that happen frequently. The individual will have several episodes and then they have about a two-month timeframe in between where there is no depression. So major depression happens in episodes with a period of two months or more in between those episodes.

Persistent depressive disorder (dysthymia) is when a person demonstrates the same symptoms as in major depression, however, the timeframe is a lot longer with episodes lasting two years or more.  So, this is a chronic condition that lasts for a long period of time. That's the difference between major depression and persistent depressive disorder.

Minor depression has symptoms that are not as serious as those in major depression or PDD. They are minor symptoms but it's not as simple as “being blue.” Everybody gets "the blues" once in a while. Minor depression includes the same symptoms, they just aren’t as severe and they don’t last quite as long.

Depression Statistics

Depression is more common in people who have other illnesses (such as heart disease or cancer) or whose functioning becomes limited. That definitely pertains to a lot of our patients that we see who are suffering from a major trauma, a chronic illness, stroke, Parkinson's disease, etc. Those individuals are more likely to suffer from depression.

Older adults are often misdiagnosed and undertreated for their depression. There is actually a lot of research about older adults being afraid to bring the topic up to their physicians or healthcare providers. They're concerned with the stigma that's attached to being depressed. I think our older population has more of that stigma idea than the younger populations do, but they're often not treated the way they should be as far as their depression is concerned.  Additionally, studies by the CDC estimate that 7 million American adults over the age of 65 experience depression each year, which is a staggering number.

Anxiety

Based on their clinical features, anxiety disorders can be divided, generally, into three categories. The first category is worry and distress disorders. These are people who have chronic anxiety, post-traumatic stress disorder, acute stress disorder. The second category is fear disorders, which is panic disorder and phobia. In reading the research and the literature, phobias among young adults or children is oftentimes different than older adults. With young adults and children, a phobia is generally a fear of a certain thing, like an animal, a dog, a snake. Whereas in our older population, fear disorders are fear of illness, fear of inability to mobilize or to walk, and the fear of falling is a big one among our older adults. The third category is obsessive compulsive disorder. This is a disorder that we see a lot, but it's not often discussed. I haven’t seen much literature on it in the speech-language pathology world.

These individuals have obsessive compulsive thoughts and behaviors such as hoarding. Hoarding is an obsessive-compulsive disorder. In my work and in the last year or so with the pandemic, I've seen an increase in a number of individuals who are exhibiting hoarding behaviors. That doesn't necessarily mean that they fill a whole house full of trash. It can be on a smaller level like collecting various items to an excessive degree.  I've also seen older adults with obsessive compulsive disorder, obsess with their bank accounts and check their bank accounts three to five times a day, every single day.

There's a tendency to underplay or normalize certain behaviors, which may be indicative of anxiety. For example, avoidance to go out of the house for fear of falls. We look at this when working with our seniors. They have a fear of falling.

This next point is really important. It’s important to assess not only the severity of the symptoms but how does that fear, phobia, or anxiety prevent them from functioning. We, as SLPs and healthcare providers, need to take into consideration:

• Fear and avoidance
• Medical disorders that mimic anxiety symptoms
• That “worried well”- individuals who are quite well physically and cognitively, yet being consumed by worry about what may happen in the future can be debilitating and paralyzing.
• Anxieties associated with dementia
• Co-morbidities like cardiovascular illness, dementia, malignancy, Parkinson's, et cetera.

Those diagnoses can have secondary issues related to anxiety as well. It's common for people with dementia to suffer from anxiety. It can make symptoms of dementia worse, particularly symptoms that affect attention, planning, organizing, and decision-making.

Anxiety vs Dementia

Anxiety seems to be more common in people with dementia who still have good insight and awareness of their condition.  Some of the most challenging folks who have dementia that I've worked with have more of a mild cognitive impairment. However, the anxiety that comes with it seems to make those dementia symptoms even worse. It is a huge barrier to them being able to function despite having a diagnosis of dementia.

Substance/Alcohol Abuse

It’s important to address substance abuse or alcohol abuse. There are a lot of startling statistics with regard to our older population dealing with addiction and alcohol abuse. Of course, we all know as healthcare professionals that alcohol and substance abuse combined with poly-pharmacy, combined with all of their medications, can definitely make their symptoms worse.

A lot of times in dealing with their diagnoses, chronic illnesses, or life changes, older individuals resort to alcohol and drugs to help them. They think those things can help them to cope with the situation and the diagnosis that they have. Opioid addiction is definitely a problem in the United States, and definitely a problem with regard to our seniors. It can also make matters worse as far as dealing with their health and their chronic conditions.

Here are some facts about substance abuse and alcohol abuse among our elderly:

• Nearly 1 million adults aged 65 and older live with a substance use disorder
• Alcohol abuse can cause some older people to be forgetful and confused. These symptoms could be mistaken for signs of Alzheimers disease or other forms of dementia.
• Older adults typically metabolize substances more slowly, and their brains can be more sensitive to drugs.
• Alcohol is the most used drug among older adults, with about 65% of people 65 and older reporting high-risk drinking, defined as exceeding daily guidelines at least weekly in the past year.
• More than a tenth of adults age 65 and older currently binge drink, which is defined as drinking five or more drinks on the same occasion for men, and four or more drinks on the same occasion for women.
• Some older adults may take substances to cope with big life changes such as retirement, grief and loss, declining health, or a change in living situation.
• Between 4-9% of adults age 65 or older use prescription opioid medications for pain relief. From 1995 to 2010, opioids prescribed for older adults during regular office visits increased by a factor of nine.

(National Institute on Drug Abuse, 2020)

Frequent Mental Distress (FMD)

I want to talk briefly about Frequent Mental Distress (FMD). All of those factors that I just talked about, the top three mental health challenges among the elderly (i.e., depression, anxiety and substance/alcohol abuse) can often be precipitated by Frequent Mental Distress.  According to the CDC, if there are 14 or more days in a 30-day period in which an individual suffers from distress or stress those are called mentally unhealthy days (2018). FMD is associated with adverse health behaviors, increased health services, and mental health disorders. Individuals who are going through some crises in their lives, if the majority of days in a month are spent dealing with frequent mental distress, they are more likely to demonstrate symptoms of mental health disorders.

Statistics show that Hispanics have a higher prevalence of FMD compared to non-Hispanics. Additionally, women age 50-64 and 65+ report more frequent mental distress than men in the same age group.

So FDS is something to keep in mind as we're working with our patients. We need to take into account factors outside of the challenges of the illness that they're dealing with. We want to be attuned to other factors that might be creating this FDS such as finances, family situations, socioeconomic status, et cetera.

Symptoms and Risk Factors

I want to discuss the basic symptoms and risk factors that we should be on the lookout for in our patients. This could be either in-person or when doing chart reviews. These are things that might be coming up as issues and we want to have them on our radar so we can deal with them effectively with our patients. 

Depression

According to the National Institute on Aging, depression is not a normal part of aging. It may be difficult to recognize in older adults as the symptoms present differently than in younger people. It’s important to know that there is a difference in how depression might show up depending on age.

With older adults, we see that they report symptoms such as feeling tired, having trouble sleeping, being a little grumpier than normal. They may be showing difficulty with attention or confusion. So, when we talked earlier about depression versus dementia, that's where you might be seeing some of these things.  But if we are on the lookout for it, we might be able to get some resolution to those issues. If we see it early and treat the depression that's active, then we may see that confusion and lack of attention resolve a bit.

It’s also important to consider that other diagnoses may be present in older adults like heart disease, stroke, cancer may have accompanying depressive symptoms, similar to how other medical diagnoses might mimic anxiety.  All of those other underlying factors could have symptoms that are similar to anxiety, so we need to keep that in mind. Additionally, some side effects of medications can contribute to depressive symptoms as well.

In terms of causes and risk factors, genetics or family history plays a role in almost everything. Personal history can also play a part. Older adults who've had depression when they were younger are more at risk for developing it later in life. Brain chemistry can be a factor as well as stress. As previously stated, anything that's going to cause a major life change like the loss of a loved one, a difficult relationship that might be occurring, stressful situations, etc. are factors that we need to keep an eye out for as possible triggers for depression.

According to the National Institute of Mental Health (2021), females are at a greater risk for depression. There is also a greater risk for depression if the person:

• Has  a chronic medical illness
• Has a disability
• Sleep poorly
• Are lonely or isolated
• Has a history of depression
• Uses medications
• Misuses alcohol or drugs
• Has stressful life events

If you know these things might be occurring or if a patient reports any of these risk factors, take them into consideration for how the person might be doing in treatment.  You may need to increase your communication with their physician or their family members in order to keep an eye on how this person is doing.

A few other symptoms include sleeplessness, grumpiness, sadness, or empty mood.  They may show a decreased interest in activities they used to enjoy.  They may exhibit slower movements or seem a bit more lethargic.  There may be some difficulty concentrating or sleeping and possibly eating more or eating less.  So, you can see those changes in weight that may be a sign of depression occurring.

Of course, any thoughts of death or suicide, or suicide attempts are a risk factor. Having a lot of pain, which can be hard to tease out because many older patients might have pain for a number of different reasons.  But if the pain doesn't seem to accompany anything else and seems to be chronic, it might be something to look further into. Finally, frequent crying is a symptom as well.

Anxiety

Excessive anxiety that causes distress or interferes with daily activities is not a part of normal aging.  This is not the typical forgetfulness that we might see from time to time. Forgetting things that impact day-to-day life on a regular basis is not typical age-related forgetfulness. That's a symptom of something bigger going on that needs further investigation. It’s the same thing with anxiety. If everyone's anxious about a lot of different things in this world, that's normal. But if it's really impacting day-to-day functioning, that's when something needs to be done about it. Additionally, anxiety may coincide with depression.

Risk factors can include chronical medical conditions like COPD, cardiovascular disease, diabetes, overall feelings of poor health, or sleep disturbances. Side effects of medications can be risk factors, as well. So, it's important to know what's going on with your patient's medications.

Additional risk factors can include alcohol or prescription medication misuse or abuse. A person may have more limitations in their daily activities physically, so that might cause anxiety. For example, a fear of falling can cause a lot of anxiety and can really limit what people do. Stressful life events, negative or difficult events in childhood, and past experiences can also cause anxiety.

We know that when people have more time to think, they can ruminate on negative past feelings or experiences.  Older adults who might be retired or might have a little more time on their hands than they used to, tend to think about these things a bit more and possibly ruminate on some of those things.  They may also worry about or be preoccupied with helath problems.  All of those things can make them anxious.

Symptoms of general anxiety disorder include:

• Feeling restless, wound-up, or on-edge
• Being easily fatigued
• Having difficulty concentrating; mind going blank
• Being irritable
• Having muscle tension
• Difficulty controlling feelings of worry
• Having sleep problems, such as difficulty falling or staying asleep, restlessness, or unsatisfying sleep

Older adults might also experience panic disorders. This is when a person has recurrent, unexpected panic attacks. A panic attack is a sudden period of intense fear that comes on quickly and reaches its peak within minutes. It can be very terrifying for the patient and for anyone around the patient. So, it’s important to know if someone is at risk for those or typically has them so that you know what to do in the event of those occurring.

Panic attacks can occur unexpectedly or can be brought on by a trigger such as a feared object or situation. People often start to worry about when the next attack is going to happen which may cause them to not want to go out of the house or not want to do certain things because they're afraid something will happen and they don't want to be embarrassed. So, that could cause the person to retreat further, which makes them more isolated and more depressed. You can see how everything is pretty circular and connected.  During a panic attack, a person may experience heart palpitations, sweating, trembling, fear of impending doom, feelings of being out of control, etc.

There are also phobia-related disorders. Again, a phobia is that intense fear or an aversion to a specific thing or situation. We may see people symptomatically show irrational or excessive worry about a particular object or situation. They may take active steps to avoid the feared object or situation  They may have immediate intense anxiety about encountering that object or thing. So, it's really important to keep that in mind.  Knowing if there's a history or if you see a patient who starts to really voice certain fears or resistance to doing certain things, that is a trigger for us to let the person's care team know (i.e., their physician, their loved ones) so it can be addressed.

Substance Abuse and Alcohol Addiction

Substance abuse and alcohol addiction can be very prevalent in the older adult population. The physical risk factors for substance abuse can include chronic pain, physical disabilities, transitions in living or care situations. People might be using this to self-medicate for the things that have really changed in their life.  It can be a coping mechanism, and that can quickly get out of control if it goes unchecked.

Symptoms of substance/alcohol addiction include solitary drinking, drinking in secret, drinking with, before, or after dinner. If there is a lack of interest in old hobbies, slurring of speech, empty liquor, wine, or beer bottles around the house, then you have to start wondering what might be going on.

You may also notice that the person might start looking a little more unkempt, not really caring about their personal appearance, or changes in their skin or hair. Those are all physical symptoms that can indicate that alcohol may be in overuse.

The psychiatric risk factors of substance and/or alcohol addiction include an avoidance coping style, a history of substance abuse or mental illness and feeling isolated. Those factors can really start to snowball in these patients.

Caregiver Burnout

When Megan and I were initially creating this course, we agreed that the focus would be on elderly patients.  However, we also need to pay attention to the caregivers who are also likely to be elderly. Their mental and physical health is important to our patients and could be a potential barrier to patients meeting their goals if their caregiver is suffering from mental health issues as well.

We want to address caregiver burnout and talk about the difference between caregiver burnout and compassion fatigue. It's estimated that 53 million American adults were unpaid caregivers in 2020 (Cleveland Clinic, 2021). About 89% were caregivers for someone related to them and about half of these cared for a parent.

Caregiver burnout is very common. 40 percent of caregivers are emotionally stressed, with almost 20% of them indicating that it has caused financial problems and about 20% felt physically strained. So, we do see this quite frequently with our patients and in their homes with their caregivers taking care of them, Therefore, it should be something that we're concerned about as well.

There are some risk factors associate with caregiver burnout.  Some of these include:

• Living with the person being cared for
• Social isolation
• Having depression
• Financial difficulties
• Higher number of hours spent caregiving
• Lack of coping skills and difficulty solving problems
• Lack of choice being a caregiver

The pandemic really threw us for a loop with walking into homes and seeing the effects of the pandemic and the isolation not only on the patient but the caregiver as well. Having depression, financial difficulties, a higher number of hours spent caregiving, lack of coping skills and difficulty solving problems, lack of choice as the caregiver, etc., all of those factors can also create a number of other issues with the caregiver as well.

As caregiver burnout progresses and depression and anxiety increase, a caregiver may use alcohol or drugs, especially stimulants to try to relieve their own symptoms. This can lead to impairment, which increases the risk of harm to the person receiving the care. Research has shown that caregivers use both prescription drugs and illegal substances more than non-caregivers. It can obviously be a dangerous situation. A caregiver should stop providing care until they're no longer under the influence of drugs or alcohol.

Healthcare providers may be providing services in the home, in an outpatient clinic, or a hospital, and they see the signs and the stress of the caregiver. I frequently spend a lot of time in conversation with caregivers, whether that is a family member or spouse, trying to find out what's going on with the relationship because I know how important that caregiver is to the success of the patient that I'm treating.

There are emotional symptoms for the caregiver as well:

• Feeling overwhelmed or constantly worried
• Feeling tired often
• Getting too much sleep or not enough sleep
• Gaining or losing weight
• Becoming easily irritated or angry
• Losing interest in activities that are normally enjoyed
• Feeling sad
• Having frequent headaches, body aches, bodily pain, or other physical symptoms
• Abusing alcohol or drugs, including prescription medications

The physiological symptoms are the body aches, pain, fatigue, headaches, all of these items that we should be keeping an eye on with our caregivers, as well as the patients, with regard to mental health.

Caregiver Burnout vs Compassion Fatigue

There is a difference between caregiver burnout and compassion fatigue. I used to think that they were the same, but after doing some research I realized that they are two different entities. There is actually a lot more research on compassion fatigue for healthcare providers, including speech-language pathologists. But the difference is that compassion fatigue happens rapidly. It's a rapidly progressing “behavior,” if you will. Whereas caregiver burnout happens over a longer period of time. Burnout occurs over time as the caregiver feels overwhelmed by the stress of caring for the loved one.

Compassion fatigue almost seems to happen overnight.  You wake up one day and you just don’t care anymore. I've even heard this come from caregivers and healthcare providers; all of a sudden, you just don't care. You lose the ability to empathize and have compassion for the person that you're caring for. It is caused by extreme stress, and it comes with empathizing with the suffering and traumatic experiences of that person that you're caring for. It's mainly, as I've mentioned, studied in healthcare workers, but it also happens to caregivers, and we need to be acutely aware of it in order to get caregivers the help that they need.

Some of the signs of the compassion fatigue are:

• Anger
• Anxiety and irrational fears
• Difficulty making decisions
• Exhaustion
• Hopelessness
• Increased use of drugs and alcohol
• Isolation
• Insomnia
• Irritability
• Lack of concentration
• Negativity

in my experience, there's just an overall negativity toward the person that is being cared for and the situation. When having conversations with the caregive, you can see that there is just a complete lack of hope.

Action Items

If we know all of these things, what are our action items?  According to the World Health Organization, the treatment and care strategies that are suggested to address mental health needs of older adults are:

• Improved training for healthcare professionals working with older adults
• A better focus on prevention and management aspects related to chronic illnesses affecting older adults
• Promotion of active and healthy aging
• Creating living conditions and environments that support wellbeing

Not only do we have to understand what the issues are, but then we have to figure out how we're going to act on them. How can we be more active in not only noticing these issues in our patients but what can we do to be more preventative and assistive in helping these patients thrive?

Promoting mental health depends largely on strategies to ensure that older adults have the necessary resources to meet their needs. Another big global push is to provide security and freedom, adequate housing through supportive housing policies, social support, health and social programs, especially for more vulnerable groups such as those who live alone, in rural populations, or who have chronic and relapsing mental or physical illnesses. There is also a push for more programs that prevent and deal with elder abuse as well as programs for community development.

Those are all important when looking at the big picture.  But what can we do as SLPs?  First, taking a course like this one and having a better awareness of the signs, symptoms, and risk factors for mental health issues for all older adult patients helps. The more that we know, the more we can look for, and the better we can provide our patients with support and resources to help them.

We want to establish consistent communication with the patient's caregivers, family, and physician regarding any concerns observed, even the smallest things.  We all know that we should trust our guts. If you're seeing something and you're putting some pieces together, it's better to say something than to not say something because these things can escalate very quickly.

As stated earlier, it's a staggering number of people who are older than 85 who take their own lives. So, we need to really be on the lookout for anything that might be a bit “off” and make sure that it is dealt with. Again, in our practice, we can promote a lot of healthy aging activities, and advocate for good socialization, exercise, healthy eating; and coming to therapy can be part of that. If they're working with us, we can talk about how that's assistive to their wellbeing. Maybe they're able to eat better because of their swallowing treatment or we're working on cognition, and allowing them to think more clearly, and stay safer.  All of those things can really be helpful.

The majority of the time we can say our patients really enjoy working with us. We might get the moans and groans every once in a while when we come to see them. But most of the time, by the end, we've turned them around and they're having a pretty good time.  That actually does a lot for how they feel about life. We might be the only person they see that day, and that's huge.

We want to be noting possible risk factors during our evaluation, including the established diagnoses of mental health disorders or medications. We want to do our homework at the start about anything that might be going on with the patient so that we are aware of possible symptoms that might occur.

We should document any concerns in the treatment notes. We all know that if it's not documented, then it didn't happen.  If you're seeing something, write it down or make the appropriate phone call so that it can be tracked.  Discuss any possible concerns with other care team members. If you're ever in doubt of what you might be seeing and there are other disciplines seeing the patient (e.g., OTs, PTs, nurses), ask if they're seeing similar issues so you can confirm your possible suspicions.

Additionally, it’s better to avoid any real direct discussion of depressive issues with the patient because it may escalate the symptoms. We do want to acknowledge and ask how people are doing, but we don’t want to go too far into it without knowing a bit more, as that might make the person feel more self-conscious or make them feel worse. Err on the side of caution and reach out to other professionals who can assist you with these issues.  If the person is seeing a mental health professional, you might be able to talk to them about ways to best handle the situation.

We should regularly review the patient’s full medication list to screen for any adverse drug interactions. Again, medications can play a big part, so you want to see what those side effects might be and be aware that they might be an issue.

Be aware of increased fall risks, especially those with possible substance abuse issues. We might have to adapt the environment to ensure better safety for those patients. As previously mentioned, some people may have hoarding tendencies. I've had a few patients in my past treatment work and it can be tricky, There is a lot of anxiety related to their items, but also a lot of danger with them falling because of the number of things in their homes.

It’s also really important to screen for mental health issues during evaluation. We can give a screening like the Geriatric Depression Scale (APA, 1986). This is something I do with a lot of my patients to self-report measure of depression in older adults. It was a bigger, 30-item instrument when it was first developed, but that was pretty time-consuming. There is now a short form that has just 15 items and it really focuses on particular symptoms that a person might be experiencing. Here is the link: https://geriatrictoolkit.missouri.edu/cog/GDS_SHORT_FORM.PDF and it is also listed on the references and resources page.

We need to know our patients in order to assist them or the caregiver in preparing for any upcoming life changes. If we know a move is coming, if someone is ill, or if there's a change in their family, we can help them prepare for that and, hopefully, cope with it better.   We can suggest or connect patients with support groups, social work, or healthcare professionals to also help them.

If a patient has suspected mental health issues or has documented the presence of mental health issues, there's no reason why we can't work through some strategies with them as part of their treatment. For example, we can teach them to recall strategies to reduce anxiety, such as the 4-7-8 breathing technique. I do this with a lot of my patients - inhale for four seconds, hold for seven, exhale for eight - and it can be really calming. I had a patient with a lot of anxiety and he would have panic attacks. We worked with him on knowing what symptoms he would have. His palms would always itch when he was getting ready to have an anxiety attack. So, we said, “All right, if your palms start to itch, what do you do?” Then we told him to reach for a card that he kept in his shirt pocket that had some strategies we worked on together. These were various strategies that he could do to calm himself down. He would use breathing, visualization, and removing himself from a situation. (If you're in that heightened state, you're not really thinking clearly.) If he noticed the symptom coming on (it was automatic) we worked on the repetition of him grabbing the card, reading it, and being able to implement it. Again, we, as SLPs, can definitely be involved in using what we know about cognitive treatment and assisting with memory, etc. to provide strategies for these patients.

We can work on strategies to help a patient think more positively, such as finding three news items on TV or in the newspaper each day that are enjoyable or teaching them to use a gratitude journal, or pairing a positive thought with a routine.  For example, after breakfast every morning, think about three things you're thankful for or three good things that you're happy about today. These are just a couple of ways to try and increase more positive thinking.

We can monitor medication management and any issues, and then target that in treatment. If patients aren't taking their medications regularly then that can cause a problem. We can assist them by working on how to better manage their medications and ensure they're taking what they need in order to manage the mental health symptoms they may have.

We can give regular written reminders to patients about their progress to improve their mood and motivation.  We can tell them that we can’t wait to see them again or that they are doing so great in therapy.  We know that reading is something that sticks around for a lot of our patients, even with dementia, so let's use that to our advantage to help people feel a little more loved and a little bit more important. That can make a big difference.

We might set goals related to the patient or caregiver’s ability to identify signs and symptoms of mental health symptoms. Similar to working on a goal related to a caregiver showing that they can thicken liquids the proper consistency, we can set goals to have the caregiver be on the lookout for certain signs and symptoms of mental health issues. We could do this with the patient as well: “Are you feeling this way?” or “What do you do if you feel this way?”

Finally, we can be the advocate and support our patients need. We need to remind them how important they are to us and to others. That can be incredibly helpful to them.  Like I said earlier, we may be the only people they see during the day, so we can make a big difference in how they're feeling and noticing if there are any issues going on. 

To summarize, some additional action items and resources are:

• Talking with Your Adult Patients about Alcohol, Drug, and/or Mental Health Problems (Substance Abuse and Mental Health Services Administration)
  • https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4584.pdf
• Linking Older Adults With Medication, Alcohol, and Mental Health Resources (Substance Abuse and Mental Health Services Administration)
  • https://store.samhsa.gov/sites/default/files/d7/priv/sma03-3824_2.pdf
• Generalized Anxiety When Worry Gets Out of Control (NIMH)
  • https://www.nimh.nih.gov/health/publications/generalized-anxiety-disorder-gad/19-mh-8090-generalizedanxietydisorder_124169.pdf

These are good resources. The first one is talking to your adult patients about alcohol, drug and mental health problems. How do you have those conversations? How do you link older adults with medication, alcohol and mental health resources? Finally, the third resource provides some more information about generalized anxiety. These websites have a lot more available, so we definitely encourage you to check those out.

Questions and Answers

What do you believe are some of the reasons why depression is so undertreated in the elderly population?

I really do feel like people are unwilling to disclose that they're having mental challenges, and so that is one big reason. We see it being undertreated in the elderly population because they're not disclosing all the things that they're feeling, and that is, primarily due to the stigma that could be attached to admitting what they might view as a weakness. Thankfully, society is getting much more inclusive about mental health, and I think our younger generations are much more open to those discussions and to talking about their feelings and changes in their feelings. But a lot of our older population is still pretty resistant to those discussions so they may not disclose it, which of course is not going to lead to them getting the treatment that they need. So, I think that's probably our biggest reason why we're seeing some undertreatment, and hopefully that will change as time goes on.

What medical disorders can mimic anxiety?

A pneumonic that can be really helpful for this that a lot of physicians use is called THINCMED, T-H-I N-C-M-E-D.  It's just a way for doctors to kind of work through different systems to determine if there are issues that might be underlying the anxiety a person might be disclosing. The T stands for tumors, the H stands for hormonal changes like with thyroid, infectious disease would be the I, in this acronym (so things like Lyme disease might be a cause for something mimicking anxiety). The N stands for nutrition, so vitamin and deficiencies, things like that. C stands for central nervous system. So, a  head trauma might be impacting or mimicking anxiety. Finally, the M is miscellaneous. Any chronic disease that may kind of illicit anxiety is a possibility. The E in MED is electrolyte abnormalities or environmental toxins, and then the D would be drugs; looking at medications and seeing if those meds or supplements are causing changes in the person's mental status or their feelings of anxiety.

Does it seem like compassion fatigue is more prevalent with treating patients during COVID-19?

I haven't.  In the literature, I've seen compassion fatigue during the pandemic with regard to health care providers, but I have not seen a lot with regard to caregivers of an elderly person. I would think that we would see it because of the increased isolation, and that is not a fact. But, the caregivers don't have an outlet or couldn't leave their home. I have family members that are suffering because of the same issue during the pandemic right now. They are locked in their house and have no outlets, aren’t able to socialize with their friends in person.  It really took a toll on my family. But the majority of literature that I see is really about the compassion fatigue with healthcare workers, because of the hours and hours that our healthcare providers, our home health individuals, our nurses and physicians working in hospitals, and speech-language pathologists had to take on during the pandemic.

Do you have any comments about social prescribing? For example, you ask the older adult, “What matters to you?” Then you try to align their response with adults in the community who tap into their interest?

I think that's an awesome point and a great idea. What matters to each of us can be very different. We're individuals and just because somebody is older doesn't mean they all like the same things. So, it's important t ask those questions and be able to see what things or people are out there that we can put you in touch with? That’s a great idea.

Do you know which medications are related to mental health issues?

There are so many so my suggestion is to do some research. But some common are Prozac, Celexa, Paxil, Wellbutrin, and Zoloft. Those might be on a patient’s med list if they're dealing with some different mental health issues. It might be good to have a cheat sheet of the most common ones, so you can use that when you're doing your med reviews.

My facility wants me to carry around the depression scale and let social services know that the patient is depressed. Is this in the SLP scope?

Yes, it is. We want to be preventative and anything that we might be able to see in a patient is within our scope. As Jenny stated earlier, we are not diagnosing and we are not treating the mental illness, but we can be aware of it. That’s what all of those screenings do. They let you know that there might be an issue, which can spark a referral. So, if you're seeing depression as something that's popping up, then you can give it to the next person in the chain who is within their scope to look at evaluation and treatment of mental health disorders. But yes, it's absolutely within our scope to screen for those things because we're looking at the patient's overall health and wellbeing.

We're utilizing a standardized tool and ASHA says it's within our scope to perform these functions. You’re merely identifying it and then you’re passing it on to somebody who has the clinical skills to take care of the situation.

References

American Psychological Association (1986). The use of Rating Depression Series in the Elderly, in Poon (ed.): Clinical Memory Assessment of Older Adults.

Centers for Disease, Control, and Prevention (2018). Frequent Mental Distress Among Adults by Disability Status, Disability Type, and Characteristics. Accessed at https://www.cdc.gov/mmwr/volumes/69/wr/mm6936a2.htm

Crabb, R., & Hunsley, J. (2006). Utilization of mental health care services among older adults with depression. Journal of clinical psychology, 62(3), 299-312.

Cleveland Clinic: Caregiver Burnout; Causes, Symptoms and Resources. Accessed at https://my.clevelandclinic.org/health/diseases/9225-caregiver-burnout on 6/21/2021.

Indian Journal of Psychiatry (2021) Clinical Practice Guidelines for Geriatric Anxiety Disorders. Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5840911/

Mental Health America (2021). Anxiety in older adults. Accessed at https://www.mhanational.org/anxiety-older-adults

Kok, R. M., & Reynolds, C. F. (2017). Management of depression in older adults: a review. Jama, 317(20), 2114-2122.

Kunkle, R., Chaperon, C., & Hanna, K. M. (2020). Formal caregiver burden in nursing homes: A concept analysis. Journal of gerontological nursing, 46(9), 19-24.

National Institute on Aging (2017). Depression and older adults. Accessed at https://www.nia.nih.gov/health/depression-and-older-adults

National Institute on Drug Abuse (2020). Substance Use in Older Adults Drug Facts. Accessed at https://www.drugabuse.gov/publications/substance-use-in-older-adults-drugfacts

McGilton, K. S., Vellani, S., Yeung, L., Chishtie, J., Commisso, E., Ploeg, J., & Puts, M. (2018). Identifying and understanding the health and social care needs of older adults with multiple chronic conditions and their caregivers: a scoping review. BMC geriatrics, 18(1), 1-33.

National Institute on Drug Abuse (2021). Substance Abuse in Older Adults Drug Facts. Accessed at https://www.drugabuse.gov/publications/substance-use-in-older-adults-drugfacts/

National Institute of Mental Health (2021). Older adults and depression. Accessed at https://www.nimh.nih.gov/health/publications/older-adults-and-depression/

National Institute of Mental Health (2018). Anxiety disorders. Accessed at https://www.nimh.nih.gov/health/topics/anxiety-disorders/  

Rehab Spot (2021). Senior alcoholism. Accessed at https://www.rehabspot.com/alcohol/who-alcoholism-affects/seniors/

World Health Organization (2017). Mental health of older adults. Accessed at https://www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults

Wasilewski, M. B., Stinson, J. N., & Cameron, J. I. (2017). Web-based health interventions for family caregivers of elderly individuals: a scoping review. International Journal of Medical Informatics, 103, 109-138.