Geriatric Mental Health Awareness Month

Geriatric Psychiatry

Geriatric psychiatry is a specialized field commonly referred to as geropsychiatry, geripsych, geripsychiatry, or psychogeriatrics. Professionals provide care in a variety of settings including private practice, hospitals, assisted living facilities, in-patient care and veteran care centers. [1]
Mental health (including emotional, psychological, and social well-being) is important at all stages of life,
though older adults face certain life changes that can directly impact mental health. The US Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Academy of Medicine have found that “less than 50% of older adults with mental and or substance use disorders receive treatment.” [2]

The American Association for Geriatric Psychiatry (AAGP) reported that [1]…

• 30% of new admissions are among persons with mental illness (NY)
• 50% of all residents have cognitive impairment (NY)
• 65-90% nursing home residents are affected by behavioral health disorders (USA)
• Most common diagnoses of this age group: Depression and dementia (USA)
• Three-fold increased risk of hospitalization in this population (USA)

Geriatric Mental Health Assessment Tools [4]

• Comprehensive Geriatric Assessment (CGA) is a holistic approach to assess the older adult which considers overall health and wellbeing, and formulates a plan to address issues which are of concern to the individual, their family and caregivers. Psychological Assessment of the older adult includes assessment of four sub-domains, with specific screening tools and resources for management. [https://www.cgakit.com/psychological-assessment]:

1. Cognitive Decline
2. Delirium
3. Dementia
4. Depression

• Reminder: Specific conditions (ie. agitation, motor or sleep disturbances) may have their own validated screening tools which are separate from CGA screening. [1,4]
• Overlap between conditions may require use of multiple screening tools.
• No one tool is perfect → Clinical judgment must augment tool guidance!

Active and Healthy Aging

In general…the promotion of Active and Healthy Aging can improve the mental health of older adults,
specifically by creating living conditions and environments that support well-being. Long-term care facilities must design sustainable policies to ensure access to all necessary resources. In conjugation with SAMHSA, CMS is developing a program to assist LTC centers by providing training and technical assistance with the following: [5,6,7]

• Mental health disorder identification, treatment, and support
• Social support for older people and caregivers
• Health and social programs targeted to vulnerable populations
• Programs to prevent or deal with elder abuse

Dementia-Like Symptoms

Some individuals…have dementia-like symptoms without degenerative brain diseases, with others the
progressive brain changes of Alzheimer’s and other dementias are associated with neuropsychiatric symptoms – known collectively as behavioral and psychological symptoms of dementia, or BPSD. [6,8]

• Range of behaviors that may be unsafe, disruptive, or impair the care of the patient
• Emotional, perceptual, and behavioral disturbances (similar to those seen in psychiatric disorders) can be categorized in five domains:

1. Cognitive/perceptual (delusions, hallucinations)
2. Motor (e.g., pacing, wandering, repetitive movements, physical aggression)
3. Verbal (e.g., yelling, calling out, repetitive speech, verbal aggression)
4. Emotional (e.g., euphoria, depression, apathy, anxiety, irritability)
5. Vegetative (disturbances in sleep and appetite) [8]

• Of nursing home residents in the United States… [1]
  • 90% have 1+ disruptive behavior
  • 45% have 4+ disruptive behaviors

Behaviors are often chronic, with different symptoms emerging over time → severity will fluctuate, with psychomotor agitation being the most persistent.
There is no current FDA approved medication treatment for BPSD. Any pharmacological management is considered “off-label,” and should only be used for symptoms that persist after all non-pharmacological steps have been exhausted. [1-3,5-8]

Center for Medicaid Services (CMS) 2022 updated policy statement for psychotropic use echoes the importance of non-pharmacological management!!

Behavior is often a response (appropriate or not) to stimuli, assess the individual and environment for causes that are linked to the presentation of their behavior.

Non-Pharmalogical Management…

Non-drug treatments do not change the underlying biology of a disease or behavior. They are often used to incorporate Active and Healthy Aging goals of maintaining or improving cognitive function, overall quality of life and engagement, and the ability to perform activities of daily living.6 General strategies are described below.
Various literature publications can be found detailing the efficacy of each strategy as first-line therapy for BPSD, as well as place-in-therapy to improve overall mental health. [1,5-8]

Psychoeducation with patient, instruction for staff → effective behavior reduction

• “Individualized special instruction” → consisted of 30 minutes of focused individual attention and participation in an activity appropriate for each individual.
  • During the intervention period, their behavior did not deteriorate, compared with deteriorating behavior before the intervention period.
• “Self-maintenance therapy” → intended to help the patient maintain a sense of personal identity, continuity, and coherence.
  • Incorporates validation, reminiscence, and psychotherapy.
  • admission of patients and caregivers to a specialist unit in which self-maintenance therapy was provided led to a significant decrease in depression and problematic behavior, compared to baseline.
• Instruct staff to implement an emotion-focused care program which consists broadly of validation, reminiscence, and psychotherapy tools.
  • Guidance to manage their interactions with the patient → tools for stress management, education, and coping skills and also leads to improvement in staff/ caregiver well-being. [8]
  • Enhance social activities and self-care of nursing home residents
  • Decrease in agitation after 6 months. [8,9]

Therapeutic activities, Cognitive stimulation therapy → variable efficacy

• Activity and music therapy by protocol → reduction in overall agitation.
  • Social interaction → decreased neuropsychiatric symptoms in one-third of patients who had enforced social interaction with nurses for 3 hours/day for 1–2 months. [8]
  • Exercise → exercise/movement/walking as an intervention for neuropsychiatric symptoms; reduction in aggressive behaviors on days when a walking group was held; no demonstration of long-term efficacy. [8,9]
  • Music therapy [8,9] → Trained protocol, typically involving “warm up” with a well-known song, first listening and then joining in with music.
    • Included playing music from specific eras or particular genres, as part of activity sessions (twice a week, for six weeks in RCT) or at certain times of day, including mealtimes or bath times.
    • Participants also played musical instruments, moved to music, or participated in composition and improvisation sessions.
    • Behavioral change was observed immediately and outside of the music/music therapy session → significantly less agitated in both settings over duration of treatment. [9]
• Sensory intervention → reduction in agitation immediately, insufficient long-term evidence. [8,9]
  • “Expressive physical touch” intervention (5.5 minutes/day of touching, including 2.5 minutes/day of gentle massage and 3 minutes/day of intermittent touching with some talking) over a 10-day period decreased disturbed behavior from baseline immediately and for 5 days after the intervention. [8]
    • Similar results with massage therapy alone (no touch therapy). [9]
  • White noise tapes led to immediate decrease in agitation.
  • RCT with simulated “natural elements” while bathing (sounds of birds, brooks, and small animals were played and large bright pictures were displayed) found that agitation decreased significantly only during bathing.
• Aromatherapy and light therapy → case-by-case benefit only, no statistical efficacy. [8,9]
  • Snoezelen therapy/multisensory stimulation → combines relaxation and exploration of sensory stimuli, such as lights, sounds, and tactile sensations (based on the idea that neuropsychiatric symptoms may result from periods of sensory deprivation).
    • Provide simple tasks (ie. folding laundry).
    • Use ‘busy quilts’ – lap quilt with interesting objects attached (ie. zippers, Velcro, beads, ties, etc.).
    • Weighted blankets at bedtime.
  • Interventions occurred in specially designed rooms and lasted 30–60 minutes → disruptive behavior improved during active treatment, and briefly improved outside the treatment setting but that there was no effect after the treatment regimen had stopped. [9]

Person-centered care, communication skills training for staff → significantly reduced agitation immediately
and for up to 6 months post-staff-training

• Staff Education → communication skills training for nursing and auxiliary staff showed significant reductions in patients’ aggression at three months and in patients’ depression and anxiety at six months. [8,9]
  • Implement an emotion-focused care program versus task-focused.
  • Focused on knowledge of dementia and potential management strategies reduced use of physical restraint use.
  • Result → decreased aggressive behavior toward staff immediately and lasting up to 8-weeks later, on average. [9]
  • Training staff in integrity-promoting care (staff gave more time, made the environment more homelike, encouraged resident activity and to wear their own clothes).
  • Dementia Care Mapping → where resident behavior is observed and assessed over period of time, noting factors improving well-being and potential triggers.
    • Design, train, and adopt implementation strategies accordingly.
    • Severe agitation decreased during and for four months afterwards.
• Environmental Interventions Combined with Staff/Caregiver Education
  • Environmental interventions → such as special care units designed for patients with dementia and staffed by specially trained workers who received ongoing training. [8,9]
    • The Alzheimer’s Association offers both online educational modules and in-person training classes. [6,8]
  • For example → resident whose behavior occurs primarily during personal care.
    • Training caregivers to deliver a protocol called “Bathing without a Battle” [available at: https://bathingwithoutabattle.unc.edu/] reduced agitation, bathing time, and antipsychotic use in randomized multi-site crossover trial. [8]
  • Admission to a “low-density” special care dementia unit, which had fewer residents and larger living areas than standard units.
    • Associated with a decrease in disruptive behavior.
    • Reduction in neuropsychiatric symptoms, especially agitation and depression.
    • Researchers noted a reduction in use of neuroleptic medication.
  • Improved emotional status and quality of life immediately and 12-months later.

If behavioral and psychiatric symptoms have the potential to cause harm to the individual or others, physicians may prescribe medication to help manage psychological symptoms and behavior. pharmacological approaches should be continued regardless of medication. [1,6,8,9]
In addition to their annual meeting, the American Association for Geriatric Psychiatry (AAGP) also has CE and CME courses available on their website [http://www.gmhfonline.org/], some of which are free!

• Late Life Depression → FREE!
• Behavioral and Psychological Symptoms of Dementia → FREE!
• Telepsychiatry and Innovations in Mental Health Care Delivery in Nursing Homes → FREE!
• Plus others, and a yearly review CE/CME which is posted on an annual basis.

The AAGP ‘patient education’ page serves as a further resource for healthcare providers who are new to,
or unfamiliar with geriatric mental health concepts. Some topics included (available in Spanish)…

• Anxiety and Older Adults
• Sleeping Well as We Age
• Aging and Alcohol
• Coping with Depression and the Holidays

Health Hotlines for reference, free and available 24/7 [3]

• Suicide and Crisis Lifeline: Call or text 988 (suicidal or emotional crisis).
• Veterans Crisis Line: Call 1-800-273-8255, press “1” OR text 838255.
  [Open to ALL veterans, regardless of registration or enrollment in VA healthcare]
• Crisis Text Line: Text “HELLO” to 741741 (any type of crisis).
• Disaster Distress Hotline: Call or text 1-800-985-5990 (by SAMHSA).

References:

1. American Association for Geriatric Psychiatry© [Internet]. McLean (VA): Geriatric Mental Health Foundation; c2023. Psychiatrists and Providers; [cited 2023 Mar 22]. Available from: http://www.gmhfonline.org/.
2. Miller, J. How to Improve Access to Mental Health and Substance Use Care for Older Adults [Internet]. Arlington (VA): The National Council on Aging; 2022 May 18 [cited 2023 Mar 23]. Available from: https://www.ncoa.org/article/how-to-improve-access-to-mentalhealth-and-substance-use-care-for-older-adults.
3. National Institute of Mental Health. Mental Health Information: Older Adults and Mental Health [Internet]. U.S. Department of Health and Human Services, National Institutes of Health; 2022 Aug [cited 2023 Mar 22]. Available from: https://www.nimh.nih.gov/health/topics/older-adults-and-mental-health.
4. https://www.cgakit.com/psychological-assessment
5. Fact Sheets: Mental Health of Older Adults [Internet]. World Health Organization; 2017 Dec 12 [cited 2023 Mar 22]. Available from: https://www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults.
6. Alzheimer’s Association Report: 2023 Alzheimer’s Disease Facts and Figures [Internet]. Alzheimer’s and Dementia; 2023 Mar 14 [cited 2023 Mar 22]. DOI: https://doi.org/10.1002/alz.13016.
7. https://www.samhsa.gov/coe-building-capacity-nursing-facilities-care-residents-behavioral-health-conditions
8. Cloak N, Al Khalili Y. Behavioral And Psychological Symptoms In Dementia. [Updated 2022 Jul 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551552/
9. Livingston G, Kelly L, Lewis-Holmes E, et al. Non-pharmacological interventions for agitation in dementia: Systematic review of randomized controlled trials. The British Journal of Psychiatry. 2018 Jan 2;205(6), 436-442. https://doi.org/10.1192/bjp.bp.113.141119.

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