Geriatric Psychiatry

Doctors, Dementia, and Driving: Impaired Operators Behind the Wheel (and Behind the Stethoscope?)

Saturday, January 27th, 2018

My colleague, a seasoned primary care physician, admitted that he hadn’t seen it coming. Worse yet, despite his years of experience, he felt ambushed and hadn’t known what to do.

An eighty-four year-old retired librarian we’ll call Millie, though that wasn’t her name, came in for a six-month checkup. She had been my colleague’s patient for many years, and they had enjoyed a warm doctor-patient relationship. Other than mild dementia, Millie had been fairly healthy. Just fifteen minutes had been scheduled for her appointment, and my colleague expected a straightforward, routine visit. So he entered the examination room unprepared to find himself in the middle of a minefield.

The first inkling of a problem was that Millie’s daughters sat with her in the examination room, awaiting my colleague. Millie had always come alone, and there had been no occasion to meet any of her children before. Initially they sat quietly, appearing on edge. But not two minutes into the visit, the older daughter interrupted my colleague, blurting that THEY had decided that their mother was no longer a safe driver. They wanted her to surrender her car keys but she was being “unreasonable” and had refused. So they expected my colleague to “talk sense into her” and to “order her to stop” driving.

Before my colleague could react to this startling demand, Millie, who had always been mild-mannered, erupted in snarling outrage. Scolding my colleague, she reminded him that she’d started driving long before he was born and had a perfect record; not even a parking ticket. Hissing a rebuke, she declaring that she’d always suspected him to be a “treacherous quack” who couldn’t be trusted. And she threatened to find a new doctor and sue him.

Reading this account, were you as stunned as my colleague? Did you find the behavior of Millie and her daughter surprising? If so, then you might be additionally surprised to learn that situations like this are not rare. I’ve found myself in similar encounters more times than I care to remember.

Each year the number of older drivers increases. Until age sixty-four, people become safer drivers as they age. But after that, declining health, both physical and mental, begins taking its toll on many abilities, driving included. Some elders remain safe drivers into their late nineties. On average, though, older adults outlive their driving ability by seven years.

Many older drivers recognize when this happens and gracefully “retire” from driving. Others need to be convinced of the necessity. Physicians’ opinions often are sought as part of this process. Whether because of, or in spite of their doctors’ input, most initially reluctant older adults eventually quit driving “voluntarily”.

And then there are those, like Millie, who present a greater challenge. Unable to face facts (in Millie’s case, symptoms of dementia and a combination of psychological and family factors conspired against her), they steadfastly deny that there’s anything wrong with their driving. They refuse to quit, often becoming angry, unreasonable, hostile, or paranoid. Not knowing how to handle this, or where to turn for help, family members can become overwhelmed. Some seek guidance from geriatric psychiatrists.

Driving cessation can be an emotional crisis for older adults; many do not cope well with it. Some, like Millie, behave maladaptively, severely challenging healthcare professionals and family members alike. I’ve worked with many such patients. Their family members all say that the struggle to curtail their older relative’s driving is the most stressful challenge they’ve ever faced. Invariably they experience one or more symptoms of anxiety, dread, anger, resentment, depression, or insomnia. They’re afraid to let their relative drive, but they’re also afraid to take away his or her keys. These are thorny problems, and usually there is no solution anyone is happy about, doctors included.

From time to time my colleague sought “curbside” consultations from me, so later that day he called me for help with Millie. He was shaken up. No novice at handling emotionally charged, contentious, patient encounters, this one had flummoxed him. Discovering what he hadn’t known rattled him: he hadn’t known how to assess Millie’s driving ability; he hadn’t known what responsibility he had to report Millie to the motor vehicle department; he hadn’t known how to respond to the daughters’ demand that he “order” Millie to stop driving. Somehow, despite his years of experience, he’d not confronted a situation like this before. But physicians increasingly are facing such challenges, and most are no better prepared than was my colleague.

Studies show that physicians generally feel untrained and unqualified to assess mildly demented patients’ driving ability. You’d think this wouldn’t be the case given the aging of the population and the increasing numbers of older adults with mild dementia who still drive. But it is.

The vast majority of physicians has had no training in assessing driving risk and don’t know how to do it. They worry about their patients’ driving safety, but they also worry about the detrimental consequences of driving cessation: loss of independence, declining wellbeing, deteriorating health, and depression. And taking away the car keys can irreparably damage both family and doctor-patient relationships, making it that much harder to provide older adults the help and support they need.

Doctors have no clear guidelines for weighing these competing harms. Society has set no standards for how much driving risk is acceptable. We let teenagers drive, and they are very risky drivers, as a group. Older drivers, on the whole, are not worse drivers than teenagers, those with dementia being a possible exception. To make things even more impossible for doctors, studies show that the tests doctors can perform in the office (other than vision tests) do not reliably predict driving safety; a behind-the-wheel, roadside test, conducted by a driving professional, is the gold standard. Lacking “rules of the road” to follow, doctors often do not know the right course of action to take. Believe me, it’s a lot harder than it seems.

In my experience, family members desperately want to prevent their older relatives, whom they feel no longer drive safely, from getting behind the wheel. But they want to accomplish this with as little emotional trauma as possible. They don’t know what to do, don’t want to do the wrong thing, and don’t know where to find the help they need. All too often they feel left in the lurch by healthcare professionals. Geriatric psychiatrists often can help, and that’s why my colleague called me. He wanted to pick my brain, but he also wanted to refer Millie and her family, to me.

Unfortunately, few families have access to geriatric psychiatrists (that’s another, even more complicated story, for another day). So, what can you do if you are worried about an older driver? If you’re a family member (or other caregiver), start by seeing your relative’s doctor. He or she may be able to offer some helpful advice or guidance. But be realistic. Understand that you may be dealing with a complicated situation beyond the doctor’s expertise.

If you find yourself in this predicament, an excellent resource you can download and read to help you understand better what to do is A Clinician’s Guide to Assessing and Counseling Older Drivers, published jointly by the National Highway Transportation Safety Administration and the American Geriatrics Society. And if you are a physician, other type of healthcare professional or elder services worker, concerned about the driving of one or more of your older patients or clients, this is an excellent resource for you too.

Two weeks later Millie and her daughters came to my office for an appointment. Despite having no idea about why she had come to see me, Millie was her usual, pleasant, mild mannered self. She had no recollection of her recent encounter with my colleague, and had nothing but glowing praise for him.

In contrast, her daughter, yes, that one, the one who demanded action of my colleague, entered my office spitting nails and breathing fire. Not granting me even the two-minute courtesy she gave my colleague, she demanding to know whether I intended to order her mother to stop driving, or was I going to be as “lame” as the other doctors (She also wasn’t too pleased with a neurologist they’d consulted). Yikes!

Want to find out how I handled this situation? Watch for an upcoming post in which I’ll describe what happened, and I’ll discuss what geriatric psychiatrists can do to help older drivers and their worried family members.

ELDERLY PATIENTS DYING OF DEPRESSION IN HOSPICE: PSYCHIATRIC PHYSICIAN ASSISTED SUICIDE?

Thursday, May 19th, 2016

In a study recently published online ahead of print in the Journal of the American Medical Association investigators described the application of physician assisted suicide (PAS) for psychiatric reasons in the Netherlands. That’s right – psychiatric reasons! Apparently the Dutch allow PAS for intractable mental and emotional suffering due to mental disorders.

In the United States, PAS remains highly controversial. The morally acceptable place of PAS has been, at least so far, generally limited to the compassionate relief of intractable, unbearable pain associated with terminal or incurable illness.

To the extent that PAS has been viewed to be a reasonable option for psychiatric reasons this has been in connection with longstanding, severe, treatment-resistant depression. In fact, this was the case in 41 percent of the 66 cases reviewed in the JAMA study. The remaining 25 patients received PAS for anxiety, PTSD, schizophrenia, prolonged grief, and substance abuse. Two persons had PAS for “incipient dementia”! Assuming they had good reason to believe that progression to full-blown dementia was inevitable, this means they chose to die rather than live with dementia.

In have reservations about PAS, in general, and I find the idea of applying it for suffering related to psychiatric disorders quite problematic. I was most disturbed to learn that many of the Dutch patients received PAS from a mobile, end-of-life clinic. Really? I’m fairly progressive about palliative care (although I remain skeptical about the adequacy of safeguards), but wow: The Dutch have a “deathmobile”.

In an accompanying editorial to the JAMA study, Paul Appelbaum, M.D., raised concerns about PAS for psychiatric disorders. Most obvious among these is that undue hopelessness, nihilism about life and treatment, and the desire to die all can be intrinsic features of depression. Patients who receive effective treatment, and respond, often give up their wish to die and feel glad to go on living. Appelbaum presciently asks, “Will psychiatrists conclude from the legalization of assisted death that it is acceptable to give up on treating some patients? If so, how far will that belief spread?” Let me tell you. It already has spread to hospice care for the frail elderly.

CASE ONE   An eighty-four-year-old man with lifelong recurrent depression had been chronically depressed for three years despite several, reasonable attempts by his primary care physician.   During this period, he also developed Parkinsonism and dementia, both of which remained mild. Throughout the course of his depressive illness he regularly talked about feeling useless and wishing to die. He became increasingly withdrawn and inactive, and this brought on deconditioning, frailty, weight loss and cachexia.

The patient’s family’s concern grew to alarm and panic, and they arranged for an evaluation by a geriatric psychiatrist. The patient had failed to respond to several antidepressants, and had been unable to tolerate several others. Family members were hoping for a “magic pill”. Unfortunately, there was no magic for this poor soul, but the geriatric psychiatrist thought trials of tricyclic antidepressants, Monoamine oxidase inhibitors or electroconvulsive therapy were reasonable, and offered some hope to reverse the patient’s inexorable decline. But the patient refused all further treatment, and his family was unwilling to impose any of the options against his will. Deciding that he was now in the end stage of dementia, they arranged for transfer to a nursing facility, where he also did not want to go, and hospice care was initiated. Two months later he died.

Hospice services are increasingly delivered to patients with end-stage dementia. In my mind, the practice is fraught with problems. But more about that in a subsequent post. This patient did have dementia, but it was mild. He was not dying of dementia; he was dying of depression. He’d become “end stage” because depression had been allowed to go untreated. This would not have been allowed to happen to a younger patient.

CASE TWO – An eighty-eight-year-old woman had recurrent major depressive disorder since menopause. The most recent episode had been especially severe and difficult to treat, and she had required psychiatric hospitalization. Eventually she responded to treatment, but her recovery was complicated by acute cholecystitis, C. Difficile infection, congestive heart failure, and respiratory insufficiency. She went from the psychiatric inpatient unit to the intensive care unit, and, from there, a rehabilitation program in a nursing facility.

Once in rehab, she remained medically stable, and was expected to recover fully. However, the stress of the ordeal triggered a relapse of depression. She became hopeless, pessimistic, and negative. She insisted, “Enough is enough”, and expressed a wish to be allowed to die. And she didn’t wait to hear what her doctors had to say: she stopped eating, and refused to take any medications.

A consulting psychiatrist evaluated her and confirmed that she, in fact, once again, was severely depressed. Moreover, the psychiatrist confirmed that this was the basis for the patient’s refusal to eat or take medications. After discussion with her rehab team, two courses were recommended to the patient’s family. The first was placement of a feeding tube, which would allow the patient to be nourished and given medications, including antidepressants. The second was ECT. Both options involved treating the patient against her will. The family wanted to consider ECT. But they ruled out a feeding tube because the patient had specified that she did not want this in her advance directives.

To their credit, the patient’s family wanted to abide by her wishes, as she had spelled them out. Unfortunately, they wrongly applied her express intentions out of the context meant by the patient. Her advance directive stated that she did not wish to be kept alive by artificial feeding or be put on a breathing machine in the event she suffered from a life-threatening, catastrophic illness from which there was no hope of recovery.

While the best course of action was being considered, the patient became dehydrated and developed pneumonia with delirium. She was transferred back to the hospital and admitted to the ICU. This time she had a different hospitalist (hospital doctor) who did not know her or her family. This doctor saw a confused patient of advanced age who was critically sick and who had well-spelled-out advance directives. Many patients fitting this description have dementia, and it has become acceptable, and common practice to withhold very invasive, aggressive ICU care (imagine a bed-ridden person with tubes in every opening and hooked up to numerous machines including a mechanical ventilator) in favor of providing only comfort measures and allowing a “natural death” to occur. Often this is the best thing to do. But the hospitalist did not know the patient before she had become critically ill, and did not realize how vitally alive she had been prior to the depressive episode which triggered her current decline. In the urgency of the ICU, he counseled against aggressive, life-sustaining treatment and recommended transfer to a hospice for end-of-life care. The family agreed. Two weeks later she died.

What do these two cases show us? In American medicine, some very old patients who are critically ill are allowed to forego treatment that might prolong their lives when further care seems futile. For those with severe dementia, terminal illness, or persistent delirium, when further treatment is futile, this can be humane and compassionate. But at the same time, maybe the practice has become so routine and commonplace that we have become inured to it. It takes training, experience, and expertise to assess the mental state, intentions, and decision-making ability of critically sick elderly patients who wish to die. The sad reality is that few clinicians in our healthcare system have geriatric expertise, and it’s become too easy for those without it to allow patients who are depressed, and refusing treatment, to die.

Scott Y.H. Kim, Raymond G. DeVries, John R. Peteet, “Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014”, JAMA Psychiatry 2016; 73(4): 362-368.
Paul S. Appelbaum, “Physician-Assisted Death for Patients With Mental Disorders – Reasons for Concern”, JAMA Psychiatry 2016; 73(4): 325-326.

 

Do Anticholinergic Medications Cause Alzheimer’s Disease

Monday, May 2nd, 2016

DO ANTICHOLINERGIC MEDICATIONS CAUSE ALZHEIMER’S DISEASE?

 

It is beyond doubt that anticholinergic medications cause cognitive impairment. Much evidence also has accumulated that these medications are associated with Alzheimer’s disease, but there has been no proof of a cause-and-effect connection. You can read the educational article elsewhere on this website to learn more about anticholinergic medications.

A new study now shows that taking anticholinergic medications increases the chance that healthy, older adults will develop mild cognitive impairment (MCI) or Alzheimer’s disease. MCI is a milder condition that often represents an early stage of Alzheimer’s disease. Researchers found that higher exposure to anticholinergic medication was associated with worse subsequent cognitive function.

The most damning finding of this study was that use of anticholinergic medications also was associated with brain structural changes on MRI scans and functional changes on PET scans. These changes are the type seen in Alzheimer’s disease, an apparent smoking gun proving anticholinergic medications are one risk factor for Alzheimer’s disease. This study provides the most compelling evidence yet that adults in mid or later life should avoid anticholinergic medications if at all possible.

 

Shannon L. Risacher, Brenna C. McDonald, Eileen F. Tallman, et al, “Association Between Anticholinergic Medication Use and Cognition, Brain Metabolism, and Brain Atrophy in Cognitively Normal Older Adults”, JAMA Neurology. doi:10.1001/jamaneurol.2016.0580, Published online April 18, 2016. Accessed April 21, 2016.

The Downside of Depression Screening

Saturday, February 13th, 2016

Recently the US Preventive Services Task Force recommended that routine screening for depression be done for adults including the elderly. Much ado has been made of this change of position, and it is a step in the right direction. There is a desperate need for older adults with depression to be identified and treated effectively.

Unfortunately, as Reynolds and Frank pointed out in a thoughtful editorial published online in the January issue to JAMA Psychiatry, more widespread screening for geriatric depression would fall short of effectively addressing this major public mental health problem. The USPSTF recommended that screening be done with adequate services in place to treat cases of late-life depression when they are found. All well and good, but, with very few exceptions, services are not in place.

Screening is not diagnosis, as the USPSTF emphasizes. A positive screen for any condition, including depression, should lead to a proper diagnostic assessment before any treatment is started. Sadly, this rarely happens in the real world.

Primary care physicians provide the vast majority of treatment of late-life depression. Some do a good job. Most often, however, they have no more than seconds to minutes to address depression, and this brief window allows only for knee-jerk prescribing of antidepressant medications. This prescription pad reflex may be in reaction to no more than patient or family members reports of what they perceive to be symptoms of depression. I’ve seen this so often that I’m no longer surprised by it, but it still gets me angry. Geriatricians are a little better. They are more likely to use screening tools such as the PHQ-9 or the Geriatric Depression Scale. Admittedly, this is light years beyond “Mom’s depressed” as a standard of care for screening. But it’s still just a screen.   My experience with many geriatricians and geriatric nurse practitioners is that they initiate treatment, usually antidepressant medication, based on an above-the-cutoff score on the GDS without any further evaluation. Typically, the GDS score is the only rationale for treatment documented in the chart.

You might say that this is better than nothing, and instruments such as the PHQ-9 and the GDS accurately pick up many cases of depression. True, But as Thase points out in an equally thoughtful editorial published in JAMA in January 2016, about half the time a positive screen results from symptoms due to other conditions than depression.

How can this happen? As I explain in my book, Beat Depression to Stay Healthier and Live Longer: A Guide to Older Adults and Their Families, there are many conditions that masquerade as depression among elderly patients. Treating these conditions with antidepressants can cause substantial harm. Antidepressants can make some of these conditions worse. Treating the wrong diagnosis means the true problem goes untreated, and may get worse. And, finally, fragile, older patients may be unnecessarily exposed to the risks of antidepressant medications.   Get a copy of my book to learn more about this. You can order it online and buy it in your local bookstore next week. It’s due out February 17, 2016.

I think you’ll find my book informative and helpful, and it helps readers to understand these diagnostic issues and how to navigate the healthcare system to find and receive the services they need.  But, ultimately, we need an adequate workforce of properly trained geriatric mental health specialists who are adequately reimbursed to provide the comprehensive services needed by geriatric patients.  Not to beat a dead horse, but there it is.  Without the input of skilled geriatric psychiatry specialists, the our healthcare systems’  attempts to help older adults with depression too often produce garbage-in, garbage-out results.

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PILL-COUNT LIMITATIONS: Backdoor Rationing?

Tuesday, July 28th, 2015

My patient needed 3-4 mg of aripiprazole per day for her bipolar disorder. She had lived with bipolar since her mid twenties, and now was in her late seventies. Most of the time she did very well on 3 mg per day. But during periods of stress, she needed 4 mg. She was going through one of those times, when she asked me to prescribe 4 mg.

The last time she needed such a dose increase it was simple. Not this time. In the interim, she had switched Medicare prescription drug plans, as many beneficiaries do each year. The new insurance company covered 3 mg but not 4 mg. “Why not?” you ask. Aripiprazole comes in 2 mg and 5 mg tablets, but not 3 mg or 4 mg tablets. To take 3 mg or 4 mg, you have to take one and a half or two of the 2 mg pills, respectively. Her new insurance company had, as many do nowadays, a pill count limitation. Some insurance companies call this a supply limit. My patient’s insurance company allowed 45 pills per month, the number needed for 3 mg per day, but not the 60 pills per month she now needed.

I could have gotten around this restriction by raising the dose to 5 mg per day. That would require only 30 pills each month, and her insurance company would have been happy to cover that. But we knew from past experience that she could not tolerate 5 mg; it gave her intolerable side effects. So this option was out of the question.

Geriatric psychiatrists and their elderly patients face such roadblocks frequently. Older adults are more sensitive to the adverse effects of medication. They also respond well to lower doses than typically given to younger patients. So geriatric psychiatrists take great pains to find the lowest dose that works. This amount may be a half or a quarter of the smallest pill on the market. Or, as was the case for my patient, it might require two smaller pills instead of one larger pill, triggering pill-count limitations.

In geriatric psychiatry practice you quickly realize that insurance companies write their coverage policies without considering the special needs of elderly patients. They are either ignorant or indifferent – I’ll leave it to you to decide. I ran into pill-count limitations at least several times each week. It represented a “hidden”, uncompensated cost of practice, which unduly burdened me financially. I don’t think my practice was unique in feeling this impact.

It’s also apparent that pill-count, or supply, limitations, represents a form of backdoor healthcare rationing. There, now I’ve done it! I’ve used the R-word, “rationing”.

Rationing of healthcare is a proverbial “third rail” of healthcare politics. Politicians, policy makers, and insurance executives, including Medicare administrators, don’t dare mention it. They adamantly deny it goes on and insist it never will. But Pill count limitations are one form of rationing. Insurance companies have others.

Of course, the insurance companies deny that pill supply limitations ration patients’ pharmacy benefits. They point out that patients who need pill supplies outside the policy limitations can get them. All it takes is for their doctor to call a 1-800 number to initiate an appeal and explain why the prescribed amount is medically necessary.

Sounds easy? Guess again. The 1-800 number appeal process is a time-consuming gauntlet for even the most patient clinicians. Here’s what happens. When you call the insurance company, the first thing they do is put you on hold for 10 minutes. Eventually you get to speak to someone who takes a lot of information about you and the patient. This person, for unexplained reasons, must then transfer you to another bureaucrat who will process your appeal further. But in the process you are again put on hold for 10 minutes. Sometimes it’s 20 minutes. The second person you speak to asks you for the same information you already provided, and then asks a few additional questions. Guess what happens next? You got it! You are transferred to yet a third person, and once again you are put on hold for 10 minutes. Assuming that you are not disconnected, finally you speak to a third bureaucrat. Lo and behold, without further questions or fanfare, this person informs you that your appeal has been granted. My experience was that insurance companies granted our appeals nearly 100% of time. That’s nice, but it takes between 30 and 45 minutes of time that doctors and other healthcare professionals cannot spare these days. Want to know why doctors have so little time to spend with their patients? This is one reason.

In my practice, we dealt with 4-6 pill-count limitation appeals per week. I suspect most practices face the same challenge. For many years I was able to pay a nurse to handle these appeals for me. Most geriatric psychiatrists cannot afford this luxury. As it turns out, neither could I. If you have been following my blog, you know that my practice became untenable financially, and I closed it. Whether the doctor personally makes these appeals or delegates them to a staff member, it still subtracts from the bottom line.

Insurance companies know that medical practices these days cannot afford the time for these appeals. They use the hassle factor to keep doctors from advocating for coverage on behalf of their patients. Sadly, this rations healthcare, either by rationing access to prescription drugs or rationing doctors’ time with patients.