Posts Tagged ‘aging’

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.

Depression and Frailty

Saturday, October 1st, 2016

Imagine a feeble, old man. Is he stooped, gaunt, thin or wasting, shuffling along slowly, relying on a cane to avoid falling? Does he seem exhausted, tentative, insecure, or weak? And is he mentally sluggish or easily confused? This fragile and vulnerable picture is that of frailty.

Much of the public believes frailty is a normal,  inevitable part of aging.   Except that it is not. Frailty affects about seven percent of those over sixty-five and eighteen percent over eighty, more or less, depending on how you count.1 The majority of older adults does not become frail, some even remaining quite robust.

What exactly is frailty? Frailty is a state of depleted reserves and defenses, resulting in heightened vulnerability. Frail individuals succumb to illness that younger or more robust individuals fight off or rebound from more quickly. It’s as if frail elders simply have worn out earlier than others their age.

No one knows why some older adults become frail. The cumulative, lifetime effects of inflammation or oxidative stress, may be at work. Age-related illnesses, such as diabetes, hypertension, atherosclerosis, and arthritis, may further chip away at physical and mental reserve capacity. Depression may be another culprit.

Numerous studies of older adults suggest that depression and frailty go hand in hand. In my book, Beat Depression to Stay Healthier and Live Longer: A Guide For Older Adults and Their Families, I described the toll depression takes on physical health, aging, and longevity. And I reviewed the evidence that depression causes or worsens many illnesses associated with aging including heart disease, stroke, cancer, diabetes, lung and kidney disease, arthritis, falling and pain. I did not include a chapter on frailty: at the time I wrote the book, I did not feel the scientific evidence for a connection with depression to be sufficiently compelling. But, recently I found a study showing that depression and frailty co-occur almost 90% of the time!1 Clearly depression and frailty overlap and have something in common.

We don’t know whether depression causes frailty or the reverse is true. Or maybe a third process, such as inflammation, leads to both. As I discussed in two different chapters in my book, having depression earlier in life doubles the chance of developing both Parkinson’s disease and Alzheimer’s disease. Could the same be true of frailty?

There are many reasons for people suffering from depression to seek treatment for it. Those who don’t, choosing to endure depression, unwittingly put their health and longevity at risk. We do not yet know whether treatment of depression prevents frailty. But it’s beyond doubt that depression is treatable, at any age. The possibility that treating depression might prevent frailty is one more reason why anyone with depression should get professional help for it.

 

  1. Patrick J. Brown, Steven Roose, Robert Fieo, et.al., “Frailty and Depression in Older Adults: A High-risk Clinical Population”, American Journal of Geriatric Psychiatry 2014; 22 (11): 1083-1095.

 

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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Book Release Date Announced

Saturday, January 16th, 2016

I’m excited to announce that my book, Beat Depression to Stay Healthier and Live Longer will be released on February 17th.

For more information about the book go to https://rowman.com/ISBN/9781442246621

Look for it in your local bookstore or at your online retailer, or order it directly through Rowman & Littlefield at a 30% discount. Use promotion code RLFANDF30 at checkout – this promotion is valid until April 30, 2017. This offer cannot be combined with any other promo or discount offers.