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Geriatric Psych - Compassionate Care for Complex Issues

Monday January 30, 2006
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A 65-year-old man sat across from Carol Selby, MS, NP, at the Veterans Administration Eastern Colorado Healthcare System in Colorado Springs, Colo. The man was a regular patient in the system's geriatric psychiatry program and Selby had counseled him numerous times, but had never seen him this agitated.
A Vietnam veteran, the patient had been diagnosed with depression and post-traumatic stress disorder (PTSD). He told Selby that news coverage of the war in Iraq had brought on a flood of memories and emotions. He was having problems sleeping, and on the nights he did fall asleep, he had horrible nightmares.
Selby is one of many nurses who work in the field of geriatric psychiatry. With the baby boom generation nearing retirement, the number of older Americans with mental conditions is expected to dramatically increase in the next decade. The American Association for Geriatric Psychiatry (AAGP) estimates that by the year 2010, there will be approximately 40 million people in the United States over the age of 65, and more than 20% of those people will experience mental health problems.
Depression is one of the most common conditions that Selby and her colleagues see in older patients. Of the approximately 32 million Americans 65 and older, approximately five million suffer from depression. These depressed patients have more disabilities, an increased risk of suicide, and generally use the health care system more than their younger counterparts. According to the AAGP, seniors have the highest rate of suicide compared to any other age group, and approximately 30% of older persons in primary care settings have significant symptoms of depression.
Selby's patients are unique in that many are war veterans who suffer from PTSD, and their symptoms often escalate with age.
"The symptoms of PTSD can become worse as patients get older," Selby says. "We've seen patients who unconsciously get more aggressive and thrash around in their sleep. Nightmares are part of PTSD and are often the most difficult symptom to treat."
In addition to treating patients with therapy and anti-depressant medications, health care providers often find themselves teaching patients coping skills and how to manage chronic pain and the realities of aging.
Most of Selby's patients have suffered numerous losses, and as a result, have become depressed and isolated.
"Many patients are living longer and are outliving their spouses, their friends, sometimes even their children," Selby says. "It's very hard for them to adjust to being alone, and to no longer have their health and independence."
Contact with Selby or a home health nurse is often the only social contact experienced by many geriatric patients. Selby took a mental health rotation in nursing school, and she has worked in the field of geriatric psychiatry for the past 12 years. For her, working with mental health patients is as satisfying as it is challenging.
"I often wish I could do more for my patients to assist them with their loneliness or their conditions," Selby says. "And then a patient will tell me how much I've helped them, and great to know I've made a difference in their life."
Inside the unit
Cheryl Puntil, MN, APRN, CNS, works at the University of California, Los Angeles Medical Center (UCLA).
The facility, which opened in 1977, was the country's first inpatient geriatric psychiatric ward.
The 20-bed unit has patients between the ages of 55 and 100.
"Patients usually come to us in crisis," Puntil says. "Perhaps they have a condition such as Parkinson's and have becomeaggressive, or their condition and symptoms have changed suddenly."
Patients typically stay in the unit approximately 10 days, while doctors adjust medications and form a new care plan.
"I compare my job to being a detective," Puntil says. "You have to delve into the patient's whole history to determine the cause of the sudden change in their behavior. Has the disease progressed or is the patient suffering from a urinary tract infection or high ammonia levels, which can also cause behavioral changes?"
Unlike many nurses who see a revolving door of patients, Puntil and her colleagues spend a considerable amount of time with patients who often stay as long as two weeks in the unit.
"Patients are assigned the same nurse from the time of admission to the day they are discharged," Puntil says. "When we discharge patients we try to help them return to their highest level of function while assuring their safety."
Puntil sees many patients suffering from depression and dementia, delirium, hypertension, diabetes, and dehydration.
"We are definitely seeing an increase in the number of patients who have two or three chronic medical problems in addition to a psychiatric condition," she says. "It can be challenging to create a successful treatment plan for patients who are already taking five to six different medications."
Nurses also work with patients on behavior management. Days in the geriatric psych program are structured to make it easier for patients with cognitive impairment. While using some reality orientation with patients, nurses steer clear of continually correcting patient perceptions.
"If a woman talks about her deceased husband, we don't constantly remind her that he's dead," Puntil says. "It serves no purpose other than to make her feel bad. Instead we steer the conversation to memories of her husband and their life together."
Unlike nurses in other hospital settings, geriatric psych nurses work eight-hour shifts, five days a week with no mandatory overtime. As the main liaison between the patient and the family, Puntil notes that nurses are very involved in assessments, family meetings, and developing treatment plans.
"There's a lot of room to grow both personally and professionally in the field of geriatric psych nursing," Puntil says. "With the aging baby boomers, and patients living longer, we will definitely need more nurses with training in this area."
Treating dementia and depression
If you ask Vince Elliott, RN, MSN, about the challenges facing geriatric psych nurses, he will cite the "double D's," which are dementia and depression.
Elliott works as a clinical nurse specialist in mental health at the Veterans Administration Medical Clinic in San Jose, Calif. With the aging baby boomers, Elliott fully expects to see an increase in the number of seniors diagnosed with depression and dementia. He also anticipates seeing more frail elderly patients who suffer from myriad medical problems combined with mental illness.
Elliott attributes much of the confusion he sees with patients to vascular dementia, where undiagnosed high blood pressure and a series of small strokes have affected a patient's cognitive ability. He hopes the future will yield better methods of managing and treating hypertension in patients.
"The challenge in treating geriatric psych patients is that in addition to having a psych condition, most also suffer from several medical conditions," Elliott says.
Depression is also a commonly diagnosed condition among his geriatric patients.
"Their whole world is shrinking," Elliott says. "Even healthy patients can become depressed when they start having numerous medical problems, are no longer able to drive and feel alone in the world."
Most patients with depression are routinely started on anti-depressants, but Elliott says the pills are not a cure-all.
"The medication fails to help patients cope with their losses," Elliott says. "It's important for patients to also participate in one of our geriatric depression groups where we can help them cope with the transitions in their lives."
The support groups, led by Elliott and a psychiatrist, address issues such as finding alternative transportation when patients are no longer able to drive, using devices such as walkers when mobility becomes a problem, and keeping chronic pain in check.
"Because we work with a lot of veterans, I use military terms to explain the strength of the medications to our chronic pain patients," Elliott says. "During the day patients may need to use mortars such as Tylenol for their pain, but at night it's time for the heavy artillery such as certain narcotics, which will alleviate pain and allow them to sleep. The 16-inch guns on a battleship are Vicodin and morphine."
Despite the challenges of his job, Elliott says he goes home at the end of each day feeling good.
"I like the close collaboration with doctors and psych staff," Elliott says. "It's also rewarding when you can help geriatric patients to look at the positives in their lives, rather than focusing on the losses."
Linda Childers is a freelance writer for NurseWeek. To comment on this story, send comments to editormtw@nurseweek.com
For more information on mental health issues affecting older adults, contact The American Association for Geriatric Psychiatry or visit their website at www.aagponline.org.