Intervention Series: Mom seems to be depressed - what you can do

Depression Interventions

In a recent study researchers found that depressive symptoms were more than twice as common among assisted living residents with mild or moderate dementia than among those without dementia.  Depressed residents often do not have positive outcomes and are greater risk of discharge to nursing homes and death. Chronic depression can lead to loss of appetite and weight loss, lethargy, and a host of other premature health complications. Findings of the study document the high prevalence of depressive symptomatology among those with dementia.  About 54% of the depressed and 33% of the non-depressed participants were taking antidepressant medication.[i] Sixty-two of the participants of the study were depressed had no formal mental health treatment.  Depression was more common among participants with severe dementia, behavioral symptoms and those with pain.  The study also found that over half of the depressed participants were undetected by staff.

These results indicate a strong need to properly assess residents for depression. Seeking interventions for those suffering who are undiagnosed and corrective actions for those currently treated for depression who may not be depressed can derail potential problems.  Identifying these at-risk residents and advising attending physicians and family members may help operators to avert unnecessary mental health triggered discharges, while improving the quality of life for each individual.

The Cornell Scale for Depression in Dementia (CSDD) was developed in response to a need in the industry for a diagnostic tool to quantify incidence of depression in elderly populations with dementia[ii].  This simple 19 question tool enables operators to identify at-risk residents who are suffering from depression and are undiagnosed so that they might be treated, and also identify those who may be already prescribed antidepressants who may not in fact be depressed.  This way attending physicians may be offered a nationally recognized diagnostic tool to use to evaluate and prescribe for their patients, rather than relying upon sporadic observations from caregivers and family members.

Alternatives for Depression Intervention:

Treatment for depression depends upon the cause and severity of the depression and, to some extent, on personal preference. In mild or moderate depression, psychotherapy is often the most appropriate treatment. But incapacitating depression may require medication for a limited time along with psychotherapy. In combined treatments, medication can relieve physical symptoms quickly, while psychotherapy enables the patient to learn more effective ways of handling his/her problems.

Personal Measures: mild exercise, music therapy, pet therapy, gardening or other hobbies, social engagement, volunteerism, intergenerational activities, reminiscing with family members or other residents, social interventions to help with isolation and loneliness (group outings, regular visits from volunteers, participation in a support group), humor, maintaining a healthy diet, religious or spiritual groups, continuous engagement in stimulating activities and craft programs.

Medical measures: treatment of underlying medical conditions, counseling, psychotherapy, anti-depressants, hormone replacement therapy, changes in prescription dosages. Antidepressant medication can help some people feel better by controlling certain symptoms. The can be helpful in mobilizing people who suvive the repair of a broken hip, but lose the will to get out of bed. It should be noted that antidepressants can potentially lead to falls as they are sedating and can cause a sudden drop in blood pressure when a person stands up. Also selective serotonin reuptake inhibitors (SSRI) drugs can create dependency and may lead to self-destructive thoughts.

Psychotherapy and Counseling and Measures: Supportive counseling includes religious and peer counseling. It can help ease the pain of loneliness and address the hopelessness of depression. Both peer counseling and pastoral counseling usually are provided without cost. Cognitive Bahavioral Therapy (CBT) helps people distinguish between problems that can and cannot be resolved, and develop better coping skills. Interpersonal psychotherapy can assist in resolving personal or relationship conflicts. Somatic or trauma psychotherapy with a professional can help bring about resolution of traumatic experiences.

 Why it is important to treat: The body often follows the mind and depression substantially increases the likelihood of death from physical illnesses. Depression can increase impairment from a mental disorder and impede its improvement, while psychological treatment frequently improves the treatment success rate for a variety of medical conditions. Untreated depression can interfere with a patient’s ability to follow the necessary treatment regimen or participate in a rehabilitation program. According to a study conducted by the Rand institute, depressed elerly patients use 6 time more prescription medications and spend four times more in total healthcare dollars than their nondepressed counterparts. Seniors who are vulnerable for depression experience more comorbidities and run a higher risk of catastrophic health failure.

The Cornell Scale for Depression in Dementia (CSDD) is a way to screen for symptoms of depression in someone who has dementia. Unlike other scales and screens for depression, the CSDD takes into account additional signs of depression that might not be clearly verbalized by a person. For example, if your loved one or patient has Alzheimer's disease, vascular dementia or other kind of cognitive impairment, he might not consistently be able to accurately express his feelings. The Cornell Scale measures observations and physical signs that could indicate depression. 

Conduct your own assessment: http://primaris.org/sites/default/files/resources/Depression/depression_cornell%20scale%20for%20depression%20final.pdf

[i] Baldini-Gruber, Ann, Zimmerman, Sheryl, Boustani, Malaz, Watson, Lea, Williams, Christianna, Reed, Peter. Characteristics Associated with Depression in Long-Term Care Residents with Dementia. The Gerontologist. Vol. 45, October 2005, Page 50-55.

[ii] Alexopoulos, G.S., Abrams, R.C., Young, R.C., & Shamoian, C.A. Cornell Scale for Depression in Dementia. Biological Psychiatry, 23, 1988, Page 271-284.

Intervention Series: Mom is losing weight - what you can do

Nutritional Interventions

Seniors have a special relationship with food. Each phase of the aging process presents different nutritional challenges. Although good nutrition is not a treatment for memory loss, it does improve quality of life dramatically. Good nutrition helps to combat infections, depression, skin breakdown, pneumonia, confusion, as well as risks for falls and urinary tract infections. Here are some of the changing nutritional needs presented with the three general progressive phases of Alzheimer's Disease.

In phase one, loss and confusion typically fuel depression, which causes changes in appetite. Weight changes may occur. People with AD may anxiously eat nonstop, or they may forget to eat all together. They may forget how to shop for food, or how to prepare a meal. They may forget how to use kitchen equipment, like a microwave or toaster, and become frustrated.

The increased activity, agitation and wandering that is prominent in phase two increases residents' energy needs. Active residents in this phase may require an extra 1600 calories per day just to maintain their body weight. Getting those extra calories may be challenging if the resident loses interest in food. Swallowing difficulties, inability to recognize or distinguish foods, tasting difficulties, shortened attention span, physical changes like tremors or Apraxia and the inability to cope with the stimulation at the meal site all work against a confused resident. 

In phase three, people with AD are usually confined to a wheelchair. Typically, they forget how much food to put in their mouths or how to swallow. Most people in phase three need to be fed. In order to ensure the maximum nutritional intake, caregivers should take their time, offering cues, coaxing and proper positioning. Appropriate food consistency is essential, as there is a risk for choking. Having the main meal midday helps, too, because that is typically when the resident is at his sharpest.

Alternatives for nutritional intervention:

Have foods available at all times.

Include the resident in choices, preparation and clean up.

Encourage hydration at least six times per day.

Have portable/ finger foods available for residents who wander, have limited attention spans, have difficulty using utensils and/or would benefit from six meals per day. (Examples of finger foods: hardboiled eggs, bananas, baby carrots, orange sections, graham crackers with peanut butter, cookies, cheese, chicken nuggets, etc.).

Offer smaller portions of food frequently throughout the day. 

Offer favorite foods, with a preference on nutrients. (If a resident likes both brown and white rice, serve the nutrient-rich brown rice.)

“Bulk Up” snacks with peanut butter, cheese and margarine. Use dry milk in sauces and soups. Add ice cream and chocolate syrup to milkshakes and desserts. Sprinkle sugar over everything (unless a no concentrated sweet diet is needed).

Choose dinnerware for special needs: large handles on mugs and bowls to increase steadiness; plates with a lip to help get food on a spoon or fork; solid colored dishes to highlight food and minimize confusion; contrasting linen colors to make food easy to see.

Move the plate a ¼-turn to compensate for vision problems. Use dark table linens, so spills won’t show up easily. Use aprons, not bibs, at mealtimes if necessary.

Consider a swallowing evaluation for residents who are observed doing the following: pocketing of food, coughing or choking after meals or liquids, frequent throat clearing, drooling, gurgly voice quality, effortful chewing, complaining of pain while swallowing, watery eyes or running nose while eating, reflux, prolongation of meals. Implement diet modifications, positioning and swallowing techniques, and modify food consistencies.

Positioning techniques: keep the resident’s head and upper trunk as upright as possible with head at midline; the head should be slightly forward in relation to the neck and shoulders; the hips and small of the back should be centered at the back of the chair; arms should be resting on the table to facilitate proper shoulder posture; keep residents feet flat; adjust the table height; and have the resident sit close up to the table.

Serving and Food preparation techniques: Talk to the resident, tell her who you are and what you will be doing; speak slowly and clearly, feed slowly while alternating foods; don’t startle the resident with the feeding utensil; feed small amounts of food at a time; alternate sides of the mouth; offer sips of liquid often and tell the resident when you are done to put closure on the activity.

Nutritional strategies: Remove or substantially modify dietary restrictions; encourage the use of flavor enhancers; encourage more frequent small meals; offer liquid nutritional supplements for use between (not with) meals; improve protein intake by adding meat, peanut butter or protein powder; treat depression with antidepressants that do not aggravate nutritional problems; remove or replace medications that may have anorexia-producing side effects.

Staff Interventions: Ensure that residents are equipped with all the necessary sensory aides (dentures, hearing aide, glasses); ensure the resident is seated upright at 90 degrees preferably out of bed in the dining room in a chair (residents eating in the dining room are much less likely to have low intake); remove or minimize unpleasant sights, sounds and smells. 

Pharmacological Nutritional intervention: Megestrol acetate is a synthetic derivative of the female hormone progesterone. It can promote increased appetite and is very tolerated. The medication is designed to increase food intake, BMI, albumin, prealbumin, hemoglobin and lymphocyte count. This will require a physician order.

              

The Mini Nutritional Assessment - The Mini Nutritional Assessment is an effective, easily administered tool designed to identify older adults who have or are at risk for developing malnutrition. It consists of 18 questions and can be completed in about 15 minutes. A short form, containing the first six questions, can be used for screening. 

https://www.mna-elderly.com/forms/mini/mna_mini_english.pdf

Intervention Series: Mom is Falling - what you can do

Ninety percent of the more than 352,000 hip fractures in the U.S. each year are the result of a fall. The remaining 10 percent of the hip fractures occur spontaneously due to low bone density or osteoporosis. Spontaneous fractures can then precipitate the fall. Women have two to three times as many hip fractures as men, and white post menopausal women have a 1 in 7 chance of a hip fracture during their lifetime.  The hip fracture rate increases at age 50, doubling every five to six years. More than one-third of adults ages 65 years and older fall each year.

Alternatives for Falls Intervention:

Physical Measures:  Using a recliner or rocking chairs, seating adaptations such as wedge cushion, lowering bed or removing of bedframe to put mattress on the floor, commode/urinal at bedside, assistive devices such as quad canes and walkers, review of current medications that may destabilize gait and balance (benzodiazapines), call bell within reach, monitor blood sugar and oxygen levels, check for presence of infections (URI or UTI), consider medications for pain relief, anti-tippers for wheelchairs, self -releasing Velcro lap belt, fall mats at bedside, orthostatic BP & P monitoring, place in high visibility areas. Discuss with physician discontinuing or decreasing doses of medications associated with cognition changes, hypnotic or sedative effects (sleeping medications), bradycardia, hypotensive episodes, or sensory changes.

Environmental Measures: anti-rollback device to wheelchair, remove wheelchair foot supports when not in transport, remove visual barriers, cleat pathways, remove clutter that can fall and pose a hazard (magazines are very slippery on the floor), brakes on beds, bed in low position, repositioning for comfort, personal items within reach, assess seating, brake extenders for wheelchair, walker/cane tips in good condition, room closer to nurses station, assess sidrail use, bed/chair tabs alarms, pressure sensor alarm, reminder signs, non-skid strips on floor, remove wheels from overbed tables, consider motion detection night lights to illuminate pathway to bathroom, non-skid socks while in bed, properly fitting footwear and non-skid shoes, clothing that does not interfere or restrict movement, toileting schedule, room monitor, storage pocket for walker/wheelchair.

Psychosocial Measures: Active listening, behavioural strategies, sensory stimulation, increased surveillance, mental health evaluation.

Activity Measures: Structured daily routines, physical exercises, evening exercises, buddy system to monitor, PO/OT screening, music therapy, restorative ambulation, frequent toileting post-opioid pain medication and constipation relief measures.

The Morse Fall Scale (MFS) is a rapid and simple method of assessing a patient’s likelihood of falling. A large majority of nurses (82.9%) rate the scale as “quick and easy to use,” and 54% estimated that it took less than 3 minutes to rate a patient. It consists of six variables that are quick and easy to score, and it has been shown to have predictive validity and interrater reliability. The MFS is used widely in acute care settings, both in the hospital and long term care inpatient settings. Conduct your own falls assessment: http://networkofcare.org/library/Morse%20Fall%20Scale.pdf

Supplements for Older Adults

The human body is a complex network of different systems, all intricate in their design and function. What each system has in common is its need for nourishment, mostly in the form of nutrients, to operate properly.  Antioxidants, vitamins and minerals work synergistically to help the body reach optimal health. Deficiencies in these nutrients can have serious consequences. The immune system, bones, vision, mental clarity, blood pressure, metabolic function and energy are just a few of the health areas influenced by a deficiency in one or more vitamins and minerals. There is no substitute for a healthy, well-balanced diet; however, in today’s fast-paced lifestyles it is important to ensure the body is getting the fuel it needs.

Ideally, consuming foods such as fruits and vegetables can provide antioxidant protection to cells from the damaging free radicals as well as offer other essential vitamins and minerals that help the body perform optimally.  Unfortunately, many foods today are grown in mass quantities in soil that has been nutritionally depleted over many years of use. In a landmark study published in 2004, nutritional data of various vegetables and fruits over a 50-year period were found to have ‘reliable declines’ in protein, calcium, phosphorus, iron, Vitamin B2, and Vitamin C. It was felt this was due to the modern agricultural practices designed to breed new crops that provide larger yields, pest resistance, and climate adaptability.[i]

Combine the nutrient-deficient soil with over-processing and refinement of our foods, then add chemical preservatives and artificial color and flavor enhancers, and there is now a great need to supplement the missing vitamins, minerals, and antioxidants on a daily basis to help combat the inflammation and free radical production that our modern lifestyle generates. [ii]

Because dietary supplements are not FDA regulated as prescription and non-prescription drugs are for standards, safety, and effectiveness, there can be a wide variety of products on the market to choose from.  These can range from poor quality supplements with high amounts of fillers and nonessential ingredients to high quality, isotonic forms that have FDA marketing approval as high quality and easily absorbable. 

Vitamins are divided into two types: fat-soluble and water-soluble. Fat-soluble vitamins (vitamin A, D, E and K) are stored in the fat tissues and liver. They can remain in the body up to six months. When the body requires these, they are transported to the area of requirement within the body with help of special carriers. Water-soluble vitamins (B-vitamins and vitamin C) are not produced nor stored in the body like the fat soluble ones and need to be replenished everyday, whether consumed in our foods or supplementation.

Choosing the right multivitamin supplement is more than just looking at the ingredients. The form in which the supplement is in can make all the difference in the quality of the supplement you are receiving.  A good multivitamin should be easily absorbed and have all of the required daily levels that are essential to maintain good health. 

One multivitamin supplement recommended is ‘isotonic’ which comes as a powdered form to which you add 2 ounces of water to drink.  Isotonic, which means “same pressure,” bears the same chemical resemblance of the body’s blood, plasma and tears. All fluids in the body have a certain concentration, referred to as osmotic pressure (which is isotonic) and allow a consistent maintenance of body tissues. This means that the body has less work to do to in obtaining maximum absorption. The isotonic state of the suspension allows nutrients to pass directly into the small intestine and be rapidly absorbed into the bloodstream. With Isotonix (Nutrametrix) products, little nutritive value is lost, making the absorption of nutrients highly efficient while delivering maximum results.

The Nutrametrix Daily Multivitamin contains all the basic daily dietary needs, and can be with or without iron as recommended by your healthcare professional.  You can then add other Nutrametrix isotonic dietary supplements according to your own personal needs, for instance, for arthritis, allergies and joint pains (antioxidants like OPC-3 and vitamin C), elevated cholesterol (Essential Omega 3 oil with Vitamin E) or nerve conduction/ nerve pain and stress levels (Activated B-complex).  These items can be found online at www.nutrametrix.com/karendoll.  There is a free “Nutri-physical” you can complete online that will help individualize your supplement needs according to your personal needs.  (www.nutrametrix.com/karendoll/nutri-physical).  Before considering any supplemental regimen, be sure to consult your healthcare provider. 

Omega 3 fatty acids have been shown to be effective in fighting inflammation

 in your body as well as in reducing overall cholesterol levels and triglycerides, improving blood flow and blood pressure, and may also help to reduce the occurrence of the more severe outcomes of heart disease. Fatty fish such as salmon, sardines, anchovies and mackerel provide essential omega 3 fatty acids, especially eicosapentaenoic acid (EPA) and docosahexanenoic acid (DHA).   The American Heart Association recommends 1000 mg per day of Omega-3 EPA/DHA for patients with coronary heart disease and 2000 to 4000 mg per day for patients with high triglycerides. For vegetarians or those who have fish allergies, flax seeds or flax seed oil provides an acceptable alternative. 

To achieve this level of supplementation, a high quality Omega-3 oil is recommended daily as you want to know it is tested to be free of fillers and non-essential ingredients, like the Nutrametrix Heart Health Essential Omega-3 with Vitamin E.  NutraMetrix Heart Health Essential Omega III comes from small anchovies and sardines that have a short lifecycle making them an ideal source of fish oil because they are less prone to accumulating environmental toxins that can be found in larger, longer-lived fish.  A good quick way to test any fish oil supplement is to place a capsule in the freezer overnight.  Pure oil will not freeze solid, but those with mostly added fillers will.  If it is firm and inflexible when frozen, it is likely to be more filler ingredients than omega-3 oil.

Another source of inflammation-fighting healthy fats is nuts—particularly almonds, which are rich in fiber, calcium, and vitamin E, and walnuts, which have high amounts of alpha-linolenic acid, a type of omega-3 fat. All nuts, though, are packed with antioxidants, which can help your body fight off and repair the damage caused by inflammation.

Antioxidants are another key supplement necessary for health, especially as we age that will reduce ‘free radical’ formation.  Free radicals are unstable molecules or compounds that react negatively with other molecules creating stress on the body.  This free radical formation is a natural process that occurs daily when the body breaks down certain substances in our environment or food, or comes in contact with pollutants.  Specifically, antioxidants provide the body with a defense against the negative effects of the free radicals, then stabilize and prevent other molecules from turning into unstable free radicals, thereby promoting good health.

Inflammation is part of the body’s immune response; without it, we can't heal. But when it's out of control it can damage the body. Chronic inflammation has been linked to many cardiovascular diseases. Cholesterol gets deposited in the lining of blood vessels and acts as an insult.  Cytokines respond to these insults in the bloodstream, which leads to systemic inflammation. Inflamed blood vessels and growing fatty plaque can cause blockages and blood clots, which then can cause heart attacks.  Foods high in sugar, saturated and trans fats, excess weight, smoking, pollution, chemical preservatives, poor oral health and unhealthy diets in general cause chronic inflammation.   In addition to cardiovascular disease, inflammation is also associated with diseases such as arthritis, autoimmune diseases, allergies, asthma, cancer, and inflammatory bowel diseases.

Three important antioxidants, OPC-3, Vitamin C, and CoQ10, have been found to be beneficial for heart health by reducing inflammation as well as the number of free radicals causing inflammatory damage in our bodies.   Oligomeric proanthocyanidins (OPCs) are bioflavonoids (complex organic plant compounds) found in fruits, vegetables and certain tree barks that provide exceptional nutritional benefits to the human body. Studies have shown OPCs to be up to 20 times more powerful than vitamin C and 50 times more powerful than vitamin E in neutralizing free radicals.  Supplementing with a high quality isotonic OPC, like the Nutrametrix (Isotonix) formulation OPC-3 taken with your daily multivitamin will help fight the free radicals and offer an effective anti-inflammatory.

Vitamin C is an essential water-soluble nutrient that must be replenished on a daily basis. It is important to know that cooking destroys vitamin C activity.  Aside from it’s well known antioxidant properties, vitamin C supports cardiovascular health in a few different ways, i.e. normalizing blood pressure and cholesterol levels, in addition to supporting our immune system and pulmonary health. A lack of vitamin C can cause general fatigue, as it helps moderate healthy iron absorption, transport and storage.  In the typical diet, most vitamin C comes from fresh fruits and vegetables. Peppers, like sweet green and red peppers, hot red and green chili peppers, are especially rich in vitamin C. Other good sources include citrus fruits and juices, brussel sprouts, cauliflower, cabbage, kale, collards, mustard greens, broccoli, spinach and strawberries.

Another powerful antioxidant and vital nutrient to promote energy production within our cells is CoenzymeQ10 (CoQ10).  CoQ10 levels in our body naturally diminish with age, and even faster with poor eating habits, stress or infections.  It is reported that the use of statins (cholesterol-lowering medications) will also reduce the body’s ability to make CoQ10 even further.  It is generally a combination of choosing the right foods containing CoQ10 with additional supplementation daily that will provide the body with the best possible amount of CoQ10 for optimal health.  CoQ10 is naturally found in high levels in organ meats such as liver, kidney, and heart, as well as in beef, sardines, and mackerel. Vegetable sources of CoQ10 include spinach, broccoli, and cauliflower with peanuts and soybeans the best non-animal sources. 

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[i] University of Texas (UT) at Austin’s Department of Chemistry and Biochemistry was published in December 2004 in the Journal of the American College of Nutrition

[ii] See also antioxidants for a definition of free radicals.

Medicare and Medicaid in Assisted Living

Today's seniors enjoy a life expectancy longer than any generation in history. An American who turned 65 in 1998 could expect to live nearly another 18 years beyond their 65th birthday. And while additional years are generally considered an blessing, it is also true that the older one grows, the more likely they will need health care services. Today's seniors, who often consider themselves among the best informed, would do well to learn about three crucial areas that pertain to their future health care needs: the potential that they may need long term care, the cost of long term care and the limited federal and state aid available.

According to a study by the Agency for Health Care Policy and Research, some 42 percent of Americans who reach the age of 70 can expect to utilize some type of long term care during the remainder of their lives. And with the number of people over age 65 expected to grow to 20 percent of the U.S. population by 2030, there is little doubt that demand for long term care services is poised to increase dramatically.

Long term care services have evolved dramatically over the past several years. Where the majority of long term care was once provided only in skilled nursing homes, long term care services today are provided in a wide range of settings, ranging from in-home care to community-based facilities such as adult day care and assisted care facilities to nursing homes. The cost of long term care can be significant, regardless of the setting in which it is provided. The average cost of a nursing home is approximately $60,000 a year, and home care costs can range from $50 to more than $250 a day.

Medicare and Medicaid provide only limited help for nursing home care. Medicare only pays for the first 20 days in a skilled nursing facility - and only after a hospital stay of three days or more. The patient or their family pays the first $99 per day from the 21st day through the 100th day, after which Medicare pays nothing. Medicaid rules vary from state to state, but as former U.S. Senator David Durenburger told the U.S. Senate Special Committee on Aging, Medicaid "dictates that people must effectively impoverish themselves in order to receive government assistance." Medicaid is essentially medical aide for those who have already spent down their assets.

Government won't help much with newer forms of long term care services, either. Though 38 states pay for some assisted living, the programs are miniscule, covering fewer than 100,000 poor people, so waiting lists are long. Medicare covers home care, but just 100 visits in the weeks following a hospital stay. So seniors increasingly are paying their long term care bills out of their own pockets.

Medicaid does not pay for assisted living services in most assisted living, typically they cover the costs of care in Nursing Homes for those who have exhausted their assets. The White House recently authorized Medicare coverage for the treatment of Alzheimer's disease. This means that Medicare beneficiaries can now receive reimbursement for mental health services that were formerly denied because the government rationalized that people with the disease did not respond to mental and physical therapy, this has since been proven incorrect, hence the reversal of their position. Medicare was never intended to cover the costs associated with custodial care, which is room and board, and activities of daily living, and these coverage changes still do not reimburse for this, further Medicare requires a three-day prequalifying hospital stay before they pay for care in a nursing home. Medicare covers certain care procedures, and some limited rehabilitation therapies. The physicians who visit assisted living are normally all Medicare certified providers, so the cost of their visits is often covered by Medicare, subject to the co-payment.