Working With the Elderly     By Elaine LeVine, Ph.D., Las Cruces

I have a general private practice in Las Cruces, New Mexico.  About 15% of my patients are children and adolescents.  I also see adults and families.  I have noticed that as I grow older, more elderly clients are referred to me . . . somehow, I do not think that is a coincidence.  On top of the fact that I am seeing an increasing number of senior citizens and geriatric patients, I have an increasing interest in helping this population.  It seems to me that the elderly are more willing to seek therapy and are more likely to be referred to therapy than in the past.  What was once considered just “old age” behavior is now recognized as depression, anxiety, and other psychological concerns; and of course, we are all aware that there are many unmet psychological needs of residents of nursing homes. 

Because of this, I had asked an internist in Las Cruces, John Glick, M.D., if I could complete a special eighty-hour practicum on psychopharmacology regarding his senior citizen/geriatric population.  I have been most fortunate to be able to follow his patients with him in three different nursing homes and in both of our hospitals.  The experience has been very beneficial to me in helping my patients, and my skills reading x-rays, CAT scans, and laboratory tests have increased significantly. 

After accompanying my preceptor on several visits with each of these patients, I began to see the majority of them for individual sessions.  During these individual visits, I was able to complete more extensive psychological histories as well as a thorough review of the patients’ records.  We have set in motion some very helpful changes for some patients by planning psychotropic intervention collaboratively, and I would like to share a few of those experiences with you.

One patient with whom I have worked appeared to be wasting away.  She seldom got out of bed.  She had a history of depression and anxiety.  She was also suffering from a number of physical illnesses.  The nursing staff was very concerned because she had lost so much weight.  She required feeding by the staff and rejected most food.  We modified her psychotropic medications, and added Remeron, which has a side effect of increasing appetite.  She became so hungry that she requested extra food before bedtime.  The patient gained about ten pounds, and with this weight gain, she became stronger and much more interested in living.  She moved from having to be at a feeding table to feeding herself and interacting more with her peers. 

Another patient in one of the nursing homes was very frustrating to the staff because she spent almost all of her day in the bathroom.  When I first visited this patient, it was quickly apparent that she was quite bright and that her behavior did not seem to be a form of dementia.  For example, when I asked her what she was doing in the bathroom all that time, her answer was, “I’m cogitating.”  When I went back to see this patient for individual evaluation and psychotherapeutic intervention, I determined that she was suffering from a severe, undiagnosed obsessive-compulsive disorder. 

She informed me that she would wake up at 4:00 a.m., go to the bathroom, and meticulously follow a systematic ritual to clean, first, one side of the body, and then the other.  It took her from 4:00 a.m. until 9:00 a.m. to complete this ritual so that she would be ready for breakfast, and her day continued in the same exhausting way. She would not leave the bathroom because she was afraid of having “an accident,” and that would be “awful and very embarrassing.”   Furthermore, she felt that people were laughing behind her back about the time that she spent in the bathroom; and this was depressing her and making her want to leave her room even less. 

At the age of eighty-nine, this patient has little insight about her psychological disorder and did not perceive herself as depressed.  However, she was very troubled about her bladder control.  A tricyclic antidepressant was prescribed that could alleviate some of the symptoms of depression and OCD and has an anticholinergic effect, which reduced her incontinence.  The patient reports that she no longer has to get up several times at night to use the bathroom, so her sleep is more restorative.  Although her behavior is still highly ritualistic, she spends less time in the bathroom and more time interacting with others.  There has been an additional serendipitous benefit in that the medication has provided considerable relief from her pain of arthritis.  Her life has broadened considerably, and she is pleased with her progress.

A third patient in a nursing home is suffering from severe Parkinson’s.  When I first met with her, that she appeared very demented.  She was extremely confused, did not recognize her physician, and could hardly respond to questions.  The nursing staff reported that they were having a great deal of difficulty managing this patient, as she became very uncooperative and demanding in the late afternoon and kept trying to leave the nursing home in her wheelchair.  Upon my follow-up visits with her and the nursing staff, I learned that she was suffering from a very severe sleeping disorder (this is not uncommon with Parkinson’s patients).  She had been placed on an antipsychotic medication in the daytime for the purposes of quieting her obstreperous behavior.  It seemed to me that if she could sleep restfully, she would be better able to deal with her emotions during the day and would not be so difficult to manage. 

Dr. Glick and I decided to focus on her sleep disorder.  We increased a nightly medication and, gradually, were able to terminate the daily antipsychotic that she was taking.  What happened was almost “an awakening.”  As she started sleeping at night, and without so much medication during the day, her thinking cleared significantly.  Her ability to communicate returned; so much so that, for example, she was able to talk to me about the attack on the school children in Russia that she had observed on television, and she expressed how much this upset her.  She definitely became oriented to person and was able to regain some quality of life.

I have more cases I wish I could share with you because the work is so fulfilling.  I hope these give you a flavor of how much I have learned from working with Dr. Glick and from getting to know these elderly patients better.  I hope you get a sense, too, of how greatly this interdisciplinary collaboration can benefit this population.