One Step at a Time
A journey of 1,000 miles begins with a single step, says the ancient Chinese philosopher Laozi.
This is how 72-year-old Mimi W.'s journey out of the grip of depression began, with a single step -- that first step out of bed, which led to a few more into the kitchen, then to the front of her Far Rockaway apartment, to the local grocery store, then to regular shopping trips with her granddaughter. Her progress was thanks in large part to an unusual -- and unusually successful -- psychiatric team that makes house calls.
According to the National Alliance on Mental Illness (NAMI), depression affects more than 6.5 million of the 35 million Americans aged 65 or older. For those who are homebound, the prevalence is even higher, with estimates ranging from 13.5 to 46 percent. To meet the growing mental health needs of these homebound elderly, the Visiting Nurse Service of New York launched the Behavioral Health Program last year and has provided in-home psychiatric care to some 1,100 New Yorkers.
"There's a lot more understanding now about the prevalence and incidence of late-life depression and anxiety among the elderly, especially in the homebound elderly," says my colleague Rose Madden-Baer, VNSNY's Vice President for Behavioral Health and Special Projects, noting that the U.S. Centers for Medicare & Medicaid Services has identified detection of depression as a major quality objective for home health organizations. "Typically, these individuals cannot access the services they need unless we can visit them in the home."
"Depression can be a vicious cycle," says Patrick Murtaugh, R.N., the VNSNY psychiatric nurse who cares for Mimi (we are using pseudonyms to protect patients' privacy) and other homebound seniors. "You stay in bed, you stop seeing people, you close the curtains so there's no ultraviolet light, meals are small and unenjoyable. The activity level drops to nothing."
To reverse that downward spiral, the VNSNY Behavioral Health team uses cognitive behavioral therapy (CBT) to help depressed or anxious patients change their behavior, one step at a time and in their own homes. "I'll say, 'Listen, I'd like you to come out to the kitchen today for the interview,'" explains Patrick. "That gets them moving. I'll open the blinds to get a little ultraviolet light. We'll walk a little more the next day, maybe 20 feet. Soon, we're going out to the front of the building, sitting on a bench. Neighbors stop by, human contact starts up. Next thing you know, they're going out to lunch."
For Mimi, the difference has been striking. She now greets Patrick at the door for his visits and reports on a shopping expedition or lunch with her daughter -- in stark contrast to when she used remain in bed at his arrival, curtains drawn, eyes closed.
Taking Action: Short-Term Goals, Long-Term Results
As people get older, they tend to suffer increasing amounts of loss -- loss of a spouse, loss of friends, loss of mobility, loss of a vocation. How, then, do you recognize depression amid the normal sadness and grief that often accompany these losses? Here are several signs to look for in a parent, spouse or friend, according to the National Institutes of Health:
- Confusion or forgetfulness.
- Inattention to eating. The refrigerator may be empty or contain spoiled food.
- Lapse in hygiene, including bathing or shaving infrequently, or a house smelling of urine or excrement. Clothes may be dirty and unkempt.
- Poor housekeeping.
- Abandoning medications or not taking them correctly.
- Withdrawing from others, including not answering the phone or returning phone calls.
Cognitive behavioral therapy is a good match for the homebound elderly because it is short-term, action-oriented and integrated into the rest of their home care. Following an initial assessment, our team often begins treatment by helping depressed patients identify and introduce one pleasurable activity into -- or back into -- their lives, whether it is a hobby, such as cards or needlework; a regular visit with a child or grandchild; walking or sitting outside; or myriad other possibilities. This helps stop the downward cycle of depression.
For 86-year-old Harold Lebow, a well-known lighting designer who recently lost his wife and struggles with advanced spinal and respiratory problems, the pleasurable activity came in the form of a new iPad. When VNSNY Nurse Edward Nolan suggested a Google search of Mr. Lebow's name, the results brought a flood of memories, stories and a new project: updating his biography for the movie-industry database, IMDb. "This was pivotal in his recovery, having something like this to motivate him," says Edward. "He likes it, and it's been helping his memory, too."
A key tenet in cognitive behavioral therapy is to help patients break the cycle of negative "automatic thoughts," especially those that come with age and infirmity. A frequent example is, "My house isn't as clean as it used to be, so I should not invite anyone over." To stave off isolation (the elderly should have at least three social encounters a week) and combat this recurring thought, there are several courses of action we might suggest, including:
- "Okay, let's keep the front room clean and entertain there."
- "Let's get a housekeeper in once a week, and invite a guest the next day."
- "Make an appointment to meet elsewhere, even if it's just on the couch in the lobby of the apartment building."
- "Realize that people do not care as much as you do about your housekeeping."
Psychiatric nurses also use breathing and relaxation techniques to reduce depression and anxiety. To treat 66-year-old Tanya R., who had recently been released from the hospital for anxiety and still mourned the loss of her son some 20 years ago, Nurse Kyrene Robles worked with her on deep breathing ("in through the nose, out through the mouth"), praying and breaking the cycle of negative thoughts, in order to calm her pounding heart, shakiness and short fuse. Over the course of two months, Tanya reported feeling much less anxious and depressed, and she reduced her score on the widely used diagnostic Geriatric Anxiety Inventory (GAI) from 16 down to 9 -- a remarkable improvement, especially without anti-anxiety or antidepressant medication.
Home Care + Psychiatric Care = Success
According to Rose Madden-Baer, the key to the VNSNY Behavioral Health Program's success has been the ability to provide "combination therapy," which is psychiatric specialist care combined with with traditional psychiatric home care -- the first such combination in the country, to my knowledge. The program provides in-home services that include clinical assessment and psychiatric evaluation; skilled cognitive behavioral therapy techniques; patient and caregiver education, including on disease state and progression; and medication management, including assessing efficacy and side effects. The Behavioral Health team includes psychiatrists, psychiatric R.N.s like Patrick, psychiatric nurse practitioners and a psychiatric clinical nurse specialist.
The program is showing a statistical reduction in depressive symptoms in the patients it treats, and it has shown preliminary promise in helping reduce confusion in patients with early-stage mild dementia. (For patients with early-stage mild dementia who also suffer from depression, the depression can mimic symptoms of worsening dementia, so it stands to reason that reducing depression could help reduce confusion.)
We hope that evaluation of the model's effectiveness will lead to its replication by other home care agencies. Just imagine the possibilities if more psychiatric caregivers made house calls.
That would mean more nurses like Laura Lau, R.N., helping more patients like Justine M., who used to cycle into a deeper depression each time she talked to her adult son. "He's always ignoring me," she told Laura. "Doesn't he know it hurts my feelings?" Laura gave a simple answer, but one so startling to Justine that it helped her change her course of behavior. "No," Laura said. "He doesn't. He may be thinking about other things. You have to tell him." Justine did, and her son, in turn, changed his behavior.
It's not a miracle cure, but it is a steady, persistent course of change. "Don't get upset if you fail at first," says Laura. "At least you're closer to your goal than when you began."
Do you know someone suffering from late-life depression? Please share your story here to keep the conversation going.