For some seniors, depression can be a sign of spring

This is an article from LivHome – for more info, go to

May 3, 2012 by Steve Barlam, MSW, LCSW, CMC

As spring arrives and rejuvenates the landscape, it would seem to be the least likely season for depression to appear. Winter’s end and spring’s increase in daylight hours are typically uplifting events, associated with renewal, rebirth and joy. Yet for many seniors, spring can trigger or exacerbate the dark feelings and lethargy of depression.

How does depression differ from the winter blues or general feelings of sadness? It’s natural for everyone to feel sad or “in a funk” from time to time. It’s a part of life. Depression, however, is a clinical state that persistently affects every aspect of daily life, relationships and behavior. Its most common signs include withdrawal, fatigue, isolation and disturbances of sleep patterns. In many cases, weight loss and memory loss, physical aches and pains or decreased attention to personal hygiene can signal that a senior is depressed.

While depression doesn’t discriminate, seniors can be particularly vulnerable simply because the aging process involves additional pressures and conditions far less common among younger sets. The physical limitations and long stretches of solitude many seniors experience can trigger depression, as can declining health. When mobility decreases, for example, the resulting increase in dependence on others can lead seniors to feel helpless or out of control. Losing the ability to drive can be a significant change which contributes to feelings of low self-esteem and loss of purpose.

Loss, too, can trigger depression. With age comes the loss of friends, family members and spouses, resulting in fewer social opportunities, increased isolation and a growing awareness of one’s mortality.

But why does depression often manifest in the spring?

First, brighter daylight and longer days can leave seniors feeling more exposed and vulnerable than they did while “hibernating” at home during the cold, darker winter months, which lend themselves well to seclusion. Spring’s bright intensity can feel overwhelming to those seniors who may already be suffering from anxiety, driving them to seek refuge indoors or in bed.

Second, spring is a time when people are naturally inclined to become more active. This makes seniors more aware of their own physical limitations. The season also sets an expectation of “feeling better.” But for seniors, this doesn’t mean their health or physical condition will suddenly improve. Likewise, springtime is often associated with cleaning and tackling other chores, and this may be a painful reminder to seniors of their dependence or frailty. All of these things can stir up feelings of discouragement and sadness.

Caregivers or family members can help depressed seniors first by recognizing the signs or symptoms. Because today’s seniors grew up when depression was considered a character flaw and, certainly, a burden not to be shared or disclosed to anyone, they’re unlikely to come forward and express depressed feelings. So it’s crucial for loved ones and caregivers to observe a senior’s routine as well as his or her physical and mental state, remaining attentive to any of the signs mentioned earlier.

Because other medical conditions such as strokes or Parkinson’s, cancer, heart disease and dementia have symptoms that overlap with those of depression, family members and caregivers should watch for signs of those that typically don’t overlap: withdrawal, decreased attention to personal hygiene and indifference to favorite activities.

Once recognized, depression is treatable. The process begins with communication. Acknowledging in advance that depression may occur—especially if there has been a pattern of it in the past—and being ready to help the senior seek appropriate treatment can mean the difference between a prolonged struggle and improvement.

Seeking professional help is also key. If it’s unclear whether depression, disease or a physical ailment is the reason for a senior’s decline, family members or caregivers should contact the individual’s primary care physician and schedule a physical exam to rule out other potential conditions.

Once depression has been identified, enlist the services of geriatric counselors, physicians, family members or friends who can help support the senior through a diagnosis and treatment. Geriatric care managers make a tremendous difference in the quality of the experience and the results by overseeing and coordinating the elements of a diagnosis and treatment process. This ensures that each step of the way, from keeping appointments to taking medications, nothing slips through the cracks.

With proper treatment, thoughtful action and consistent support, depression can lift, bringing vast improvement to a senior’s quality of life and to his or her relationships with loved ones—as well as the simple pleasure of enjoying spring.

Steve Barlam, LCSW is Chief Professional Officer and co-founder of LivHOME, a home care provider, in 1999. Since 1984, Barlam has worked exclusively in the field of geriatric care management as a Certified Care Manager and Licensed Clinical Social Worker. He is past president of the National Association of Professional Geriatric Care Managers and is he is actively involved in the professional credentialing process for care managers through the National Academy of Certified Care Managers.

Discovered: The Magic Word

May 30, 2012, 6:00 AM
Discovered: The Magic Word

The word “hospice” usually evokes a shift, a pivot from trying to cure to providing comfort and support at the end of life. Hospice workers help people through the final weeks and months of terminal illness, easing dying people’s pain and fear, bolstering their exhausted families.

But in one case I heard about recently, the word served a different function: It became a kind of magic shield. Simply saying it could protect against unwanted medical treatments for a vulnerable old woman who possibly wasn’t dying at all.

Sarah Kyung Lee with her grandson, Wyatt Lee.
Dr. Sei Lee, a geriatrician and palliative care specialist at the University of California, San Francisco, who told me the story, described this use of hospice as “an amulet to ward off overly aggressive care.” He put that potent word to use a few weeks ago; the woman in question was his mother.

Sarah Kyung Lee, 76, lives in a small board-and-care home in Foster City, Calif. A tiny woman, she was out for a walk in March when she was grazed by an S.U.V. whose driver, backing up, evidently didn’t see her. “It was by all accounts, including the police report, a very low-velocity collision,” Dr. Lee said. It didn’t even dent her walker. “But it was enough that she fell and hit her head on the sidewalk.”

She was admitted to Stanford Hospital. At first, “I was hopeful she could go home in two or three days,” Dr. Lee said. Though E.R. doctors saw evidence of bleeding in the brain, subsequent scans showed it had stopped.

Hospitalizations rarely go so smoothly for older people with multiple health problems, however. Mrs. Lee had undergone two heart valve replacements and was on a blood thinner. She’d suffered two strokes and had high blood pressure. The stress of the accident kicked off an episode of recurrent atrial fibrillation, sending her heart rate to dangerous speeds. She developed delirium, as many hospitalized older people do.

Placed in a transitional care unit, “she had all these lines to monitor her heart, IVs in case they had to give her additional meds,” Dr. Lee recalled. Aides interrupted her sleep for blood tests before dawn. Fearful that she might fall if she tried to get up to use the bathroom, doctors inserted a urinary catheter.

Let me point out that if you’re a confused, hospitalized 76-year-old, the advocate you want at your bedside is Dr. Lee, author of numerous research articles on caring for frail, elderly patients. He had the expertise to know that atrial fibrillation could reverse itself. “We wanted to give my mother a chance to get better,” he explained. “In a week, there was a good chance she could snap out of this.” But he also knew how hospitals function.

His sister arrived from Oregon. “We were trying as best we could to minimize the interventions that would make our mother uncomfortable,” he said. What he wanted was “high-touch, low-tech care”: people to reorient her in Korean (Mrs. Lee spoke little English), to offer her favorite foods instead of bland mush, to let her sleep. University hospitals don’t tend to operate that way.

“I had to be hyper-vigilant,” he said, describing his conversations with every new doctor and nurse. He feared further procedures and medications. “It was exhausting feeling I had to be constantly on the lookout against the vast machinery of the hospital.”

So Dr. Lee summoned the power of the H-word and asked for hospice care. The palliative care team agreed that this patient had better than 50/50 odds of dying within six months, the prognosis required for enrollment. Yet, “I told the hospice doctors that my best guess was, she’d graduate from hospice,” Dr. Lee said. “These were all problems that with time could get better.”

Once he wielded the amulet, “the change was fairly instantaneous.” And well-timed: The next day, as his mother awaited discharge, nurses noticed flecks of blood when she vomited, which sometimes signals internal bleeding. The normal procedure would have involved a naso-gastric tube (something Dr. Lee had tried on himself as a medical student and found intensely uncomfortable), then sedation and insertion of a second tube through her esophagus, into her small intestine. “But they didn’t do it,” Dr. Lee explained, with relief, “because she was under the care of a hospice.”

Instead, he took his mother home. Over the next four weeks, Pathways Hospice sent nurses, social workers, aides and a chaplain to her residence. Because she wasn’t a typical hospice patient, the Lees still encountered policies that didn’t quite fit her needs; for example, she didn’t need pain medication. Nonetheless, Mrs. Lee recovered her mental clarity, ate and slept better, regained strength.

“Invoking hospice allowed me and my sister to relax and have some confidence that the care she was getting was what she needed,” Dr. Lee said. Mrs. Lee, who was indeed discharged from hospice last month, is doing well.

Each year, more than 15 percent of elderly patients leave hospice care, usually because their health has stabilized, according to a 2008 study; some will return as their decline resumes. Discharge can be nightmarish for a family that’s come to rely on hospice help, but those are the Medicare rules hospices must play by.

Caring for those expected to recover is not what hospices are designed to do, of course. And Dr. Lee’s gambit wouldn’t work for most of us; we lack his knowledge.

But it’s a cautionary tale, if we needed another, of how hospital policies can be at odds with the needs of frail elders. The way to ensure the most personalized, least invasive care for Mrs. Lee was to say, in effect, “We’re taking her home to die.”

What’s wrong with this picture?


FOR IMMEDIATE RELEASE                                Contact: CMS Media Relations Group

May 30, 2012


Government partnering with providers, caregivers, patients to ensure appropriate use of antipsychotic medications

Today, Centers for Medicare & Medicaid Services (CMS) Acting Administrator Marilyn Tavenner announced the Partnership to Improve Dementia Care, an initiative to ensure appropriate care and use of antipsychotic medications for nursing home patients. This partnership – among federal and state partners, nursing homes and other providers, advocacy groups and caregivers – has set a national goal of reducing use of antipsychotic drugs in nursing home residents by 15 percent by the end of 2012.

Unnecessary antipsychotic drug use is a significant challenge in ensuring appropriate dementia care. CMS data show that in 2010 more than 17 percent of nursing home patients had daily doses exceeding recommended levels.

“We want our loved ones with dementia to receive the best care and the highest quality of life possible,” said Acting Administrator Marilyn Tavenner. “We are partnering with nursing homes, advocates, and others to improve the quality of care these individuals receive in nursing homes. As part of this effort, our partnership has set an ambitious goal of reducing use of antipsychotics in nursing homes by 15 percent by the end of this year.”

CMS and industry and advocacy partners are taking several steps to achieve this goal of improved care:

Enhanced training: CMS has developed Hand in Hand, a training series for nursing homes that emphasizes person-centered care, prevention of abuse, and high-quality care for residents. CMS is also providing training focused on behavioral health to state and federal surveyors;

Increased transparency: CMS is making data on each nursing home’s antipsychotic drug use available on Nursing Home Compare starting in July of this year, and will update this data;

Alternatives to antipsychotic medication: CMS is emphasizing non-pharmacological alternatives for nursing home residents, including potential approaches such as consistent staff assignments, increased exercise or time outdoors, monitoring and managing acute and chronic pain, and planning individualized activities.

“A CMS nursing home resident report found that almost 40 percent of nursing home patients with signs of dementia were receiving antipsychotic drugs at some point in 2010, even though there was no diagnosis of psychosis,” said CMS Chief Medical Officer and Director of Clinical Standards and Quality Patrick Conway, M.D. “Managing dementia without relying on medication can help improve the quality of life for these residents. The Partnership to Improve Dementia Care will equip residents, caregivers, and providers with the best tools to make the right decision.”

These efforts will help achieve the 15 percent reduction goal by the end of this year. In addition, to address this challenge in the long-term CMS is conducting research to better understand the decision to use or not to use antipsychotic drugs in residents with dementia. A study is underway in 20 to 25 nursing homes, evaluating this decision-making process.  Findings will be used to target and implement approaches to improve the overall management of residents with dementia, including reducing the use of antipsychotic drugs in this population.