Isolation, Comorbidities Play a Part in Psychiatric Issues

Consider “the whole patient” when treating anxiety, memory disorders

Physician talking with patient

Psychiatrists who treat older adults for anxiety, depression, memory disorders, and psychiatric manifestations of neurological diseases often encounter complex and interconnected circumstances that contribute to the development and exacerbation of patients’ conditions.

Geriatric psychiatrist Kim G. Johnson, MD, who also serves as chief of memory disorders for the Department of Neurology, says it’s important to evaluate and treat the whole patient—looking beyond the condition that may have brought the patient in for care and recommending and coordinating treatments with other specialists.

In this Q&A, she explains some of the comorbidities that make treating patients with psychiatric disorders challenging and how clinicians can help older adults who are coping with depression and anxiety, particularly amid the COVID-19 pandemic.

Q: What Duke specialties do you involve in the care of older patients?

Johnson: I see patients with cognitive decline, late-life and post-stroke depression, anxiety, psychosis, and other psychiatric issues. Many of these patients also have Alzheimer’s disease, Parkinson’s disease, vascular issues, and cardiac comorbidities, so I coordinate care with neurologists and cardiologists. I think the overlap between psychiatry and neurology is particularly important for this patient population, as patients over 65 tend to have more neurological diseases, and those tend to cause a lot of psychiatric comorbidities.

I also coordinate care with physical therapists for preventing falls, occupational therapists for cognitive rehabilitation, speech and hearing therapists for those having issues with language or communicating, and sleep specialists for patients with sleep disorders.

Q: What are some of the ways you help patients who are experiencing cognitive impairment?

Johnson: I often prescribe cholinesterase inhibitors for cognitive impairment. If patients already have a diagnosis of dementia, they sometimes have behavioral issues, psychosis, or agitation, so there are different non-pharmacologic and pharmacologic therapies to target those behaviors. Patients with Parkinson’s disease often have depression and anxiety so there are medications we use that can be effective.

But beyond medication management, a large part of what we do for older patients is provide counseling for patients and families on how to manage symptoms and help them develop a plan for the patient’s care. I like for my patients to have a primary care provider in their area, which gives them the security of a local provider as well as access to Duke specialists.

Q: How has the COVID-19 pandemic affected older patients with cognitive impairment?

Johnson: In preventing the spread of COVID-19, there’s been a lot of social isolation, which is not beneficial for this patient population. When you have cognitive issues, your brain really needs stimulation, and we tend to underestimate how much stimulation the brain gets from daily routines, keeping up with a schedule, and interacting with other people every day. When patients with dementia do not have this stimulation, their cognition worsens.

Patients with Parkinson’s disease are having a particularly hard time now because exercise is a big part of success in managing the disease itself and helping alleviate depression and anxiety, but many haven’t been able to go to a gym and have gotten off their normal schedules, which causes depression, anxiety and movement to worsen.

Q: What advice do you have for psychiatrists when helping older patients with anxiety and depression?

Johnson: When older patients start to experience new depression or anxiety, it may be secondary to cognitive decline, so I recommend a cognitive assessment and questions about how they are functioning. Often anxiety results from trying to function at previous levels, and also results from uncertainty about the cause.  It’s important to help patients develop lifestyle strategies to help manage their mood and anxiety levels. These are the tips I usually give my patients:

• Do as much as you can do—safely.

• Exercise and eat a Mediterranean diet.

• Keep your blood pressure, blood sugar, and cholesterol levels under control.

• Find some enjoyable activities to do at a safe distance to stay socially engaged with others, such as bringing your own food to an outdoor area and eating with friends.

• Have your hearing checked and treated if you notice any changes.

• Have any sleep disorders evaluated and treated.

• During COVID, consider living with a family member temporarily if you live alone and are experiencing stress or isolation.

• If going out is stressful, take someone with you to help you manage stress, and make sure you’re wearing your mask and washing your hands properly.