Chapter 35: Older Adults in Psychiatric Nursing

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You know, usually when people talk about a tsunami in the news, it's about climate change or some geopolitical disaster.

But there is a different kind of wave coming, one that is going to fundamentally break and hopefully remake the way we practice health care.

And for once, I'm not being hyperbolic.

You're talking about the silver tsunami.

Exactly.

Welcome back to The Deep Dive.

Today we are taking apart chapter 35 of Psychiatric Nursing, seventh edition.

The focus is older adults.

And before you tune out thinking, okay, geriatrics, that's a niche specialty for people who like nerfing homes.

You need to look at the numbers we found in introduction.

This isn't a niche.

It's definitely not a niche.

It's the future baseline of medicine, the source material projects that between 2010 and 2030, the population over age 65 is nearly doubling.

Doubling.

We are looking at a jump to 72 .1 million people.

That is a massive, massive chunk of the population.

And it's not just that people are getting older, it's the kind of older they are getting.

The text highlights a specific group,

the old old, which I have to say is a term that feels a little on the nose, but it's scientifically distinct, isn't it?

It is, yeah.

We aren't just lumping everyone over 65 into one big bucket.

The old old refers to the over 85 demographic.

And by 2050, that specific group is expected to increase fourfold.

Fourfold.

So we have people living longer with more complex physiology and crucially, for our discussion today, much more complex mental health needs.

The National Institute of Mental Health dropped a statistic in the text that just stopped me in my tracks.

They estimate that by 2030, which is right around the corner.

It's basically tomorrow.

Right.

15 million older adults are going to need mental health services.

15 million.

And the terrifying part of that stat is that our current system just isn't built for it.

We are structurally, fundamentally unprepared.

So our mission today is pretty clear.

We need to decode how mental illness looks different in this population because it does look different.

It really does.

We need to understand the biology that makes medicating them like a high -stakes game of 3D chess.

Exactly.

And we need to give you, the nurse, the student, the tools to assess the difference between just getting old and a treatable illness because, and this is the big takeaway, being miserable is not a normal part of aging.

Say that again.

That feels like the thesis statement for this whole deep dive.

Being miserable is not a normal part of aging.

It's a symptom.

Okay.

So here is the roadmap for today.

We are going to start with the barriers to care.

Why are these 15 million people falling through the cracks?

Then we'll look at the continuum of care from prevention all the way to the legal landscape.

After that, we get into the clinical heavy lifting, psychopathology, we'll break down depression, the surprisingly high suicide risk, psychosis, and the hidden epidemic of substance use.

And finally, the how -to.

The how -to assessment and interventions, what you can actually do about it.

Let's get into it.

Let's start with those barriers because the text presents this paradox.

We have this exploding population, a massive market for healthcare, and yet older adults are consistently the most underserved group in mental health.

Why is that?

What's going on?

It's a perfect storm of three things.

The patient, the provider, and the system.

And honestly, it starts with the mindset of the patients themselves.

You have to remember the generation we are treating right now.

We're talking about the greatest generation or the silent generation, people born in the 20s, 30s, 40s.

Precisely.

Think about their upbringing.

They grew up in an era where you didn't talk about your feelings.

You didn't air your dirty laundry.

You pulled yourself up by your bootstraps.

Right.

It was a sign of weakness to complain.

A huge sign of weakness.

So right off the bat, there is a massive stigma.

They often view mental struggle as a character flaw, a personal failing rather than a biochemical issue.

They think I should be tough enough to handle this on my own.

But even more dangerous than the stigma is what the text calls the myth of normal aging.

Yeah.

Can we unpack that?

Yeah.

Because I feel like even I have fallen for this trap.

Oh, it's pervasive.

The myth of normal aging is the belief held by seniors and often their families, which is really key,

that feeling sad, having the blues, losing your memory, just feeling worthless is an inevitable part of the deal.

It's just what happens when you get old.

Exactly.

They think I'm 80.

My friends are all gone.

My back hurts.

Of course I'm depressed.

Who wouldn't be?

So they don't report it because they don't view it as a medical problem.

They see it as just life.

Yeah.

They normalize their own suffering.

And beneath that stoicism, that tough it out mentality, there is fear.

The text is very specific about this.

They fear that admitting a mental problem is a one way ticket to a loss of independence.

They are terrified of being put away.

The fear of the nursing home.

The fear of the nursing home.

Or even before that, just the fear that if they admit they can't handle things, their children will step in and take away the car keys or the checkbook.

The symbols of autonomy.

The absolute core symbols of autonomy.

So they stay silent to protect their independence.

Which brings us to the provider barriers.

Yeah.

Because even if a patient does seek help, or at least shows up at the doctor's office for their blood pressure, the medical system often misses it entirely.

This is what we call the primary care bottleneck.

And it's a huge issue.

Older adults are far more likely to see a general practitioner or a primary care physician than a psych specialist.

Of course.

Now think about a standard 15 minute appointment for an 80 year old.

It's a race against the clock.

It's impossible.

You're checking blood pressure, diabetes, cholesterol, arthritis, kidney function, maybe a weird mole on their back.

Mental health is number 10 on a five item list.

If it makes the list at all.

Right.

And this is compounded by professional ageism.

The text defines this clearly as negative stereotyping where professionals dismiss treatable conditions as just old age.

A nurse sees a confused patient and the first thought is dementia.

The brain just jumps right to that conclusion.

Jumps to it.

Instead of asking, wait, is this a CUTI?

Is this dehydration?

Is this depression?

Is this medication side effect?

We leap to the irreversible conclusion.

There's also a technical barrier here regarding how older adults communicate their pain.

The text mentions somatic complaints.

Break that down for us because this is so important for assessment.

This is critical.

Older adults, especially from that generation, often lack the emotional vocabulary to say, I feel despondent or I feel empty inside.

They weren't taught to speak that way.

So they can't label the emotion.

They can't.

So instead, they somatize.

They express the psychological distress through the body.

They will come into the clinic complaining of a stomach ache, chronic back pain, profound fatigue or insomnia.

So they say my stomach hurts, but what they really mean is I am grieving.

Yes, exactly that.

And if the clinician isn't trained to look for that translation, they end up chasing the physical symptom.

They order endoscopies, colonoscopies, MRIs, a battery of blood work, all the expensive stuff.

Right.

And everything comes back negative.

The doctor says, good news.

You're perfectly healthy.

And the patient goes home just as depressed as before.

But now they also feel like a burden or like they're crazy, which leads us directly to the system economic barriers, the wallet,

because chasing those phantom symptoms isn't cheap.

It's incredibly expensive.

The text cites a study here that I found mind blowing regarding the cost of untreated depression.

They analyzed Medicare claims.

Older participants with a diagnosis of depression incurred about $22 ,960 in total healthcare costs per year.

$23 ,000.

Okay.

Compare that to someone without depression, about $11 ,956.

So wait, depression literally doubles the cost of keeping that person alive and functioning doubles it.

That is a staggering financial impact.

It's unbelievable.

But here is the kicker.

Here's the part that just makes you want to scream specialty mental health care, a psychiatrist, a therapist accounted for less than 1 % of those total costs.

Wait, wait, let me get this straight.

The cost double,

but virtually none of that extra money is actually going to treat the root cause.

Correct.

It means we aren't spending money on treating the depression.

We are spending that extra $11 ,000 treating the consequences of the depression, the heart attacks, the poor compliance with diabetes meds, the physical decline, the ER visits from falls.

We are paying a fortune for the fallout because we won't pay pennies for the cure.

And for the patient on a fixed income, Medicare has pretty strict limitations on mental health reimbursement, which means they're often caught in a terrible bind.

Right.

If you have a limited budget and you have to choose between your heart medication, which you know keeps you alive today, and an antidepressant, which makes life worth living, what are you going to choose?

You are going to choose the most basic, impossible choice that the system forces them to make.

Let's move to the continuum of care.

The text describes this delicate ecosystem that keeps an older adult functioning.

It's not just about biology.

It's about their whole world.

It's a balance of three pillars, physical function, social function, and emotional function.

And the text describes a domino effect.

If one of those pillars cracks, the whole house can come tumbling down.

Walk us through a scenario of this domino effect.

Give us a concrete example.

Okay.

Take a physical event, seemingly purely orthopedic, like a broken hip from a fall.

That's domino one.

Happens all the time.

Because of the hip, they're in rehab for a month, and when they come home, they can't drive.

Domino two, loss of independence.

Because they can't drive, they stop going to the bridge club or church or even just the grocery store.

Domino three, social isolation.

And what does isolation lead to?

Isolation is the fast track to depression.

Yeah.

So you see how it works.

One slip on a rug can lead to a major depressive episode in a matter of months.

It happens so fast.

One day they're active and engaged, and three months later they're isolated and depressed, all starting from a fall.

The text calls out specific stressors in box 35 -2.

Relocation seemed particularly harsh to me.

Relocation trauma is very real.

Imagine living in a home for 40 or 50 years.

Your identity is tied to that neighborhood, that garden you planted, the height of the counters in the kitchen you know by heart.

It's the center of your universe.

It is.

Moving to a facility, even a nice one, isn't just a change of address.

It's a stripping of identity.

It disrupts their entire connection to the world.

Independence.

The text frames this as perhaps the ultimate fear.

It is the loss of autonomy.

It's terrifying.

This is why mastery is such a crucial adaptive mechanism for them.

And this is something nurses can directly influence.

And so?

By giving choices.

It sounds so trivial, but asking do you want your bath at 9 a .m.

or 10 a .m.

or would you prefer the window seat in the dining room?

Restore is a tiny fragment of agency.

It tells the patient you still have a say in your own life.

It's a small act of restoring dignity.

A huge act of restoring dignity.

The text also emphasizes meaning as a coping mechanism.

What's that mean in this context?

It's how older adults find their place.

They're constantly comparing themselves to their peers to meaning.

You'll hear them say things like, well, I might have arthritis, but at least I'm not in a wheelchair like Bob.

Or at least I still have my mind.

At least I still have my mind.

Exactly.

It's a way of validating their own survival.

I'm still here, so I must be doing something right.

It's a powerful psychological tool for them.

What about the resources available?

The text highlights the AAA, which I think a lot of us might not know about.

The Area Agency on Aging.

If you are a nurse working in the community, you need to memorize this.

Put it in your phone.

The AAA is a lifeline.

They help negotiate access to care, but specifically they coordinate things like transportation.

Which we just said is a major link to the outside world.

It's everything.

We just said that lack of driving leads to isolation.

The AAA is the logistical bridge that keeps these people connected to their doctor's appointments, to the senior center, to society.

Before we get to the thesis, we need to talk about the legal environment.

A little history lesson.

We hear about

deinstitutionalization a lot in mental health, but how did it impact the elderly specifically?

It was a massive and in some ways catastrophic shift.

Post -1963, following the Community Mental Health Act, we emptied the big state psychiatric hospitals.

The idea was compassionate move people to community -based care.

That's good on paper.

Sounds great.

But the community centers weren't ready.

They weren't funded.

So thousands of older adults with chronic mental illness were essentially dumped into nursing homes.

Which became warehouses, right?

That's the term the text uses.

That's the brutal, the accurate term for it.

And because the staff at these nursing homes wasn't trained for psychiatric care, they were trained for bedpans and blood pressure, they didn't know how to handle behavioral issues like agitation or wandering.

So what do they do?

They used restraints, physical restraints, tying people to beds and chairs, and chemical restraints, sedating them into a stupor with powerful drugs.

That sounds like a horror movie.

It was a dark, dark period in American health care until 1987.

Enter OBRA.

The Omnibus Reconciliation Act.

Why was this such a watershed moment?

OBRA brought down the hammer.

It set strict federal limits on the use of physical and chemical restraints.

You can't just sedate a patient because they're annoying you or wandering at night.

You have to have a medical reason.

A documented medical reason.

It regulates psychotropic drugs.

There are strict rules on dosing, duration, and justification.

And crucially, it requires pre -admission screening.

It basically said you cannot use a nursing home as a dumping ground for mental illness without providing actual documented treatment.

It forced a standard of care.

That is a vital protection.

Okay, let's get into the clinical meat.

Section 3, psychopathology.

We are starting with the big one, depression.

They call it the common cold of geriatrics.

But don't let that nickname fool you.

It's not benign.

It's lethal.

Let's look at theta.

Table 35 to 1 shows the prevalence.

It's not a flat line as we age, is it?

It's not like you get depressed at 65 and it just stays there.

No, not at all.

It's an upward curve.

Severe depressive symptoms increase with age.

By the group we talked about, the rates are over 22 % for both men and women.

That is nearly one in four people walking around with severe clinical depression.

One in four.

It's an epidemic hiding in plain sight.

We mentioned they somatize the stomach aches and back pain.

Okay.

But there's another presentation that is a major, major trap for nurses.

Pseudo -dementia.

This sounds like a trick question on a board exam.

It is a classic board exam concept, but more importantly, it's clinical mind field you'll encounter in practice.

Here's what happens.

Severe depression in an older adult can cause memory loss, disorientation, difficulty concentrating, and poor hygiene.

Which looks exactly like dementia.

Exactly.

To the untrained eye, it looks like Alzheimer's.

But here's the huge life altering difference.

Dementia is currently irreversible and progressive.

Pseudo -dementia, which is actually just depression in disguise, is treatable.

So if you treat the memory comes back, the dementia is cured.

That is incredible.

So how does a nurse tell them apart in the moment?

If I'm standing there with a patient who is confused and forgetting things, what do I look for?

What's the tell?

You have to be a detective.

The text gives some great clues.

In true dementia, the patient often tries to hide the deficit.

They'll confabulate.

They make up stories to fill the gaps in their memory because they are embarrassed or unaware.

Right.

They're the patient is often just checked out.

They don't try to hide it.

They'll just say, I don't know, or I don't care to your questions.

There's an apathy to it.

So the attitude is different.

The attitude is completely different.

And you look for the affect, the mood.

In dementia, the mood can be shallow or lay ball changing quickly.

In pseudo dementia, look for a consistent downcast mood.

If you see that heaviness, that apathy, you have to screen for depression before you even think about slapping on a dementia label.

That distinction changes a life.

One is a diagnosis of decline.

The other is a diagnosis of potential recovery.

Now we have to talk about the most severe outcome of depression.

Suicide.

The statistics here are sobering.

Older adults make up about 12 % of the population, but account for 16 % of all suicides.

But we need to drill down into the demographic data in table 35 -2 because one group is screaming for attention.

Who is at the highest risk?

It is by a huge margin, white men over the age of 85.

The rate is 49 .8 per 100 ,000.

For comparison, the rate for teenage girls is about five per 100 ,000.

So it's 10 times higher.

10 times higher is an astronomical rate.

Why is it so high and why is it so lethal in this group?

It's lethal because of intent and method.

Adolescents might use suicide attempts as a cry for help or an impulsive act.

There's often ambivalence.

Older adults, especially older men, generally do not make gestures.

If they attempt, they intend to die.

And the methods reflect that?

Absolutely.

They use firearms.

They use lethal doses of medication.

They don't leave room for rescue.

There's also the concept of silent suicide.

This gave me chills when I read about it.

Can you explain that?

This is what kills me because we see it all the time in hospitals and nursing homes and don't name it.

This is death by self -neglect.

It's the patient who just stops eating, the patient who forgets their heart medication three days in a row, the patient with diabetes who starts eating candy bars all day.

It's a passive slide into death.

It is.

It's a choice to give up.

It doesn't get recorded as a suicide on the death certificate.

It gets recorded as heart failure or failure to thrive.

But it is a conscious or semi -conscious choice to end the suffering.

We have two clinical examples in the text that illustrate the mindset here.

Mr.

Nelson and Mr.

Timchuck.

Let's talk about Mr.

Nelson first.

Mr.

Nelson was 86.

He had a tragic history.

He had outlived two wives.

He tried to be intimate with a new partner and failed due to erectile dysfunction.

And the shame of that just broke him.

He told the nurse, I'm just no good anymore.

That loss of function struck at his core identity as a man.

Exactly.

It wasn't just about the physical act.

It was about vitality, about being a man.

And then there was Mr.

Timchuck.

He was a COPD patient struggling for every single breath.

He couldn't walk to the mailbox without gasping for air.

He flat out told the nurse, I'd be better off dead.

The takeaway for the nurse here is about directness, right?

You can't dance around this.

You cannot beat around the bush.

You can't worry that asking about suicide will plant the idea.

That is a dangerous myth.

You have to ask directly and without judgment, are you thinking about hurting yourself?

Do you have a plan?

It might be the first time anyone has ever asked them that question, and it might be the only lifeline they have.

Let's pivot to the other disorders.

Section four, bipolar, psychosis, and anxiety.

Let's start with bipolar.

Is bipolar in the elderly just bipolar I grown old?

Not always.

We distinguish between early onset, which they've had all their life, and late onset.

Late onset bipolar is defined as starting after age 40, and the presentation is, well, it's muddier.

It's less classic.

You see less of the euphoric high top of the world mania.

Instead, what you often see is more irritability, confusion, and paranoia.

Structurally, late onset is often triggered by medical issues, a stroke, a metabolic imbalance, sometimes even a brain tumor.

It's often a sign that something is wrong physically in the brain.

We have the story of Mrs.

Ellington to illustrate mania.

It's quite a picture.

A very vivid picture.

Mrs.

Ellington was 72.

She was found outside a homeless shelter wearing animal print leggings,

thigh high white boots, and a wide brimmed hat.

And throwing her dentures.

Throwing her dentures at the staff and claiming to be a famous Hollywood star.

It sounds almost comedic when you describe it, but it's a tragic display of grandiosity and a complete failure of judgment.

It illustrates that mania in the elderly can be disruptive and bizarre.

It's not just energy.

It's a complete break from social norms.

What about schizophrenia and psychosis?

Again, late onset is distinct.

It often hits women more than men, which is different from early onset.

And the symptoms are heavily, heavily paranoid.

The neighbors are typing gas into my apartment.

The mailman is stealing my spoons.

The small persecutory delusions.

Exactly.

But interestingly, they often maintain their personality better than younger patients with schizophrenia.

They have less of that flat affect or disorganized speech.

They can hold a conversation with you, but the content of the conversation is delusional.

Why the paranoia?

The text offers a psychological explanation that makes a lot of sense to me.

Think about it from their perspective.

As you age, your senses fail.

You can't hear well.

You can't see well.

You're physically frail.

The world feels dangerous and you feel vulnerable.

Paranoia is almost a defense mechanism.

It explains the danger in a way that protects the ego.

It's not I'm losing my keys because my memory is failing.

It's I'm losing them because someone is stealing them.

It makes the world make sense, even if the sense it makes is scary.

However, and this is a big however, we have the cruel hoax story, the story of Mrs.

Justice.

This is a warning to every single clinician.

Mrs.

Justice was 81.

She came in telling her nurse that haunts ghosts were breaking into her house at night and stealing her things.

Easy to chart that as delusional disorder, paranoid type and prescribe an anti -psychotic.

Which would have been a disaster.

The nurse thankfully actually listened.

She went to the home.

She found broken window latches.

She got the police involved.

They set up surveillance and they found two young men hiding in the shrubbery wearing white sheets to terrorize and rob her.

The haunts were real.

They were real.

The lesson is always investigate reality.

Never ever assume it's a delusion until you have ruled out the truth.

Older adults are prime targets for abuse, scams and theft.

If a patient says someone is stealing from them, check the bank account, check the locks on the windows, be a detective.

Let's touch on anxiety.

It's the most common comorbidity with depression.

And it is the great mimicker of medical crises.

If you look at box 35 to five, it lists the symptoms.

Anxiety in the elderly presents with chest pain, palpitations, shortness of breath, GI upset, dizziness.

Which looks exactly like a heart attack.

Exactly like a heart attack.

So you have to rule out the MI first, obviously.

But you have to realize that anxiety due to a general medical condition is huge in this population.

If you have COPD and you can't breathe, you are going to be anxious.

It's a physiological feedback loop.

The air hunger creates panic and the panic worsens the air hunger.

Now section five,

the text calls this the invisible epidemic substance use.

It's invisible because grandma isn't out robbing liquor stores to get a fix.

She's drinking sherry in her living room every afternoon to numb the loneliness or the arthritis pain.

It's hidden.

But the physiology,

this is the key insight I want everyone to get.

Alcohol hits an older person harder.

Why?

It comes down to body composition.

As we age, we lose lean muscle and crucially, we lose total body water.

Alcohol is water soluble.

It needs water in the body to dilute it.

So if you have a 30 year old and an 80 year old and they both drink the exact same glass of wine, the 80 year old has less water to dilute it.

Far less.

So the concentration of alcohol in their blood is much higher.

How much higher?

Significantly.

The text says a drink at age 65 produces a blood alcohol level 20 % higher than the same drink at age 30.

Their body reacts as if they binge drank even if they only had one or two glasses.

And the symptoms,

falls, confusion, self -neglect, slurred speech.

He just looks like getting old.

Right.

A family member sees grandma stumbling or slurring her words and thinks, oh, her dementia is getting worse.

They don't think she's intoxicated.

So it gets missed over and over again.

Then there are prescription drugs, benzodiazepines.

The text really goes after them.

They are the villains of geriatric psychiatry.

Valium, Xanax, Ativan.

These drugs are lipid soluble, meaning they are fat soluble and they are sedating.

They cause falls.

And a fall for an older adult can be a terminal event.

A broken hip leads to surgery, leads to pneumonia, leads to death.

The text is very firm on this.

Older women are at an especially high risk here.

And we have to mention polypharmacy.

The prescription cascade.

A patient takes a pill for high blood pressure.

A side effect is urinary frequency.

They think they have a bladder problem.

So their doctor gives them a pill for that.

That pill makes them dizzy.

So they get a pill for vertigo.

Suddenly they are on 15 medications and half of them are just treating the side effects of the others.

It's a mess.

So we need to screen for this.

The text mentions CAGE and GMAST.

Simple, effective tools.

CAGE is great because it's short and easy to remember.

Have you ever felt you should cut down?

Have people annoyed you by criticizing your drinking?

Have you ever felt guilty about it?

And have you ever had an eye -opener first thing in the morning?

Four simple questions that can uncover a hidden life -threatening problem.

Okay, we have covered the problems in depth.

Now, section six, assessment strategies.

How do we actually talk to these patients to get this information?

What's the approach?

Rule number one, patience.

That's the clinical skill.

You have to slow down.

If you rush, they will shut down.

They feel like a burden and they'll just start saying yes to everything to get you out of the room faster.

The text gets specific about the physics of sound in box 35 to 9.

This was fascinating to me.

It's not just about speaking louder.

No, in fact, shouting can make it worse.

Presbycusis is the technical term for age -related hearing loss.

It affects high frequency sounds first.

So the worst thing you can do is shout in a high -pitched loud voice.

It just lowers your pitch.

Speak in a deeper tone, a baritone if you can.

Face them directly so they can see your lips.

And turn off the TV in the background to cut out competing noise.

Simple things that make a world of difference.

And psychologically, the text suggests listening to stories.

It's called life review.

And it's a powerful assessment tool.

Older adults process their lives through storytelling.

A novice nurse hears this and thinks, I don't have time for this rambling about the war or the farm.

An expert nurse listens for the themes.

Is this a story about loss?

About guilt?

About unresolved conflict?

About pride?

The story is the assessment.

It tells you their mental state.

We also need to distinguish between ADLs and IADLs.

This isn't just alphabet soup.

It's a functional hierarchy that tells you a lot.

Right.

ADLs are the basics of self -care.

Bathing, dressing, toileting, eating.

If you lose those, you need 24 -hour care.

But IADLs, instrumental activities of daily living, are the complex executive tasks.

Things like managing a checkbook, using a smartphone,

shopping for ingredients, and cooking a full meal.

Why does the distinction matter so much for assessment?

Because IADLs go first.

You will lose the ability to balance your checkbook or figure out your complex medication schedule long before you lose the ability to put on your pants.

Spotting a decline in IADLs is the early warning system for cognitive decline, dementia, or severe depression.

Finally, section seven, psychotherapeutic management, the interventions.

It starts with the nurse -patient relationship.

We have to combat the ageism we talked about earlier, and the best way to do that is by restoring the power of choice.

Even in very small ways.

Especially in small ways.

Do you want to wear the blue shirt or the red shirt today?

It seems trivial to us.

But to someone who has lost their home, their job, their spouse, and their health, choosing a shirt is a declaration that I am still a person with a will.

I still exist.

Let's look at the case study of Mrs.

Othelia Thatcher.

This case really ties so many of these concepts together for me.

Ms.

Thatcher is 78.

She has a history of severe depression and has been hospitalized twice before.

She responds well to ECT, electroconvulsive therapy.

Her cousin brought her into the hospital because she stopped eating.

She has to be spoon fed.

And there's a backstory of loss that is just heartbreaking.

A brutal one.

Her son abandoned her to the state and sold all her furniture while she was in the hospital for pneumonia.

She lost her home, her belongings, and her family connection in one single cruel swoop.

So she has depression, but also paranoia.

The cousin says she has a paranoid view of life.

But you have to ask yourself, given her son's betrayal, is that paranoia or is it a rational learned response to reality?

Her care plan involves nutrition.

We have to get her to eat and establishing a routine.

But it illustrates how complex these cases are.

It's not just biology.

It's biography.

You can't fix her just with a pill.

You have to understand the loss.

Speaking of biology, though, we need to do the deep dive into psychopharmacology, the start low, go slow rule.

We hear it all the time, but I want to understand the why.

What is happening in the body?

It comes down to pharmacokinetics.

This is how the body moves the drug around.

We need to look at four steps.

Absorption, distribution, metabolism, and elimination.

Absorption.

The stomach has less acid and it moves slower.

So drugs take longer to get into the system.

It's a delayed effect.

Second, and this is the most important one,

distribution.

This is the fat water issue again, isn't it?

It's absolutely the fat water issue.

As we age, we gain body fat and we lose total body water.

Now, many psych drugs, like most antidepressants and benzodiazepines, are lipid soluble.

They love fat.

They soak into that body fat like a sponge.

So they get trapped in the fat tissue.

They get stored there, and then they slowly leak back out into the blood over time.

This extends the half -life of the drug.

A dose that clears a young person's body in 12 hours might stay in an older person's body for 36 or 48 hours.

So if you give the next dose on the standard 24 -hour schedule, you are stacking the new drug on top of the old drug that hasn't left yet, and that leads to toxic accumulation and horrible side effects.

Wow.

And at the same time, because they have less body water and less albumin, which is a protein in the blood that binds to drugs, the water -soluble drugs have nowhere to go.

So their concentration in the blood spikes too high, too fast.

It's a double -edged sword.

The metabolism and elimination.

The liver, which metabolizes drugs, has reduced blood flow, so it cleans the blood slower.

And the kidneys, which eliminate drugs, have reduced function, a lower GFR.

So they excrete the drugs slower.

Everything enters slower, stays longer, acts stronger, and leaves slower.

Hence, start low, go slow.

So practically speaking for a nurse on the floor, what medications do we choose?

For depression.

SSRIs like Zoloft or Lexapro are the gold standard.

They are generally much safer and better tolerated.

We avoid TCAs, the tricyclic antidepressants.

Why avoid TCAs?

They used to be common.

Orthostatic hypotension.

TCAs make your blood pressure drop dramatically when you stand up.

That leads to dizziness, which leads to falls, which leads to broken hips, which leads to death.

The risk profile is just too high in this population.

And for antipsychotics?

We prefer the atypicals, like Risperidone or Seroquel.

The older traditional drugs like Holoperol have a very high risk of tardive dyskinesia, those permanent involuntary jerky movement disorders.

We want to avoid that at all costs.

And anxiety.

We already said

Avoid long -acting Benzos like Valium.

Use Busperone if you can.

It's non -sedating and non -addictive.

If you absolutely have to use a Benzo for acute panic, use a short -acting one like Lorazepam and for the shortest time possible.

One last intervention area.

The environment.

Million management.

It's all about normalizing the environment.

You want it to feel less like a hospital and more like a home.

Let them have personal items, photos from home, their own bedspread.

Staff should wear street clothes, not scrubs, to reduce the institutional feel.

And safety is paramount.

Table 35 -5 in the text is a great checklist.

Think about vision.

High contrast colors are key.

If a floor is white and the wall is white, an older adult with poor vision can't see the corner and will walk right into it.

Use contrasting colors.

A dark baseboard.

A red toilet seat on a white toilet.

Non -slip floors.

Grab bars everywhere.

Proper lighting that reduces glare.

And therapies.

The non -pharmacological stuff.

Pet therapy is wonderful for lifting depressive symptoms.

Music is amazing for mood and for making contact with non -verbal patients.

It taps into deep old memories.

And reminiscence therapy.

This isn't just encouraging them to live in the past, right?

Not at all.

It's a structured recall of the past.

It validates their life.

It improves self -esteem and helps them face their own mortality by seeing their life as having had meaning and purpose.

It brings it all back to that search for meaning we talked about at the beginning.

It does.

It closes the loop.

This has been a really comprehensive look at Chapter 35.

Let's recap the cheat sheet for our listener.

The absolute must -knows.

Okay.

Number one, barriers.

It's not just cost.

It's ageism and the myth of normal aging.

Depression is not normal.

Number two.

Depression itself.

It's common.

It presents with somatic symptoms like pain and fatigue.

But again, it is not a normal part of getting old.

Number three, suicide.

The risk is highest in white men over 85.

Look for lethal intent and ask direct questions.

Number four, meds.

Start low.

Go slow.

Remember the pharmacokinetics?

The fat -water ratios change everything.

And finally, number five, the ultimate goal of care.

Safety and independence.

Everything we do should be aimed at maximizing those two things.

I want to leave you in the final provocative thought.

We talked about silent suicide.

The act of slowly giving up on life by refusing food or medication.

It's the most haunting concept in the entire chapter, I think.

So the next time you are on the floor and you see that older patient who is just quiet or not hungry today or forgetting their meds, I want you to challenge yourself.

Are they just aging?

Or have they made a quiet, desperate decision to let go because they've lost their autonomy and their connection to the world?

It's a heavy question, but asking it even just to yourself might save a life.

Absolutely.

It changes how you see them.

Thank you for listening to this deep dive.

From the Last Minute Lecture Team, thank you.