Mental Health Care for Older Adults

Senior Retreat is an in-patient program offered by MUSC Health that is helping older adults and their families navigate dementia or psychiatric crises. In this episode, Dr. Kevin Nasky, explains MUSC Health addresses serious mental health concerns or dementia-related crises in older adults and offers guidance to caregivers struggling to care for their loved ones.

"The more complicated things get, the more we can help, because we do approach patients comprehensively and from a multidisciplinary perspective, where if we need to we can have formal neuropsychological assessment, psychiatric assessment, a full medical work-up. We have the capability to do imaging, to get lab tests. … At any stage, whatever the illness is…the goal is to restore that person to the best version of themselves as possible."

– Kevin Nasky, D.O.

Topics Covered in this Show

• The Senior Retreat program was specifically created to fill a gap in psychiatric care for adults 65 and older who have special needs due to mental health as well as age-related psychiatric conditions.
• It's not uncommon for patients treated at Senior Retreat to have comorbidities. Managing medications for conditions such as hypertension, heart failure, chronic obstructive pulmonary disease (COPD), and diabetes, for example, must be strictly regulated in order to navigate unintended medication-related side effects that can be psychiatric in nature.
• Common causes of delirium in older patients are urinary tract infections (UTI), dehydration, and medication side effects. Medication minimization when possible is a priority for this reason.
• Senior Retreat staff include a wide variety of healthcare professionals, including social workers, activities therapists, internists, neurologists, neuropsychologists, and of course the nursing staff.
• ● Senior Retreat is a 20-bed facility with an average patient stay of a few weeks. Typical patients arrive often from emergency departments, assisted living facilities, skilled nursing facilities, and memory care centers.
• Nasky offers advice to families who are dealing with aging relatives, offering suggestions on caregiver burnout and the difficulty of transitioning a family member to a facility where more help is provided than the home environment.
• The transition from functioning dementia to incapacitating dementia can be gradual, yet difficult, because it may not always be clear how impaired an individual is, leading to conflict.
• Nasky advises family members and caregivers to "choose your battles" when it comes to dealing with loved ones with dementia, and follow the acronym "TADA" which stands for Tolerate, Anticipate, Don't Agitate. Unless there is a safety risk, it's best to let disagreements go and make efforts to de-escalate.

Read the Show Transcript

Erin Spain, MS [00:00:04] Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Addressing serious mental health concerns or dementia-related crisis in older adults may require inpatient care from a comprehensive team that includes psychiatrists, social workers and other specialists. MUSC Health offers this type of care through a program called Senior Retreat. Dr. Kevin Nasky is the medical director of Senior Retreat, which is located and MUSC Health's Kershaw Medical Center. He joins me today to talk about this program and how it's helping older adults and their families navigate dementia or psychiatric crisis. Welcome to the show, Dr. Nasky.

Kevin Nasky, D.O. [00:00:58] Thank you. Thank you for having me.

Erin Spain, MS [00:00:59] Tell me about senior retreat. When did it start and why did MUSC Health create this in-patient program specifically to address the needs of adults 65 and older?

Kevin Nasky, D.O. [00:01:11] It was summer of 2018. There was an opportunity for the hospitals then Kershaw Health to acquire the license through the state, to get 20 beds to dedicate to the 65 and up community for psychiatric, inpatient, acute psychiatric care, which there is a dearth of resources for in the community. The needs of 65 and up are different than the needs of folks in their twenties and thirties.

Erin Spain, MS [00:01:35] What are some special considerations when working with this older population who may be experiencing a dementia-related episode or a psychiatric crisis?

Kevin Nasky, D.O. [00:01:46] You have both populations. Folks that have lived and struggled with illnesses like schizophrenia, bipolar illness or depressive disorders sometimes need hospitalization. And those needs don't go away just because they're 65 or older. And then, of course, with dementia, as dementia progresses, it is common to see behavioral manifestations of dementia that sometimes require inpatient treatment. So what's unique in terms of this population's needs are they can be more frail. And of course, 65 is a lot different than 85. But frailty sometimes is independent of age because there's a lot of factors that will affect that. There's chronological age and then there's physiological age, the medical comorbidities. And of course, sometimes we have this and you can have a 25 year old with diabetes on an adult psych unit that's going to have some needs for some medical supervision. But in our population, folks are coming in sometimes with multimorbidity, COPD, heart failure, hypertension, diabetes, and all of this has to be managed. And sometimes there's even acute medical issues that are complicating factors, such as the most common that people hear about and talk about is probably urinary tract infections, which a younger person can sometimes shake that off. The older we are and and if we have any any pre morbid cognitive impairment, the delirium associated with so-called minor medical illnesses like a UTI or an upper respiratory infection can now become really incapacitating from a neurological psychiatric perspective, caused a lot of impairment. The brain is more affected and takes longer to recover.

Erin Spain, MS [00:03:12] A lot of these patients are dealing with multiple medications that they're on, and that's something else that your team is qualified to handle.

Kevin Nasky, D.O. [00:03:20] Elderly people with more complex, complicated medical conditions are going to be a lot more sensitive to drug interactions, medication side effects and just the sheer number of medications. You know, if you have somebody on 20 medications, it takes a lot more vigilance to go through that list and figure out. I mean, I would say that after infectious and metabolic causes, like I was so UTI and dehydration are very high on the list of what causes delirium as an exacerbating factor in dementia. Number three is probably medications. And some of them some of those culprits are psychiatric medications, too. And sometimes they're supposed to be a short term treatment, like a sleep aid or an anxiety medication that no one's really paying attention. And of course, five years later, that person may have lost weight. There may be metabolic reasons that the dose of a sedative five years ago is now impairing and causing problems. So upon every admission, we're taking a close look at it. Sometimes we get pharmacy involved and we try to thoughtfully prescribe. There's also a pill burden as well. And you see some folks that are in facilities. I mean, they're literally getting a cup of pills. And sometimes you just have to say, time out. Let's look at every single one. Again, you want to coordinate this and you want to talk to primary care. And if I have any questions, I stay in my lane as a psychiatrist. And if I'm uncertain, if someone, hey, do they need to be on for antihypertensive agents even if their blood pressure is low? We have internal medicine physicians here in the hospital that we can consult and say, hey, we take a look at this for us and see if we can optimize this person's medications, which often means minimizing.

Erin Spain, MS [00:04:50] Well, that's a good point to bring up. This is comprehensive care. Tell me about the different types of folks that a patient or their families may encounter at senior retreat.

Kevin Nasky, D.O. [00:05:00] There's myself, a psychiatric nurse practitioner. We have social workers, activities, therapists. Obviously, our nursing staff, many of whom have been with us for the duration now of almost four years, acquired quite a bit of expertise in all the aspects of managing folks in this population. We have hospitalists and internists that we can consult and then sometimes there is considerable overlap between us in neurology. There are some conditions, there are some neurological conditions that can have psychiatric manifestations and vice versa. And we also have a neuropsychologist who really specializes in formal cognitive assessment. It's one thing to say somebody has dementia or even mild or moderate or severe. It's another thing to really grade and stage that dementia and determine, hey, where are the specific weaknesses or vulnerabilities and sometimes even also strengths. It's good to identify those. And because that can help inform families about care needs at home or sometimes in that very difficult time where a decision needs to be made, can this person's needs be met in a home setting anymore? Do we need additional home resources or between these start looking at various levels of facilities. Sometimes it's obvious, but there are cases where it's nice to have a second opinion and a more formal assessment to identify those needs.

Erin Spain, MS [00:06:15] You mentioned this is a 20 bed facility and the average stay is a couple of weeks. Tell me about what happens during the stay. They're going to encounter these specialists that you mentioned and how do people find their way to senior retreat?

Kevin Nasky, D.O. [00:06:29] Typically, I would say that the typical patient is probably coming to us from an emergency department because a lot of times when there's a psychiatric emergency, which often means someone's in danger or potentially in danger, and you have somebody usually family or a caregiver calling 911. And then in that emergency department, usually the decision there is to figure out, is there an acute medical situation that needs to be addressed? Sometimes you have to figuratively stop the bleeding. So if there's an acute medical issue that requires more intensive medical treatment, that may need to be done first and then psychiatry is brought in later. Normally, folks are coming from emergency departments, sometimes from a hospital's medical floor. If that patient could get admitted medically and then either psychiatric issues, acute psychiatric issues emerged or the medical concerns were ruled out. So we get some folks that way. We get some direct referrals from facilities, assisted living, memory care, sometimes from skilled nursing facilities. At any stage in someone being institutionalized, there's risk for psychiatric issues, especially for someone with dementia. I would say the first few weeks or months, that's a high risk time. It's a very difficult transition for everybody and that person often and not understanding why, not having insight into their illness has now lost autonomy agency, lost their their home setting, familiarity, comfort people comfort items, their favorite foods. It's very difficult. And so we do get some folks from facilities that, hey, they just got admitted here a week ago and they're not doing well. Primary care officers who are aware of us. Sometimes even specialty officers. The word is slowly been getting out and very occasionally we'll get a direct call from a family member and then we kind of talk them through the referral process.

Erin Spain, MS [00:08:22] Families are so important when it comes to this type of care. Tell me how you involve families in the care of their loved ones and what kind of advice you would give to family members who are dealing with this type of situation.

Kevin Nasky, D.O. [00:08:37] So there are issues of privacy and it depends on the diagnosis and that patient's capacity for making decisions in general. And we assess that. And if the patient gives us permission and or they don't have the capacity to advocate for themselves. So health care proxy has been invoked and we're now dealing with a power of attorney and in some cases an assigned guardian or conservator. So as long as there's no patient privacy issues, we are absolutely talking to families. From the moment patients are admitted. We usually do a formal treatment team call with everybody - social worker, discharge planner, case manager, myself, nurse practitioner, nursing staff, activity therapist - everybody. Because we're really one of the advantages to in-patient hospitalization is this kind of 360 perspective. People are seeing that person at different points in a 24-hour day under different settings: the dayroom, sleeping, doing hygiene care, which is a disadvantage that you really don't get in a 15 or 20 minute office visit. We usually wait a couple of days to get to know the patient and then we have that phone call and we discuss. Sometimes it's a discussion about diagnosis or like I said, grading or staging that dementia. And again, there are other illnesses too. We could be talking about their bipolar mania or schizophrenia. And then a prognosis. And then we start getting an idea for what's going on at home if they are from home. And we try to assess the safety and just if it's if it's realistic for the person to go back home, you kind of have to feel out where everyone's at because sometimes the caregiver is a spouse and they're elderly, they could have their own health issues. They could have their own issues with activities of daily living. It could already be a challenge. So they might not have the physical capability or bandwidth to possibly care for someone with escalating needs. We're really trying to assess what the family is capable of. And of course, there's caregiver burnout. And you hear people there's so much guilt when they finally have to kind of tap out and acquiesce that, hey, I'm not a superhero. A lot of people see it's a failure when they have to start entertaining the idea of having a person placed in a facility. But really, it's a challenge. Even if you were to arrange a home caregiving or even in a facility, those people work shifts. They have days off, entire days off. They also have support. It's not one person in those folks who have training and support and days off and shifts off, they get burned out. So we've had some family members that have been a sole caregiver with little to no resources do this for years. Sometimes these meetings and conversations are aimed at helping them realize that it's okay that you can't do this anymore. You're human, and at some point it gets to be impossible or it's a detriment to your own health. And then now who's benefiting from this?

Erin Spain, MS [00:11:29] What are some of the practical advice that you give to caregivers, especially those who are dealing with a new diagnosis such as Alzheimer's? What are some things that they should keep in mind?

Kevin Nasky, D.O. [00:11:38] If you look at Alzheimer's dementia as a ten year illness and I'm generalizing here, but and you break that up into thirds 3 to 4 years mild, where you're still fairly highly functioning. But there's obvious memory issues which a lot of times people develop systems and ways to remind your systems, calendars, people to help you figure out your appointments, medications, paying bills, etc.. And at that point, folks are still aware they're amenable to the help from family and outside sources because they know that they have impairment. I would say somewhere in the middle of that, to the 5 to 7 year mark, you get a lack of awareness into your own deficits. There could be a denial of the illness and you get people start saying, I'm fine, I don't need your help with that. I can do this. I can do that. Or you tell them you need to take your meds. I really took my meds. I don't take that med anymore. You start getting into all these arguments and that's usually where it starts. And then obviously family members quarrel anyways, just that's normal. So to the advice part, and this can be very difficult because a lot of times you have a concerned spouse or a son or a daughter who's trying to make sure that their loved one is taking their meds on time, that they're eating, that they're sleeping enough for going to bed on time, hygiene, care, to do the things you need to do to try to keep your loved one with dementia healthy can get difficult, especially if you're that person's spouse or child. A lot of times it's kind of loaded. So for people who are still probably capable of returning home, but there's been a lot of conflict and turmoil between the caregiver and the person with dementia. My first advice is to pick your battles. There's an acronym called Tada! it's Tolerate, Anticipate, Don't Agitate. The first one of that is tolerate. And we teach this not just to families, but to people who are going to be working with dementia patients in the hospital. The tolerate can be one of the hardest parts. For some people. It's a struggle to tolerate mom skipping a meal or to tolerate their mom staying up till two in the morning. How many days do you let someone go if bathing is always a fight? How long can you tolerate that? Medications? Even in the hospital ward, sometimes we get to ward. Nurses are really trying to encourage patients to take their meds. First of all, start to say, hey, what are the morning meds? Some meds are more important than others. Okay, if it's the morning aspirin and maybe a multivitamin, maybe something for incontinence, we're not talking about life and death medications. So some of picking your battles is prioritizing. Well, what are we really fighting about right now? We just keep the peace. I think that's the number one piece of advice I could give to any dementia caregiver is picking your battles. Tolerate what you can until it becomes unsafe. Obviously, the anticipate one is when you start realizing there's a pattern certain times of the day. Now, some of this can't be done by caregivers at home. We can do it here on the unit, like this concept of sundowning, where there's this pattern common in dementia patients, where there is an increase in just activity in general and agitation at night. Sometimes I wonder if it's really initially agitation or if it's just their overall activity and energy level that might not match the energy and activity level or expected level of the environment they're in. So if everybody else is kind of winding down for the day and someone else is winding up, there's going to be a conflict there. And so sometimes there are some medications that can help with that. And sometimes it's not even about adjusting the type of medication or specific medication or its dose. It's just adjusting the timing. We accomplish a lot. Sometimes we can even sometimes minimize or reduce psychiatric medications, but get more of a benefit by careful, thoughtful timing of when those meds are administered. And then there are folks that argue not about these practical things. They argue about just anything in general, because a lot of times dementia patients are disoriented. Sometimes they are disoriented to time or their place in time. They think they're 20 years younger. A lot of times people, especially if they struggle with anxiety. But I think anybody could do this. You could have a mother that's concerned that she has to pick up her kids from school or that maybe her baby needs to be fed. I've had people that worked in a certain setting their whole life that had to have a certain report done by every time, every day. They're worried, sometimes early in the illness. The advice is to kind of help people with reality, because you can gently reinforce, Hey, Dad, remember what year it is or who the current president is. If they're disoriented and they're wrong about something arguing with a patient with dementia. Nobody wins. There is a point where reality testing capacity is maintained where they they can, through a conversation, be shown that they were incorrect about an assumption about something. But then eventually that goes away. And it's usually pretty obvious when you get there because everything's in argument all the time. Usually redirection is your best friend, distraction redirection. If you're finding that a certain topic, well, heck, we can pick the news. If there's something on television that's upsetting eventually, just don't put that on anymore. I've had people with dementia who watched True Crime all day long and then they become extremely paranoid. So you have to manage the content that people consume at some point that that don't agitate the last two. And that kind of goes with not arguing unless there is a safety risk. I would just let it go. And a lot of times the family members, we eventually learn if folks are with us for any length of time, we usually end up figuring out the type of music they like, a topic that they would like to talk about, something they like on television, a magazine about cars. Once you find out what is a pleasant distraction for that person, usually if you're in an argument, you can just quit arguing and bring up something pleasant. It can be a snack. I've seen situations de-escalated with ice cream. Caregivers get better at this, but you have to learn and you have to become more flexible. And there's you just have to shift your approach.

Erin Spain, MS [00:17:31] As we wrap up today, what message would you like to give to caregivers? What do you want them to know about Senior Retreat and this resource that's available if they need it?

Kevin Nasky, D.O. [00:17:42] Well, to start with that, we're here for when there's concerns about safety, and that can mean a lot of different things. Agitation has escalated to violence or threats of violence, or if behaviors have become so impulsive and erratic that the persons finding themselves in unsafe situations, wandering out at night, getting lost. Any obvious safety concerns err on the side of getting that person help. And another thing, and this is a really valid reason for hospitalization is sometimes you're not able to get any clarity on what's actually happening. You might have been told different things by different people. You don't understand what the diagnosis is. Sometimes it is confusing. Someone could have a history of one mental illness, but then start to develop signs of another. Or there could be something medical going on. I think the more complicated things get, the more we can help because we do approach patients comprehensively and from a multidisciplinary perspective where we if we need to, we can have formal neuropsychological assessment. Obviously there's going to be psychiatric assessment. We can have a full medical workup. We have the capability to do imaging to get lab tests. So in especially if things have gotten to the point where the person's not even willing to go to an outpatient appointment anymore, you need a timeout and you want diagnostic clarity and give everybody a chance to come up with a comprehensive plan about how to go forward. And at any stage, whatever the illnesses and or whatever stage it's at, the goal is to restore that person to the best version of themselves as possible. I'm an advocate for keeping somebody home as long as possible. That doesn't mean families should do that to their own detriment if they've reached that limit. But if you talk to most people, quality of life usually outweighs every other factor. Most people don't want to go to a facility. So if we can make some adjustments in medication or if we can and some again that can be adding a med it might be taking two or three away or if by educating the family about the diagnosis and like we were talking about ways to manage it at home, sometimes I can buy somebody another six months in their home environment with their loved ones. And to me, that's that's a win.

Erin Spain, MS [00:19:50] Well, thank you, Dr. Kevin Nasky, for joining us today, telling us about Senior Retreat and sharing your expertise. This is a topic that affects a lot of families, and I'm sure that this advice is going to be taken to heart. So thank you today.

Kevin Nasky, D.O. [00:20:03] You're welcome. Thank you.

Erin Spain, MS [00:20:09] For more information on this podcast, check out advance.muschealth.org.

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