Helping Our Depressed Senior Adults
Clabby J, Howarth D. Managing CHF and depression in an elderly patient: Being open to collaborative care. Family, Systems, and Health: The Journal of Collaborative Family HealthCare, 2007; 25, (4), 457–464.
Introduction
There are 2-3 million cases of Congestive Heart Failure (CHF) in the US and 400,000 new cases are diagnosed each year. It is the most common discharge diagnosis in patients over the age of 60, and the most common diagnosis for readmission to the hospital for the elderly. Nine percent of people over the age of 80 suffer from congestive heart failure. This disease costs over 10 billion dollars per year, in part because it requires so much inpatient care. The average length of stay for CHF is 9 days. Congestive Heart Failure, like many chronic diseases is progressive and debilitating over time .Patients experience such symptoms as increasing shortness of breath, difficulty lying down when sleeping because of fluid retention and growing fatigue. It is a deadly illness as well with a 5 year mortality rate of 50%. The symptoms, if not controlled, often lead to depression for patients who have concerns about the quality of their lives, overall functioning, and mortality. Their families and friends often share the same concerns. Certainly CHF manifests itself both physically and emotionally.
. Many studies have shown that elderly patients hospitalized for CHF have co-morbid
diagnoses of major depression. In one outpatient study (Gottlieb, Khatta, Friedmann,
Einbinder, Katzen, & Baker, 2004) 7% of patients with stable CHF were prescribed
antidepressant medications and 48% scored in the depressed range on the Beck
Depression Inventory (BDI). Moreover, the depressed patients reported significantly
poorer quality of life than non-depressed patients. Lane, Chong, & Lip (2006) raised the
concern that patients who are depressed are less likely to take their medications
and modify their lifestyle appropriately, which increases the likelihood of recurrent
cardiac events and death..
Illness Narrative
George lived in the same town his entire life. He loved his hometown and
community. In fact, the cover of the historical book commemorating his town featured a
picture of George and his two brothers when they were young boys. A major
national magazine prominently featured this picture in one of its issues. George and his
brothers are depicted sleeping on the banks of a canal near the river in their community.
The boys are sleeping away a hot summer day, fishing poles by their sides, near the
coolness of the canal. It is a picture that seemed to define their early life and encourage
their love for the area they call their home. George always took particular pride in this
picture which he prominently displayed in his home and would at times bring it to the
office to show his health care providers.
He lived with his wife of many years in their single family home, which George had built himself. He was retired from his work as an air-conditioning and refrigeration mechanic. George and his wife raised three sons. Two lived near them and one lived across the country. George’s youngest son and his wife were expecting their first child when George first started having problems with his heart.
George was hospitalized at age 82 for an acute episode of Congestive Heart Failure (CHF). His disease was significant and characterized as a Dilated Cardiomyopathy, probably caused by Coronary Artery Disease. His heart functioned at less than a third of its normal efficiency. A normal Ejection Fraction (EF) is 55% and above. George’s EF was 20%. He experienced shortness of breath with minimal exertion and sometimes at rest.
After his discharge from the hospital, George visited the cardiologist. When the cardiologist told him the prognosis, George was shocked. He remembers, “he told me that normally you’d live 1-2 years. I said to myself “Who is he talking to? He must be talking to someone else. I don’t accept things like that. I just don’t believe it!”
Following the closing of the Health Mainatnance organization thet had provided his care, George sought care from Dr. Howarth (second author), a family physician After receiving his prognosis from the cardiologist of a life expectancy of 1-2 years, he scheduled an appointment with Dr. Howarth. . Dr. Howarth enjoyed being George’s doctor. Dr. Howarth’s father had been a friend of George’s so he knew him as a child. And, George and Dr. Howarth attended the same church.
Dr. Howarth was somewhat surprised by the manner in which George had been given his diagnosis. He focused on helping George identify and explore his feelings about the situation, and how he was dealing and coping with this new disease. When he asked “How did you feel?” George became sad and tearful. He responded, “Terrible…I had looked forward to the birth of my first grandchild…now this guy is telling me this? I felt crushed.”
Dr. Howarth was well aware of the link between heart disease and depression, and recognized that many patients might feel depressed after receiving such devastating news. He used the SIGECAPS (Sleep, Interests, Guilt, Energy, Concentration, Appetite, Psychomotor Retardation/Acceleration, Suicidality) mnemonic to screen for depression. George acknowledged that he had “difficulty sleeping at night” and “I don’t have the desire to do things.” “Guilty? No, why would I feel guilty? Energy? Well yeah, maybe because I haven’t been sleeping very well… I do feel a little apathetic. My concentration is fine. Appetite is fine too. I’ve felt a little sluggish lately. Like I said it’s like I’ve withdrawn somewhat. Concentration? Fine. No way would I ever ever hurt myself but sometimes I do feel like my life is over…I can’t do the things I desire…I’m not going to hurt myself…I just feel down.”
Dr Howarth felt it very important to establish a climate in which George felt comfortable asking questions about his disease and the treatment options. He wanted to help George gain some sense of control and agency in his life. He hoped even the smallest of gains and victories would help George feel more in charge of his life.
Dr Howarth was especially concerned because George’s health issues were but one issue facing the family. In addition, George’s wife had terminal colon cancer.
Dr Howarth recognized that a support system of family and other caregivers who could provide the emotional support and guidance was needed to optimally treat his CHF and depression. Towards this end, he established a schedule of regular office visits and phone contacts to manage any crises or questions that George or his family members might have. Dr. Howarth facilitated these meetings to establish close follow up, clarify a very complex diagnosis, and provide an outlet for any concerns that may arise. The frequency of the visits with Dr. Howarth was very close in time initially, as other support systems were gradually put into place. Dr. Howarth would regularly review the medications at those times and would also address George’s emotional concerns. At that time, George was on multiple medications including Accupril, Toprol, Lasix, Digoxin, Aldactone, and Coumadin.
Dr. Howarth recognized that George’s family needed to be involved directly in his care. He held two family meetings, one with George and his wife, and one that also included his youngest son. Dr. Howarth recognized that complex diseases such as CHF and Major Depression could have complex treatment plans. He made efforts to simplify this for George and his family and to help all understand the treatment plan. Dr. Howarth also would be consulting with George’s cardiologist and providing the support that was essential in fulfilling the treatment plan. Dr. Howarth also offered to provide the psychological support through regular follow-up visits.
Being open to a disease management program
Dr. Howarth recognized that George, like many patients with CHF, was vulnerable to hospital readmissions if he did not follow the treatment plan closely, and because of the complexity of his medical condition. He felt an interdisciplinary team approach would optimize George’s care, and encouraged him to enroll in a Disease Management Program (DMP) offered by his health insurance company. Dr. Howarth’s experience with this program was that it significantly reduced hospital readmission rates. He spoke with George about the benefits of enrolling in a Disease Management Program.
George initially was reluctant to enroll. He was unsure what the Disease Management Plan entailed, and the impact it would have on his day to day life. Also, George did not want his care with Dr. Howarth to be replaced. He found their familiarity and trusting relationship comforting. Dr. Howarth assured George that he would still be providing care like he always had and that the DMP would elevate the care. He used his relationship with George to present the benefits of the DMP. He described how nursing interventions such as symptom identification, diet therapy, drug therapy, and close monitoring of blood work could reduce the likelihood of further hospitalizations and might improve his overall quality of life. He also discussed the program’s supervised exercise programs .Dr. Howarth stressed that the DMP would expand George’s access to professionals who could respond quickly to his questions and concerns. It would give him another level of support and comfort. Ultimately, George began to see that the DMP offered a therapeutic relationship that would ensure that he was not alone, address his concerns, alleviate his fear, and help him develop the belief and confidence that he could get better. George agreed to combine his care provided by Dr. Howarth with the Disease Management Program.
Initially, nurses from the DMP program made several home visits. And, they frequently followed up with phone calls. George was enrolled in the DMP program for more than 24 months and during that time, he did not have any hospital re-admissions. George and Dr. Howarth both felt supported by the Disease Management Team. George had the opportunities he needed to discuss his symptoms, and received the interventions he needed early on. Dr. Howarth appreciated the medical back- up provided by the DMP, and the updates and communication that the team provided him optimized George’s care. This collaboration resulted in an educated, motivated patient, who understood the implications of his disease and how to manage symptoms. For example, if George suddenly gained weight he knew it was important to have an office visit to adjust his medication. George understood the importance of his blood work, and therefore always completed it in a timely manner. Close monitoring and quick interventions controlled his symptoms avoiding recurrent hospitalizations.
These advantages are reflected in George’s comments about his experience with the DMP. He reported that the Disease Management Program “gives a feeling of security” when he couldn’t reach Dr. Howarth. He came to appreciate the relationship he ultimately developed with the nurses in the DMP, stating, “I can pick up the phone any time and talk to 1-2 nurses who know my case. And the phone calls are never short…they go into a lot of questions!…so I really feel they know what is going on.
“They even called and offered to come over. She even looked in my refrigerator…can you believe that!?”
Being open to psychological consultation
Although the DMP was helping to improve George’s physical health through proper management of the CHF, he needed to make better progress with his depressed feelings. Despite his symptoms of depression, George and Dr. Howarth decided against antidepressant medication. They wanted to avoid the perils of polypharmacy. Dr. Howarth recognized that George might require more than the kind of supportive counseling that he typically provided in his practice. He wanted to intensify and better organize the mental health interventions he could offer. Dr. Howarth recognized the importance of his relationship with George. He reassured George that he would be the one who would continue to “be there” for him to provide counseling. (Does this still go here?)(Freudenstein al, 2001)
Dr. Howarth provided care for George in a Family Medicine Residency Program, where he also supervised residents. In these programs, a psychologist or social worker is on faculty in the role of Behavioral Scientist. The role of the behavioral Scientist is to teach resident physicians to identify mental/behavioral heath problems, how to provide counseling, and how to best refer out if appropriate. Dr. Clabby (first author), a psychologist, had recently joined the faculty in this capacity. Aside from occasionally co-precepting some of the residents on some clinical cases, he and Dr. Howarth had not closely worked together. On one typically busy afternoon, Dr. Howarth “curb-sided” Dr. Clabby about George’s depression. He mentioned his goal of wanting to elevate the level of counseling that he was starting to provide. Dr. Clabby, getting more and more used to the fast pace of primary care settings, quickly mentioned that a form of cognitive behavioral therapy might be helpful.
They agreed to meet at a time when Dr. Howarth could spend more time explaining George’s case. When they did meet, Dr. Howarth as a physician and Dr. Clabby as a psychologist learned they had some things in common. Each was married with four children, had family in England, and coached youth basketball. In the hectic world of primary care medicine and resident education, these kinds of personal connections help make the collaboration fun and something to look forward to.
In recognition of the tremendous connection between this patient and his physician, Dr. Clabby validated Dr. Howarth’s decision to continue to be the provider of the counseling. Their agreement would be that Dr Clabby would introduce Dr. Howarth to a model of CBT that was particularly designed to bridge psychology and family medicine.
Practical Counseling works best
Cognitive-Behavioral Therapy (CBT) had a practical appeal to Dr. Howarth in his role as a family physician. As he came to understand it, CBT promotes psychological change in a lively and active manner, consistent with the active role that family physicians often take with their patients. Dr. Howarth liked the appeal of CBT because its use of homework and the healthy re-framing of events made practical sense. CBT’s emphasis on directly enhancing self-control, perception of personal efficacy, rational problem solving skills, and participation in activities that bring a sense of pleasure or mastery seemed well-suited for family medicine.
SPEAK refers to (Schedule, Pleasurable activities, Exercise, Assertiveness, Kind words to myself). J. Cristensen (1997) specifically developed this as an organizer of CBT interventions for depression to help the busy primary care physician. The doctor can select to teach the patient any one or more of the elements of SPEAK, based upon what might most appeal to the patient. Here is the SPEAK approach, as used in this collaboration between Dr. Clabby and Howarth on behalf of George.
SCHEDULE: Drs. Clabby and Howarth recognized that that when patients like George
are acting depressed, they often struggle with initiating, planning, and organizing
activities of daily living. Dr. Clabby felt strongly about the benefits of social activation. He spoke to Dr. Howarth about his belief that patients benefit from developing and implementing a modest “to do list” even though the patient may not feel like doing this. It made sense to Dr. Howarth as well. In his meeting with George, Dr. Howarth empathized with George’s sense of “stuckness”, that what he would be asking George to do would be tough, but that he felt George could handle it. He suggested to George that many patients who are feeling depressed work on elevating their mood by getting busy again. George used to walk several blocks in his neighborhood so Dr. Howarth used this metaphor. He explained to George that his mood may be several “blocks” or “miles” behind his actions. As basketball fans, Drs. Clabby and Howarth discussed sharing with George the old Nike sneaker motto of “Just do it!” Dr. Howarth asked George to make up a simple schedule of daily activities such as preparing lunch, taking a walk for a few blocks, and so on. He told George that he thought that his mood of the patient would start to perk up in time.
Once George got he message of “schedule” Dr. Howarth would check in with how he was doing. George reported; “I maintain my activities…even if I might not feel quite up to it. I see my grandchild every night…unless I have a meeting. If I wake up in the morning worrying about some mistake I made in the past…I do not dwell on it. I go on to do something in a week and a half we are having our 63rd high school reunion…I’m going! He added “I belong to the Air Conditioning and Heating group.it’s a professional organization…I’m going to start going to those meetings again.” He got himself back into some of the civic volunteer activities he used to do. For example, he mentioned “I am president of our local cemetery… we keep accurate historic records. It’s important and it keeps me busy.”
PLEASURE: Drs. Clabby and Howarth discussed the importance of combating
George’s anhedonia. They were concerned about his drift to withdraw from the mood-enhancing experiences of fun activities. Dr. Clabby spoke about the helpful approach of the Solution-oriented Psychotherapy School (Walters, 1992). Here the physician helps patients to recall and then start doing simple, attainable, pleasurable activities. Dr. Howarth learned from George that he used to listen to some mood-elevating music and …perhaps even dancing in a silly way! For George, it also meant getting back to calling up some high school classmates that were still in the northeast. George also used to watch comedy movies. On one occasion when Dr. Howarth asked George to talk about his progress in starting to schedule some pleasurable activities, he talked about his wife’s death and his decision to go forward. In one conversation, he grew positively animated when he discussed that he was starting to see another woman. “I’m dating a woman I’ve known for year.” (George was smiling here) “We go out to dinner together…I like physical affection….I like to put my arms around someone (gestured. George also told Dr. Howarth that “I like to dance…I’m chair of our HS 63rd reunion. I’m going to make sure we have dancing!”
EXERCISE: This was a natural extension of what Dr. Howarth was already advising his
patients since the exercise heals and prevents so many disease states. Drs. Clabby and Howarth discussed how even exercising moderately three times per week helps elevate the mood. George would not have to do too much in order to start acquiring the mood elevating benefits. Even the kinesthetic movements that come with the dancing that George had discussed would help break up the somatic rigidity that can perpetuate a feeling of depression. This was more a case of Dr. Howarth giving his enthusiastic medical endorsement of George going back to what he used to do. With pride, George told Dr. Howarth “I hook my feet under the sofa and do sit-ups every day” (When George told Dr. Howarth about this he even offered to demonstrate in the exam room how he does this! George also shared that he had begun to “walk 1.5 miles every day around my neighborhood…I don’t feel as good if I do not exercise. Activity is good for me mentally and physically.”
He added, “Dave, did you know that I boxed some in the Navy?” (George was particularly proud of this accomplishment and his identity as a man who could “take care of himself” if he needed to).
ASSERTIVENESS: With what he understood about George’s stoical approach to life, Dr. Clabby expressed his concern that George might be using a lot of energy to repress his affect and feelings…energy that could be made available to put into the other SPEAK elements. This element of CBT for depression is often the least understood. Usually this related to confusing assertiveness with aggressiveness. Dr. Clabby wanted George to understand that it also means being more honest with others about the positive feelings that we have, e.g., complimenting others and directly showing our appreciation. Dr. Clabby advised Dr. Howarth to bring this to George’s attention as well. Dr. Howarth took this approach with George. He described assertiveness as a way of being more honest and direct with ourselves and others about what we think and what we feel. He asked George to elevate his level of expression with others just a bit more. He also mentioned to George that that counts even in their patient-physician relationship. When George takes a risk by disagreeing with him, Dr. Howarth said that this was an appropriate sign of assertiveness. He also kidded George by mentioning that he could well handle a compliment from time-to-time if George wanted to give him one! George shared this about how he saw himself expressing his mind more and more. “I listen to Rush Limbaugh and Sean Hannity…” These are politically conservative talk radio and TV personalities. I’ll argue these points with the woman I’m dating who is a Democrat.” Learning of this Drs. Clabby and Howarth were later able to obtain a baseball cap with the logo of Sean Hannity’s television program and presented this to George who seemed genuinely touched and excited by the gesture. With regard to his communication with Dr. Howarth he also added “I’m not promising (you) what I won’t be able to do”
KIND THOUGHTS TO SELF: This is the hallmark approach of cognitive therapy. Here the doctor would be calling the patients’ attention to the fact that with any of life’s
events, we always have four options: We can change it, accept it, reframe it, or leave it
(Clabby, 2006). With Kind Words to Myself, the emphasis is on the “re-framing” of an
event so it is less psychologically toxic. The physician explains that the language we use
to describe what has happened to us has power over our feelings. The physician mentions the kinds of unfortunate phrases that tend to add insult to the injury that the patient has already sustained. For example, the physician can suggest avoiding such language as this is a “catastrophe”, or “awful”, or “terrible” or “the last straw” or “I can’t stand this” or “This always happens to me!” In place, the patient can use more self-kindly phrasing such as “It would be better if (this…….did not happen) but the truth is …. (this did happen)…and “This is not a catastrophe” or “I can handle it” or” I refuse to add insult to injury.” Some of George’s approach to this concept of Kind words to Myself was a connection to his spiritual and prayer life. Perhaps because George and Dr. Howarth are members of the same church, it was easy to discuss…“I have a strong belief in God and Christ…that I’d be taken care of…I am part of his family” When I was 8 or 10… I fell from a beam and dropped 20 feet to the ground.” I passed out and woke up on the ground. This feeling that God would take care of me was solidified.” George also spoke about his reminding himself of his blessings and what he felt proud of “I’m so lucky to have this grandchild.” He also proudly related “You know, I have to have goals and accomplishments…“I built this house myself you know.”
Openess to a home visit
To reinforce George’s progress in learning and using the SPEAK approach, Dr. Clabby and Howarth visited him in his home one afternoon. George proudly and energetically served as host, sharing what he felt would help other persons take on CHF and depression with their doctor. George enthusiastically took center stage and vigorously shared his ideas. Dr. Clabby specifically asked George about his connection with Dr, Howarth and what features made it work out as well as it has. . Looking directly at Dr. Howarth, George reported: “I have the confidence that you are doing what you should. Our personal relationship is such that I trust that you do not think I am a complainer…..we can talk”
Looking at Dr. Clabby he said “I made an effort to work with Dave when our health
plan went under.” “It’s a personal relationship and we could talk…Dave is sincere.”
“The outreach from Dave is an extension of our friendship” “We have the same religious background”
Closure
George’s wife passed away within one year of his diagnosis with CHF and Major Depression. Despite this setback, George continued to do well, to enjoy life and to engage in his favorite activities. He thoroughly enjoyed his two young grandchildren. He traveled 2-3 times a year. George served as the chairperson for his eagerly anticipated 65th year high school reunion. He volunteered in his community’s historical society. He lived a life of activity, maintaining his relationships with many organizations (Timeframe in relationship to treatment), George lost control of his car and was in a serious automobile accident. He went into a coma and was placed on a respirator, living many months until its removal. His family kept a visitors’ journal by his bed that ultimately reflected his life, filled with sentiments from those who truly cared about him. With his cherished childhood photograph of himself and his brothers sleeping on a summer day by his bedside, George passed away surrounded by those who loved him.
Although family members and friends asked Dr. Howath to attend the wake he was unable to do so. He did attend the funeral. There, George’s 5 year old granddaughter, who he feared he would never see, let alone develop a relationship with, spoke. In the simple way only a child can, she summed up what all were feeling when she said,
“I am going to miss my Grandfather and I hope you will too”.
George taught us much about trust, the human will, and the capacity for change. Our collaboration included physician, family, psychologist, and disease management team. But it also included our patient who wanted also to advise other health care providers. So, at the end of the home visit mentioned earlier, Dr. Clabby asked George what advice he could give to other physicians and those who collaborate with physicians. This is what George left us with:
“Any doctor….develop a conversation about the person’s life. You almost have to delve into the person’s life to a certain degree. That would help you understand the illness. No? It would help patients not complain as much. I’m -I work as a plumber…and work with heating systems. If a system goes down, you change a nozzle. You have to look at the whole system. In medicine, you deal with a person’s mind too. It seems to me that’s pretty important. I have a lot to live for”
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