Managing Psychosocial Issues in Clinical Geriatrics

Managing Psycho
Clinical Geriatrics

Ron Adel
Pamela An
Risa Breckm

Amy Ster

Weill Cornell M
Division of Geriatric

April 17

osocial Issues in
s

lman, MD
nsell, MSW
man, LCSW
rn, LCSW

Medical College
cs and Gerontology
7, 2008

Presentation O

  1. Review goals an
  2. Provide overview

issues

  Definition and do
  Impact on health
  Detection metho

  3. Explore the MD’s

Outline

nd objectives
w of geriatric psychosocial

omains
h/QOL
ods/barriers

s Role: Case Studies

Goal and Obje

  Goal: To increas
about geriatric p
provision in med

  Objectives: To ed

  the spectrum of g
problems; and

  the skills needed
problems in the

ectives

se fellows’ knowledge
psychosocial care
dicine
ducate about:

geriatric psychosocial

d to manage these
practice of medicine.

What is mean
Psychosocial?

  Social and psychol
life influencing thou
health, functioning,

nt by the term
?

logical aspects of person’s
ughts, feelings, behaviors,
, well-being and/or QOL

Psychosocial D

  Social Support
  External Stressors
  Self-Care Concerns
  Emotional Health
  Alcohol Use
  Drug Use
  Advance Directives
  Religious and Cultural Ne
  English Language Fluency
  Educational Background
  Patient-Identified Concern

Domains

eeds
y and Literacy
ns

What are Ger
Psychosocial

  Psychological or s

  Associated with su
  Influence

  disease progressio
  medical adherenc
  quality of life

  Interventions avai
problems

  Many psychosocia

riatric
Problems?

social adversities that are

ubstantial morbidity

on
ce

ilable for many of these

al problems are prevalent

Case Study

  Mr. Smith, 83 yo retire
  Barely meets monthly

  Living alone in Manhatt
  Paying for medications

manage Parkinson’s D

  Married > 50 years: wi
  No family or friends:

  Feels helpless to take m
routine as he did with w

  Each night, alone in th
sips several glasses o
his life, wondering if it

ed salesman, residing in NYC
expenses

tan in rental apartment
s and co-pays for medical visits to
Disease

ife died 6 mo ago

medications properly or do exercise
wife.

he quiet of his kitchen, he slowly
of wine and ponders the value of

is worth living.

Case Study: P
Problems

  What are psycho

  Grief from loss
  Social isolation
  Financial stress
  Depression
  Suicidal ideation

Psychosocial

osocial adversities?

n

Detection of G
Psychosocial

  Older adults regu
monitor chronic i

  Opportunity exis
psychosocial pro
addressed

  What possible w
come to the atten
care physician?

Geriatric
Problems

ularly visit MDs to
illnesses.

sts for geriatric
oblems to be identified and

ways would these issues
ntion of the primary

Barriers to Comm

  Patient-level Barrie

  Not wanting to “was
  Stigma
  Deference to autho

  MD-level Barriers

  Unfamiliarity/discom
  Role confusion
  Time constraints

  Systems-level Barr

  Lack of reimbursem

munications

ers

ste” MD’s time

ority

mfort with issues

riers

ment

Case Study:F

  Mrs. Martha Apple,
retired nurse

  Social Support:

  Contentedly marrie
retired; husband es

  Son, age 53, lives 3
2 teen-age sons; se

  Only sibling died 2
  2 close women frien

worries with; 5 frien
occasionally and on

First Visit

, patient, female, age 79;

ed to husband 55 years, age 80;
scorted wife to medical office
30 minutes away; widowed with
elf-employed
years ago
nds in building can share
nds in the community sees
n phone

Case Study: F
(continued)

  Sister-in-law with A
in LA

  Husband escorts to
per week

  Appearance: Looks
animated, well-groo

  Housing: Lives in re
apt. in Queens

  Finances: Live on s
small savings. Mod
comfortable and sa

First Visit

AD in nursing home; 2 nephews
o senior center for exercise 3x

s younger than years,
omed, modestly dressed
ent-stabilized, 1 bedroom
social security, pension and
dest lifestyle but
atisfying

Case Study: F
(continued)

  Alcohol/Drug Use:
each evening

  Religious: Protesta

First Visit

1 glass of wine at dinner
ant; non-practicing for years

Case Study: F
(continued)

  Medical problems:
  Diabetic, hypertens
being treated
  Medications for dia

  Ambulates with cane
  Uses hearing aid
  Instrumental Support:

  Independent of ADL
prep (arthritis preve
tasks); housekeepe

  Reason for Medical Vi
  Prior MD retired; ro

First Visit

sion, arthritis, hearing loss--all
abetes, hypertension, arthritis

LS; husband markets, food
ents her from doing these
er 1x per week
isit
outine; establishing care

Questions

  Any psychosocial is

  IADL dependent
  Adequate emotiona

  What psychosocial
exploration?

  Routine screen for

  PHQ-9/2 and GAD-

  Husband’s possible

  How does MD explo
  Should MD ask the

husband is not the p
  How does MD best

can be addressed?

ssues evident?

al support; limited instrumental

l domains need further

anxiety/depression

-7/2

e caregiver burden

ore the caregiver issues?
husband questions directly if the
patient?
manage time during visit so this issue
?

Questions (co

  What medical interv
employ?

  Is the cane adequa
  Discuss diet, exerc

  What psychosocial
employ (depending

  Educate caregiver a
care

  Referral to social w

ontinued)

ventions would you

ate—right height, proper tip?
cise, blood glucose monitoring

l interventions would you
g on assessment findings)?

about need/methods for self-

worker for home aide support

Questions (co

  What are possible o
interventions?

  Reduced caregiver
  Knowledge of resou

  What are possible o
intervene?

  Caregiver burden le
negative impact on

ontinued)

outcomes of these

r burden
urces should need arise

outcomes if MD does not

eading to depression and
n health/QOL

Case Study: Sec
(Scenario 1)

  Patient returns for s
months later

  Husband died sudd
  Patient lost 15 poun
  Appears withdrawn

frequenting senior c
complains of poor m
concentrating and f
  Patient reluctant to
neighborhood for fe

cond Visit

scheduled appointment 2

denly of MI 7 weeks ago
nds
n; untidy appearance; not
center/exercising;
memory, problems
fatigue
o take bus/walk in
ear of falling or getting lost

Case Study (c

  Records reveal pat
appointment; did no
medications, as ne

  Blood sugars low; b
hearing aid not func
arthritis pain flare-u

  Son supportive and
possible considerin

  Close friends and n
supportive

continued)

tient missed last medical
ot refill prescription
eeded
blood pressure low;
ctioning; complains of
ups
d attentive as much as
ng his busy schedule
nephews in LA emotionally

Questions

  Any psychosocia

  Depression
  Reduced social s
  Transportation c

al issues evident?

support/ Social isolation
concerns

Questions (contin

  What psychosocial domai

  Assess for increased ADL/I
  ADL/IADL assessment i
  If has increase ADL/IAD
psychosocial concern is

  Assess social support
  Questions from PSST

  Assess financial ability/desi
  Question from G-PSST

  Assess alcohol/drug use
  Question from G-PSST

  Screen for depression/suici
  PSST: PHQ-9/2; GAD-7

nued)

ins need further exploration?

IADL dependence
instrument
DL dependence, another
s loss of independence

ire to pay for increase home care

idal ideation and anxiety
7/2

Questions (contin

  How does MD work
the medical visit? C

  Patient’s engageme
  Time
  Physician’s attitude
  Availability of other

  Screens can impac
can improve billing

nued)

k these assessments into
Consider:

ent/Receptivity

e/familiarity with issues
r team members

ct on coding; proper coding
practices

Questions (contin

  What medical interv
employ?

  Treat for depressio
appropriate)

  Address anxiety
  Address arthritis/pa
  Refer to audiologist
  Anything else?

nued)

ventions would you

on/suicidal ideation (if

ain
t for hearing aid needs

Questions (contin

  What psychosocial
employ (depending

  Empathy regarding
  Referral to social w

interventions for an
counseling; referral
ADLs/IADLs; help w
  Encourage attenda
  Psychosocial hando
depression, anxiety
independence; tran

nued)

l interventions would you
g on assessment findings)?

g her losses
worker psychosocial
nxiety, depression (grief

ls for support group); help with
with transportation issues
ance at senior center
outs (possibilities include
y, loss of spouse; loss of
nsportation; social isolation)

Questions (contin

  What are possible o
interventions?

  Decreased depression;
  Reduction in arthritis pa
  Social supports/exercis

with senior center
  Improved health status

adherence and exercis
  Nutrition and hygiene n
  QOL/social engagemen

addressed
  Mobility within the comm

appointments

nued)

outcomes of these

; anxiety
ain
se increased due to reengagement

s due to improved medication
se
needs met w/ HHA
nt improved with hearing aid problem

munity, ability to travel to MD