Often, signs of aging are obvious as time takes its inevitable toll. Shoulders slump forward. Joints groan. Hands tremble. Hair accumulates in brushes and combs.
But aging also plays out on a far less visible stage: the brain. The consequences may be creeping memory loss and slower cognition. Many people adapt to these neurologic changes on their own or with the help of loved ones. In others, however, changes in the brain progress to serious problems, including dementia, Alzheimer’s disease, and Parkinson’s disease, all of which may wreak havoc on their lives and loved ones.
These physical brain battles may, in turn, intertwine with psychiatric problems, like depression, anxiety and psychosis, and emotional demands posed by aging. It’s unwise to treat them separately, said Dr. Samantha Holden, assistant professor of Neurology at the University of Colorado School of Medicine. Holden practices at the UCHealth Neurology Clinic – Central Park, specializing in movement and cognition disorders.
“It really is a false dichotomy to say, ‘This is neurologic and this is psychiatric and never the twain shall meet,’” Holden said. “It’s all your brain.”
Holden noted, for example, that psychiatric issues like depression, apathy and anxiety frequently accompany Parkinson’s disease, a progressive neurologic movement disorder. The clinical line between the two is blurry, at best, she said.
“We have to make sure that we look at the whole person and see how your condition affects you and your well-being,” Holden said.
Geriatric mental health resources
Holden is part of a team that is doing just that. She joined last July with Drs. Karina Drake and Evan Plys to launch the Geriatric Mental Health Clinic, part of the UCHealth Outpatient Psychiatric Clinic – Anschutz Medical Campus. Holden, along with four other Neurology Clinic colleagues, refer patients they think will benefit from geriatric mental health resources to the clinic.
Drake, an MD who completed a fellowship in geriatric psychiatry, helps patients safely balance their often complicated medication regimens, while also providing psychotherapy and other support. Plys, a PhD geropsychologist, focuses on individual therapy with patients who have mild or no impairment from their neurologic conditions. He also offered group therapy for caregivers last winter and spring and hopes to do so again in the fall.
The Geriatric Mental Health Clinic aims to help patients and their loved ones regain at least a measure of control over the disruption caused by their neurologic disorders. The challenges may be psycho-social: grief, anger, depression, and apathy over the idea of losing the life they anticipated to an incurable disease. Left untreated, these symptoms – the most common being depression and anxiety – can further deteriorate patients’ health, Plys said.
Individual therapy to restore meaning and purpose
“Patients with these psychological concerns can have low motivation to engage in routine healthy behaviors, like exercise, diet and social engagement,” he said. “Particularly as we get older, it’s essential to engage in these behaviors. When we see mood becoming a barrier that is often a good time for people to come in for therapy.”
Plys said he uses cognitive behavioral therapy to help patients identify the thoughts that create barriers to pursuing healthy habits and work on ways to overcome them. He described the sessions as collaborative, with patients developing “action plans” aimed at finding activities that produce a sense of meaning and purpose. Those are unique to each person: spending time with grandchildren, working in the garden, developing new hobbies, and connecting with old friends, for example. The idea is to build “mastery,” as Plys put it, over the mental disorders spurred by disease.
The process is not open-ended, Plys said. He typically starts patients with six, 50-minute sessions, then “renegotiates,” based on their progress toward meeting their goals.
“The whole idea of therapy is to promote a patient’s function without a therapist,” he said. “I want to help you build skills and apply them to your own life. If I’ve done my job successfully, I’ve essentially made myself obsolete in the life of the patient.”
Medication management for neurologic disorders is crucial
Some patients Holden refers to the clinic suffer from acute changes in the brain that produce not only depression and anxiety but also psychosis, delusions, and hallucinations. In these cases, Drake works to evaluate and manage patients’ medications to safely treat both neurologic and psychiatric symptoms. She said she also considers the “complex medical histories and cognitive disorders” that increasingly emerge as people age.
Drake said she conducts a full psychiatric evaluation of symptoms, medical issues, the neurological workup, and the progression of the patient’s neurological disorder. She then develops a treatment plan to address each patient’s psychiatric issues, depending on the underlying cause. That may include referring a patient to Plys for individual therapy.
A big part of Drake’s work is evaluating all the medications a patient is taking, because those prescribed for different problems may have dangerous interactions.
“Polypharmacy can be a huge issue in older patients,” Drake said. “It’s important to know a patient’s updated medical issues, not only for prescribing medications, but sometimes deprescribing.”
The goal: eliminate medications that are redundant and those that produce unwanted side effects. She noted, for example, providers frequently prescribe benzodiazepines, such as Xanax and Valium, to treat anxiety. They produce short-term benefits, but also long-term side effects like changes in cognition and confusion.
“The long-term risks of these medications increase as people age,” Drake said. “The question is how do we manage anxiety while working to get patients off these medications? It must be done slowly and cautiously.”
Drake emphasized that her work forms an interdependent triangle of care with neurology and psychology.
“We are working together to address the far-reaching effects of cognitive disorders,” she said. “We must approach the problem from multiple angles, given the complexities. Addressing one without the others is a losing battle.”
A ‘gut punch’ diagnosis
The experience of Dennis and Sue Stretar of Aurora illustrates both the life-changing challenges presented by neurologic disease and mental health issues and the benefits of the collaborative care and resources provided by the Geriatric Mental Health Clinic.
The Stretars, now married for 26 years, met in 1994 through a “Sunday Night Club” for older singles through Colorado Free University. After marriage in 1995, they co-hosted “Colorado Today,” a public affairs program on KEZW-AM radio covering lifestyle and health-related aging issues that ran from 1999 to 2006. In 2002, they expanded the program to public television and print through a Health and Human Services grant. During this period, Sue survived a bout with breast cancer – chronicled in a documentary Dennis produced for National Breast Cancer Awareness Month – and made a complete recovery.
Dennis, now producer and host for the Aurora-based Our Community Broadcasting Network, noted that he and Sue worked extensively with the Alzheimer’s Association during their days with “Colorado Today.” That helped prepare them in 2010, when Sue’s mother, now 94, was diagnosed with Alzheimer’s disease.
“Between the two of us, we knew a lot about Alzheimer’s and dementia in general,” Dennis said.
Then came another blow. In 2019, Sue, then only 63, began exhibiting signs of mental decline, including frequent rounds of confusion and forgetfulness.
“She’d suddenly be in the fog and very quizzical about what was going on and what she was supposed to be doing,” Dennis said.
He recalled a key incident that occurred on a morning he needed to pick up their car from a local repair shop. He woke Sue up to remind her to drive him over, then went back to his office to wait for her to get ready. He heard her go down the stairs, then listened to the sound of the garage door going up and the car pulling away. Startled, he waited about 10 minutes for her to return, with the explanation that she thought Dennis was going to make a long, cold-morning walk to the repair shop to meet her.
After more instances of forgetfulness that she frequently blamed on Dennis, Sue finally conceded that there was a problem they needed to address. The two met with a neurologist, who verified that she had a memory issue. After a lengthy battery of tests, she received a diagnosis of dementia, which Dennis described as “a gut punch.”
Dementia and depression form an explosive combination
The problem was to worsen, as neurology and psychiatry crossed paths. Sue had also managed clinical depression for 30 years. But in March 2020, she began experiencing violent hallucinations, delusions and bouts of paranoia, Dennis recounted. In one particularly frightening encounter, her neurologist witnessed Sue “coming apart before her very eyes,” he said. Sue received prescriptions for anti-psychotic medications, but by May 2020, Dennis said, she was close to needing hospitalization.
Fortunately, Sue received a referral to Holden for further treatment of her dementia. He and Sue met in December 2020 with her for a complete evaluation, but it was a rocky encounter. Dennis described Sue’s behavior as “very hostile,” and Holden’s recommendation as blunt.
“Dr. Holden told me after that session that unless we can Sue’s mood enhanced, we won’t be effective in treating her [dementia],” Dennis said.
With that, Holden referred Sue to Drake, who met with the Stretars via Zoom in January 2021. Dennis said the collaboration between the two specialists was crucial.
“Dr. Drake came in knowing what Sue was dealing with,” he said. After evaluating Sue, Drake prescribed a combination of medications for anxiety and clinical depression. With that issue handled, Holden prescribed Aricept, a medication to bolster cognition in early-onset Alzheimer’s patients. Dennis said Aricept, while not a cure, has helped Sue improve her short-term memory retention and moderate her confusion.
“The meds are working fine. I would call her very stable,” Dennis said.
Neurologic disorders: Adapting to a new way of life
He is clear-eyed about the challenges that lie ahead, however. He recognizes that Sue will withdraw at times and enter periods of confusion that he describes as “the fog rolling in.” He accepts that she will no longer connect with friends of longstanding and that he “can’t push her to do that.”
Dennis strives to find ways to help both adapt to their new reality. They go out to eat, walk the dogs, and stroll through open malls to watch kids play in fountains. Sue loves to garden, so Dennis expanded the flowerbeds around the house to encourage that. He even went a bit against the conventional advice to keep people with dementia away from crowds and high-intensity situations by taking Sue to a Colorado Rockies game. He did so cautiously, purchasing club-level seats that would give them easy escape if she panicked. That went so well that in late July they attended another game, where she mingled with crowds in the rooftop section of Coors Field.
As important as it is to support loved ones with neurologic and cognitive issues, Dennis added, caregivers must take care of themselves.
“You have to avoid at all costs giving up your own personality, your likes and your loves,” he said. “Find something that is yours that is away from the caregiving issue.”
In his case, he finds time to visit old friends himself, usually in the mornings while Sue sleeps. “I need socialization,” Dennis said simply.
He credits Holden and Drake for helping to stabilize a situation that can be untenable for patients and caregivers who lack resources.
“The concept of coordinated care is very important, and the time for it is now,” Dennis said. “Dr. Holden and Dr. Drake are the best of the best when it comes to [that].”
Geriatric mental health resources: An increasingly important service in an aging world
Holden said the Geriatric Mental Health Clinic fills a vital need for an aging population still wary of admitting the need for counseling and therapy. Fears of mental deterioration loom large in the imaginations of the elderly, she said.
“If my brain is threatened, that’s existential in a way that no other health condition is,” Holden said.
Too often in the past, she added, treatable mental health issues deteriorated to the point where admission to an inpatient psychiatric unit was the final option.
“We see the clinic having overall benefits for quality of life,” Holden said. “We’re bringing psychiatry more into the fold of the normal standard of care.”