Stressed Out Caregivers Are Using ER Visits for Respite, Study Finds

Emergency room staff call it a “pop drop” – when a disabled older person comes in for medical attention, but it seems like the person who takes care of them at home is also seeking a break from the demands of caregiving.

It’s been hard to actually study the phenomenon. A new University of Michigan study suggests that tired family caregivers are associated with greater ER visits and higher overall health care costs for the person they care for.

In a paper in the new issue of the Journal of the American Geriatrics Society, the team reports their findings from a study of 3,101 couples over the age of 65, each with one spouse acting as caregiver for their disabled partner.

The researchers looked at the Medicare payments and emergency department visits for the disabled spouses in the six months after the caregiver spouses took standard tests to measure their fatigue, mood, sleep habits, health and happiness.

Even after they took into account many factors, the researchers found that in just those six months, emergency department visits were 23 percent higher among patients whose caregivers had scored high for fatigue or low on their own health status.

Patients with fatigued or sad caregivers also had higher Medicare costs in that same time period: $1,900 more if the caregiver scored high for fatigue, and $1,300 more if the caregiver scored high for sadness, even after all other factors were taken into account.

The cost of unpaid help

“Many of us who work in clinical settings feel that patients with high home caregiving needs, such as dementia, often rely on the medical system as a source of respite for their spouses or other caregivers, because other respite isn’t paid for,” says lead author Claire Ankuda, M.D., M.P.H. “But there hasn’t been a lot of data about it, and only recently has our society been talking about caregivers and potential ways to incentivize and support them as a way of keeping patients living at home.”

Ankuda, who led the study during her time at in the Robert Wood Johnson Clinical Scholars program at U-M’s Institute for Healthcare Policy and Innovation, is now training in palliative care at the Icahn School of Medicine at Mount Sinai.

“Informal caregivers, including spouses, enable older adults with functional disability to stay out of the nursing home and live at home where they’d prefer to be,” says senior author Deborah Levine, M.D., M.P.H., an assistant professor of internal medicine and neurology at U-M.

We need to do a better job of identifying and supporting caregivers experiencing distress, in order to help caregivers feel better and hopefully improve outcomes in older adults with disability.” Deborah Levine, M.D., M.P.H.

Long-term data gives key insights

The couples in the study were all taking part in the long-term Health and Retirement Study, conducted by the U-M Institute for Social Research on behalf of the National Institutes of Health. Ankuda, Levine and their colleagues probed HRS data because it allowed them to correct for factors that other, short-term studies can’t – such as the baseline level of Medicare costs, demographic differences including income and education, and even whether the couples have adult children living nearby.

The findings add hard new data about the link between caregivers’ own experiences and the amount the Medicare system pays to take care of those the caregivers take care of at home.

Nearly 15 million older adults get help with everyday activities from spouses and other family or friend caregivers. In the new study, the researchers included couples where one spouse got help from the other with activities such as bathing, dressing, walking, getting into or out of bed, shopping, cooking, and taking medications.

Helping with these tasks on a daily basis, without pay or respite, can take a toll on the caregiver’s own health, wellness and mental state – which can lead to burnout. Medicare does not offer payment or formal respite coverage for family or friends who take regular care of older adults – and only covers home care by certified agencies under certain circumstances.

More research & services needed

Ankuda notes that studies on the impact of supporting family caregivers more formally are just beginning to produce results.

Meanwhile, health policy researchers are beginning to suggest that it may make fiscal sense to incentivize home caregiving, to keep seniors from needing more expensive nursing home care.

“I definitely think there are specific services that could help caregivers, if we can identify those people who are highest risk and provide a basic level of support such as an around-the-clock geriatric care call line that could help caregivers feel less isolated and talk to a nurse about whether, for example, to go to the emergency department,” Ankuda says. “This is a high-cost, vulnerable population.”

Formal respite care, peer support groups and other options could also help stave off fatigue and sadness – and the hospital staff who notice “pop drop” practices could help steer caregivers to such options. So could the primary care clinicians who take care of both the disabled spouse and the caregiver.

Because the new study takes into account the level of Medicare spending for the disabled spouse in the six months before their caregiver was interviewed, it may actually underestimate the impact of caregiver fatigue, she notes.

Indeed, before the authors corrected for the full range of factors, they documented that Medicare costs were lower for patients whose spouse-caregivers who reported being happy or rested. They also saw higher costs among patients whose caregivers had higher depression scores on a standard mood questionnaire.

One factor that wasn’t associated with higher costs in the new study was the caregiver’s score on a standard measure of sleep habits. Sleep disruption is harder to quantify in older people, Ankuda notes. But the measurement of fatigue, which can result from both the strain of caregiving and poor sleep, was clearly associated with both higher rates of emergency department visits and higher overall costs.

Geriatric Depression: Symptoms, Risk Factors and Treatments

By: Brian Neese

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Around 7 million of the nation’s 39 million adults ages 65 years and older are affected by depression, according to the Centers for Disease Control and Prevention (CDC). Although a majority of older adults are not depressed, they have an increased risk of developing depression, which is a persistent sad, anxious or empty feeling, or a feeling of hopelessness and pessimism.

Unfortunately, depression in older adults is often not recognized or treated. Symptoms may be mistaken for natural reactions to illness or life changes that occur during aging. Geriatric depression is associated with an increased risk of suicide, decreased physical, cognitive and social functioning, and greater self-neglect, reports the Annual Review of Clinical Psychology.

Due to its consequences, geriatric depression is regarded as a major public health problem. On a more positive note, the CDC says that it is “fairly easy to detect” and “highly treatable.”

Symptoms

Depression can cause feelings of sadness or anxiety that last for weeks at a time. Additionally, a wide range of other symptoms may be present.

  • Feelings of hopelessness, pessimism, guilt, worthlessness and helplessness
  • Irritability and restlessness
  • Loss of interest in activities once pleasurable
  • Fatigue and decreased energy
  • Difficulty concentrating, remembering details and making decisions
  • Sleeping difficulties or irregular sleeping patterns
  • Overeating or appetite loss
  • Thoughts of suicide
  • Persistent aches or pains that do not get better, despite treatment

Depressed individuals over the age of 65 are less likely than younger individuals to exhibit dysphoria, which is a state of unease or general dissatisfaction with life, a study in the Journal of Gerontology found. Older individuals with depression are more likely than younger individuals to experience sleep disturbance, fatigue, psychomotor retardation, loss of interest in living and hopelessness, according to Psychological Medicine.

Additionally, older depressed individuals commonly complain of poor memory and concentration. The Archives of General Psychiatry found that patients with late-life depression had slower cognitive processing speed and performed poorer in all cognitive domains.

Risk Factors

“Non-genetic biological risk factors for depression are particularly important in old age,” says the Annual Review of Clinical Psychology. Several factors have been associated with late-age depression.

  • Endocrine dysregulation, bone loss and certain medications (beta blockers, central nervous system medications, hormones, anti-Parkinson agents, certain cancer medications and others) may cause late-life depression.
  • Around 20 to 25 percent of heart disease patients experience major depression, and another 20 to 25 percent experience symptoms of depression not meeting criteria for major depressive disorder, according to Biological Psychiatry.
  • Dementia may be a risk factor for depression, but diabetes is not. Rather, the evidence suggests that depression is a risk factor for diabetes.
  • Stroke patients have the highest rates of major depression (20 to 25 percent) among other neurological disorders. Rates are intermediate (15 to 20 percent) for Parkinson’s disease compared to Alzheimer’s disease (10 to 15 percent).
  • Anxiety disorder and sleep disturbance are also risk factors for depression among older adults.

Social risk factors for depression, though less important in old age, can become more significant in very old age when individuals face greater losses and fewer resources. As with other ages, Psychology and Aging found that late-life depression is linked to the number of stressful life events experienced. Also, troubled relationships can explain depressed older individuals, including spousal depression, marital conflict and perceived family criticism. In The Journals of Gerontology, financial trouble is one of the most common stressful life events experienced by older adults.

Treatment and Prevention

In a review of evidence-based therapies for depression in older adults, Clinical Psychology: Science and Practice named the following as beneficial: behavioral therapy, cognitive behavioral therapy, cognitive bibliotherapy, problem-solving therapy, brief psychodynamic therapy and reminiscence therapy. A behavioral treatment plan for depression in nursing homes was successful in Clinical Case Studies. It found a strong increase in positive affect and activity level after a 10-session program for increasing pleasant activities was administered. In the Journal of Mental Health and Aging, a meta-analysis found that psychotherapeutic interventions changed self-rated depression and other measures of psychological well-being in older adults by about one half standard deviation and clinician-rated depression by more than one standard deviation.

In 2007, an expert panel recommended home- or clinic-based depression care management (DCM) along with cognitive behavioral therapy for older adults with depression, the American Journal of Preventive Medicine reports. DCM uses a team approach with a trained social worker, nurse or other practitioner alongside a primary care provider who prescribes treatments in consultation with a psychiatrist. Clinical trials link DCM to a reduction in depression symptoms, higher remission rates and improvements in health-related quality of life, reports the CDC.

Prevention efforts are often directed to those who are at an increased risk of disorder. The American Journal of Psychiatry found that treating all patients with subsyndromal depressive symptoms could prevent 24.6 percent of new depression onsets in that period. In Aging & Mental Health, cognitive behavioral therapy demonstrated significant benefits in the prevention of depression in nursing home residents. Treatment of insomnia and other sleep disturbance is a valuable opportunity to prevent depression in older adults, given the highly effective nature of cognitive behavioral treatments for insomnia in this age group. The American Journal of Geriatric Psychiatry identified that individual educational interventions for subjects with chronic illness, individual therapy for at-risk bereaved older adults, cognitive-behavioral interventions to reduce negative thinking and life review were interventions with the most empirical support. Programs to reduce social isolation may also help prevent depression in older adults.

Helping Seniors in the Community

Human services professionals can join healthcare professionals and families to provide support for older adults who have or are at risk for depression. From clinics and nursing homes to homeless shelters, a variety of environments exist where individuals are particularly at risk for developing depression. Professionals trained to work with older adults and lead initiatives in the community can make a difference.

Southeastern University offers an online B.S. in Human Services and an online M.A. in Human Services to positively impact seniors. Both programs equip graduates with the knowledge and skills needed to work in and lead human service environments. The master’s program offers a gerontology specialization, and both degree options take place in a convenient online format.

Interested in Medical Social Work: Interview with Sally Dagerhardt

Are you curious about what medical social workers do? Read this interview with Sally Howell Dagerhardt, MSW, LCSW, a clinical social worker for a primary care setting. She has worked for the past six years in various departments and capacities of medical social work, including Geriatrics, Gero-Psychiatric Nursing Home Unit, and Primary Care. Prior to her medical social work positions, she was a working in residential and community mental health.

How did you decide to go into medical social work?

Medical-social-workI was drawn to social work by the diversity of opportunities. After two years of being in rural mental health, I was feeling a bit burned out and I began to apply for opportunities within the medical field for a change of scenery. It would be dishonest to say that the pay increase wasn’t a big motivator as well. I firmly believe in the “clinical” (aka therapeutic) aspect of my social work practice as a medical social worker. I provide intervention during times of stress and crisis, and I assist patients in making changes to maintain their wellness. I also provide a more holistic, social work perspective to my medically trained co-workers – doctors, nurses, etc.

In your opinion, what are the best aspects of your job?

While there are problems and pitfalls with every employer, I try to actively focus on the best aspects of my job, and honestly, there are a number of them. First and foremost, I get to work directly with people and provide them with needed assistance. My employer values my position, as do my co-workers. I perform a variety of social work interventions throughout the day, and I enjoy the fact that each of my days is different. I think being a part of a medical team also helps with self-care, as I do not feel solely responsible for my patients’ care. I can take leave and know that my patients will be cared for, and we can collaborate as a team to ensure good care on a daily basis. I cannot leave out that another great aspect of my job is the pay and benefits, which also enable me to be more focused on my job, and are often unavailable in other social work positions.

What are the most challenging aspects of your job?

Two challenging aspects immediately come to mind. In each of my social work positions, including this one, navigating inadequate systems is always a challenge. Whether it’s your employer or an entity in the larger community upon whom you rely for assistance, there’s nothing more challenging or frustrating for me than inadequate resources or institutional barriers to care for someone who is working hard to make change. My second biggest challenge as a social worker will always be self-care and avoiding burnout, cynicism, etc.

What would you change about your job, if you could?

While I feel that my employer does an amazing job at valuing social work and the importance of what I can bring to the table, I still think that there are ways that my clinical skills could be better utilized. As a medical social worker in an outpatient primary care clinic, my job tasks are diverse, but at times I still feel compartmentalized. I think that this is a result of the way my employer is organized: primary care, mental health, specialty care, etc. and at times, it limits my ability to assist the “whole person” by directing me to refer patients to other services lines or departments for assistance, when my social work license would theoretically allow me to assist.

How long do you see yourself in this field?

Working for a large medical institution offers me a diversity of positions and moves that I can make within this organization. As a result, I plan to stay within the medical social work field indefinitely, secondary to the ability to work within different departments, thus avoiding burnout, and have an adequate retirement.

What advice would you give to someone considering medical social work as a career?

I think that there are a number of great opportunities within the medical field for social workers. I think as social workers we need to consider the diversity of our skills and the myriad of settings to which they can be applied. So many of us graduate from social work school with limited ideas as to the kind of work we would like to do. Opening your mind to the range of opportunities that exist for a licensed clinical social worker may improve your job satisfaction. There are so many environments where people in need can benefit from great social work intervention. It’s possible that you will improve your own job satisfaction and day to day life in the process.

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