End of Life Care in Frailty: Psychological support

Although life does not necessarily get worse with age, and clinical depression and anxiety affect a minority, these remain the most common mental health problems in later life.¹ People with frailty are a high-risk group.²

There are multiple and complex links between mental and physical deterioration, and people with frailty are challenged across many domains as they develop illness - they may lose their role, their social supports and contacts. As frailty progresses, they may also feel they are a burden on others. There may be a struggle with existential issues of anticipating dying after a life long-lived. There is added complexity as partners, carers and their support system may also be ageing. As people become less mobile, there is an increasing likelihood of physical and psychological distress, adjustment and loss, as well as depressive and anxious symptoms.³ Cicely Saunders articulated the concept of ‘total pain’ with all of its dimensions, which can certainly apply here.

Several empirical studies support the bi-directional association between depression and frailty in later life,¹ indicating that frailty and physical health difficulties increases the likelihood of co-morbid mental health difficulties. The risk is higher with multiple physical health conditions.³ The attention given to chronic physical health problems or functional decline may mean that depression is overlooked.⁴

Identification and assessment

Screening to identify who is most vulnerable or has low motivation, is isolated and lonely, feels hopeless or frightened about the future is vital to intervention. Identification is through detailed clinical history taking and validated tools,⁵ for example the adapted Geriatric Depression Scale, Cornell.^6,7 The distress thermometer is a simple, validated tool which provides screening and prioritisation for physical, psychological, social, spiritual, family and financial needs. The brief PHQ2 consists of two questions – ‘Over the last two weeks have you been feeling down, depressed or hopeless?’ and ‘are you able to enjoy things and feel pleasure’, and is a useful baseline indicator of low mood.

Talking about mood and emotions may be difficult for older people with frailty, and cultural as well as personal history have a great influence on their beliefs about speaking about feelings and seeking help. Questions such as ‘Do you feel guilty needing help? What would you do if someone you cared about asked for help?’ may assist the person in accepting support.

Common mental health conditions

• Dysthymia⁸ and distress
  There is an incidence of dysthymia and distress (a form of sub-clinical depression) – feeling sad, not your usual self, reduced interest in hobbies or activities and low motivation.
   
• Depression⁸
  Rates of depression (and anxiety) are increased with certain diagnoses such as after a stroke, heart attack, cancer or neurological disorders. It is not caused by the illness per se, it is instead the person’s interpretation of the situation that will influence both mood and behaviour. People who think they can recover and adapt, behave, think and feel very differently than those who feel life is over and nothing will ever be the same.⁹
   
• Anxiety⁸
  Both depression and anxiety can lead to changes in behaviour. People may become less active and may avoid situations or people, due to for example fear of falling, or a tremor being an embarrassment. In the short term this reduces stress, but over time erodes confidence and lowers mood and reduces coping.⁶ In reality, the one thing people don’t seem to fear – avoidance – is the thing to fear the most, as it will make these problems bigger.

Interventions

All health professionals have the ability to listen, and to offer practical advice, to explain and manage side-effects, fear, worry and concerns about the future. Listening well, hearing properly and offering targeted advice, problem solving or reassurance is key and the responsibility of all.

The National Institute for Health and Care Excellence (NICE) recommends activities to maintain mental health and wellbeing.¹⁰ The types of effective intervention link to the four key 'pillars' of positive mental health and wellbeing: functional ability, psychological attributes, power and resources and 'social connectedness'.^10,11 Doing more of the things that bring pleasure, interacting with others and overcoming avoidance are all good ways to promote improved mood and coping.

Depression and anxiety in later life, irrespective of cause, is as treatable as at any age. Available treatments for depression are effective, with moderate to large effect sizes.¹² Studies show that for both anxiety and depression, high-intensity interventions, individual and group-based cognitive behavioural therapy (CBT) were more effective than standard care,^5,15 including group-based cognitive and behavioural interventions.⁵ There is some evidence for the benefit of combining medication with psychological and psychosocial interventions for people with moderate to severe depression and anxiety. Current treatment choices should therefore be based on patient preferences within evidenced-based guidelines, contraindications and treatment access.^14,16 Asking the patient what their preference would be between talking therapy, activity, medication and any medications they have tried which have helped previously is key. Ensure people are aware antidepressants are very different from benzodiazepines and sedation and do not cause mental clouding.

For low level problems early intervention is vital. Mental health services operate on a ‘stepped care approach’ and recommend low intensity and GP input first. Psychosocial interventions, physical activity, peer (self-help) support and individual guided self-help (based on cognitive and behavioural principles) are more effective than standard care.⁵ GPs, care managers, health visitors and social workers are able to signpost, assess and refer on. Social prescribing now exists with navigators who can signpost to groups and signposting to wider community assets

Increasing Access to Psychological Therapy (IAPT), Older Adult Community Mental Health Teams or Memory Services will see people with more complex needs. Interventions include support groups, interagency working and CBT.

For both anxiety and depression, the recommendation is to offer those with frailty or mild acquired cognitive impairment, the same interventions as for others, adjusting the method of delivery or duration of the intervention if necessary, to take account of frailty.^5,15 When considering an antidepressant with comorbid physical health problems always refer to the British National Formulary (appendix 1)¹⁷ and NICE guidance on depression in adults with a chronic physical health problem (appendix 16)⁵ to view drug interactions.

It is not the case that old age inevitably brings worsening mental health or increased distress. In fact, despite the increasing burden of long-term conditions and frailty, older people are less likely to become depressed than working age adults.¹⁸ As people get older, they typically report higher levels of life satisfaction and can be on the whole more accepting, so rates of psychological distress, anxiety and depression may reduce.

However, a lack of understanding means that distress, depression and anxiety can be overlooked as professionals can believe it is inevitable. Listening well, using validated assessment tools and avoiding a sole focus on physical frailty will allow a thorough assessment and the means to plan an evidence-based approach to treatment.

References

1. Mezuk B, Edward L, Lohman M, Choi M, Lapane K. Depression and frailty in later life: a synthetic review. International Journal of Geriatric Psychiatry 2012;27(9)879–892.
2. Mitchell AJ, Chan M, Bhatti H, Halton M, Grassi L, Johansen C, Meader N. Prevalence of depression, anxiety, and adjustment disorder in oncology, haematology and palliative care setting; a meta-analysis of 94 interview-based studies. The Lancet Oncology 2011;12(2):160-174.
3. Brosnan L, Westbrook D. The Complete CBT guide for Depression and Low Mood, An Overcoming Publication. Robinson; 2015.
4. Tiemens BG, Ormel J, Jenner JA., et al. Training primary-care physicians to recognize, diagnose and manage depression: does it improve patient outcomes? Psychological Medicine 1999;29:833–845.
5. NICE. Depression in adults with a chronic physical health problem: recognition and management, Clinical guideline [CG91]. The British Psychological Society & The Royal College of Psychiatrists; 2009.
6. Lesher EL, Berryhill JS. Validation of the Geriatric Depression Scale—Short Form among inpatients. J Clin Psychol 1994;50:256-260.
7. Alexopoulos. GS, Abrams. RC, Young. RC, Shamoian. CA. Cornell Scale for Depression in Dementia. Biol Psychiatry 1988;23:271-284.
8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing, Washington; 2013. Pages 160-168.
9. Moorey S, Lavender A. The Therapeutic Relationship in Cognitive Behavioural Therapy. Sage; 2018.
10. NICE Surveillance report 2018 – Mental wellbeing in over 65s: occupational therapy and physical activity interventions (2008)/NICE guideline Public Health 16; and Older people: independence and mental wellbeing (2015) NICE guideline NG32.
11. Forsman A, Schierenbeck I, Wahlbeck K. Psychosocial Interventions for the Prevention of Depression in Older Adults: Systematic Review and Meta-Analysis. Journal of Aging and Health 2010;23(3):387-416.
12. Pinquart M, Duberstein PR, Lyness JM. Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy. American Journal of Psychiatry 2006;163(9):1493-501.
13. Blackburn P, Wilkins-Ho M, Wiese B. Depression in older adults: Diagnosis and management. BC Medical Journal 2017;59(3):171-177
14. Pinquart M, Duberstein PR, Lyness JM. Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy. American Journal of Psychiatry 2006;163(9):1493-501.
15. NICE (2011, updated 2019). Generalised anxiety disorder and panic disorder in adults: management. Clinical guideline [CG113].
16. Pinquart M, Duberstein PR, Lyness JM. Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy. Database of Abstracts of Reviews of Effects (DARE), Produced by the Centre for Reviews and Dissemination, University of York; 2019.
17. British National Formulary 2019. Appendix 1. British Medical Association & Royal Pharmaceutical Society of Great Britain.
18. National Institute on Ageing. Depression and Older Adults. US Dept of Health and Human Services; 2017. Available at: www.nia.nih.gov/health/depression-and-older-adults