Podcast: The Golden Years and Mental Health

Episode Transcript

Jenn: Hey everyone, welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Hi, everybody. Thank you so much for joining us today to learn more about the golden years and our mental health as we get older. I hope wherever you are in the world, you are doing well. And I will formally introduce myself. I’m Jenn Kearney and I’m a digital communications manager at McLean Hospital.

So, today’s session all about older populations and embracing our mental health as we get older. And I know the older that we get the more we talk about physical ailments, right? Like, “My knee needs to be replaced,” “I wake up every morning and I need to crack my neck,” or one that my grandma used to say at her four foot nine height, “I’m just not as tall as I used to be.” So, things like that.

But with all of the physical lamenting comes mental health concerns too, right? So, there’s been some studies that show that in older adults, depression and anxiety are just as if not more common than dementia as we get older.

So, how exactly are we ensuring that older adults including our own population have better mental health as we age? And does technology actually factor into caring for our own mental health or for the mental health of our loved ones?

So, over the next about an hour, Dr. Ipsit Vahia and I are going to talk all about mental health in our later stages of life, how technology can help older populations flourish when managing mental health and other conditions and more.

So, if you are unfamiliar with Ipsit, I will formally introduce him. Dr. Vahia is a geriatric psychiatrist, clinician, and researcher. He is the medical director of the Geriatric Psychiatry Outpatient Services at McLean Hospital and the McLean Institute for Technology and Psychiatry.

He’s also director of the Technology and Aging Laboratory and is currently overseeing a program on aging, behavior, and technology.

And a fun fact, before I ask your first question, Ipsit, I actually met you within my first six weeks of working at McLean because you were the unbiased judge for our Holiday Cookie Competition that we had in Public Affairs.

And I have never been so kindly informed that I don’t know how to make oatmeal chocolate chip cookies if my life depended on it. So, thank you for that. And for the love of God, nobody ask me what that recipe is.

So, Ipsit, hello, welcome and thank you for joining me. This is your inaugural session and I’m super excited. I would like to get started first and foremost by saying you can come off mute whenever you’re ready. And I’d love to ask, if I wasn’t dedicating attention to my mental health when I was younger why should I bother doing so when I’m older?

Ipsit: Oh, what a place to start? Is that a way to get back at me for the cookie comment?

Jenn: Yes, I figured I’d throw it all in there.

Ipsit: That’s an excellent question. And I think the reason is that as people get older I think the dynamics of how the connections between the brain and the body work, it changes. I think there are things that one is able to deal with or sort of brush past when one is older when it comes to mental health, just because one tends to be busy with family, with work, with a lot of different things to do.

And there is a higher level of physical and brain resilience. As when one is younger. I think as we get older, resilience increases in many ways, but the body is just capable of handling less. So, what we often find is that, you know, it used to be called the mind body connection though.

It’s not a term I particularly like but the idea that changes in the body be it an illness, be it chronic medical conditions can impact the way the brain functions.

The opposite is also true. I think if someone is experiencing depression or anxiety or some other neuropsychiatric symptom it impacts all of your physical health in a way that it might not have when you were younger.

So, I think no one here would argue too much with the idea that there is no health without mental health, but that phrase becomes sort of much more tangibly and concretely true as one gets older. So, the short answer would be think about your mental health as you get older because your life and wellbeing really depends on it much more than it used to when you were younger.

Jenn: So, what are some of the mental illnesses that are commonly occurring in older populations that we might not necessarily be talking about?

Ipsit: Yeah, I think as a geriatric psychiatry there’s all of the mental illnesses that I work with. There’s the dementias and there’s the mental illnesses that are not dementia. So, kind of, we learned to think of it as a mental illness symptoms in the context of dementia or outside of the context of dementia.

About 40 to 50% of the work that I do involves working with people that have dementia. But dementia is not the most common thing we see. The most common illness we see is probably depression.

We also see things like anxiety, and I think that’s become especially noteworthy in the past year or so since the pandemic hit I think there’s just anxiety levels are up. And then we do a lot of work with people that have had a whole range of mental illness when they were younger and then they age. And all mental illness changes across the lifespan. So, it’s really quite diverse.

I think what’s also important is that the stressors and the burdens of late life bring their own challenges and a lot of work that we do even though it’s not treating mental illness, per se it’s helping people deal with the everyday stressors and conflicts of aging, loss, for example, or grief.

Or conditions like anxiety around not generalized anxiety or panic disorder in the pathological sense but a broader anxiety about financial wellbeing, survival on fixed income, the what if’s around end of life. So, there are things that don’t necessarily fall under pathology but do represent well, you know, things that impact wellbeing that are also part of late life mental health.

Jenn: So, I would be totally remiss not to highlight the fact that I don’t know COVID in 2020 and all of that crap that’s happened. There’s been so much isolation in so many populations. And I know that a lot of older adults worry about even when there isn’t a pandemic going on, they’re concerned about isolation. So, I got to ask how have older adults fared during the pandemic?

Ipsit: So, I think the answer to that question is one of the few honest to God pieces of good news we’ve had during the pandemic. And I’ll tell you why, because I remember about a year ago when the pandemic hit us folks me you were concerned that we were going to be hit with a mental health or mental illness tsunami because we know the virus impacts older adults disproportionately.

We know that isolation and loneliness are issues, especially in people that lived in these communities that were just sealed off from the outside world. So, we assumed that we would see a lot more depression. We would see a lot more anxiety. As it turns out the exact opposite has happened.

The pandemic has been terrible for mental health but of all the age groups, older adults seem to have handled it better than any other age group. And it’s actually not particularly close. If you look at the data and there’s a lot of data.

There was a report from the CDC that came out last August. That was sort of the first big study that found that nuance at depression rates among older adults were about six to 8% compared to those in that 18 to 25 groups where the rates were closer to 45 to 50%. So almost six times lower than younger adults and these were American data.

But since then, we’ve seen studies from China, from Taiwan from Hong Kong, from India, Italy, Spain and England, Brazil, literally every region of the world that has found exactly the same thing. For those of us that are plugged in with data you just don’t see this.

You don’t see this consistent finding around anything really. And a lot of our work is now focused on, well, what’s driving this? And you know why are older adults doing better? And we think that the answer is multifactorial.

Some of it probably has to do with the strengths of older adults. We know that people tend to be more resilient. They tend to have more emotional equanimity as they grow older. Some of it just comes down to experience.

I mean, I’ll tell you a story from a patient that I saw where early on I commented to her that even though this had been a stressful two months that she seemed to be doing okay and her response was, “Honey this ain’t my first pandemic.”

And that stayed with me because I had sort of lost track of the fact that she had clear memories of the Asian Flu Pandemic of 1950s. And, she remembered SARS and MERS, and some of the others that many of us do.

But it kind of drove home the point that just by virtue of having lived longer, older adults have seen a crisis or two and are less reactive to it than someone that’s younger that hasn’t witnessed anything like this in their lifetimes.

You know, some might call it wisdom. I think you can call it by many names, but older adults have some innate strengths that allow them to deal with this. There are practical issues too. I think some of it has to do with younger adults have had to deal with stressors that older adults just don’t have to.

Employment, childcare, child schooling, care of loved ones. I mean, many older adults are on fixed incomes. They have Medicare, their lives tend to be relatively streamlined and just haven’t been disrupted as much.

So, I think that’s a factor too. But I find myself just in both my professional but also as a citizen of the world going through COVID like everyone. Turning to my patients occasionally for counsel or asking them what’s the secret to their dealing with anxiety because there’s a decent chance on a given day I’m more anxious than they are even though I am ostensibly their treating provider.

Jenn: I love that you said that because, so my partner and I have been married just under two years and when we were traveling, and we met couples that had been married for decades. So, we were like, “Well what’s the secret to 34 years of marriage.” And it’s always like, you can find, you can seek counsel and people who have lived longer and have more lived experience than you.

So, I love that you turn to your patients sometimes for advice, like “I’m freaking out a little bit. How can I be as relaxed as you are?”

Ipsit: Right and that’s, and you get the best. I think one of the not often publicized but anyone that works with older adults will tell you that one of the great joys of doing geriatrics is that you have the privilege of working with these people that have these extraordinarily rich life stories and every now and then you get to hear them. And it’s amazing.

My favorite is the time that I was working with someone that was seeing me for depression in later life. And I think we had successful treatment. She didn’t need medications, and I’d worked with her for a good couple of months and something happened, and we got into a conversation about Hawaii.

I don’t remember what led to it. But she told me she had lived in Hawaii. And I asked her for a little bit, just as, you know, it was part of my effort to get to know her better and build rapport.

And it ended up with her telling the story of how she actually stood in her balcony and watched the Japanese bomb Pearl Harbor in the flesh. And it just blew my mind that, you know, I work with people that have been witnesses to history and have learned from it, have grown from it.

During the pandemic it has helped them make it through this a lot less scared than many of us that are younger

Jenn: I could not agree more. But I know you had previously mentioned that older adults, they’ve lived through more. So, they’re often more resilient. Does this mean that the common causes of depression and anxiety in older adults are actually different from those that are younger?

Ipsit: Depression looks different in older adults. As to so many mental illnesses. We know, for example that older adults are less likely to say, “I am depressed.” It often manifests in physical terms.

You know, backaches, body aches, just a general lack of energy, a lack of motivation, maybe some apathy. In psychiatry, most of our diagnoses are reliant on the DSM-5 or other standardized criteria.

But we’ve known for years that older adults don’t necessarily meet these criteria because they were developed for a different age group and the nature of the illness changes. So, I think part of geriatrics is kind of picking up this ability to recognize what might be depression but it’s not being called that. And help is not being sought for it.

The vast majority of depression in late life never makes it to a geriatric psychiatrist. It’s something that’s seen by primary care providers or psychotherapists or even nurses. And, there’s a term for it.

It’s called subsyndromal depression which is defined as the presence of depressive symptoms that don’t meet criteria for major depression. And the presence of even one of those symptoms like loss of appetite or a disruption in sleep is significant enough to have a quite a large impact on quality of life.

When I speak to groups of professional colleagues and PCPs I spend a lot of time sort of driving home this idea that you may be dealing with people that see you for hypertension or diabetes or arthritis or whatever but there may be a depression that you might not pick up on if you don’t know to look for it I think the converse is also true.

I mean, ageism while now being addressed is still quite common. And I feel like the most harmful form of ageism is self-ageism where someone that is older and struggling with symptoms of depression may not seek care for it because they themselves don’t recognize that this is not a normal part of aging.

So it’s often that people will feel depressive symptoms but they just sort of assume that if I’m feeling tired and I don’t feel like getting out of bed and I’m thinking about the end of my life that this is the way it’s supposed to be because I’m in my 80s.

Not true. Not true. Preserving a sense of, you know, within the context of having chronic medical illnesses, I think preserving a sense of vitality is what you should expect for yourself.

Jenn: So, I know you had mentioned like, it can be hard for someone who has depression and doesn’t realize it to get out of bed.

And they think it’s part of aging because with folks aging comes a lot of change and a lot of it has ties to grief and loss, whether it’s you’re retiring and you’re losing that part of your identity, your kids are leaving your home or your friends and loved ones are passing away. Those are all very common things that in your later years you have to wrap your head around.

So how do we navigate all of these really major life changes and handle all the emotions that come with them. And I guess an additional question would be how do we know if we’re having a hard time handling them and when we should reach out for additional help?

Ipsit: One important point to make is that there’s a distinction between bereavement, grief, and depression. This is a teaching point, but bereavement is the actual fact of losing a loved one. But also, you know, you can have other losses that are not bereavement.

Like, as you said, Jenn, the loss of a role when you retire or the loss of stature for someone that’s held a high position and then doesn’t have it anymore. It could be the loss of functioning for someone that develops cardiac disease late in life.

It’s the loss of the ability to be able to, you know, be as physically active, as one would want to. Loss and bereavement are a part of life. Grief is a normal reaction to this loss. So, grief is not depression. There is a process of recovering from grief.

Many older adults will tell us that, that, you know, they’ve accumulated the experience of grief over the course of their life. I think it might be part of why older adults are doing a little bit better than the general population because even for those of us that have not lost someone to COVID, we’ve still had losses, even if it’s nothing but the loss of life as we knew it.

And I think going through that process of grief is jarring when one is younger. But when one is older, there’s a equanimity to it. They know how they’re supposed to feel. And they know that yes, you do actually recover.

If it’s been six months and those symptoms of grief don’t resolve, if there are still flashbacks, if the process has stalled, I think then there’s a condition known as persistent grief disorder that overlaps with but it’s not the same as depression.

So, I think the idea of dealing with grief and the idea of dealing with depression, they’re similar but distinct entities. Specifically, around grief. I think if there has been the loss, especially if there’s been a death that someone is struggling to move on from that’s one indication to seek care. There are specialized therapies for it. Occasionally medications help though they are not first-line.

But depression can happen without there being grief or without there being a loss. And it often presents with similar symptoms. Ups and downs in terms of emotion are normal. Everyone experiences them across the age span.

But I think if it’s ups and downs and especially if it’s downs and emotion that lasts for two weeks or longer, and most importantly if they’re getting in the way of living life, as one is used to, if functioning decreases, if you know, sleep, appetite those sorts of things decrease, then it’s probably time to at least bring it to the attention of a clinician.

Jenn: So, we had someone write in saying, “When I speak with younger people, they sometimes feel like they have a lack of purpose or they feel lost.” And I get this, I personally think that social media and having a constant highlight reel and technology has some influence on it.

But as a geriatric psychiatrist when you personally interact with older adults, do you see similar responses in these populations, or do they tend to have a more positive outlook on things?

Ipsit: It varies widely from person to person, right? So, the other point I will make is that older adults are not one group. For one, I think we sort of think of 60 or 65 and above as older adults. When I would tell you and anyone that works in geriatrics would tell you that a 60-year-old and a 70-year-old and an 80-year-old and a 90-year-old are really quite distinct from each other.

And, you know, as we see in earlier life that every decade is different. I wouldn’t have a hard time convincing anyone that you should not think of 50-year olds the same way as you would 20-year olds. So that’s a 30-year age gap. So why would you think of 50-year olds and 80-year olds as kind of part of the same group?

You know, not to get to much of an advocate. But I think that is in some ways implicit ages and just at a societal level that we kind of lump everyone that’s over 60 as one age group and they’re not. I mean, we’re not better at thinking of the younger old versus the older old.

But, so the point I was building up to, so thanks for the reminder, the point that I was building up towards is that it’s very different when you talk to a 65 year old, that’s a, you know, a baby boomer, that’s freshly retired and is ostensibly looking at another two or three decades of meaningful, hopefully healthy life, right?

We aren’t great at planning and society especially in the U.S. is not great at equipping people for life after retirement. I do think that people in their 80s and older, they worry less about purpose and meaning in the here and now. And I think their focus changes more to not what do I want to do, but what have I done? And doing things that build legacy.

When we treat people like this, this often enters the picture. I will often talk to people about not what their symptoms are or how they’re feeling but getting them to think more in terms of what has the value of your life been, what has the meaning of your life been?

They’re actually therapies around this called reminiscence therapy and narrative therapy where the treatment for a late life depression is in fact getting people to recognize what their life has meant, what they have contributed? And the very act of doing that can be therapeutic and it can help cope with depressive symptoms.

I think the sense of, it’s an excellent question because the idea of a sense of purpose is something that we used to talk about only in late life. And you’re spot on that people feel lost when they are younger. That’s new.

I haven’t seen the studies yet, but it’s hard not to imagine that social media is somehow playing a role. But for a lot of the people in their 60s, it’s common to have a depressive disorder relatively speaking, just after retirement.

And I think that has to do with that loss of stature, that loss of a day to day routine. So very often with that subset of older adults work has to do with helping them recognize that they do have a higher purpose. It’s often what leads to remarkable second acts. Either it’s a late life job or it could be philanthropy, or it could be mentoring, or it could be advising.

Sometimes people will return to hobbies that they had abandoned in their 20s. There’s a lot of room. And I think the fun of the work of geriatrics is individualizing this because it is as far from one-size-fits-all as you could possibly get.

Jenn: I know we have like very lightly touched upon technology. So, I got to ask you, ‘cause you’re so heavily involved in it. How has connectedness through technology helped older adults with their mental health?

Ipsit: So, technology cuts both ways. I think the biggest thing I would say about technology is that technology is agnostic. Without someone using one of these and having certain life functions that run through their cell phone, I mean, it’s just a bunch of wires and circuits and chips, right? So, it’s not about the technology it’s about what you do with it.

I’ll return to the example of the pandemic. And I’ll share a story that when the pandemic started we had to transition the 1000 plus older adults we care for in our service to virtual care, more or less overnight.

And to do it right, we elect to do a needs assessment and study our own patients to find out how many had what access to what types of technology? How many could do video-based sessions? How many were just on the phone?

And as we expected, you know, almost 40% didn’t have the tech, they just had phones. But many had the devices, they just didn’t know how to use it for Zoom. So, we built a training program in-house where we took on the responsibility of teaching our patients how to use teleconferencing for Telecare. And we found that almost 30% of the patients we saw had the tech, but not the know-how.

So, when we give them the know-how they started using it, but what was even more remarkable was just how many people who had no interest in Telecare were now able to do it. And the reason was they figured out how to use Zoom.

And the reason they figured out how to use Zoom had nothing to do with us. It had to do with the fact that their churches were now doing service on Zoom. Their grandkids, the only way they could talk to them was on Zoom.

And, you know, I have no relationship with Zoom but that has emerged as the platform of choice. But when they had to do what they did. And not only did they do it, they probably tied more aspects of their life into it for the better than many younger adults did.

And I think therein lies the lesson. The lesson is that older adults tend not to be explorers of technology so they will not pick something up just out of curiosity.

And I think that the idea that older adults are technophobic is a myth. They’re not, not as a group. They tend to not be heavy users, so that’s true. But if you can make the use case for how technology will benefit them, we know from research not only will they use it, but they will use it more diligently and more methodically than younger adults.

So, we’ve learned that technology when used to maintain connectedness, to maintain relationships can actually promote wellbeing. We know that older adults that have been able to adopt video-based telecommunication have withstood the impact of loneliness and isolation better than those that have not been tech savvy. So, it’s been just straight protective.

There are issues of equity and access to technology that I think factor into this. So, I certainly don’t want to say tech is marvelous and everyone should use it. I think from where we sit, it’s important to realize that there are things that tech can do but there may be people that don’t have the ability to or cannot learn or have no interest in using tech.

So, I think optimizing technology where you can while also making sure that we don’t do things that are solely reliant on technology is the way to go. It makes for a heavier load but it’s an approach that makes sure that you minimize rather than worsen just inequities based on tech use alone.

That being said for those that are able to do this I think you are limited only by your own creativity and how technology can help improve quality of life.

Jenn: So I know that you had said you had talked a little bit about some of the myths around older adults and technology but what do you think are some of the other misconceptions when it comes to older adults on technology use, aside from they just don’t want to learn or it’s too complicated for them to learn?

Ipsit: I think exactly that, the fact that they are able to learn, they will learn, how you teach them matters. So, I’ll give the example. There was, it’s now been 12 years but there was an important study. It came from Japan that found that older adults that lived in multi-generational households were more likely to use technology than older adults that live by themselves.

And the reason was that in multi-generational households there is a grandkid or a grand-nephew or somebody that teaches them. I think that act of being able to learn, and there’s a human interaction piece to it, really goes a long way.

The other thing that I think this is a realization I’ve settled on after a while that there is a suite of what they call senior friendly technologies. So, you know, senior friendly tablets or senior friendly smartphones or whatever. I have mixed feelings about that.

The reason is that the act of, so there may be scenarios where it is helpful but I think for the average older adult that’s not cognitively impaired the act of giving them senior friendly technology compared to just tech at large is an act of exclusion well-intended but an act of exclusion.

I once had someone phrase it and I’ll paraphrase what they said which is don’t give grandma a grandma friendly cell phone because really who wants to find themselves using a senior friendly cell phone, instead of give her an iPad, preferably one, that’s a newer model than the one you use and teach her how to use it.

And that will make her feel included. It will make her feel better about the fact that she has something that her grandkids want to use. And she will feel better for the fact of having learned it, not just that, but the act of learning to use the technology is actually good for cognitive stimulation.

Jenn: It’s definitely a point of pride. And, I know, so I’ve got two nieces, one is eight months and one is three. And after they were born, my parents started extensively using technology more and more because for them it’s really easy to FaceTime during COVID.

So, it’s something that allows them to stay connected and they can do things together. They know how to use a fire stick. They know how to do this. And it’s something that allows them to bond even though there’s 65 years between my niece and my dad.

Ipsit: Yeah, mine, I had a couple of early moments of realization that drew me into the field of tech study. One was, One of them was a professional experience. This was when I was a trainee and I was rotating on the Geriatrics Inpatient Unit.

And what happened then was that a day on the unit began with what we call community meeting, where all of our patients would gather in the morning and there would be a review of the day’s news and a summary of what the day schedule was going to be like on the unit.

And, it would always begin with someone getting the newspaper and like just going through the headlines, now inevitably on 50% of the mornings, the newspaper never made it to the unit. It disappeared somewhere along the way. On the day when I was to lead the meeting, this happened the newspaper was not there.

Now on this day, I happened to have my personal iPad on me. And I couldn’t tell you why I did it, but it was an act of maybe because I had been reading the newspaper on my iPad that morning, but I pulled out my iPad and like we don’t have the newspaper, but it doesn’t really matter. We can just access the newspaper on the iPad.

And I read the news. And then what was interesting was one of the patients asked, he’s like so you should be able to read any newspaper you want on that, right. I’m like, you know, yes. This person happened to be from Pittsburgh. So, he’s like, can you pull up the Post-Gazette and see what they’re saying about how the Pirates did last night? And I’m like, you know, yeah, sure, I can do that.

So, I read out a report on the Pittsburgh Pirates from the previous day, and then it caught fire. Then someone wanted to know about the gossip column in St. Louis and another person wanted to read about or hear about the restaurant review in the Atlanta Constitutional Journal.

What stayed with me from this experience is that technology used the right way, allows you to personalize. And this wasn’t even really care. It was, I mean it was, but it was an experience.

So, this idea that technology allows you to personalize care at the level of the individual, I think that was a powerful insight. And, you know, that it was all of this took maybe 20 minutes, but it’s been 20 minutes that have shaped my career since--

Jenn: I think that’s wonderful. And you know, it also speaks a lot to people holding onto the parts of their identity that they love the most. Like you were a resident of St. Louis, that was the best 15 years of your life. So, the things that remind you of that time you’re going to want to hold onto and technology can help with that.

Ipsit: It really can. The second experience was this goes back a decade or so but I’m from India originally. And my grandparents were in India. They’ve since passed away.

But I remember that there was a wedding in the family of one of my cousins and my grandmom could not travel because at that point she was not in great health. We’re talking about the early days of smartphones and iPad here.

So I think the timeframe is important, but what ended up happening was that someone had the brilliant idea of using FaceTime and someone at the Indian end had to teach her how to use FaceTime and set it all up for her, which was easy enough to do.

But this is commonplace now, right now we don’t even think of this, but the sense that you could use this device to have her virtually present and witnessed her grandson’s wedding and then Indian weddings are elaborate affairs.

So, we did, she joined the first ceremony like three days later, there was like a bank of iPads with a suite of uncles and aunts in India all attending the wedding virtually this is now life. This is no longer novel, but back then it was, and it was a huge deal. This idea that technology can eliminate the geographic boundaries.

Jenn: I love that so much. One of my sisters lived in London for four years. She also lived in Hyderabad for four months. And my grandparents’ favorite thing was Face Timing her. And they would hold the phone really close because their vision was terrible.

And they’re like, oh, I can see you look wonderful. She’s like, I can see your eye. That’s not what matters here, though. What matters is that you like, you know what you’re doing we’re able to connect 7,000 miles. It doesn’t make a difference.

Ipsit: That I think has been one of the long after we control the pandemic. I think this mass shift too, I mean for care but also for everything else. I think that will stay with us. Geography doesn’t mean what it used to.

Jenn: So, we had someone ask if you have any suggestions around how to address and encourage independence with older adults.

Ipsit: That’s a broad question. I assumed they were asking about living independently and person who asked is welcome to clarify. A big one is physical health and physical activity. Loss of physical function is one of the primary drivers of loss of independence.

So, I mean, we all know diet and exercise are good for you, but diet and exercise it turns out are good for you. So, I think maintaining physical activity is a simple thing, but it matters.

It’s also like things like preventing falls and maintaining ambulation are so important because when one gets older any period of prolonged sedentary time you lose muscle mass much faster than you do when you are younger.

This is why for those that undergo hip or knee replacement surgeries assertive rehabilitation is so important because if you don’t do that and they’re not mobile, they lose muscle mass. And a lot of independence is lost just from loss of the ability to move.

The second big driver of loss of independence is cognitive decline. This is one where I think technology can have some role. So, for example, someone that’s not able to drive anymore if they figured out how to use Rideshare can still get around and do the things they need to do while living by themselves. Same with, I mean, there’s apps for food delivery, grocery shopping.

So, there’s ways for people just to live independently even with loss of function because technologies can help mitigate that to quite a great extent. And finally, you know, just good medical and psychiatric care, I think helps promote independence. I hope I answered that question. It’s a good one.

Jenn: So I know you had mentioned that there’s both like the physical, but the psychological component of falling when you’re older if someone falls seems kind of inevitable how do we help them not become depressed or feel like they’re losing hope because of whatever may come up for them as a result?

Ipsit: Falling and fear of falling, two intertwined entities. You know, a fall can be a major life-threatening event if there’s a hip fracture involved or if there’s a head injury. So, I think fall prevention and fall education are important and there’s a whole bunch of preventative interventions you can do to minimize fall risk for people that are on a lot of medications.

For example, you know, looking into whether that can be controlled for people that have loss of sensory function. This is something that falls in the domain of good primary care assessment of fall risk and assessment of functioning, and then minimizing fall risk.

But fear of falling I think is often under-recognized and understated, even in people that have not had a fall. I think the fear of having one often leads them to restrict their own activities and their own abilities. And I think that starts off this vicious cycle where they’re no longer living life to the maximum of their capabilities.

And it becomes more constricted that amounts to a loss that leads to the sort of grieving that we talked about, and that can easily spiral into depression. I think when fear of falling triggers lifestyle changes, negative lifestyle changes and restrictions, I think that’s when it becomes problematic.

For those of us that are younger and have older adults in our lives, I think this is something to keep an eye on that is fear of falling because people don’t talk about fear of falling, it often lurks just under the surface. And the best thing to do is just ask.

Jenn: So, what are some of the signs that I should be on the lookout for, in myself or for loved ones that might be an indicator of a change in mental health? I know it’s kind of a loaded question.

Ipsit: It is a loaded question. And I think we could spend the rest of our time just talking about that, but a very, very simple one is if you find a change in them, pay attention some ups and downs are common, but if they’re quieter, if they’re turning down invitations to meet, if they’re more withdrawn.

It need not be negative, sometimes a sign of mental illness and especially dementia is people, you see them trying too hard, they’re more active and forcing conversations or forcing things. They may be more inappropriate, or you know, say things that they didn’t say, use phrases that they didn’t use to say or use before.

They may be more irritable and frustrated because they recognize that they’re not themselves. And, you know, it’s a terrible thing for a lot of people that the very earliest signs of cognitive impairment, the sense that they don’t remember the way they used to and are acutely aware of it can be quite traumatic.

I think from the point of view of someone that’s working with a loved one I think the idea is that you would, you would pay attention and you don’t need to immediately take action but you do need to track how this is playing out because these tend to be slower moving changes.

So, I think keeping an eye on when someone’s attitude or behavior or mood is not what it used to be. That’s a simple screener that something may be going on beneath the surface that you should probably pay attention to.

Jenn: I’m curious, because I know you said when everything shut down and folks started using Zoom, a lot of it was because all the church and temple services, everything was going online. So, for people to end up going to service regularly they had to learn how to use Zoom. Do you find that spirituality is often incorporated into older adult treatment?

Ipsit: Is it often incorporated? Probably not. Should it be incorporated more? Yes, yes.

Jenn: So, what exactly is the role that faith or spirituality could play in their treatment?

Ipsit: When I use the term spirituality I use it in its broadest possible sense. So, I’m not necessarily referring to religion or attending a service or having a faith. I think the broadest possible definition of spirituality is feeling some sense of connection to something that is greater than one’s self.

I’ve heard older African-American patients say that the experience of, you know, that moment in 2008 and when Barack Obama became the president and you know this is not intended to be a political comment, it’s the sense that for a lot of people that moment represented the culmination of something grand, a journey, a movement, if you will.

And they talk about that as a spiritual experience even though for someone who is not them this was a political or a current event. And I like giving that example because that sort of tells us that spirituality can be a deeply personal thing not even necessarily involving a higher power or a God or whatever.

It could just be the sense of being a part of something that is greater than oneself. I think a lot of people derive comfort from it. A lot of people derive meaning from it. This is not to say that people that are not spiritual are somehow different or lesser.

So, I think it’s more the idea that if someone has a spiritual belief we would be well-served understanding it, exploring it, and leveraging it in the interest of their own betterment. And it can be quite a powerful tool if thought of the right way. I think the idea of spirituality gets muddied with religion and it shouldn’t be if done correctly.

Jenn: I like the idea that you brought up too that spirituality is just feeling tied to a cause or something meaningful. And I feel like that might contribute to why a lot of folks in what you called like the second act end up doing a ton of philanthropy because that’s their own form of spirituality. And that’s what they believe in. So, they’re just, you know, it helps them out.

Ipsit: Yeah, there is actually a growing body of research now on approaching mental health and mental health care through the lens of positivity. And I don’t mean positivity in sort of a Pollyanna way.

I mean, the idea that what we call positive qualities so wisdom, altruism, emotional control, spirituality that these are definitive entities, many of which actually may have a neuro-biological basis.

They may be things that you can modulate. They may be things, some of them may be things that you can teach. Wisdom is kind of the broadest off these but it’s a multi-dimensional construct in the sense that some aspects of wisdom like emotional control, maybe grounds for intervention and that you can with things like CBT or narrative therapy teach people to regulate their emotions better.

If you conceptualize wisdom as a quantifiable entity then is it possible to give it a score? In fact, there is there are scales for wisdom now, and I think some of these traits can mitigate, you know they help people cope with the stressors of late life better. They cope with dealing with the impact of, you know early life trauma or early life illness, better.

The brain changes in late life so that a lot of psychopathology just isn’t as severe anymore or it changes in its appearance. And I think this ability to leverage some of these positive traits like spirituality, like philanthropy we’re only now starting to understand how, you know understand the true potency and power but then how to integrate them into contemporary psychiatry which has skewed almost exclusively towards symptom management.

But I think there is a movement afoot to be more holistic and thinking of wellbeing and functioning and incorporating some of this. I think it’s a slow change but it’s one that has started definitively.

Jenn: So due to the potential onset of mental health challenges during our older years and the fact that sometimes conditions can get overlooked how often should older adults be communicating with their primary care physicians and how can they bring up mental health with their care team?

Ipsit: About every six months is a good rule of thumb. I think most primary care doctors that work with older adults would agree. In general, primary care doctors are getting more sophisticated about screening if for nothing else than depression and anxiety.

But I think older adults can just as easily be advocates so that if your mood and your overall emotional well-being has not been addressed by a PCP ask, simply point out that you didn’t ask me about whether I’m depressed or anxious.

If done the right way, and older adults are usually able to do this the right way. I think it’s to everyone’s benefit. We know, and this is a little bit of shift in topic that there are never going to be enough geriatric specialists to meet the demands of the population.

We know that there aren’t enough healthcare providers to meet the demands of the population the average primary care doctor, well, you know the average primary care visit lasts about 20 minutes. The average older adult has about six or seven healthcare problems that have to be addressed during this visit.

So simple math will tell you that the average PCP has three to four minutes to work on a given healthcare problem, right? So, most of them don’t have the time to get into emotional wellbeing and things like that. I mean, if you’re depressed, if you talk about depression, sure, but they don’t.

So, I always say that older adults should just recognize that their health and wellbeing is it should be the responsibility of the care system and their care providers. And in many ways it is, but don’t make the assumption realize that in the end, no one cares about your mental health and wellbeing as you so take charge of it, advocate for it and demand it.

Jenn: I just, it’s so hard for me to wrap my head around 20 minutes six or seven issues. That’s like asking somebody to run a 10K in 20 minutes. It’s just, it’s nearly impossible.

Ipsit: Yeah, so in geriatrics anything that involves the PCP doing anything, any intervention, any program, any plan it’s destined to fail because PCPs have I think we have to think about reducing, not adding to the burden on PCPs and there’s many ways to do that. That could be an hour-long discussion on its own.

But I think a simple answer is for older adults to feel empowered, to advocate themselves and their own wellbeing, it does not have to be confrontational or aggressive. It just has to be a recognition that they’re feeling how they’re feeling and maybe that they would like some attention to things that the PCP may not inquire. Don’t wait for someone to ask, bring it up.

Jenn: So, I know oftentimes there’s more conditions you’re on more medications, you’ve got to deal with more side effects. For folks who are dealing with insomnia and who have already tried things to sleep better like taking melatonin, CBD tinctures, weighted blankets to offset anxiety. What other suggestions do you have for older folks who just don’t sleep well?

Ipsit: So, the first thing is that, you know the need for sleep decreases with age. So, if an older adult is sleeping six to six and a half hours relatively continuously, maybe getting up once in the night to go to the bathroom that’s actually considered normal.

You measure the importance of sleep not by whether or not you’re sleeping enough but how you feel. Is someone feeling refreshed when they wake up in the morning? Are they able to go through their day-to-day without sort of feeling continuously tired or heavy?

A good, simple trick for whether you’re sleep deprived is keeping tabs on whether so whether you doze off while reading a book or watching a not very interesting TV show or listening to a not very engaging lecture.

It is actually not normal for someone to doze off while watching TV or reading a book. If that happens, I mean, I don’t mean reading at bedtime, but midday if you doze off then that it’s actually probably a sign that you may be sleep deprived.

So, in that case, yes. First try the simple things over the counter remedies a good sleep hygiene, exercise is actually really important for good sleep. Exercising in the daytime can help with sleep later.

I think beyond that, if we’re talking about a condition where someone is sleeping five hours or less a night, but technology helps here too. So, all of us are actually really quite poor at knowing how well or how much we’ve slept. It’s just not something that people are good at.

So, a simple wearable sleep monitor like a fitness monitor that can allow you to get data on sleep that can actually help. I think if you find after all that that they’re still less than six hours of sleep then pharmacotherapy is probably in order and bring it up with your PCP. Using medications to manage sleep. Again, that could be a one-hour chat in and of itself. That’s a complicated topic.

Jenn: Do you find that technology has helped to de-stigmatize mental health and mental illness in older populations?

Ipsit: Oh, that’s a great question. I don’t know if we are there yet, but we are holding out hope that it will.

Jenn: And my last question for you, which I think is going to be your favorite of the hour, any resources for older adults that want to become more tech savvy?

Ipsit: Ooh, the simplest answer is find some technology and it could be something fancy like a computer or an iPad or a smartphone and learn how to use it. If you’re already doing that and if you’re already, you know if you have basic proficiency, then think about what you want to learn.

These days a simple YouTube video or a Google search it makes it so easy to learn basic technology. Beyond that there are resources there’s one called seniorplanet.org. It’s a nonprofit based in New York City that actually specializes in working with older adults that want to become, you know above average tech savvy.

So, they will teach people how to use Twitter or Facebook or other social media. They will teach people how to build websites and how to blog. I’ve really recommended a lot of people to go to seniorplanet.org for that reason.

In how we’re using technology for mental health care, the technology in the aging lab we have a website and we frequently hear from people in the community that just are interested in this or that. For example, we’re starting to explore how virtual reality can help with late-life care. We’ve played with the idea of doing some public education on using tech. We’re not there yet.

I would say because we have an audience today from all around the world or at least around the country, do a Google search. Type in where you live and put older adults technology education and you will probably find something. A lot of churches or senior centers actually have tech classes and little interest groups are sort of you know, little cafes that they organize.

Learn you know, use Google, find something that’s nearby find something that’s easy to get to, find something that wouldn’t take a lot of effort for you to engage in. And there is no short you’re limited only by our own imagination.

Jenn: I actually think that’s a really good way to end the session because we’re at the hour. Ipsit, clearly I could talk to you for like days at this point because you’re just such a wealth of knowledge.

I cannot thank you enough for joining me and for taking the time to share all of your expertise. I know we’re just scraping the surface of everything you’ve got in your brain. So, thank you immensely. I hope you enjoyed this as much as I did.

Ipsit: Let’s do this again sometime.

Jenn: Oh, I would love that. I won’t bring chocolate chip or oatmeal cookies this time, don’t worry. But to everybody who joined, thank you so much this actually concludes our session. So, until next time, be nice to one another and be nice to yourselves. Thank you again. Have a great day.

Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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