Psychiatry & Psychotherapy Podcast - Depression and Anxiety in Geriatric Patients

Episode Date: February 28, 2019

On this week's episode of the podcast, I am joined by Dr. Carolina Osorio, a geriatric psychiatrist (and one of my favorite people). After she finished her psychiatry residency, she also went on to finish a fellowship in geriatric psychiatry to take care of her favorite people. Dr. Osorio runs a special program that treats elderly people with depression and anxiety. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video. Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. Welcome back to the podcast. Today, I am joined with Dr. Carlina Asori, a geriatric psychiatrist. So after she finished her psychiatry residency, she also went on to finish a fellowship in geriatric psychiatry. So today we are going to be talking about a special program that Dr. Osorio runs.

It treats people with depression and anxiety who are elderly. So tell me a little bit about the program and maybe a little bit about the passion that led to you starting the program. Sure. So basically when I was a resident, I was doing my rotations in the inpatient. unit and we will discharge these patients and they didn't have any good place to continue following up with their treatments. So that sort of like planted the seed in my head that, you know, there was something more that needed to be done. So when I went to do my fellowship, I sort of like got a new set of lenses that allowed me to see the importance of older adults to get the treatment that they need. And so a general outpatient partial program wouldn't benefit

them and actually sometimes it would make them a little worse because older adults tend to become parents to their younger peers in a group. So when I came back to Loma Linda, I said, okay, this is the place where I have to be so I can develop this program. And so with the support of the administration here, I was able to create my little project and now we are going on our third year and it just has been really amazing. And I can see the benefit from my patients who at the end of the program will bring me like poems or cards and show of gratitude of how much they improve while they were here. Oh, that's really, that's really wonderful. So it was coming from a experiencing kind of a hole in the psychiatric community, a whole of like, what do we do with these

patients when they get discharged from an inpatient psychiatric hospital they've been suicidal they've been severely anxious and how do we help them move back into life and move back into thriving so what are some unique points of your program that maybe aren't usual for a partial program like a day treatment program so these you know and on another note these I don't know of any other program in the Inland Empire. I think there's one other partial somewhere here, but this is a very unique. This is a very unique program. Basically, patients will come three times a week. So we know that older adults have a lot of comorbidity, so they get tired easily. They're slower into processing. That's part of normal aging. But when on top you have depression or anxiety, it becomes

even, you know, more challenging. So we, our groups are small. We don't want them to be more than eight at a time because it takes them a lot of time to process. They, a lot of them are going to have hearing impairments. And so, you know, you have to speak loud in these groups. You don't, you cannot have a lot of people talking around because they get easily distracted. So the group format is a small group. They meet three times a week for three hours. Older, cannot be here five days a week from nine to three. It's just they are going to be exhausted. And what I did is I basically put together a program where each intervention has evidence-based to be effective for the treatment of older adults, depression, and anxiety. And I put them

together in a bundle because I believe that you need to provide whole patient care. So you are doing therapy. We do CBT, we do problem solving, we do reminiscence therapy. All of them have evidence base that have shown that are effective in older adults. On top of that, we do nutrition education, we do medication education, because all those variables will affect the outcomes of the symptoms in this population. Okay, so let's walk through one of those components at a time maybe and talk about, you know, how they're useful and what you've learned in the process. So maybe let's start with medications. Right. So what are some of the common medications that people come in on that you try to get off? And what are medications that you feel are more safe for this population?

Yeah. So unfortunately, most of them come on benzodiazepines. They're, you know, a lot of primary cares, they, you know, their jobs are very busy and they have this really tiny, short appointments. And so when an older adult comes with a mental health complaint that is put at the bottom of the list. So they address the hypertension, the diabetes, those two proses, and then the later one is, it will be the mental health. And so, you know, it's very short time and, you know, they just give them a benz-o and they go home. And so with time, they become, you know, the body gets used to the benz-so, they start increasing the dose, and then they become even more depressed and then they end in my program. So what I do is I taper them off.

A lot of these patients are 20, 30 years on a benzo. So ideally you want to do this like super, super slow. I have patients that finish the program and they're still on the benzo because if you taper them very quickly, they will get delirious. And sometimes, you know, you have to use your clinical judgment, sometimes maybe you need to leave them on a very small dose. But my goal is to reduce the amount and if I can't completely stop it. So that's something I learned from you, like how slow to go, especially in the elderly population. So we're talking about, like let's say they come in on Xanax four milligrams a day. How slow are you going down on that? Right. So I usually, what I do is I convert them to clonopin because it's because of the half-life, they are going to have less of the

withdrawals we just start going down. And then I would probably do like three milligrams of clonopine and that will take me from six months to a year. Wow. Yeah. Okay. Well, that's, I think that's really important to emphasize. And so if you do taper them off too quickly, you said they go into like a delirium? Yeah, they can get delirious. We actually, you know, Dr. Bolton, who's the other nutrition and inpatient, we see a lot of these. patients who are taper too fast, they end in the psych unit, psychotic, but they really are delirious. And it takes them, you know, we had patients that are being there for a month after they have been taking off the benzos. And so this is, this is like an observation that we both,

Dr. Bolton and I, we have seen. Okay. And so that's one class of medication that you try to get off. Are there any other classes of medications that you try to get off in general? Yeah, absolutely. So any medication with an anticholinergic burden, So, you know, as we age, our brain changes, and there are parts of the brain that are going to have a little bit of, you know, synapsis are going to decrease. And acetylcholine actually decreases with age. But if you add a medication that is anticholinergic, you are putting a bigger burden into that normal process. And so then you're going to have the bad side effects. They're going to get confused.

they're going to have, you know, they are going to look sort of like demented. And so you really want to minimize that. So paroxetine, it's a no-no in my practice. Yeah, mine too. Yeah. I said it's very anticholinergic, is really not good for older adults. So from the antidepressants, that's probably the only one that I can say I definitely don't like to use.

That tricyclic antidepressants are also very anticholinergic. the only one that I would use is nortriptylene because it has much, much less of the anticholinergic burden. Yeah, that one as you increase the dose, if you get into a higher dose range, it does become anticholinergic, but at the lower doses, it's much of a less of a burden. But yeah, that's okay. Are there, okay, so the anticholinergic medications, and what I'll do is I have a list of anticholinergic medications, an Excel sheet that one of my medical students has put together and we're probably going to do an episode on in the future,

but I will put it up on my website and my resource library for you guys if you want to look at all the different medications. What we've done is we've gone through, there's about six different really good review articles, and we've put it all in one Excel sheet, so you can see in one glance what every single different review has thought about in terms of anticholinergic burden of each medication. So we'll put that up on.

And there's actually the beers list. You can go Google it. And it's basically this list of medications that are contraindicated in the older adult. So if in doubt, you can always go online, put beers list, and then take a look at that. Okay, any other big early wins that you can do in this population in terms of medications? Right. So the other things is that you have to work very closely with their primary care doctors. A lot of primary care doctors, do you have primary care doctors who also have a fellowship on geriatrics?

But most of the primary care do not have this specialized training. So sometimes you want to guide them into medications. I don't want to make that decision because, first of all, I didn't start the medication. Second, I am not their primary care. So what I do is I collaborate with them. So there are medications that, you know, we are getting more and more influential. that are not good for long term for many reasons. So I'm not only thinking about the brain, but I'm also thinking about the whole body in general. So sometimes I have a case of a patient

who came with a diagnosis of depression. So when I started treating her, I noted that her heart rate was ranging between 50 and 55, and she was on metoprol. So, you know, I said, you know, what about if we first look at your medical side and see if we do some changes, your mood is going to improve. And so I communicated with the primary care. The primary care cut the metapult to have heart rate went up, patients start feeling better. So, you know, there are a lot of medical problems that are confounding and they can present like depression. So being very aware of these and knowledgeable of other medical problems and their medications is extremely important in geriatrics. Absolutely. Yeah, it's one thing I've learned from you also, as you always

measure blood pressure and heart rate in your outpatient clinic in all your patients. And you went out and you bought like an electronic blood pressure cuff to make that happen. Yeah. And I have, you know, I have patients that I have sent to urgent care and they end with a pacemaker just because I'm taking vitals in my office. Yeah. I think that's a good pearl as well. Okay. So we talked about the benzodiazepine. the anticholinergic medications, looking at all the other medications. And obviously there's a lot of nuance, and this is probably why you really study this stuff. Are there any stories that pop in your mind?

Maybe you could change a couple of the details, but like of big wins that just came from decreasing, you know, any of these medications? Like psychiatry medications? Or everything? Everything, yeah. Yeah, yeah. I mean, so there is a big movement on Twitter. It's called deep prescribing.

And so it's like all these doctors that are coming together to, you know, make an emphasis on the prescribing medications. A lot of older adults, when you start decreasing meds, they start feeling better. So they were just depressed because it was not like a major depressive disorder. It was a side effect from medications. And that really is the first thing you want to think when you have a new patient and you see a very large list of medications that they're taking. So, for example, last week I was in SAC clinic with one of our residents, and we had a new

patient, 70-year-old lady, super sweet. She came by herself, but she's one of these very complex patients because she has insulin-dependent diabetes, she has kidney problems, and so she has a care manager from primary care. Later on, the care manager came to make sure that she was going to know what our recommendation where. Anyways, we did the psych evaluation, and then when we went into the chart and we look at the labs, she had had blood drawn a week before we saw her. And when I saw those lab results, they were completely abnormal. Now, when she came to the visit, she was a little confused. She thought that she was there for a diabetes checkup, and she didn't know a lot of, like, was not clear about the date,

and she will have difficulty finding words. And she was complaining of depression. And she would say, if the good old Lord takes me, I am ready to go. I feel like life is, you know, I have reached my ultimatum, and I don't want to live any longer. She was not having thoughts about hurting herself, though. But why I'm bringing this up is because people, older adults who are delirium, 37% will present with suicidal ideation or passive wishes of death. Yeah.

So when you see an older adult who is depressed, don't think immediately is depression. Anyways, we went to look at their medicine, potassium 6.1. So I have this walking lady with a 6.1 of potassium. So I start to get worried. And so the care manager said, yeah, they drew the blah last week. They told her to go to urgent care. And the patient said, yes, but I forgot. So immediately we did an AKG, and her two ways were picked.

So we had to send her to the ER. We call AMR. And she's now admitted here at La Malinda. So, you know, when I see another person who is a little bit confused and depressed, my first thing is a medical thing. Yeah. I just saw this just a couple weeks ago. Got referred a patient, depression, anxiety.

And the more I took the history, it coincided with infections, with falls, with surgeries. And the timing was just laid out perfectly like that, you know. And so the first thing I did was not. not, you know, an antidepressant, it was not therapy. It was like, okay, what we're going to do is we're going to get you off of these medications and, you know, incredibly high anxiety about it. You know, and also, you know, you have to write down the directions. You have to involve family members sometimes. Yeah. I mean, I know that many times when you train in psychiatry, they will tell you, don't bring family. In a geriatric mentality, I want to bring family as much as I can. Because they, really need that support. Yeah. Okay. So this is the first line. You go through their medications. You make sure they're not having side effects of medications. And then they're in the treatment therapy, the milieu, group therapy, and they're getting pieces of different therapy. Now, you talked about problem solving therapy? Yeah, there's problem solving therapy in which,

you know, when they are depressed or anxious, they have a problem, right? And that problem is is 100 times worse. But some of these problems are, most of these problems are real. So you want to understand that older adults are going to have increased amounts of worrying about falling. And falling is a big problem in geriatrics, right? Because once you fall, you break your bone, we know people within a year can die from that. So it is a valid concern, but they will sort of like magnify it. So problem soul therapy is a way of teaching. them how to find ways to solve that particular problem that they're worrying about. Sometimes you cannot solve the problem per se, but the process of doing that gives them different

options that they can pick at if the worrying starts coming again. So give me a little piece, like, let's say a patient was listening to this or a provider who's struggling, who wants to use this type of therapy, like what are some simple steps that you take people through? So let's say you have an older lady. So I'm going to give you this case. I have a patient right now that she came severe. She has like a very, very bad anxiety.

She's constantly shaking. She was in the hospital for about three weeks and she's depressed. So unfortunately, while she's attending my program, she falls at home and breaks her arm. So now she's in complete despair because everything is falling apart. she doesn't get better, and now she broke her arm. And so it put her in a situation of, like I said, despair. She feels guilty because she cannot help family cleaning the house, and she feels she's a burden to them.

So I told her, okay, we have a problem. You broke your arm, right? And she's like, yes. And I said, okay, if you worry, can you solve that problem? And she said, no. And then she even said it can make it worse. And so we started to go, okay, so if you have a broken arm and you cannot help fixing the house, let's go through different things that you can do while your arm is healing.

And so you make them think and you make them come with the solutions. And so you start telling them, let's think of any solution. It might be a possible solution or an impossible solution, but let's just make a list. So you start with this huge list. And then that list, you divided in two. You divided, okay, this possibility is definitely. possible. But these three here, they are possible. So I want you to pick one of these solutions, and I want you to start implementing it at a home. And so that's how you do problem solving with

that. That's good. I like that. I like that. And that's a simple, it's a simple win, right? And so often, although we're, you know, intelligent human beings, we run into a problem and we just kind of freeze. And so I think it's just good to make one step forward to find one potential solution. Yeah. Okay. That's really good. And you also mentioned reminiscence therapy. So talk me through how you do that. Yeah. Reminiscence therapy really is one of my favorites. And the reason why, so one of the things I love working with older adults is that I learn so much from them. They have a frame of reference that is completely different than ours. Some of them, I have few patients who were living during World War II.

And so I have, my favorite ones are old African-American ladies who truly lived segregation time. I had one that she told me when she was a little kid, she would pick the cotton in these big, you know, plantations or fields that the white people would have. She said, you know, even though I had all these limitations and I was a black woman, I knew the power of education. And I know that if I educated myself, I could have a voice. And this lady put herself through school and she became a nurse practitioner. Incredible. Amazing. Amazing.

So I've been working with her for about three years. She now has dementia and she has advanced pretty severely. So she's now total care from her family. But, you know, this is an amazing experience as a provider, is to hear all these stories. So in reminiscence therapy, you're... So in reminiscence therapy, what you do is you go, you're reminiscence on the good things. And so, for example, you will show them like a picture of a turkey, right, if you're in a group. Yeah, yeah.

And then you start telling them, okay, what does this remind you off? And everybody starts lighten up. And they start talking about Thanksgiving with their families and, you know, and they say, and when you talk about, you, what is your member, what is the smell, and you go through the senses. And that start to, you know, fire up the positive emotions in your brain. And so you can also do reminiscence therapy even in patients who have dementia. Because patients with dementia, their long-term memory is pretty solid. So, you know, they go into the past and they start brightening it up, and it's just a beautiful thing to watch.

That's really good because I know there, it's likely that some, people will be listening who have parents with dementia. Yeah. Who have friends with dementia. And so what you're saying is try to use pictures, use imagery. Yes, absolutely. Yeah. So they love pictures because, you know, they are not like cause of our pictures are in a phone, right?

They like the print paper, photo albums. So what I tell always to my family members is go, if you have pictures, print, all of those pictures and start creating photo albums with your loved one who has dementia. And that is really something that they can do together as a family and it helps the patient tremendously. I think that is another great win. I'm working with residents on psychotherapy and one of the residents, just a real gentle soul.

And he had a patient bring in their photo album of their deceased loved one. one. And it was just yesterday and we were just going through page by page and listening to her brag and, you know, rejoice. You are doing reminiscence therapy right there. Yeah. So it's sometimes just focusing on the positive, focusing on the strengths in that group, you find really helpful. And so, but the importance of that is bringing memories that have a positive emotion. So, Even when people are demented and they're like on their late end stages, they might not remember your face, but they will emotionally remember who you are

and they will react to you emotionally. That's really helpful because, yeah, one of my mentors who I'll probably have in the future, his wife had dementia and he would visit her and she wouldn't remember his name, but when he walked in the room, she would brighten up a little bit. Exactly.

And she would express needs that she had. You know, and some of them were simple needs. Like, I really need some food today, you know? Right, right. And so there was this kind of like connection that's still possible, but it can be hard, of course, as a caregiver. Yeah, no, I mean, I am telling you this and it's easy for me. And actually, when I talk to my families, I tell them,

what I'm going to tell you comes very easy to me, but I know that it's going to be extremely hard for you to do. So I warn them because, you know, you're going to say, oh, you need to do those, this, this and that, and this is how you communicate with them. But we don't have that emotional connection. And when that happened, I always say, you know, I don't know if my husband or my mom or whoever, I don't know if I'm going to be able to know how to manage. Even though I'm the expert, when it comes to your family, is a completely different story.

It's completely different, yeah. And also, you know, you don't always have only positive experiences with your parent. And now when they develop, you know, dementia, if they do develop dementia, it's like all of a sudden you have this like mixture of emotions. And that can be, that can complicate things as well. Yeah, absolutely. Okay. And you also talked about cognitive behavioral therapy. So what is the behavioral aspect that you recommend?

So we do behavioral activation, right? So they have a hard time scheduling routines. And so what we do here is we help them scheduling those routines. And we held them accountable because you have to break the cycle, right? You're depressed. You want to be in bed. Stay in bed. You get more depressed.

So first you do education on this process. And then you start helping them find ways in which they can break that routine. So maybe that is going on Sunday to visit your grandkids. So one simple thing that that Sunday is going to break this cycle. So instead of you being in bed all Sunday, you're going to go visit your grandkids. So you have some sort of worksheet calendar of the week and you have them think through what are the activities

that give them a sense of meaning, that give them a sense of pleasure, and how do I schedule these activities into my day? Right. And so what you do is you tell them, I want you to choose an activity, not something that you have to do, but something that you want to do.

Because there is a big difference. Like, for example, I have dogs, right? And I love them. And, well, I have to bathe my dog. But it's something that I have to do. Do I really want to bathe my dog? Like, is it pleasure? Is it relaxing?

No. So what is something that I want to do, not that I have to do? And you have to be very, very strong making that difference. With some patients with behavioral activation, if you get really depressed, you're less likely to enjoy anything. Absolutely. And so I always ask patients when I'm looking at these activities and what do you want to do, or maybe it's a what did you want to do before you were depressed?

Because then it's like if they're completely anodonic, you know, they have no pleasure in anything, then hopefully by doing the things that they enjoyed in the past, it can help pull them out of the depression. Yeah, absolutely. Okay, so any other tips on behavioral therapy? Do you schedule, do you recommend any types of exercise? to them. Yes, I always, always. We know, so the evidence for brain health is physical activity, socialization, nutrition, and stress management. So the second one, being with friends and family,

that can help the brain as well. Yeah, because if, I mean, if you imagine, like just you and me sitting here talking, our brains are firing up, you are using, you're using vicious spatial, you're using your social skills, you're using your cognition, you're using so many different areas of the brain, but we take it for granted. Right. Yeah. So the first one's exercise. Yeah, exercise.

So the number one exercise that I always recommend is Tai Chi. And the reason why is because there is a big burden of evidence that shows that Tai Chi decreases the risk of false in older adults by 85%. Oh. Actually, there are insurances that are starting to pay for Tai Chi for older adults because it's cheaper to do that than to fix a broken hip. Much cheaper. Mm-hmm. Yeah.

Yeah. So, yeah, my one to go is Tai Chi. It's very easy. It's very smooth. Pretty much anyone can do it. Now, if you are wheelchair-bound, then my recommendation is to do chair exercises. And they're, like the Dreson here, they have chair exercises for older adults. Where they're moving their arms.

Yes. They're moving their arms. Their torso. They're in eggs. Yeah. And sometimes you can move the legs. I mean, maybe you cannot walk because you're very debilitated, yeah. Sarcopenia.

Yes. Yes. But you can lift the legs from your knees up and down, right? So you're sitting on a chair and then you just extend and flex your knee. Okay. And then sometimes when they are doing this really well, you can put weights. Weights is very important because when you do weights, your muscles are contracting and you're impacting in those bones. So that is a good way to decrease osteoporosis.

Any types of weightlifting exercise you would recommend in particular, Dr. Osirio, that have been helpful for you? Well, I received great benefit of weightlifting thanks to your team. How's it going? Well, it's on hold for now. We got it. We got to get back. We've got to get you a home gym. Yeah. That's where it's at.

When you're a busy provider, sometimes a home gym will work, yeah. will work. But I would say the hack that I've found, or like the thing that's the most important is to have people come to your home gym. I know. Three times a week to lift with you. And they could be people you're teaching or people that are teaching you. But that, for me, is the most important.

Accountability. Because I have people who show up to my house. I don't text them. I had six people in my home gym just this last Sunday night. And it was like, you know, I can't not lift, right? Because they're there. Exactly. So, okay.

So weightlifting. So weightlifting is so important. It's very important. Yeah. And everybody can do it regardless of the age. You just need to have someone that has the expertise to help you and guided you through. With the elderly, muscles can get stronger. Yes.

Strength can increase. You can increase strength. Now, so this is the thing very important. When as normally everyone, we will. are going to develop some degree of sarcopenia as we age. But if you start doing weightlifting from young age, so let's say you have 100 muscle cells and you bummed that by exercising to 200. So when you start developing sarcopenia as you get old, then you're going to go down from 200 to 100. So you're still going to be pretty fit and strong compared to a person who never worked out.

And in my earlier episode on, I did one on exercise in cognitive function, talk about how exercise in the elderly pretty much halted the dementia type of process. Just exercise. So, I mean, we're talking about multiple domains that can be helpful, but just exercise alone, just specifically weight training because it helps the bones. It helps decrease falls. Right. You know, when you're stronger, you're less likely to fall.

And I think especially I'm a proponent of free weights and learning how to squat with a bar, you know, without like, you know, a bunch of machines around you. Because that teaches you the balance as you progress in the weights, you know. And a lot of a lot of the patients that I see in my clinic, I have them squat just out of their chair. And if they can't squat out of their chair, I get them bands that they can attach to a door or to the ceiling. at a specific chair of their house so that they can use the bands to help them squat out of a chair. And if they do like three sets of five

and then two days later, they can use a little bit less band or a little bit less help, and then they can slowly get to a place where they can air squat. And when they can air squat, maybe they can eventually squat deeper and then they can add a little bit of weight.

You know, I just hold a gallon of milk, you know, and squat with that. And then, you know, get to a gym and get some free weights. Okay. But so you involve, you talk to your patients about this. How many, how do you get your patients to actually follow through with exercise? It's very difficult.

So I'm talking about a population of older adults that are pretty sick and they're fragile. And they have a lot of social restraints. So this is the population I work here in Loma Linda. So it's very difficult for many, many different reasons. because the Tai Chi has proven to be so effective, there is senior centers now offering Tai Chi. I think that Drayson did offer it, but they had a grant for that and they don't have any more money for that. And so really, you know, we need to start work within the communities in creating or making communities that are aging friendly. We don't have that.

And that's a huge problem. Yeah. Okay. So the first component you said to brain health was exercise. Second was socializing. And then nutrition, the third one you mentioned. Talk to me about nutrition. What changes?

Do you most advocate if you were to make one change, what would it be? Yes. So I'm going to go back to this thing about the physical exercise. So geriatric population is very diverse, right? You can have a 60-year-old who literally is going to drop that any time because of so many problems. And you can have a 90-year-old who's pretty healthy. So you have to really be doing clinical judgment in terms of these exercises that you're going to recommend. But my first thing that I do is I ask them about their balance.

If they tell me, oh, I sometimes lose my balance or I feel like my legs are weak, I immediately put a referral for PT. Okay. So even though you're a psychiatrist, don't think that, oh, I'm just going to do medication or whatever. I'm mental health. I'm just going to do therapy. No. Think about balance. think about gait and if there's any concern whatsoever, put a referral for PT.

I have put many referrals and I have never had a problem with that. So that is another very important topic. Yeah, so sometimes as a psychiatrist, we're like the main coach, right? And we're guiding treatment. We're looking for what's the biggest win. And sometimes, yeah, if they have balance, the biggest win that they can have is just not to fall. Exactly. Because if you fall, you end up in the hospital, you end up with the hip fracture,

you end up with worse delirium or delirium. So, okay, that's good. That's a good pro. Yeah. So the next one is socialization. Socialization. Yeah. So it's very important.

The Framingham study showed that the higher risk factor for morbidity and mortality was isolation. Isolation is toxic for our brains. And what happened in the United States with these communities that are so poorly aged equipped? Mm-hmm. They isolate. Right? Isolate. Absolutely, yeah.

And so they isolate and then they will die faster. So socialization is very important. It doesn't mean that you have to be or have tons of friends. It can be just one person. The importance is the level of trust and vulnerability that you can have with that person. And so that's where the difference is. This is huge, yeah. Connection is necessary throughout all of life, right?

And to have a couple close connected friends makes a huge difference. And a lot of what we do, I do with the residents, if they're older and they're having issues, making friends is, you know, create some behavioral activation to get them to places where there's the potential of friends. You know, so for some people, it's like, okay, you used to go to church 30 years, you know, now you can't drive. You might do some, the problem solving therapy to think through how to get to church so you can have those connections. Or, yeah, I don't know if you have any other. No, yeah, that's accurate. So, you know, that is one of the big barriers. Transportation is huge.

And because we lack of the transportation, then these patients cannot go where they used to do. And they start losing relationship with friends. And then maybe they cannot even visit their grandkids. And you know for a grandparent not to be able to see their grandkids is really not a good thing. Yeah. Okay, so the socialization, and then the third one was diet. Right, so nutrition. So I personally, what I recommend everyone is the Mediterranean diet, and the reasons are various.

Number one, we know that plant-based is really the goal outstanding best way to nourish your body. But most people were not born or raised in a plant-based family. and food is highly, highly related with culture and upbringing. So it's going to be very difficult for an older person to go vegan when they were raised on eating animal products. So the Mediterranean diet is a diet that consists of grains, lots of fish, olive oil, avocado fruits and vegetables. This year, it came up as the number one diet recommended by the medical field. And so there was a study done where they combined Mediterranean diet with a dash diet, which is the diet with low sodium for hypertension. And they did two groups.

One group was people with mild cognitive impairment, and they followed the Mediterranean dash diet. The other group had mild cognitive impairment, but they just continue eating whatever they eat. The group who did the intervention did not convert it to dementia, and while the other group, they had a higher conversion rate. So we know that this is effective and there's evidence for that. Yeah. So I did one of my prior episodes. I actually talk about cognitive issues and diet. And specifically when you're looking at the Mediterranean diet,

I wonder if the, you know, you have high omega-3s in the fish. You have high poly and monosaturated fats in the olive oil, in the nuts. And then, you know, you don't have a lot of sugary products. No. So you have low, you know, high fructose corn syrup. Oh, yeah. You're not having a lot of added sugar. And then a lot of plants, you know, so you're having lots of salads.

So, yeah, we try to do a lot of salads, a lot of those nuts and salmon and that kind of stuff. Yeah. Yeah, that's absolutely correct. Any other thoughts on diet that you would want to put. out there as like, you know, a quick win that someone can have a single, maybe a one change. Like if they were to make one change their diet, what would you usually tell someone? Stop processed foods. Process foods. Just stop that. Yeah. So what is like an example of like bread, cookies, cakes, TV dinner, food, anything that you can microwave, it is a processed food.

Yeah. Yeah. Yeah. So what you want to do is you want to use whole. products, products from the earth, right? So things that you can grow, things that are, you know, we're all interconnected. You know, our bodies are connected to nature. And, you know, we have all these things that are very good for your body, but we don't use them because we live in such a fast-paced society. Things have to be now, now, now. And so you don't spend the time on, you know, cutting your vegetables or cooking and that, I mean, that's what we call the standard American diet. the sad diet. It's a terrible diet.

It makes people sick. Yeah. Okay. Did you mention there was another brain health recommendation as well? Was there a fourth one? Yeah. Stress reduction. Stress reduction.

Yeah. Okay. And so stress reduction, give me your short on how do we reduce stress? There are so many things you can do. I mean, mindfulness, visualization. And so there is this concept of something called precision medicine, which is basically you do your assessment in very, very detail. You even do like a personality test.

And so basically when you know your patient fully in detail, then you can start matching that person to different ways that you can do to promote health. Okay. So let's say you, so you're a vegetarian. So you know you can talk about plant-based food. Now you're not a vegetarian. I'm not going to talk to you about that because I know that is not going to be sustainable for you. you might be able to do it for a month, but you're not going to be able to do it for the rest of your life.

So when it comes to stress reduction, there is a lot of exercises. There are people who are very resistant to do meditation. So you don't want to talk to them about meditation. Maybe what they like to do is swimming in a pool. So you encourage them to put that as a routine. And to do stress reduction is not you're going to do this when you get stressed out. No, you're going to do this every day. you're going to master that because when in case you get an episode of stress,

you already can nail that down. But if you do it only as needed, that's not going to work. Okay. Yeah. So when you think stress reduction, you mentioned exercise, meditation, healthy diet. Healthy diet, visualization, body scanning, you know, aromatherapy. I myself, I use aromatherapy.

I really feel, you know, using your senses. Yeah, yeah. To calm down your sympathetic responses. Yeah, we should, next time we do an episode, we'll have a little aromatherapy going in here. We'll put a little lavender. Mm-hmm. I don't know, what's your favorite scent? Orange.

You like orange? Yeah, it's energizing. Okay. Yeah. Yeah, well, I don't know. Do you need more of that? Okay, well, kind of bringing this to a close. So, we're just talking about prevention here.

We're talking about prevention, but we also talked about your program. Right. We talked about things that you've learned about medications, getting people off medications. Yeah, are there any other big wins that you would like to share to someone who's a provider, something that they should, maybe the biggest pet peeve that you have that other providers who are not geriatricians do? On terms of medications, so I will give you this little pearl. We have a couple of studies that have talked about serotonin in older depressed patients and how that can delay the progression of a mild cognitive impairment into Alzheimer's.

So this study showed that SSRIs are the best medications. There's actually a study that they did with older adults who had mild cognitive impairment and they had a history of depression. And so those who were taking SSRIs, it delayed progression of the mild cognitive impairment by three years. But those patients who were put on another type of antidepressant, actually the progression was faster. Which type of antidepressant was faster? Well, eutriens, SNRI, tricyclics. Okay.

Anyone that is not an SSRI specifically. Wow. Yeah. So I always go first with an SSRI. Mm-hmm. And then the other thing that people don't think about is lithiums, lithium. Lithium is brain protective.

It does a lot of things for the brain that are very healthy and it actually produces neurogenesis. So if you have a patient on an SSRI and they might not be doing great, they're partially responding, I add a little tiny dose of lithium because I know that it's going to help that brain. By a tiny dose you mean? Like no more than 600, 150, 300. You don't care about blood levels.

That doesn't matter for you. I check the blood levels because, you know, older adults, you know, the problem with them is that when you get older, you lose the sense of thirst. So they are at higher risk of dehydration. So because of that, I do check blood levels. Okay. That's a nice pearl. What is your go-to for aggression? Like, let's say you have an elderly patient who's, you know, becoming aggressive.

What is- For depression, treating depression? Or aggression? Aggression, you know, they may be, I guess there's a lot of reasons why people can get aggressive. So you need to understand why are the patient aggressive. Is it they're depressed? Is it they're delirious? Yes.

Is it their frontal lobe dementia? Okay. So let's say they are frontal lobe dementia. What's your go-to treatment? I mean, I usually put everybody on an SSRI. There is a study called DeCatalopramalibal. M. Cetalopram is very good for behavioral problems.

S. S. Cytalopram. Lexapro? No, Clexa. So that is a good one. The problem is that this FDA came with this warning about the QTC, whatever. So that will be a completely different topic.

So you go and look into the meds, you see how many of those can prolong QTC. You do an AKG if you need to. Not everybody needs an AKG, but I really like Selexa. And then if it's a meds, a frontal, it's a desinhibition, I definitely go for depocote. That's, you know, it's a very good medication for frontal problems. Okay. Dr. Sorio. One other thing you need to know about Dr. Sorio is the residents love Dr. Sorio. They really do. Like we had this, we had this day where people, we put up a face of the different attendings and people could text up anonymously

thoughts that they had on the attendings. And we used this, we used it approach only once because it got a little rowdy. But for you, it was like just an onslaught of positive comments. People love Dr. Osorio. People love being mentored by you. They feel a maternal warmth, a kindness. You know, people aspire to be an attending like Dr. Osorio. So thank you for coming on.

Thank you for invitation. This is an honor to be here. We're going to have you back. If you have any questions about the episode, feel free to email me at DR atpsychiatrypodcast.com. I will put a link in the show notes and on my website to the Wisdom program. Yeah, that's Dr. Osiris program. And if you're in the L.A. area, I think it would be reasonable to commute out to go to that program. Absolutely.

It is pretty full normally. Is there a wait list at this point? I don't have a wait list. It very fluctuates. It fluctuates, yeah. But know that there is a resource for your patients. Know that this group is highly effective because it also fights isolation. it makes them socialize.

Yeah. And it is, it's not because it's mine, but it's definitely a wonderful program. And the patients, when they leave, they are just absolutely happy with their results. There is a lot of stigma in ultra adults, and they don't want to be perceived as a mental patient. So work in your relationship.

And once you build a trust and reports, send them. Right. Yeah, and that's one thing when I've other providers, talk to me, oh yeah, I told so-and-so about the program. You know, they definitely didn't follow through. You know, maybe on the fifth or sixth time. Yes, exactly. You know, they're like, oh, okay, maybe there is something here.

So don't give up, keep referring to a program that's going to be helpful, whatever that is. And don't stop talking about things that are going to be helpful for them. Exercise, diet, sleep. We didn't even talk about sleep. Oh, yeah. People who don't sleep, how high a risk for that? dementia. It's a terrible thing. Well, so many topics.

We're going to have to have a second episode, Dr. Soria. So thanks for coming on. If you want CME for this episode, you can follow the website to get CME for it. If you're a provider, if you're a nurse practitioner, a nurse, recently had a nurse, submit the CME and got CME for it. And, yeah, Dr. Osori, thank you so much. And we will have part two. if you have any questions that you want answered

in part two by Dr. Osorio, feel free to shoot me a message through my social media, Instagram, Facebook, or through my email or through the website. There's lots of different ways. And I usually compile those for future episodes.

So thank you, Dr. Osirio. Absolutely.