Taking Healthcare by Storm: Industry Insights with Dr. Abhilash Desai

In this captivating episode of Taking Healthcare by Storm, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Abhilash Desai MD, Geriatric Psychiatrist.

Ageism: Combating Common Myths Surrounding Aging podcast episode.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website. 

This material was prepared by Quality Insights, a Quality Innovation Network-Quality Improvement Organization under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication number 12SOW-QI-GEN-072624-GK

Transcript

Welcome to Taking Healthcare by Storm, Industry Insights, the podcast that delves into the captivating intersection of innovation, science, compassion, and care.

In each episode, Quality Insights Medical Director, Dr.

Jean Storm, will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys.

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania, and the nation.

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Hello, everyone, and welcome to Taking Healthcare by Storm.

I am Dr.

Jean Storm.

I am the Medical Director at Quality Insights, and I am truly excited today to be interviewing our guest that is joining us.

He is really a force in behavioral health for older adults in the outpatient hospital and nursing home setting.

Today, we are joined by Dr.

Abhilash Desai, who is a geriatric psychiatrist.

And I am sure we are all going to learn a tremendous amount of information.

And again, as I say, whenever I bring a physician on, we're going to call each other our first names because we are more relaxed on our first name basis.

So Abhilash, thank you so much for joining us today.

Thanks, Jean.

Delighted and honored to be here.

Great.

So we are just going to jump right in.

So tell us how you came to do what you do.

So as some of you may recognize my name, I'm from India.

I did my medical schooling there and psychiatry residency, and I wanted to do specialized training, which we didn't have there.

So I came to US and then I did geriatric medicine fellowship after finishing four years of psychiatry residency because I love neurology and medicine also.

So I found all that in geriatric psychiatry.

And I love older adults, I call them chronologically gifted.

It gives me a lot of meaning to try and help them improve their lives.

And I've been doing that practice now for 25 years, Jean.

Oh, wow.

That's a long, long time.

So some of our listeners may not be aware that there are psychiatrists and then there are specialized psychiatrists.

Maybe they've heard of adolescent psychiatrists or child psychiatrists.

So tell us the difference between a psychiatrist and a geriatric psychiatrist.

Yeah, great question.

So in geriatric psychiatry, we learn a lot of the key aspects of geriatrics.

For example, you might have heard of the four M's of age-friendly health systems.

What matters, so we train to really inquire about what matters to the person, quality versus quantity of life, end of life issues, meaning, purpose, so forth.

The second is M's, medications, and we all have heard about how much we over-medicate.

So, rational de-prescribing is one of the unique skills that geriatric psychiatrists provide.

Besides rational prescribing, judicious, appropriate rational prescribing, the S's, the fourth, third M is mentation.

And although originally it focused on dementia, depression, and delirium, which is, you can say, the bread and butter of geriatric psychiatrists, but it can be expanded to all mental health challenges.

So, I would include anxiety, insomnia, people are aging with chronic mental illnesses, trauma now.

So, that's the third M, and the fourth is movement.

So, again, we all understand the importance of physical activity, but it's to me even more important in older adults and geriatric psychiatrists really routinely focus on all these four M's besides now the fifth M, right, multimorbidity.

So, and again, we train in not only these areas in the outpatient setting, but also in the hospital setting.

So we try and make hospitals more age-friendly, dementia-friendly, and then in the long-term care setting, where long-term care psychiatry is radically changing.

And at this point, geriatric psychiatry fellowship offers the best intensive training in knowledge, skills, and practice.

Yeah, I would agree.

And it's, you know, the long-term care facilities are in desperate need of geriatric psychiatrists, most definitely.

So what, in your opinion, is the biggest psychiatric issue facing older adults?

So, the biggest to me would be ageism, you know, how negatively we view aging in our culture.

And then dementiaism, it's a new term written by experts.

It's similar to ageism, where we view individuals with dementia very negatively.

We just don't realize that there's just so much potential for growth, creativity.

We can learn so much from the wisdom of older adults.

We are all aging.

I'm definitely less neurotic and more mature now than even 10 years ago, Jean.

So, and then again, I've been amazed by the resilience and creativity that individuals with dementia show in how they navigate life and overcome the problems that often we have created for them.

Yeah, I think ageism is so interesting.

You mentioned we don't often think about that's ageism stigma.

It's almost underlying our culture.

You compliment somebody and tell them they look 10 years younger than they actually look.

There's something wrong with getting older.

It's really, really interesting.

So we talk a lot about depression in older adults.

Do you feel it's being undertreated?

Yeah.

So let me answer that.

But before that, I just wanted to mention a podcast I did for St.

Alphonse's Hospital.

It's part of the Trinity Health Systems.

It's in Boise.

And we have a podcast called St.

Alphonse's WellCast, W-E-L-L-C-A-S-T.

It's wonderful.

So in last year in July, I did something on ageism, combating common myths surrounding aging.

Because it's really important for all of us to really have a better understanding of what it is and how harmful it is and how we can help.

Moving to your depression question.

So depression in older adults, is it under treated?

To me, it is number one, over-medicalized.

So whenever I see individuals, especially in long-term care, but even in outpatient settings, who are depressed, many times their depression is, quote unquote, normal, related to all kinds of other challenges that we can help them address better.

And it could be like the pain management, hearing impairment, medications that are causing them, social factors, loneliness, helplessness, boredom, and then environmental factors again, ageism, stigma, interpersonal environment that is negative, physical environment that is not helpful.

So if we address all that malnutrition and so forth, then I would say nine out of 10 people would not qualify as, quote, depression in the traditional sense.

That's really, really interesting.

Just in the face of, we're getting hints that CMS is going to be more focused on depression in long-term care facilities coming up in the near future.

So how big of an issue do you think depression is in long-term care facilities?

It's really big.

But again, it's important for CMS and everybody to approach it very holistically where our first job is to look for low-hanging fruits, reversible causes, as I mentioned, pain and loneliness and so forth, and address that almost in a routine, proactive, preventative basis.

And then when you have something significant in terms of depression, approach it also holistically rather than just give a diagnosis and start an antidepressant.

So we can do so much now that includes all the things we have learned in younger people.

So individual counseling, behavior, activation therapy, mindfulness-based cognitive behavior therapy, problem-solving therapy, problem-solving therapy, interpersonal psychotherapy are equally effective, if not even more effective in many older adults, including in long-term care.

And I've seen just in the last few years, the growth of services of individual counseling provided to many individuals in the nursing homes.

So to me, that's where you'll see a much return for investment in terms of outcomes.

And antidepressants are just one part of that whole comprehensive treatment.

Yeah, I would agree.

You talked about looking at individuals holistically in both inpatient and outpatient setting.

What impact do you feel the COVID pandemic played on depression in long-term care facilities, and then also in the outpatient and older adults living in the outpatient setting?

Yeah, so, you know, the biggest learning that all of us had as society is how important being with another human being is.

And so just for you and me, you know, so you can imagine the effect of this on individuals who are living alone or who are in nursing homes and then with all the lockdowns, I've seen devastating effect on their mental health.

Depression is just one outcome, but anxiety, exacerbation of their chronic medical illnesses, severe pain, almost demoralization, sometimes even trauma.

So the effects of COVID go way beyond.

And again, you know, to me, I focus on the silver lining, like what did we learn from this experience?

And the key thing we learned is the importance of connection, human to human, in person, whenever it's possible, but high quality virtual connection is actually now even more important than our traditional medical care.

So when we think about older adults, we obviously need to talk about dementia.

As we get older, we have higher risk of developing dementia.

So if we're talking about depression, does depression look different in patients with dementia?

Should we be looking for different symptoms if a patient does have dementia?

Right.

So, yes, but again, pain is often underdiagnosed and not adequately treated.

They have nutritional deficiencies.

They experience a lot of medication-induced adverse effects.

They'll look like depression.

Even SSRIs can cause apathy, and sometimes they have apathy related to dementia that is misdiagnosed as depression and they are put on SSRIs that worsen apathy.

Then obviously, social factors, environmental factors.

But having said all that, individuals with dementia do have higher prevalence of clinically significant depression that's not due to all these other factors.

And many a times, you won't see them traditionally expressing like, I'm sad or that I feel hopeless or the cognitive symptoms of depression.

The past is horrible, the present is horrible, the future is horrible.

So all these are cognitive symptoms.

You might not see them as often as behavioral symptoms and physical symptoms, like increased somatic complaints, insomnia, agitation, irritability, anxiety.

And sometimes even when you ask them, are you sad or depressed?

They might say no, but they do show a depressed affect or they might have an obvious reduction in interest in all kinds of activities that they actually you know enjoy.

They would brighten up by presence of a grandchild and now they don't.

That would be a sign of depression.

That's so interesting in learning about how we should be approaching patients with dementia differently based on their diagnosis.

What about when these patients, if a patient with a dementia diagnosis is admitted to the hospital, do you think that care in the hospital needs to look different based on their diagnosis?

No question.

Now the hospital care has become so complex that even you and I would need help because if we are in the hospital, we ourselves are suffering, so we might not have all our cognitive faculties, our prefrontal cortex.

Then you add in older adults, then obviously they need even more help, and then you add dementia, then the whole systems of care need to be radically altered.

Most of the hospitals are still traditional hospitals that focus on providing complex care as if these are younger individuals.

So hospitals themselves have to move towards age-friendly hospital systems, routinely following those four M's, what matters, medications, mentation in terms of delirium prevention specifically, and then mobility in terms of early, high-intensity physical therapy, occupational therapy, mobilizing them out of bed.

So that is even more important in dementia.

And then you have to add certain other things, like having a team member in the hospital who is a dementia expert, a dementia champion, and who can provide very simple guidance to the ground team on dementia-friendly care systems that would routinely say address hearing deficits, vision deficits, and provide socialization, cognitive stimulation, deep prescribing.

Currently, the system unfortunately focuses on management of agitation after it happens rather than prevention.

So prevention of delirium would apply to same principles, would apply to prevention of agitation in hospitalized dementia patients.

And then when they have agitation, then be focused too much on what medications to give.

So often, antipsychotics are the go-to drugs for all agitation in hospital settings, not just elderly and dementia persons.

And the harms in older adults and in individuals with dementia are dramatically higher than we use antipsychotics, in many cases, excessively or in judiciously or in doses that are much higher.

And then our expectations from medications to reduce agitation are unrealistic.

Again, the staff, the nursing staff, I totally get it.

They are so stressed out and overburdened that they are looking at you and me to give something, right?

But that's not really going to help and it might cause more harm in terms of falls and even longer hospital stays.

Yeah, you touched on the hot topics that I was going to talk about.

So let's start with agitation.

I'll say just as a nursing home doctor, I think that this is one of the biggest issues that I get called with or have to address in the interactions with the nurse practitioners that I collaborate with.

Agitation associated with dementia is a big issue and big challenge in long term care facilities.

So in your opinion, how big of a problem is it?

Is it just maybe that it appears to be a big issue because when it happens, it's so difficult maybe to handle?

And then any best practices to share specifically for handling agitation associated with dementia in long term care facilities?

Yeah, so it is really a big problem.

And the staff really have not been given adequate education about different reversible causes of agitation.

And even step before that, what can we do when the person comes in proactively to reduce their agitation?

So we need to come up with systems in place that do certain things routinely.

So I work with many phenomenal nursing home teams.

One of the best teams that I work with is in our state hospital, state-run nursing home.

We have phenomenal team, including medical director, physician, primary care physician who routinely attends our weekly meetings to review cases.

We have a superb physician assistant who manages psychiatric and medical issues, the whole nursing team, including social workers, activity therapists, and superb pharmacists who give a very detailed report of each resident.

They go through which medicines are on the beer's list, what is the anticolynergic burden, what are the PRNs used, how many of them are on antipsychotics, and so forth.

So the best practice is, the top thing is to have a team approach.

You can't just have the staff calling you and saying, do something, and then you say, okay, let's try this medicine.

Let's talk about this properly so that we address the cause of the agitation properly.

Many a times agitation is best seen as an expression of an unmet need, and it could be biological need, like pain relief, hearing impairment, vision impairment, psychological need, like I feel helpless, you don't take my choices into account.

Social need, that I'm spending too much time alone.

Environmental needs, like, listen, I need to get out of this place.

You can't just be busy and expect me to just be happy over here.

So it's best to see that agitation is an unmet need, and help the staff join them in figuring things out.

Eventually, it could be that one may have to give psychiatric medicines in certain cases, but we are also doing other things.

So it's best to assume that it's multi-factorial.

Dehydration, by the way, I've seen is very, very common.

Nutritional deficiencies are very common.

And sometimes they are not like the cause, but if you address them, your outcomes will be dramatically better, whatever else you do.

Yes, I would agree.

I've seen similar, and that when you say agitation and dementia is often an unmet need, it's not necessarily a need for antipsychotics, which are often what staff ask for in the nursing home.

Like we're kind of in need of a culture change, I think.

You know, I think we're moving, perhaps we're trending to think in the right direction towards antipsychotic use, but do you feel that long-term care facilities are moving in the right direction when it comes to managing antipsychotics?

Yes, but sometimes I feel, my goodness, it's so slow, and I just won't make it if it doesn't speed up, you know.

But yes, things are improving, but really, to me, when the staff call me or call you, I also hear that they are saying, listen, you know, you guys need to help me.

And in all kinds of ways, in terms of more staffing, more training, more support, this is hard work.

The amount of money we are paying them is just very low compared to the complexity and the value that they provide and so forth.

So when we talk about culture change, we need to realize that it's not just sort of in our minds, you know, like in that burnout in the physicians, we saw that 80% is, you know, our internal work, sorry, 20% and 80% is, you know, the health systems need to really support us in a radically different ways so that we can function better, you and I, and that would apply to CNAs and individuals working day to day on the ground.

Yeah, I would agree.

And I also share your sentiment that, yes, it's moving, but maybe not moving fast enough that we would like.

So talking, you mentioned pain.

So, yeah, huge, right?

We could do a whole podcast on pain.

I'm just going to ask you one question about it.

Are we doing a good job in treating pain in older adults?

So similar story to anti-psychotics.

So better if we compare it to like 10 years ago, but so slow and not even close to what we can do if we truly understood.

So again, go back to health literacy.

We need to all educate all the team members about pain, the biological, psychological, social, and spiritual dimensions of pain, different causes of pain, and evidence-based treatments, and then approach it in a step-wise manner, especially for chronic pain where we are really bolstering the non-opioid alternatives and thereby reducing the number of individuals who eventually might need judicious low-dose opioids.

And I think we are underutilizing topical analgesics, non-opioid, safer prescribing medications for pain like deloxetine, individual counseling, relaxation exercises, and all kinds of other holistic approaches including in some cases, interventional pain management.

We go too quickly to tramadol, which I think is an opioid.

And opioids, we need to really slow things down and address a lot of these chronic pain issues with better, safer interventions.

Yeah, I'm glad you mentioned that tramadol is an opioid, because that's one of my biggest pet peeves is when people say, I'm going to give them tramadol so I can avoid an opioid.

So we talked a little bit about that.

Jean, for tramadol, people don't realize that it is also going to interact with antidepressants if they are on it.

You and I know how many people in long-term care are on antidepressants, especially SSRIs and SNRIs, then tramadol will interact with them negatively.

So you might have too much of serotonin or norepinephrine related agitation.

And also tramadol is converted to an active opioid in the liver.

So we don't know in which person it's converted to the right amount and so forth.

And then there are other factors like renal dosing and so forth.

So again, we need to learn much more about safe use of tramadol or minimize its use.

I agree 100% with you.

I talk a lot about tramadol, and I think I heard one pharmacist say it's tramadont.

Right, so we talked a little bit about opioids.

We talked about opioids.

So let's just touch briefly, and I understand that opioid use disorder could be a whole podcast in itself.

But I think a lot of people don't think about opioid use disorder as associated in older adults.

So is opioid use disorder an issue in older adults?

And the issue is growing with the aging of the baby boomer generation.

And also we need to realize that for every one opioid use disorder, there is at least two, if not more, opioid misuse.

And the dangers, especially in long-term care population and elderly, are very high, even if it doesn't reach the level of addiction, opioid use disorder.

Misuse is very dangerous.

It leads to falls and head injury and fractures and overdose, ED visits and hospitalizations.

And so I would expand the problem to opioid misuse and opioid use disorder.

Yeah, that's perfect.

And like I said, a lot of the nursing homes are struggling right now in knowing that they are actually, they're required to admit these patients with opioid use disorder who are on medication for treatment of their disorder as they should be.

A lot of the nursing homes are really struggling.

So perhaps we'll have you on again to expand.

Let me give you one good news.

So there are pockets of excellence, right?

So locally over here, we have a superb physician assistant who has mastered prescription of buprenorphine, appropriate diagnosis of opioid use disorder.

And he collaborates with primary care physician, who's the medical director in these nursing homes.

And we have opioid stewardship program that includes early diagnosis, accurate diagnosis of opioid use disorder, opioid misuse, and then using buprenorphine.

And we've had phenomenal success.

Actually we've had reduction in agitation and anxiety and even, you know, staff who thought this person had personality disorder, we've cured it.

Obviously they didn't have personality disorder.

It was all, you know, addiction related, severe problems, you know.

Oh, so, so interesting and so fantastic if you just find the right treatment, the right cause and then you find, if you find the right, you know what the cause is, you can find the right treatment.

But we have the treatment.

It's underutilized.

You know, if you say, what is underutilized in terms of, you know, psychiatric medicines, I would say buprenorphine.

People are so uncomfortable and so scared and, you know, I could go on and on but you get the gist.

Yeah, well, perhaps we will have another, we'll have a part two.

So just in, we're touching on person-centered care as we were just kind of talking about that, maybe associated with opioid use disorder.

I know you've lectured extensively on person-centered care and it's something I'm very interested in and I think all of the nursing homes in the country or in the world should be focused on as, you know, in this country, CMS is really tasking them with utilizing person-centered care and changing the culture of their facilities to be focused on person-centered care.

So can you just give us some quick tips on how to utilize person-centered care for treatment of psychiatric issues in the long-term care facilities?

So the key thing to remind ourselves is something called PERMA, P for Paul, E for Elephant, R for Rome, M, A for Apple.

So PERMA is a way to understand the positive psychology science and how we can operationalize it and utilize its principles to routinely improve lives of all individuals in a very person-centered manner.

So the goal is that the more you know the person, the resident in this case, say in long-term care, the more you can help them experience more positive emotions every day.

Engage them in activities where they are really into it, they have tuned out the world and are engaged in that activity.

And they are surrounded by relationships that are very positive, supporting, that see them in a very positive light.

They are routinely every day engaged in meaningful activities, meaningful by their definition.

They find feeding the squirrels and watering the plants meaningful, and then you get them to routinely do that.

And then they feel accomplished.

And that can apply even to persons with dementia, that at the end of the day, they feel good about themselves because they have accomplished something.

So we need to utilize all the advances in positive psychology science to apply PERMA and PERMA principles.

And University of Pennsylvania is leading this charge of training people in PERMA.

I have not heard of PERMA.

I am going to...

I am definitely going to check it out after this.

I mean, that just sounds...

I mean, it's basic, right?

It is common sense.

Yes, absolutely.

So we covered so much today in just a short period of time.

So I have one last question.

If you were in charge of healthcare in the United States, what is the first thing that you would do?

The first thing I would do is make all healthcare financing transparent.

Obviously, then the next thing I will see is that I've been kicked out of my job, but that's all right.

So it's incredible how much waste and fraud is going on.

And we are spending so much money in healthcare, and we all know the outcomes are just not there.

And Dr.

Donald Berwick has written an op-ed in JAMA in February of 2023, Salve Lucrum, the Existential Threat of Greed in US.

Healthcare.

So I would urge people to read about it.

And then one of my sort of people I look up to, Dr.

Michael Wasserman, he's a geriatrician, he's a certified medical director, a leader in long-term care medicine in California.

And he talks about nursing home industry, that how he feels that there needs to be more transparency of where all this money is going for nursing home as an industry.

He criticizes the industry, not the care that you and I routinely do and all the nursing home staff does in improving lives.

So I would say healthcare financing transparency.

Yeah, that's huge.

And I do know Mike Wasserman, he and I met on an AMDA collaborative, and I would agree, he's a huge advocate.

He's amazing.

Yeah.

I haven't met him just for you to know.

I've read about it and I read what he says and it's superb.

Yes.

Yeah.

So, Dr.

Abhilash Desai, thank you so much.

Perhaps we can get you on again.

I think that we have a lot more to talk about, but thank you for these wonderful insights and tips that you have given our audience.

We really appreciate it.

Absolutely.

I'm delighted to be here and perhaps we can talk more about improv and creative care that my friend Anne Basting has shared.

Sounds fantastic.

Sounds like the next podcast.

Thanks, Jean.

Thank you.

Thank you for tuning in to Taking Healthcare by Storm, Industry Insights, with Quality Insights Medical Director, Dr.

Jean Storm.

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So, until next time, stay curious, stay compassionate, and keep taking healthcare by storm.