Aging and Mental Health: Current Concerns, Challenges

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Aging and Mental HealthCurrent Concerns,
Challenges Future Directions

• By
• Maria C. Hernandez-Peck, Ph.D.
• Center for Studies in Aging
• Eastern WA University

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As We Enter the 21st Century

• An aging population of 35 million in 2000
• With 1 in every 8, or 12.4 and older American
• With 5,5574 individuals reaching age 65 each day
• With those reaching age 65 having an average life
  expectancy of an additional 17.9 years

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Categories of Older People

• Young old (65 to 74) 18.4 million
• Middle Old (75 to 84) 12.4 million
• Old-Old (85) 4.2 million, the fastest growing
  group
• Centenarians (100) 50,545

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Some Current Statistics

• Older women outnumbering older men 20.6 million
  to 14.4 million
• With 143 women for every 100 men at age 65 this
  ration increases from 117 for the 65 to 69 age
  group, to 245 for the 85
• With almost 400,00 grandparents age 65 having
  primary responsibility for their grandchildren
  who live with them

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Projections for 2030

• The older population will more than double to 70
  million
• The 85 population will increase from 4.2 million
  in 2000 to 8.9 million
• Members of minority groups will represent 25 of
  the older population, up from 16 in 2000

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The Older Foreign Born

• Accounted for 3.1 million of persons 65
• 1/3 from Europe 31 from Latin America 22 from
  Asia, and 8 from other parts of the world
• Anticipated future foreign born elders will be
  from Latin America or Asia
• 2/3s of all foreign born elders have been in the
  U. S. over 30 years

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Facts About Mental Health in the Later Years

• The majority of older Americans cope
  constructively with the physical limitations,
  cognitive changes, and various losses, such as
  bereavement, that frequently are associated with
  late life.
• On the other hand, a substantial proportion of
  the population age 55 and older, almost 20 of
  this age group, experience specific mental
  disorders that are not part of normal aging.

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Severely Impairing Conditions If Unrecognized
or Untreated

• Depression
• Alzheimers Disease
• Alcohol and Drug Abuse and Misuse
• Anxiety
• Late-life Schizophrenia

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Challenges in Assessment and Diagnosis

• Clinical presentation of older adults with mental
  disorders may be different from that of other
  adults, making detection of treatable illness
  more difficult.
• Many older adults present with somatic complaints
  and experience symptoms of depression and anxiety
  that do not meet the full criteria for depressive
  or anxiety disorders.

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• Detection of mental disorders in older adults is
  further complicated by high co-morbidity with
  other medical disorders.
• The symptoms of somatic disorders may mimic or
  mask psychopathology, making diagnosis more
  taxing.
• Older individuals are more likely to report
  somatic symptoms than psychological ones, leading
  to further under identification of mental
  disorders.

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• Primary care providers carry much of the burden
  for diagnosis of mental disorders in older adults
• However, the rates at which they recognize and
  properly identify disorders often are low.
• With respect to depression, a significant number
  of depressed adults are neither diagnosed nor
  treated in primary care.

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• One study of primary care physicians, only 55 of
  internists felt confident in diagnosing
  depression, and even fewer (35 of the total)
  felt confident in prescribing antidepressants to
  older persons.
• Researchers estimate that an unmet need for
  mental health services may be experienced by up
  to 63 of older adults aged 65 years and older
  with a mental disorder.

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Identified Barriers to Treatment

• Patient barriers (e.g., preference for primary
  care, tendency to emphasize somatic problems,
  reluctance to disclose psychological symptoms).
• Provider Barriers (e.g., lack of awareness of
  manifestation of mental disorders, complexity of
  treatment, and reluctance to inform patients of a
  diagnosis).
• Mental Health Delivery Systems Barriers (e.g.,
  time pressures, reimbursement policies).

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• Stereotypes about normal aging can also make
  diagnosis and assessment of mental disorders in
  late life challenging.
• Ageism within the Mental Health Delivery System

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Depression in Late Life

• Depression is strikingly prevalent in older
  adults
• With 8 to 20 of older adults in the community
  and up to 37 in primary care settings
  experiencing symptoms of depression.
• Depression is a foremost risk factor for suicide
  in older adults.

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Depression and Suicide

• Older people have the highest rate of suicide in
  the U.S. population.
• Suicide rates increase with age, with older white
  men having a rate of suicide up to six times that
  of the general population.
• Depression is neither well recognized nor treated
  in primary care settings, where most older adults
  seek and receive health care.

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• Studies have found that undiagnosed and untreated
  depression in the primary care setting plays a
  significant role in suicide.
• Depression training for general practitioners
  reduces suicide.
• Suicide interventions, especially in the primary
  care setting, have become a priority of the U.S.
  Public Health Service.

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• Treatment for depression is typically successful,
  with response rates between 60 to 80, but the
  response generally takes longer than that for
  other adults.

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Depression Suicide in the Elderly

• More than half, or 51 of older individuals who
  have committed suicide have seen their primary
  care physician within one month of the suicide.
  (Caine, et. al. 1996)
• Almost half had psychiatric symptoms. However,
  symptoms were recognized in less than one third.
• Treatment was offered in less than 1/4 of the
  cases.
• Treatment rendered was considered adequate in on
  2 of the cases.

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• Depression and suicide prevention strategies also
  are important for nursing home residents.
• About half the patients newly relocated to
  nursing homes are at heightened risk for
  depression (Parmelee et.al., 1989).

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Economic Toll

• Depression as a whole is one of the most costly
  disorders in the U.S.
• The direct and indirect costs of depression have
  been estimated at 43 billion each year, not
  including pain and suffering and diminished
  quality of life.
• Late-life depression is particularly costly
  because of the excess disability it causes and
  its deleterious interaction with physical health.

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• Older primary care patients with depression visit
  the doctor and emergency room more often, use
  more medication, incur higher outpatient charges,
  and stay longer in the hospital.

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Alzheimers Disease

• 8 to 15 of people over age 65 have Alzheimers
  disease
• The prevalence of dementia (most of which is
  accounted for by Alzheimers disease) nearly
  doubles with every 5 years of age after 60.
• Studies also reveal age-related increases in
  Alzheimers disease.

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Incidence by Age Group

• One percent of those age 60 to 64 are affected
  with dementia
• 2 of those age 65 to 69
• 4 of those 70 to 74
• 8 of those 75 to 79
• 16 of those 80 to 84
• 30 to 45 of those 85

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Schizophrenia in Late Life

• Although commonly thought of as an illness of
  young adulthood, schizophrenia can both extend
  into and first appear in later life.
• The economic burden of late life schizophrenia is
  high. The mean cost of mental health service for
  schizophrenia has been found to be significantly
  higher than that for other mental disorders.

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Alcohol and Substance Use Disorders in Late Life

• Older people are not immune to the problems
  associated with improper use of alcohol and
  prescription drugs, but as a rule, misuse of
  alcohol and prescriptions medications appears to
  be a more common problem than abuse of illicit
  drugs.
• It is anticipated that alcohol abuse or
  dependence will increase as the baby boomers age,
  since that cohort has a greater history of
  alcohol consumption than current cohorts of older
  adults.

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Misuse of Prescription and Over the Counter
Medications

• Older persons use prescription drugs
  approximately three times as frequently as the
  general population, and the use of
  over-the-counter medications by this group is
  even more extensive.
• Annual estimated expenditures on prescription
  drugs by older adults in the U.S. are 15 billion
  annually.

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Current Challenges

• Transitioning to a Medicaid only system in
  providing Mental Health Services.
• The fact that older persons in greatest need of
  mental health services will not self-refer.
• Inadequate ways of identifying older persons in
  need mental health services.

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• Inability of primary health care providers in
  identifying depression in older persons.
• Inadequate reimbursement for psychiatric and/or
  mental health services and its impact in
  community based systems.
• Downsizing of geriatric beds in State Mental
  Hospitals and relocating those patients to
  community based settings.
• Definition of medically needy as those with an
  income of 582 per month.

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Some Potential Solutions

• Achieving Mental Health Parity.
• Increasing the income level for medically needy
  from 582 to 771 per month.
• Increasing State funding for mental health
  services to non-Medicaid eligible older persons.
• Integrating aging and mental health services at
  the community level.

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Some Potential Solutions

• Implementing ways of identifying frail elders at
  risk (e.g., Gatekeeper Program).
• Educating primary health care providers on how to
  identify depression and other mental disabling
  conditions in older persons

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• Co-locating mental health service providers in
  primary care physicians offices.
• Postpone premature hospitalization by funding
  counseling and other support services to
  caregivers of Alzheimer's patients.

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• Providing Extended Community Services to older
  persons who have been discharged from State
  Mental Hospitals
• Increasing health promotion and disease
  prevention efforts in mental health services to
  older persons (e.g., depression screening
  programs).

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Non-Title XIX Elders in Spokane

• Elder Services serves approximately 1,200 at risk
  elders each year
• Currently 378 are non Title XIX
• Average age is 80 (youngest is 60 and oldest is
  97 with 26 who are 90 or older)
• These elders have co-morbidity (complex problems
  that are a combination of psychiatric, physical,
  financial, social, and environmental)

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• Psychiatric diagnoses include schizophrenia,
  Bi-polar Disorder, Major Depression, severe
  Anxiety disorders, late life Paraphrenia,
  dementia, psychotic disorders.

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The Spokane Aging and Mental Health Partnership

• One Stop - No Wrong Door access to a
  comprehensive, integrated and interdisciplinary
  system of care and not just specialized
  services(I.e.,
• medical, legal, financial).
• A coordinated and seamless set of support
  services/resources that include in-home
  assessment, clinical case management,
  psychiatric/medication management, follow-up,
  treatment groups tailored to elders, peer
  counseling, in-home pharmacy consultations/educati
  on, special transportation, family caregiver
  support (including respite), disease
  prevention/health promotion.