Aging and Mental Health:Current Concerns, Challenges

& Future Directions

By Maria C. Hernandez-Peck, Ph.D.

Center for Studies in AgingEastern WA University

As We Enter the 21st Century

An aging population of 35 million in 2000With 1 in every 8, or 12.4% and older AmericanWith 5,5574 individuals reaching age 65 each

dayWith those reaching age 65 having an average

life expectancy of an additional 17.9 years

Categories of Older People

Young old (65 to 74) 18.4 millionMiddle Old (75 to 84) 12.4 millionOld-Old (85+) 4.2 million, the fastest

growing groupCentenarians (100+) 50,545

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

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

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

2/3’s of all foreign born elders have been in the U. S. over 30 years

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.

Severely Impairing Conditions If Unrecognized or Untreated

DepressionAlzheimer’s DiseaseAlcohol and Drug Abuse and MisuseAnxietyLate-life Schizophrenia

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.

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.

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.

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.

Identified Barriers to TreatmentPatient 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).

Stereotypes about normal aging can also make diagnosis and assessment of mental disorders in late life challenging.

Ageism within the Mental Health Delivery System

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.

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.

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.

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

Depression & Suicide in the ElderlyMore 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.

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).

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.

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.

Alzheimer’s Disease

8 to 15% of people over age 65 have Alzheimer’s disease

The prevalence of dementia (most of which is accounted for by Alzheimer’s disease) nearly doubles with every 5 years of age after 60.

Studies also reveal age-related increases in Alzheimer’s disease.

Incidence by Age Group

One percent of those age 60 to 64 are affected with dementia

2% of those age 65 to 694% of those 70 to 748% of those 75 to 7916% of those 80 to 8430 to 45% of those 85+

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.

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.

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.

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.

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.

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.

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

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.

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).

Non-Title XIX Elders in Spokane

Elder Services serves approximately 1,200 at risk elders each year

Currently 378 are non Title XIXAverage 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)

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

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/education, special transportation, family caregiver support (including respite), disease prevention/health promotion.