Matters of the Mind
By Lori Solomon
May 21, 2001 -- As America continues to get grayer, much research is looking at ways to increase seniors' quality of life through physical means, such as weight-resistance training and Tai Chi. But a growing group of professionals are concerned for the mental health of seniors and the question of who will care for them if they develop a psychiatric condition.
"With medical advances and improvements in lifestyle and public health, many more people are entering old age and experiencing problems that weren't as prevalent in years past," says Joseph D'Afflitti, MD, medical director of the Mount Auburn Hospital Wyman Center in Cambridge, Mass.
"The prevalence of dementias is much greater now because we are exposed to degenerative changes in the brain as we age," he says. "We are also better able to define, diagnose, and describe psychiatric disorders including dementias, depression, and delirium."
Is There a Specialist in the House?
According to the American Association for Geriatric Psychiatry (AAGP), nearly 20% of those who are over 55 years old experience mental disorders that are not part of normal aging. The most common disorders are anxiety, impaired thinking ability, and mood disorders. Several studies show that mental disorders in older adults are underdiagnosed.
Alarmingly, those who do have psychiatric conditions often don't receive treatment. A 1997 study from the National Institutes of Mental Health found that only half of older adults who acknowledge mental health problems receive treatment from any healthcare provider, and only a fraction of them receive specialty mental health services. Most receive mental health care from their primary care physicians.
"Never would we say that older people should only see a geriatric psychiatrist," says Gary Kennedy, MD, president-elect of AAGP. "Most will do just fine with a generalist. But we are not training enough specialists."
Specialists in geriatric psychiatry are necessary, he says, to sustain faculty that can provide training to others and to engage in research. Geriatric psychiatrists are also invaluable team players who work closely with primary care doctors on complex cases.
"Treating older adults is more complicated because of coexisting medical conditions. They are more sensitive to medications and their side effects, and they are taking multiple medications, increasing the risk of drug-drug interactions," explains D'Afflitti, a clinical instructor of psychiatry at Harvard Medical School.
Older Americans, according to the AAGP, account for only 7% of all inpatient mental health services and 9% of private psychiatric care, even though they currently represent 13% of the population -- a number that is expected to grow significantly in the coming decades. The association says this underutilization is in large part due to the stigma of mental illness, denial of a problem, barriers to access, funding issues, and shortages of appropriate health professionals.
More Challenges, Fewer Families to Face Them
Experts say that dementia, which affects more than four million Americans over age 65, typifies the challenges of providing mental health care for the aging and also demonstrates how one condition can significantly change the field of geriatric psychiatry.
"There have been breakthrough developments in drugs for cognitive impairment," says Jim Ellison, MD, MPH, clinical director of geriatric psychiatry program at McLean Hospital in Belmont, Mass. "Also there is a greater awareness of the illness. We pick up dementia at an earlier stage and there is more to do to help it."
"Everybody knows it involves memory problems, but half of patients have a behavioral component as well, with depression or irritability being the most frequent," Kennedy tells WebMD. "If it was just forgetful, the family can fill in."
But families are not always there.
"The demise of close extended families means some psychiatric problems [are no longer] dealt with by families," says D'Afflitti. Nursing homes make psychiatric problems more evident and the growth of nursing homes is a major factor behind the growing need for [geriatric psychiatry] services."
Despite ever-increasing physical distances, family does play a key role in assisting seniors access mental health care. While there is greater public acceptance of mental health issues, especially among younger family members and caregivers, the elderly grew up in a time when the stigma was very strong.
"The stigma is gradually fading, but older adults are frightened by mental health professionals," says Kennedy, professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine in New York. "Fifty, 60, 70 years ago, psychiatrists were in state hospitals," and to many older adults, thoughts of such institutions bring with them fears of being "committed" and losing autonomy, he says.
"The reality is, of course, we want to do exactly the opposite," Kennedy says.
Supportive families and professionals who are trained to deal with their fear and reluctance are helping to get older people the care they need.
Kennedy says he has seen family members introduce the geriatric psychiatrist as a "specialist in aging," which "softens the blow."
There Oughta Be a Law
The growth of the geriatric field has been remarkable over the past 30 years, Kennedy says. Effective this year, candidates becoming board certified in psychiatry are now required to spend at least 1 month training exclusively with older adults. Expansion of the field can also be witnessed by the growth in the number of training programs in geriatric psychiatry growing from "a handful to more than 50" mostly at major medical training centers. An even larger increase has occurred in the number of geriatric inpatient units across the country.
"Geriatric psychiatry inpatients have very different needs," says Ellison. "Because of sensory difficulties, the environment needs to be modified so that it is safer and more user-friendly. Younger inpatient populations can be more aggressive," and it may be unsafe to mix the populations.
While the number of inpatient facilities has increased, we need more, says D' Afflitti "But acute care is time limited. In acute care we do a good diagnostic evaluation, stabilize the patient, and set up appropriate support and treatment. But the focus is on the elderly living outside the hospital."
While the medical community and the general public are showing increased interest in geriatric psychiatry, many in the mental health field believe the future of mental health care for seniors rests with the expansion of parity laws. In April, Sen. Paul Wellstone (D-Minn.) and Rep. Fortney (Pete) Stark (D-Calif.) introduced the Medicare Mental Health Modernization Act of 2001, which calls for improved coverage of mental health services under the Medicare program.
The legislation was prompted by a belief that Medicare institutionalizes the stigma of mental illness by requiring a 50% co-pay for psychotherapy compared with a 20% co-pay for physical medical treatments. By equalizing benefits for physical and mental health care, the bill aims to eliminate discrimination toward seniors who seek treatment for Alzheimer's disease, late-life depression, and other mental illnesses, says the AAGP.
Lori Solomon is WebMD's Atlanta regional staff reporter, writing about health and medical news throughout the metro area.
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