Aging and Mental Health:
Current Concerns, Challenges
& Future Directions
By
Maria C. Hernandez-Peck, Ph.D.
Center for Studies in Aging
Eastern WA University
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
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
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
Depression
Alzheimer’s Disease
Alcohol and Drug Abuse and Misuse
Anxiety
Late-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 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).
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 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.
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 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+
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 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)
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.