Doris Bersing, PhD
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Elders, Mental Illness, and the Expertise Gap

Copyright : fotoluminate
Copyright : fotoluminate

The US population is aging rapidly. Advances in medicine have led to the expectation that the US population of seniors will grow from12.4 Million in 2000 to 19.7 million in 2030 (US Census data). As the oldest baby boomers become senior citizens in 2011, the population 65 and older is projected to grow faster than the total population in every state. Twenty-six states are projected to double their 65-and-older population between 2000 and 2030. The impact of this anticipated population increase, which has been described by some as an “age wave” and by others as an “aging tsunami,” would be felt in every aspect of society. This “tsunami” predicts that humane healthcare will soon be financially out of reach or simply unavailable for tens of thousands of elderly Americans. There is an urgent need to expand training opportunities for geriatric care providers to meet the growing demand for psychological, medical, and social services. Older adults are commonly represented in the current literature as presenting co-morbidity of many conditions and illnesses about what we will talk a little more further along but we need to  say that meaningful and engaging aging happens as well but it is often underscored. A great number of older adults lead a meaningful life, a healthy one where they take advantage of  exercising, changing dietary patterns, seeking information, relying on spirituality and/or religion, and engaging in life, I would also like to stress the positive coping skills of many other older adults.

However, mental health issues among the elderly have reached epidemic proportions and are expected to worsen in the next few decades.  Elders with mental illness find more difficult dealing with adjustment in lifestyle, such as isolation or loss of independence, and this is complicated by medical conditions or physical diseases. The most common diagnoses in gero-psychiatric patients include depression, dementia, psychosis and anxiety.

Elderly suicide currently accounts for 20% of suicides in the U.S. – the highest suicide rate in the country compared to other age categories.[1] One in four elderly over 85 years old is diagnosed with dementia and one in two with Alzheimer’s Disease.[2] A landmark report estimated that by 2030 the number of elderly who suffer from a mental illness will grow to approximately 15 million;[3] and in California alone the projected number of elderly persons diagnosed with depression will reach 1.2 million by 2025.[4] A lack of access, education, and awareness lead many older individuals and their doctors to accept depression and mental illness as a normal part of aging when it is not. Among the elderly, mental health conditions are frequently untreated or inappropriately treated; more than one in five older persons with mental disorders are given an inappropriate prescription and are at increased risk for inappropriate medication treatment.[5] As a result, many older persons with mental disorders have a lower quality of general health care and associated increased mortality.[6]

However, researchers expect there will not be enough gero-psychologists trained to handle the increasing demand for psychological services from this age group. The National Institute on Aging estimates that 5,000 full-time, doctoral-level gero-psychologists will be needed by 2020 to accommodate the increasing demands of aging baby boomers. In 1991, slightly more than 700 psychologists who spent at least half of their time working with older adults were listed in the National Register of Health Service Providers. Along with the need for more gero-psychologists, the number of adults with mental disorders and behavioral health problems in 2030 is expected to reach 15 million–four times the prior census. In addition, older adults have the highest rates of suicide of any age group.

Experts agree that adequate staff is the most important factor in good patient care. However in spite of the growing demand for elder care, the education system and the pool of medical and mental health care providers with appropriate geriatric training are extremely inadequate.[7] A lack of training and institutional support has resulted in the 27% decline in certified geriatricians since 1998.[8] In 2005, there was one geriatrician for every 5,000 Americans 65 and older.[9] Nationally, geriatric mental health specialists comprise one of the smallest groups of health care professionals. By 2010, an estimated 5,000 psychiatrists, 19,000 gerontological nursing specialists, and over 50,000 social workers will be needed to provide mental health care for elderly patients.[10]

The “expertise gap” is among the greatest challenges to mental healthcare for the elderly,[11] and the effects are already apparent in many regions of the country where two out of three skilled nursing facilities failed to meet the state’s minimum nursing staff requirements[12] and a majority of surveyed primary care physicians considered themselves only “somewhat” (66%) or “not very” (20%) knowledgeable about geriatric mental health issues.[13] Even many specialists, internists and emergency room doctors said they felt “unprepared” to deal with depression and other mental health and end-of-life issues of elderly patients.[14] Of the 145 medical schools in the United States, only 9 have departments of geriatrics; most teaching hospitals graduate internists with as little as six hours of geriatric training. Only about 10% of U.S. medical schools require course work or rotations in geriatric medicine. While many more offer geriatric courses as electives, fewer than 3% of medical school graduates choose to take those courses. In nursing there is no gero-psychiatric certification and only one-third of masters level programs offered a course in aging.[15]

The integration of mental health services in the system of care for the elderly has proven to raise the quality of care to patients and support the larger network of care facilities to increase access to, and build capacity in mental health services. Research demonstrates that the integrated mental and medical health service arrangement achieve a higher level of access to mental health care[16] and is associated with better health and treatment outcomes at a lower cost.[17] Traditional models of service and professional training programs are frequently costly, disjointed and ineffective due to their inability to incorporate contemporary research findings and evidence-based practices into usual care.[18]

There is an undeniable need for professionals who would develop a humanistic and comprehensive approach to care for elders and to see the aging process as a fulfilling part of life as well as to offer a different, humanistic approach to approach aging and to treat those older people afflicted with Alzheimer’s and other dementias, and mental challenges, while implementing the best practices with seniors diagnosed with these phenomena. These professionals will challenge their attitudes towards aging and their attitudes for working with older adults. They will attempt to develop a humanistic-existential perspective to the creative and meaningful phases of aging and the possibilities of growth and development in later life. In particular, they will be able to articulate the relationship of the humanistic tradition to this specific subject and the importance for a new paradigm that encourages unfolding wellness versus the Cartesian dichotomy of mind-body separation.

Wellness is an alternative to the split between health and illness because people move along the continuum toward optimal wellness at each stage of life by way of their own efforts. As Dr. Judah Ronch says in his book Mental Wellness in Aging: “… People have more options than to be sick or healthy; they do not have to be sick in order to take advantage of the means to improve wellness. …this is an especially important outlook for aging as a process — people can have an array of illnesses as they age and yet enjoy wellness and a good quality of life.”

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References

[1] Mentally Healthy Aging: A Report on Overcoming Stigma for Older Americans. US Department of Health and Human Services & SAMHSA, 2005

[2] The Mental Health Workforce: Who’s Meeting California’s Needs? California Workforce Initiative, February 2003

[3]Consensus Statement on the Upcoming Crisis in Geriatric Mental Health: Research Agenda for the Next 2 Decades, Archives of General Psychiatry, 1999

[4] The Mental Health Workforce: Who’s Meeting California’s Needs? California Workforce Initiative, February 2003

[5] Mentally Healthy Aging: A Report on Overcoming Stigma for Older Americans. US Department of Health and Human Services & SAMHSA, 2005

[6] Ibid.

[7] Consensus Statement on the Upcoming Crisis in Geriatric Mental Health: Research Agenda for the Next 2 Decades, Archives of General Psychiatry, 1999

[8] Wanted: Geriatricians. Dani Dodge. Ventura County Star, September 5, 2004

[9] Geriatrics Lags in an Age of High-Tech Medicine. Jane Gross. The New York Times, October 18, 2006

[10] The Mental Health Workforce: Who’s Meeting California’s Needs? California Workforce Initiative, February 2003

[11] Bartels, Stephen, et al. Evidence-Based Practices in Geriatric Mental Health Care. Psychiatric Services, Vol. 53, No. 11, November 2002

[12] Nursing homes: Stronger Complaint and Enforcement Practices Needed to Better Ensure Adequate Care. U.S. General Accounting Office (Testimony before Senate Special Committee on Aging), 1999

[13] Halpain, Maureen, et al. Training in Geriatric Mental Health: Needs and Strategies. Psychiatric Services, Vol. 50, No. 9, September 1999

[14] Decision Making at a Time of Crisis Near the End of Life. David E. Weissman. The Journal of the American Medical Association, October 13, 2004; 292: 1738 – 1743.

[15] The Mental Health Workforce: Who’s Meeting California’s Needs? California Workforce Initiative, February 2003

[16] Bartels, Stephen, et al. Improving Access to Geriatric Mental Health Services: A randomized trial comparing treatment engagement with integrated verses enhanced referral care for depression, anxiety, and at risk alcohol use. American Journal of Psychiatry, Vol. 161, No. 8, August 2004

[17] Bartels, Stephen, et al. Evidence-Based Practices in Geriatric Mental Health Care. Psychiatric Services, Vol. 53, No. 11, November 2002

[18] Ibid.

[19] Ronch, Judah L. &Goldfield, Joseph A. (2003). Mental Wellness in Aging: Strengths-Based Approaches. Baltimore, MD. Health Professions Press, 2003


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