Geriatrics and Mental Health – The Facts

Demographics of the Elderly Population

• According to the U.S. Census Bureau, America’s population age 65 and older grew by 74 percent between 1970 and 1999 – from 20 million to almost 35 million. The median age of the population has increased significantly from 28 in 1970 to almost 36 years of age in 1999. However, this recent growth of the elderly population will appear slow when compared to predictions for the next three decades. The elderly population will grow even more rapidly as 76 million baby boomers reach age 65 and older between 2010 and 2030. By 2030, older adults will account for 20 percent of the total population – up from 13 percent in 2000. Within this cohort, persons 85 years and older comprise the most rapidly growing segment of the U.S. population.
• Most older persons are women, at 65 – 69 years of age; there are 118 women for every 100 men. At age 85+, there are 241 women for every 100 men.
• Minority populations are expected to represent 25 percent of the elderly population in 2030, up from 16 percent in 1998.
• The emotional and economic well being of older Americans is strongly linked to their marital status. At age 65-74, 79 percent of men and 55 percent of women were married in 1998. These numbers decrease significantly in the 8th decade of life with 50 percent of men married and 13 percent of women married at age 85+.

Mental Health of Older Americans

• Nearly 20 percent of those who are 55 years and older experience mental disorders that are not part of normal aging. Most common disorders, in order of prevalence, are: anxiety, severe cognitive impairment, and mood disorders. Studies report, however, that mental disorders in older adults are underreported. The rate of suicide is highest among older adults compared to any other age group – and the suicide rate for persons 85 years and older is the highest of all – twice the overall national rate.

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Access to Mental Health Services

• It is estimated that only half of older adults who acknowledge mental health problems receive treatment from any health care provider, and only a fraction of those receive specialty mental health services (3 percent) (Lebowitz, et al, 1997). This rate of utilization is lower than for any other adult age group.
• Over half of older persons who receive mental health care receive it from their primary care physicians.
• Older Americans account for only seven percent of all inpatient mental health services, 6 percent of community based mental health services, and 9 percent of private psychiatric care, despite comprising 13 percent of the population. Reasons cited for this underutilization include: stigma, denial of problems, access barriers, funding issues, lack of collaboration and coordination between mental health and aging networks, and shortages of appropriate health professions.
• In 1996, 18 percent of psychiatrists had a geriatric caseload in excess of 20 percent, this represented an crease of 148 percent and 25 percent from 1982 and 1989 respectively (Colenda, 1999), however this does not come close to meeting the projected need for at least 5,000 in each psychiatry and psychology specialty (Jeste, 1997).

Financing Delivery of Mental Health Services to the Elderly

• Most mental health funding comes from state and local governments, Medicaid, and private insurance. Federal government augments state and local funding through community Mental Health Services Block Grant which awards formula grants to states to provide community-based mental health services to adults with serious mental health illness and children with serious emotional disturbance. The Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Mental Health Services administers the Block Grant.
• Although Medicare represents a critically important source of health insurance for older Americans, its coverage is not comprehensive. Medicare requires substantial cost sharing for many covered services, it only covers 50 percent of mental health services, and it does not cover any prescription drugs. Medicare beneficiaries age 65 and older (in the community) spent an aver of $2,430 or 19 percent of income for out of pocket health care costs in 1999. This excludes the costs of home care and long term nursing services. Over half of that amount was used to pay for goods and services and the remainder was used to pay for Medicare Part B premiums and private insurance. Poor beneficiaries – those with incomes below the poverty level spent 33 percent of income, on average, for out of pocket health expenditures in 1999.
• Prescription drugs account for the single largest component of out of pocket spending on health care, after premium payments.
• The impact of mental illness on the economy is significant. According to the World Health Organization, the projections show that with the aging of the world population and the conquest of infectious diseases, psychiatric and neurological conditions could increase their share of the total global disease burden by almost half, from 10.5 percent of the total burden to almost 15 percent in 2020.

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The Role of Caregiving – General

• Caregiving will preoccupy American families well into the 21st century as the 76 million baby boomers join the ranks of older Americans. Currently, nearly one out of every four U.S. households provides care to a relative or friend aged 50 or older; informal, unpaid care from family, friends, or neighbors is the main source of help for the majority of older people with disabilities living in the community. The average age of these primary caregivers is over 60 years of age and over 75 percent of them are women. Studies show that caregiver’s experience a sense of burden and estimated 46 percent are clinically depressed (Cohen et al, 1990, Gallagher, 1985). Up to half of the primary caregivers caring for someone with Alzheimer’s develop significant psychological distress (Schultz et al, 1995).

Depression

• The prevalence of major depression declines with age, while depressive symptoms increase. Eight to 20 percent of older adults in the community (Alexopoulos, 1997) and up to 37 percent in primary care settings suffer from depressive symptoms (Gurland, et al, 1996).
• The underdiagnosis and undertreatment of depression in primary care represents a serious public health problem; one study found that only about 11 percent of depressed patients in primary care receive adequate antidepressant treatment, while 34 percent received inadequate treatment and 55 percent received no treatment (Katon, et al., 1992).
• Several studies have found that many older adults who commit suicide have visited a primary care physician very close to the time of the suicide – 20 percent on the same day, 40 percent within one week – of the suicide (Conwell, 1994).
• An estimated 6 percent of Americans ages 65 and older in a given year or approximately 2 million individuals in this age group have a diagnosable depressive illness.
• 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 that it causes and its deleterious interaction with physical health.

Alzheimer’s Disease

• Alzheimer’s disease is the most common cause of dementia in older people. It is estimated that four million Americans currently suffer from Alzheimer’s disease or some form of dementia; nearly 10 percent of all people over age 65 and up to half of those over age 85 are thought to have Alzheimer’s disease or another form of dementia.
• Approximately 19 million Americans have a family member with Alzheimer’s; approximately 300,000 new cases each year are diagnosed. These numbers will increase as the cohort of elderly increase whereby the Alzheimer’s Association estimated that by the middle of this century over 14 million people will suffer from Alzheimer's Disease or a related disorder.
• AD costs the United States at least $100 billion per year. Medicare and private health insurance pay for a portion of the health care related expenses, but not the costs associated with care giving or the type of long term care needed by most patients at the most severe stage of the disease. In addition, it is estimated that AD costs US business at least $33 billion per year – either through lost productivity by caregivers or related health and long term care costs. The average lifetime costs per patient is $174,000.
• The Federal Government spent $466 million on AD research in 2000; it is scheduled to increase to $500 in 2001 as appropriated by the 106th Congress.

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Anxiety

• About 11.4 percent of adults aged 55 years and older meet criteria for an anxiety disorder in one year (Flint, 1994). Phobic anxiety disorders are among the most common in late life as opposed to panic disorders and obsessive-compulsive disorders.

Schizophrenia in Late Life

• Prevalence of schizophrenia among those 65 years or older is reportedly around .6 percent as compared to 1.3 percent that is estimated for the population ages 18 to 54 years. The economic burden, however, of late life schizophrenia is high. While the use of nursing homes and state hospitals for patients with all mental disorders has declined over the past two decades, this decline is very slight for older patients with schizophrenia.

Alcohol and Substance Abuse Disorders in Older Adults

• Very few studies have focused on the incidence or prevalence of substance abuse among older adults, but the perception is that problems are more often associated with the improper use of alcohol and prescription drugs as opposed to abuse of illicit drugs. A persistent research problem is that the diagnostic criteria for substance abuse were developed and validated on young and middle-aged adults.
• The prevalence of heavy drinking (12-21 drinks per week) among older adults is estimated at 3 to 9 percent (Liberto et al, 1992). Alcohol abuse are approximately four times more common among men than women ages 65 and older.
• 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 United States are $15 billion annually, a fourfold greater per capita expenditure on medications compared with that of younger individuals (Jeste&Palmer, 1998). Substance abuse problems are usually linked to underuse, overuse, or erratic use of medications, which may become drug abuse. Prescription drug dependence is not uncommon and women are more likely to be the abusers.
  
• Older adults infrequently use illicit drugs – less than 0.1 percent.
• Projections suggest that the cost of alcohol and substance abuse are likely to rise in the near future. Across age ranges, drug abuse and alcohol abuse have been estimated to cost over $109.8 billion and $166.5 billion, respectively (Harwood et al, 1998). No studies have estimated the annual costs of alcohol and substance abuse among older adults, there is evidence that the presence of drug abuse and dependence greatly increases health care expenditures among individuals with co morbid medical disorders.

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