Geriatric Psychiatry
The Problems of Aging Can Be Difficult.
Understanding goes a long way toward coping.
Geriatric Psychiatrists are medical doctors trained in the specialty of Psychiatry and with additional special training, knowledge and experience in the diagnosis and treatment of the mental and emotional and cognitive conditions that affect older individuals. These disorders include such problems as depression, anxiety, schizophrenia, paranoia, and other psychotic disorders, bipolar disorder, and other psychiatric conditions, as well as mixed medical and psychiatric syndromes, late-life family, situational, and relationship problems, cognitive disorders including the various types of dementia and delirium, together with the effects of various medical conditions and various medications that influence the mind, the emotional state, and brain functioning in older individuals.
A Geriatric Psychiatry Expert Consultant and Witness is a Psychiatric Physician who is able to consult, advise and testify about the multiple, complex mental, emotional, and cognitive issues, and the physical conditions, including medical conditions, illness and treatment, that may affect the mental and emotional functioning of older people.
Depression is not a Normal Part of Aging
Depression and Stress are Treatable Conditions
It is important that they be recognized
Isolation and Loneliness can contribute to these situations
Have You Called Someone Important to You Today?
The Demographics of the Older Population of the US
As of 2019, 54 million people in the US were over 65 years old, out of a total population of 330 million. Since 2010, there has been a sizable 34% increase in the 65-and-older population, a growth of approximately 13.8 million people. During this period, the median age (the age at which half the population is younger and half is older) also increased from 37.2 to 38.4 years. In 2019, more than half the states had a median age greater than 38.4. Over the next 25-30 years, that number is expected to climb to about 100 million, or nearly 25% of US residents.
As of 2017, about 15.7% of the population of America was over 65; of these 44.4% male, 55,6% female.
In 2018, the US average life expectancy was 78.7 years, including 76.2 years for men and 81.2 years for women.
76 million Baby boomers were born between 1946-1964. 71.6 million remain alive as of 2019.
The aging of baby boomers, those born between 1946 and 1964, who were aged 55 to 73 in 2019, is partly driving the growth in the older population. The slow decline of the younger population, which has decreased by 657,000 people (1.1%) since 2010, is in part due to a general decrease in fertility, ongoing since 2007.
Issues in Geriatric Psychiatry
Knowing About Late Life is Essential. It is our future.
The Wealth and Disposable Wealth of Older People and the Amount of Transfer of Wealth as Older People Age and Die
Older Americans hold the largest percentage of the nation’s wealth.
In 2020, 25% of the American workforce was over 55 years old.
As of 2019, more than 30% of households had incomes > $100.000 per year, and > 30% had net worth > $250,000. The top 1% household income > $525,000/yr.
In 2013, family average net worth (excluding pensions and social security) of the older population was substantial:
Age group Median Mean
55-64 $165,720 $795,390
65-74 $232,100 $1,047,310
75 or more $195,720 $795,390
Between 2020 and 2050, there are going to be trillions of dollars of wealth that will be transferred to children and other heirs of the Baby Boomers.
In a 2020 survey, 31% of Boomer millionaires in the US indicated a preference to pass inheritances to charities rather than their children. 57% believed it important for each generation to earn their own money. 54% believed it was more important to invest in their children while they were growing up. Only 44% thought they had a responability to pass on their wealth to their children.
Since 1998, Boomers have had a growing interest in discussing end of life issues, including Estate planning, but there is still a perception that a portion of Boomers are in a state of denial regarding aging and death, which may cause an excess burden on their children.
Elder Abuse, Financial Abuse and Scams Perpetrated Against the Elderly
Elder abuse includes physical abuse, emotional abuse, sexual abuse, financial exploitation, confinement, willful deprivation, neglect, and abandonment. Perpetrators can include children, other family members, and spouses—as well as staff at nursing homes, assisted living, and other facilities. According to the National Council on Aging, approximately 1 in 10 Americans aged 60+ have experienced some form of elder abuse. Some estimates range as high as 5 million elders who are abused each year. One study estimated that only 1 in 14 cases of abuse are reported to authorities. Abusers are both women and men. In almost 60% of elder abuse and neglect incidents, the perpetrator is a family member. Two thirds of perpetrators are adult children or spouses.
The amount of annual financial loss from financial abuse scams against the elderly are estimated to be about Three Billion Dollars per year, and involve hundreds of thousands of seniors.
Financial scams also often go unreported or can be difficult to prosecute, so they’re considered a “low-risk” crime. However, they’re devastating to many older adults and can leave them in a very vulnerable position with little time to recoup their losses.
It’s not just wealthy seniors who are targeted. Low-income older adults are also at risk of financial abuse. And it’s not always strangers who perpetrate these crimes. Over 90% of all reported elder abuse is committed by an older person’s own family members, most often their adult children, followed by grandchildren, nieces and nephews, and others.
Fraudulent telemarketers direct anywhere from 56% to 80% of their calls at older adults.
Many different types of scams are directed at the elderly. These include:
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Schemes to change inheritance documents such as wills and trust documents
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Undue influence to obtain money or property
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Manipulated marriages or similar personal relationships
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Medicare/health insurance scams
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Counterfeit prescription drugs
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Funeral & cemetery scams
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Fraudulent anti-aging products
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Telemarketing/phone scams
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Internet fraud
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Investment schemes
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Homeowner/reverse mortgage scams
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Sweepstakes & lottery scams
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The grandparent scam
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And others
Psychiatric Issues in the Elderly
Psychiatric problems and symptoms are often overlooked and under-identified by older people and their loved ones, and by their healthcare professionals. These Mental Health problems are commonly attributed to “aging” and felt to be “normal for their age.” However, approximately 15-20% of older people suffer some diagnosable mental or emotional disorder. These psychiatric problems are associated with a decreased quality of life, impaired functioning, and excess burden.
Depression is among the most common conditions, with significant clinical (major) depression affecting about 5.4%, and milder depressive conditions affecting as many as 20-25% of people at some point in their lives. Depression may be more persistent in older people compared to younger ones. Multiple stressors in late life are ubiquitous, and contribute to depression and other psychiatric conditions. These include multiple losses (e.g. illnesses and deaths including parents, spouses, siblings, and even children), life changes including retirement, relocation, loneliness and isolation, diminished income, caregiving, and the occurrence of medical and psychiatric and cognitive conditions in self or loved ones. Depression and anxiety may result from, or may contribute to, co-occurring medical conditions, and may worsen mortality risk. Depression may contribute to poor health behaviors such as alcohol and other substance dependence, excessive smoking and obesity, and can be associated with refusal or non-compliance with medical care and treatment, as well as with impaired self-care. Suicide is a significant risk in untreated major depression in the elderly, especially in older Caucasian males, and in those with access to more lethal means of self-harm, such as firearms. The annual costs (in 2010) of treating major depressive disorder in the United States was estimated at $210.5 billion.
Cognitive disorders including the various dementias occur in about 5.5% of older individuals.
Anxiety disorders affect almost 4%, and substance abuse disorders another 1%.
As of 2015, among US Veterans, 71% of World War II vets had dementia or other neurocognitive disorders, and 56% of Vietnam vets had depressive disorders.
Medical Issues in the Elderly
While many older people live fulfilling and active lives into advanced age, approximately 80-85 percent of older adults have at least one chronic health condition, and 60-70% percent have at least two chronic conditions. Generally, especially when these conditions have a gradual onset, people adapt and accommodate and cope with these, and continue on despite these conditions, and the possible limitations involved.
Age brings a higher risk of chronic diseases, such as heart disease, type 2 diabetes, arthritis, cancer, and dementia, which are the nation’s leading drivers of illness, disability, deaths, and health care costs.
Heart disease remains the leading killer of adults over age 65, accounting for 489,722 deaths in 2014. As a chronic condition, heart disease affects 37 percent of men and 26 percent of women 65 and older. As people age, they're increasingly living with risk factors, such as high blood pressure and high cholesterol, that increase the chances of having a stroke or developing heart disease.
Cancer is the second leading cause of death among people over age 65, with 413,885 deaths in 2014, according to the CDC. The CDC also reports that 28 percent of men and 21 percent of women over age 65 are living with cancer.
Chronic lower respiratory diseases, such as chronic obstructive pulmonary disease (COPD), are the third most common cause of death among people 65 and older, with 124,693 deaths in 2014, according to the CDC. Among people 65 and older, about 10 percent of men and 13 percent of women are living with asthma, and 10 percent of men and 11 percent of women are living with chronic bronchitis or emphysema.
The CDC estimates that 25 percent of people ages 65 and older are living with diabetes, a significant senior health risk. According to CDC data, diabetes caused 54,161 deaths among adults over age 65 in 2014.
Alzheimer’s disease and other dementias are most common in adults 60 and older, and the risk increases with age. Health care and long-term care costs associated with Alzheimer’s and other dementias are an estimated $277 billion
In the United States, 23% of all adults, or more than 54 million people, and 49.7 percent of all adults over 65 have arthritis and osteoporosis which can lead to pain and lower quality of life. It is a leading cause of work disability, with annual direct medical costs of at least $140 billion.
Medication Use by Older People
In 2018, $335.1 billion was spent on prescription drugs in the United States.
Along with the increased frequency of psychiatric and medical conditions, the elderly typically take more prescription and non-prescription medications. Some research estimated that 25 percent of people ages 65 to 69 take at least five prescription drugs to treat chronic conditions, a figure that jumps to nearly 46 percent for those between 70 and 79. As of 2017, the number of older Americans who take three or more medicines that affect their brains has more than doubled in just a decade. While such medications may be beneficial, they might also have adverse reactions.
As a person ages, there can be body changes that affect the way medicines are absorbed and used. Changes in body weight can influence the amount of medicine you need to take and how long it stays in your body. An older digestive system can change how fast medicines are digested and enter the bloodstream. The heart and circulation system may slow down, which can affect how fast drugs get to the liver and kidneys and the other parts of the body. The liver and kidneys also may work more slowly affecting the way a drug breaks down and is removed from the body.
Because of these body changes, there is also a bigger risk of drug interactions for older adults. Drug-drug interactions happen when two or more medicines react with each other to cause unwanted effects. This kind of interaction can also cause one medicine to not work as well or even make one medicine stronger than it should be. There can also be changes in the interactions between the medicines, the body and food, and with the interactions with alcohol and other substances.
Side effects may occur, especially because older people tend to be taking more medications than younger ones. Some of these may be milder and tolerable and even go away. Others may be more problematic, and the medication regimen might need to be altered. Sometimes the effects of medication may overlap with or be taken for symptoms of a medical problem.
A related problem is medication noncompliance, which is when the patient does not take the medication as prescribed, including taking too much or too little or stopping it altogether. Various estimates are that noncompliance might occur in 40-75% of people.
Side effects and adverse medication reactions, and medication non-compliance, can contribute to compounding medical problems and a need for further treatment and even hospitalization.
In older people, many different medications can potentially adversely affect the physical condition, and the cognitive, emotional or behavioral state of older people, to a lesser or greater degree. Such adverse effects might include contributing to drowsiness, dizziness, weakness, unsteadiness confusion, forgetfulness, disorientation, sadness and depressive symptoms, altered sleep, altered appetite, agitation, delusions, hallucinations, psychosis, and changes in behavior.
Cognitive Impairment and Dementia in the Elderly
Dementia is the name given to a syndrome in which there is deterioration in aspects of memory, thinking, behavior, and the ability to perform everyday activities. Dementia has a physical, psychological, social, and economic impact, not only on people with dementia, but also on their caregivers, families and society at large. Dementia is one of the major causes of disability and dependency among older people worldwide.
Although dementia mainly affects older people, it is not a normal, inevitable part of aging, and not every older person develops a memory disorder. Twice as many Americans fear the loss of mental capabilities as the loss of physical ability.
About 5-8% of the general population aged 60 and over is estimated to have some type of dementia at a given time. Of these, an estimated 5.8 million Americans, 10% of the people over 65 years are thought to have Alzheimer's type dementia. Eighty percent of Alzheimer’s sufferers are age 75 or older. At the end of life, one in 3 seniors will die with Alzheimer’s or another dementia. Alzheimer’s in the 6th leading cause of death in the US overall, but it is the fifth-leading cause of death among those age 65 and older and a leading cause of disability and poor health.
Almost two-thirds of Americans with Alzheimer's are women.
People age 65 and older survive an average of 4 to 8 years after a diagnosis of Alzheimer’s dementia, yet some live as long as 20 years with Alzheimer’s. This reflects the slow, uncertain progression of the disease.
There are felt to be over a hundred different conditions that can cause cognitive impairment and dementia, with some people suffering from combinations of more than one condition. Estimates of the most common types of dementia are Alzheimer’s Disease (about 50-70%), Vascular (about 25%), Lewy Body Disease (about 15%), Frontotemporal Dementias (15%). The boundaries between different forms of dementia are indistinct and mixed forms often co-exist.
Community Living Settings and the Frequency of Facility Placement of The Elderly
As of 2020:
About 90% of seniors intend to remain in their current homes for the next five to 10 years. Of these individuals, 85% are confident that they can stay in their residences without making significant home modifications.
There were approximately 28,900 assisted living communities with nearly 1 million licensed beds in the United States as of 2016. The average number of licensed beds in an assisted living community is 33. There are more than 800,000 Americans residing in assisted living. The majority of these residents are the "oldest old," age 85 and older, are female, and non-Hispanic white.
Of these assisted living facilities, approximately 14.3% have a designated dementia care unit.
Approximately 1.5 million Americans live in nursing homes. These individuals typically need assistance with one or more activities of daily living (ADL) such as: Eating or preparing meals, bathing and dressing, going to the toilet, managing medications, moving around in the residence or getting to other locations. When the extent and degree of the problems and limitations, cannot be managed in the community, for example, at home or in an assisted living facility, the individual might move into a long-term care placement in a nursing home.
The stay in the long-term care nursing home might be paid out-of-pocket by the resident or the family, to the extent that the person’s (not necessarily the family’s) financial resources permit. Depending on the individual State regulations, when the resident has exhausted their assets to a specified degree, the State’s Medicaid program takes over payment for the resident’s stay in the nursing home.
Some people go into a nursing home temporarily, for skilled nursing and rehabilitation. This is typically after an acute illness, often after a hospitalization. Most of these people are elderly but some of them are younger. These people are expected to improve to the level that the nursing home/skilled nursing facility care is no longer required, and they can be discharged back into the community or to a lesser level of care.
People living with Alzheimer's or other dementias make up a large proportion of all elderly people who receive community-based adult day services and nursing home care.
The Paucity of Geriatric Psychiatrists in the US
Despite the growing need for psychiatrists and other medical care providers for the older population, there are relatively few new medical trainees going into the various geriatric specialties. Similarly, there are relatively few non-physician health care providers being trained in geriatric fields, especially in geriatric mental health.
This is a significant challenge for the current and future care of the psychiatric and cognitive problems of older Americans, whose mental, emotional, behavioral, and cognitive difficulties may go unrecognized, and untreated, under-treated or incorrectly treated. Aging people have a host of unique factors that need to be considered and that are often different from those of younger adults. Often it is extremely important for older individuals to have someone involved in their care and treatment who can bring that knowledge and perspective to bear.
As of 2020, there were only about 1000 members of the American Association for Geriatric Psychiatry, fewer than one for every 39,000 people over 65. There are only a limited number of psychiatric residents who choose to take an extra year of subspecialty training in Geriatric Psychiatry. In 2020, there were 62 specialty training programs for a post-residency Fellowship training in Geriatric Psychiatry, with about 200 positions per year, but often many of those training positions are unfilled.
There are an unknown number of general psychiatrists and psychologists who are providing care for older people either part-time or full-time, but who have not had formal graduate training in geriatric psychiatry or geriatric psychology. Many of these individuals may have obtained continuing education or certifications in these geriatric areas, or have extensive experience in practice, but others may not.
There is no designated sub-specialty in geriatric psychiatry for Nurse Practitioners and Advanced Practice Nurses, or Physician Assistants. Nurse Practitioners have specialty areas of study in Psychiatry, and in Geriatrics separately, but most NPs only take training in only one of these areas.
Medicare
Medicare is a federal social insurance program and was introduced in 1965. Its aim is to provide health insurance to older and disabled people, covering 61.4 million people, including 52.9 million people over 65 years old, including 12% over 85. About 18% percent of all people in the United States are covered by Medicare. Over one third (22.9 million) are enrolled in Medicare Advantage managed care plans, and the remainder (38.5 million) in traditional fee-for-service care. Unlike Medicaid, Medicare eligibility is not related to lower incomes or a certain state of poverty. Medicaid is the federal social health insurance program for low income individuals and families. About 6.2 million (11%) of Medicare beneficiaries are also enrolled in Medicaid due to low economic resources.
Total Medicare spending in 2019 was $792 billion, 21% of all healthcare spending in the United States.
As of 2018, there were 6,072 Medicare eligible hospitals and 598 Medicare eligible psychiatric hospital facilities in the United States.
From the time of Medicare’s creation in 1965 until 2009, there was a built-in prejudice against seniors with psychiatric problems. For other medical problems and their treatments, Medicare paid for these services at a rate of 80% of the Medicare approved fee schedule. For outpatient treatment of mental and emotional and cognitive problems and other psychiatric conditions, Medicare only paid 50% of the approved fee schedule and patients were responsible for payment of the other 50%. This excess cost burden was a significant barrier which prevented many older people from seeking and obtaining psychiatric help. It was also a major disincentive against psychiatric providers accepting and seeing older patients. This differential payment system was finally phased out from 2009 to 2014. Currently, outpatient psychiatric care is covered at 80% like other medical conditions.
For many years of his career, Dr. Stein has given lectures, taught courses, written articles and book chapters, and has taught psychiatrists and other physicians about the Clinical Practice of Geriatrics and Geriatric Psychiatry, as well as about private practice and about Medicare, with the desire and goal of encouraging them to devote more of their time and medical care working with older people.
Working with Older People is Thought-provoking.
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