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Position Statement 35: Aging Well

Policy

The public resources available for healthcare in America seem to be increasingly in jeopardy (in 2011), as debates over federal and state entitlements become more and more polarized. Medicare and Medicaid reductions or reorganizations loom, just as the baby boom demographic tsunami is starting to be felt. It is critical for the solvency of Medicare and the health and welfare of people enrolling in Medicare that Americans be encouraged to "age well,"(1) and that government at all levels reorient public health programs accordingly.

Mental Health America (MHA) urges that the budget discussions of all levels of government recognize the emerging needs of older people with mental health and substance use conditions. This priority needs to be addressed now, as the baby boomers begin enrolling in Medicare in increasing numbers. Innovative programs will be required to maintain and increase wellness as the American population goes through dramatic demographic change. This issue should emerge as a major focus of health care reform implementation under the Affordable Care Act, to contain costs and encourage wellness by promoting "positive aging."(2)

The three primary goals should be:

  • to enable older people with mental health or substance use problems to live where they prefer, generally in the community - to "age in place;"
  • to assure access to clinically appropriate, culturally and linguistically competent care in the community and in congregate living settings for people who need more help as they grow older; and
  • to encourage people to age well by helping them to preserve their mental as well as general health and sense of vitality and fulfillment as they age.

Background

The population of people over age 65 in the United States is projected to double between 2000 and 2030, from 35 million to 70 million.(3) While mental illness is not an inevitable part of aging, and older people actually experience fewer mental health conditions (excepting cognitive impairment) as they age, approximately 6.9% of people aged 65-74 experience "frequent mental distress," (4) and many experience mental health and substance use conditions associated with loss of functional capacity even though a formal diagnosis may not be justified. Anxiety and depression must be addressed for people to age well, and MHA envisions a supportive, integrated system of psychosocial care that encourages people to overcome such challenges by applying a recovery orientation to the aging process.

As stated by Deborah Padgett in the conclusion to her Handbook on Ethnicity, Aging, and Mental Health, aging need not be a time of "irreversible decline and loss," and depression and emotional distress can be successfully mastered and are actually less prevalent as people age. In fact, she concludes, "declines usually associated with aging are quite malleable and influenced less by aging per se than by a host of psychosocial and lifestyle factors such as stress, diet, and exercise. Among the [most important] psychosocial factors associated with successful aging are sense of control and autonomy and social support."(5)

Given the fact that more than half of each class of new Medicare beneficiaries is already coping with arthritis, it is important to acknowledge that virtually all older people will have coexisting impairments eventually, and more than half start out that way. So "positive aging" needs to work with whole persons to bring about overall wellness for individuals that is focused on their personal goals and current place of residence, social support system, and community. The primary method is by strengths-based therapies(6) that build the healthy habits that MHA refers to as "wellness." These strengths and supports are critical to aging well.(7)

Padgett explodes the "double jeopardy" concept that has stigmatized "ethnic aging." After accounting for the educational deficits that are associated with cognitive disorders in the African-American community and the underreporting common in minority communities that experience distress more as a set of physical symptoms than as a mental health or substance use disorder (the "somatization of distress"), Padgett concludes that mental health conditions are no more prevalent in Black and Hispanic elders.(8) In fact, she argues the contrary. Since, "adaptive [psychological, social and cultural strengths and] strategies formulated over a lifetime of struggle are keys to successful aging,"(9) ethnic elders who have coped with deprivation and stigma over their entire lives may have better mastered the skills required to cope with late life challenges.

Still, nearly half of people over age 65 with a recognized mental or substance use disorder have unmet needs for services.(10) Older adults with mental health or substance use conditions often do not seek specialty mental health care. They are more likely to visit their primary care provider- often with a physical complaint.(11) Those that do receive treatment are too often misdiagnosed or under- or over-treated. The interaction between physical and behavioral conditions is complex in older people:

  • Psychological stress may lead to general health problems;
  • General health problems may lead to psychiatric decompensation;
  • Coexisting mental and general health challenges and responses may interact; and
  • Social and psychosocial resources and medical and complementary treatments may affect all of the above.

However, treatment works when older people are accurately diagnosed and appropriately treated. Recent studies demonstrate that up to 80% of older people recover from depression with appropriate treatment.(12)

The ramifications of lack of treatment, misdiagnosis, and poor treatment reach beyond the mental well-being of the individual. There are serious physical consequences of untreated mental illness. Older people with chronic medical conditions such as diabetes and heart disease and co-occurring depression are at increased risk for disability, premature mortality, and high health care costs. Older people with depression are more likely than their peers to:

  • heal slowly from hip fractures;(13)
  • suffer heart attacks and die from these heart attacks;(14) and
  • succumb to cancer.(15)

In addition, people with serious mental illness are at high risk for obesity, hypertension, diabetes, cardiac conditions, respiratory problems, and communicable diseases that contribute to a life expectancy many years less than that of the general population.

Suicide is a devastating consequence of untreated mental illness in older people. In 2003, adults aged 65 and older constituted 12 percent of the population but represented 16.7 percent of the suicides. Adults aged 65 and older have a suicide rate 50% greater than the general population. The rate peaks in white males aged 85 and over who die by suicide at six times the rate of the general population.(16)

Older people with mental health problems are a diverse population including:

  • People with lifelong serious and disabling mental illnesses;
  • People with dementia (often with co-occurring depression and anxiety);
  • People with severe depression, anxiety, and behavioral problems that contribute to high rates of suicide, social isolation, and preventable institutionalization;
  • People with less severe disorders that nevertheless limit their ability to age well; and
  • People who abuse substances, primarily alcohol and pain medications but increasingly including people with lifelong addictions and those who use illegal substances recreationally.

Older people also face developmental challenges with emotional consequences such as retirement, loss of status, reduced physical and mental abilities, losses of family and friends, and the inevitability of death. Older people with mental health challenges inevitably face physical and social challenges and have a broad range of needs in order to pursue positive aging.

Older people with mental health or substance use problems are not yet a public policy priority. In addition, because their needs usually overlap the mental health, substance use, general health, and aging services systems, they often fall between the cracks. Specialized mental health and substance use services have not secured the resources necessary to provide appropriate care and treatment for older people. The general shift in mental health policy towards evidence-based, individual-centered care, consumer empowerment and recovery has not been reflected in improved services for older people. The generalist services that are the main source of care and treatment for older people with mental illnesses and substance use disorders rarely identify the particular needs and interests of this group. There is a widespread failure to integrate the aging, mental health and substance use treatment systems. A review of the evidence base found the greatest support for community-based, multidisciplinary, geriatric mental health treatment teams.(17) But little of that is happening, yet.

The President's New Freedom Commission on Mental Health, Older Adults Subcommittee, outlined the major barriers impeding older Americans from accessing appropriate mental health care.(18) The committee identified three overarching issue areas: (1) access and continuity of care, (2) quality of care, and (3) workforce capacity and caregiver supports.

Identified barriers included a mismatch between the current system and the needs and preferences of older adults, stigma associated with mental illness, drug dependency, and advanced age, and a fragmented service system. There is inadequate research dedicated to mental health and aging and a lack of preventative interventions and recovery-oriented services. The asylums that used to house older people with serious mental illnesses are replicated by the nursing homes that admit people with serious mental illness much earlier than others, and condemn them to an institutional existence that is incompatible with aging well.(19)

Of particular concern is the inverse relationship between the diminishing workforce trained in geriatric mental health issues and the "elder boom." Although peer support has shown its worth with younger adults, it has yet to be widely adapted to older consumers. Research supporting the use of peer support with this population is needed, along with training and implementation of this new workforce.

Effective Services for Older People.(20) Evidence-based health care should be the foundation for building exemplary care tailored to needs of our aging population. Evidence-based health care:

  • supports flexible and individualized care based on individuals' unique needs, histories and other factors, and does not dictate "one-size-fits-all" treatment;
  • develops research that should be widely disseminated and vetted by consumers as well as researchers;
  • develops research that appropriately represents all major cultural and linguistic groups so that group differences can be understood and addressed;
  • emphasizes safety and consumer recovery as the overarching goals; and
  • supports clinician and consumer-informed decision-making as the principal determinant of care

A service system that is built on the available evidence will include:(21)

  • outreach services, including community education and training, prevention and early intervention efforts, and screening and early identification;
  • community-based, multidisciplinary, geriatric mental health treatment teams;
  • comprehensive home and community based services, including integration with primary care, case management, peer and consumer-run services, caregiver supports, crisis services and long-term care;
  • mental health promotion interventions that seek to improve the quality of life for older adults, not simply mitigate the negative effects of aging; and
  • policy and legislative changes that address the problems of workforce development, funding, research, coalition-building and integrated service systems.

Integration of care is the key:

The vast majority of older adults with a mental health or substance use disorder also have other chronic conditions. In addition, people with a serious mental health condition are at increased risk for other general health conditions. Thus, it is critical to integrate mental health and substance use with other health services including primary care, specialty care, home health care, and residential-community-based care. There are various models for integrating mental health and general health services including:

  • training primary care providers in mental health, co-locating health and mental health services, using integrated treatment teams of health and mental health professionals;
  • using care managers to follow up with consumers outside of the office;
  • establishing primary care centers that specialize in serving older adults with mental disabilities, establishing health satellites at mental health centers; and
  • using community-based, multidisciplinary, geriatric mental health treatment teams.

The "health home" concept imbedded in the Affordable Care Act is the most recent federal initiative promoting integration of care.(22)

Unfortunately, there are numerous barriers to implementing and sustaining these approaches, including:

  • Providers' lack knowledge of the various models for integrating mental health, substance use and general health services;
  • Integration runs counter to the current service traditions. Providers tend to work independently rather than in close collaboration;
  • Older people's mental health needs are not usually integrated into their overall discharge plan when they leave inpatient treatment; and
  • Cost can constrain options, as Medicare, Medicaid, and private insurances may not adequately reimburse for mental health and substance use services or collaborative care.

Older people with mental health or substance use problems also often receive services and supports through agencies specializing in aging services. These include senior centers, case management, adult day care, adult protective services, etc. Unfortunately, there is currently a lack of cross-system knowledge and collaboration. Professionals who work in the specialty mental health, substance abuse, general health, or aging systems typically do not know about the services readily available in other systems, making it difficult to find appropriate services for older consumers.

Workforce Development. The behavioral health system is not ready for the elder boom, which is predicted to hit in full force as the baby boomers retire. To this end, it is imperative that training in geriatric mental health be expanded and incorporated into curricula for health care professional education, especially for physicians, nurses, psychiatrists, psychologists, social workers, mental health counselors, peer specialists, and rehabilitation specialists. Currently there are roughly 2,425 geriatric psychiatrists in the United States with an estimated current need 4,400 and a future need of 8,840. In regards to geriatric social workers, there are only 6,000 nationwide with a current need of 32,600 and a future need of 65,480.(23)

The Dementia Dilemma. In addition to mental health conditions, older people suffer from Alzheimer's Disease (AD) and from many other symptoms of the aging brain, which the diagnosticians have grouped under the term "Mild Cognitive Impairment," somewhere short of AD. This terminology appears to serve only as a rough measure of severity and will surely evolve as we learn more. As recent attention has been focused away from AD as a differential diagnosis of brain physiology, researcher/clinicians like Peter Whitehouse have begun treating all of the symptoms of the aging brain on a continuum, and used a "positive aging" model as a way to respond.(24) This means that as people age, wellness matters more, not less, making activities like exercise, a good diet, reading, social interaction, study and service increasingly important. With brains, as with so much else in life, you use it or you lose it. Those most involved in life stay involved. Effective prevention and appropriate treatment of dementia may be the greatest public health challenge posed by the aging of the boomers.

This view does not minimize the struggles that people experience as their brains age. But the disease is never bigger than the person. "Neurodegenerative conditions do not ‘claim' older people, nor do they dominate them or degrade their humanity. They simply alter how they live their lives."(25)

Finding the recovery paradigm in the care of aging brains is the most important focus of research. No pill is likely to cure AD, nor is Ginkgo biloba or any other substance going to prevent the aging of the brain, though some may be helped, but cognitive impairment can be slowed along the way by a supportive system of psychosocial care grounded in the logic of positive aging. The recovery model is the best way for our society to address all of our aging brains.

Call to Action

  • Aging well is everyone's business. A positive aging agenda will require dramatic expansion of available services-including:
    • access to appropriate housing;
    • improved quality of care;
    • integration of care among the mental health, health, substance use, and aging services systems;
    • building a much larger clinically and culturally/linguistically competent workforce; and
    • increasing and re-inventing funding sources to develop a match between funding mechanisms and service needs.
  • Health care reform is a promising avenue for this reform, and aging well should be adopted as a core value in the care of older people under the Affordable Care Act.
  • Affiliates are urged to adopt an aging well agenda for their communities, and promote it in partnership with others, since many services, especially housing, will need to be provided by local and state governments and nonprofit agencies, and
  • Affiliates may act as catalysts to make elder cooperative and congregate care more available in their communities.

Effective Period

The Mental Health America Board of Directors adopted this policy on June 12, 2011. It is reviewed as required by the Mental Health America Public Policy Committee

Expiration: December 31, 2016

  1. Thanks for the phrase to Valliant, G.E., Aging Well: Surprising Guideposts to a Happier Life (Little Brown 2002).
  2. Hill, R.D., Positive Aging (W.W. Norton & Co. 2005) quotes Seligman, M.E.P. & Csikszemmihalyi, M, "Positive Psychology: An Introduction," American Psychologist 55:5-14 (2000) in defining the term, focused on well-being, contentment, satisfaction, hope, optimism, and happiness. According to Hill, the traits to be emphasized are: " the capacity for love and vocation, courage, interpersonal skill, aesthetic sensibility, perseverance, forgiveness, originality, future-mindedness, spirituality, high talent, and wisdom." Introduction, at p. xi-xii.  The terminology of "positive aging" is a more recovery-oriented version of the earlier term, "successful aging." Even a person with one or more chronic conditions could age positively, if not fully successfully. And even "negative" aging is far preferable to "pathological" or "diseased" aging, the terms formerly in use. According to Hill, positive aging has four characteristics: "a person mobilizes resources to cope with age-related decline; a person makes lifestyle choices to preserve well-being; a person cultivates flexibility across the life span; and a person focuses on the positives versus the problems and difficulties of growing old." Id. at 18-23.
  3. U.S. Bureau of the Census, "Population Projections of the United States by Age, Sex, Race and Hispanic Origin: 1995-2050, Current Population Reports, P25-1130 (2000).
  4. Segal, D.L., Qualls, S.H., & Smyder, M.A., Aging and Mental Health (2nd ed.), (Wiley-Blackwell, 2011), at p.7, quoting the CDC (2007). People aged 75 and older actually had less frequent severe symptoms.
  5. Padgett, D.K., ed., Handbook on Ethnicity, Aging and Mental Health (Greenwood Press, 1995), at pp. 304-5.
  6. See Vickers, R., "Strengths-based Health Care: Self-advocacy and Wellness in Aging," in Mental Wellness in Aging, Ronch, J.L., and Goldfield, J.A., eds. (Health Professions Press 2003)
  7. For more information about wellness programs, see MHA Position Statement 17, Promotion of Mental Wellness, http://www.nmha.org/go/position-statements/17 , and MHA's wellness website, "Live Your Life Well," http://www.liveyourlifewell.org/ . The ten factors stressed on the website are:
    1. Connect with others
    2. Stay positive
    3. Get physically active
    4. Help others
    5. Get enough sleep
    6. Create joy and satisfaction
    7. Eat well
    8. Take care of your spirit
    9. Deal better with hard times
    10. Get professional help if you need it
  8. Padgett, op. cit., footnote 5, supra, at p. 306. Other groups have not been adequately studied.
  9. Id.
  10. George, L.K., Blazer, D.G., Winfield-Laird, I., et al., "Psychiatric Disorders and Mental Health Service Use in Later Life," in Epidemiology and Aging, Edited by Brody, J.A. and Maddox, G.L. (Springer, 1988)
  11. U.S. Department of Health and Human Services, Older Adults and Mental Health: Issues and Opportunities (Rockville, MD: 2001).
  12. See generally, Segal, D.L., Qualls, S.H., & Smyder, M.A., Aging and Mental Health (2nd ed.), footnote 4 supra.
  13. Mossey, J.M., Knott, K. & Craik, R. (1990). "The Effects of Persistent Depressive Symptoms on Hip Fracture Recovery," Journal of Gerontology Series A: Biological Sciences and Medical Sciences 45:163-168.
  14. Gallo, J.J., Bogner, H.R., Morales, K.H., Post, E.P., Have, T.T., & Bruce, M.L., "Depression, Cardiovascular Disease, Diabetes, and Two-year Mortality Rates Among Older, Primary Care Patients," American Journal of Geriatric Psychiatry, 13:748-755 (2005).
  15. Phennix, B.W., Guralnik, J.M., Pahor, M., Ferrucci, L., Cerhan, J.R., Wallace, R.B., & Havlik, R.J.. "Chronically Depressed Mood and Cancer Risk in Older Persons," Journal of National Cancer Institute 90:1888-1893 (1998).
  16. National Center for Injury Prevention and Control, Center for Disease Control and Prevention, "Mortality Reports," http://www.cdc.gov/ncipc/wisqars/
  17. Bartels, S.J., Dums, A.R., Oxman, T.E., Schneider, L.S., Areán, P.A., Alexopoulos, G.S., & Jeste, D.V., "Evidence-based Practices in Geriatric Mental Health Care," Psychiatric Services 53(11):1419-1431 (2002). http://psychservices.psychiatryonline.org/cgi/reprint/53/11/1419
  18. Bartels, S.J., "Improving the System of Care for Older Adults with Mental Illness in the United States: Findings and Recommendations for the President's New Freedom Commission on Mental Health," American Journal of Geriatric Psychiatry, 11:5, 486-497 (2003).
  19. Segal, D.L., Qualls, S.H., & Smyder, M.A., op. cit., footnote 4, supra, at p. 162. Thus, according to Andrews et al. (2009), people with schizophrenia enter nursing homes at a median age of 65, compared to a median age of 80 for other persons.
  20. National Association and Mental Health Planning and Advisory Councils, Older Adults and Mental Health: A Time for Reform. DHHS Pub. No. (SMA) XXXX. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. (2007), http://www.namhpac.org/PDFs/01/olderadults.pdf.
  21. Id.
  22. See MHA Position Statement 71, Health Care Reform, http://www.nmha.org/go/about-us/what-we-believe/position-statements/position-statement-71-health-care-reform/position-statement-71-health-care-reform.
  23. http://www.mhawestchester.org/advocates/workforcedevelopmentoct2007.pdf.
  24. Whitehouse, P.J., with George, D., The Myth of Alzheimer's (St. Martin's Press 2008).
  25. Id., introduction, at p. xi.

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