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By Dilip Jeste, M.D.
The United Nations has declared 1999 as the International Year of Older Persons. This is hardly surprising given the demographic revolution sweeping the United States and the rest of the world. As psychiatrists, it is important for us to advocate for the mental health needs of the growing elderly population. I want to compliment APA President Rodrigo Muņoz, M.D., for making geriatric psychiatry one of the four main initiatives for APA to pursue during the coming year and beyond.
The 20th century has witnessed an exponential growth in the number and proportion of Americans over age 65 (from 3 million, or 4.1 percent, in 1900 to 34 million, or 12.7 percent, in 1997), yet this historical rise will be dwarfed by that which will begin in the year 2011 as the first of the postwar baby boomers (those born between 1946 and 1964) reach the traditionally defined "old" age of 65. Thus the number of the elderly will rise to about 69 million in just 30 more years.
Psychiatric illnesses are common in the elderly. Ten percent to 15 percent of those over the age of 65 have Alzheimer's disease or another type of dementia. Approximately half of the patients with dementia have psychosis or depression, while a large majority have agitation or aggression, especially during the later stages of their illness. The prevalence of clinically significant psychiatric symptoms (including those of depression, anxiety, psychosis, and so on) in the nondemented persons ranges from 15 percent to 25 percent.
Geriatric psychiatry has made impressive strides in the United States during the past two decades. The American Association for Geriatric Psychiatry (AAGP), founded 20 years ago, has become a thriving organization promoting education, research, and good clinical practice in the field. The first-ever examination for added qualification in geriatric psychiatry was given by the American Board of Psychiatry and Neurology in 1991. Since then 2,360 psychiatrists have passed that examination. There are 39 ACGME-accredited geriatric psychiatry fellowship programs. To meet the growing demand for services, we will need more geriatric psychiatrists, but we also need to add more geriatric psychiatry training to medical school and general psychiatry residency curricula, since most physicians including psychiatrists will be providing care to increasing numbers of elderly people during the coming decades.
There are several barriers to achieving progress in this area. Elderly mentally ill patients face the dual social stigma of aging and mental illness in a society that puts a high premium on youth and health. Another concern is financial. Major changes in the structure and financing of long-term care and managed care are proceeding at a rapid pace across the nation, with a virtual lack of attention to older adults with severe mental disorders. The many unresolved issues include assurance of quality medical health care for this group and identification of the optimal mix of services necessary to maintain the older person with severe persistent mental disorders in the community as long as possible. There is also a growing concern that regulators are removing Alzheimer's disease from the category of psychiatric disorders. We must resist this irrational and dangerous trend and assert that Alzheimer's disease is a psychiatric illness and psychiatrists bring special skills to manage individuals with this condition. At the legislative level, modifications of Medicare contracting to the managed care companies should be sought to require mental health screening and services.
A number of useful strategies need to be pursued. These will involve collaboration among various relevant organizations and groups such as APA, the AAGP, the National Institutes of Health and other federal agencies, private industry, and advocacy groups. There should be a joint effort to formulate a 15- to 25-year plan for the development of new programs in clinical care, training, and research on mental disorders in the elderly. Large-scale intervention studies of the effectiveness of pharmacologic and nonpharmacologic treatments as well as preventive interventions are warranted. Most of the psychotropic medications were developed and tested primarily in younger adults. Issues of polypharmacy, medical comorbidity, greater risk of side effects, as well as age-related changes in pharmacokinetics and pharmacodynamics make it vital to conduct large-scale psychopharmacologic investigations in geriatric populations.
Special attention should be paid to investigations of inadequately or poorly studied serious late-life mental disorders since illnesses such as schizophrenia, anxiety disorders, alcohol dependence, and personality disorders in the elderly have been largely ignored in psychiatric research despite the fact that these conditions take a major toll on patients, their caregivers, and society at large. Furthermore, such studies are likely to provide new insights into these disorders across the life span. For example, the reports of remission of schizophrenia in older age even after decades of illness (recently illustrated by the inspiring story of the Nobel laureate Dr. John Nash), along with investigations of late-onset schizophrenia, challenge the traditional Kraepelinian notion of dementia praecox and provide opportunities for revising our thinking about schizophrenia in general.
Through research, education, collaboration, and innovations in health care delivery, we will be able to convert the challenges posed by the rising demand for mental health services for the elderly into opportunities for growth and advancement.
Dr. Jeste is a professor of psychiatry and neurosciences and chief of the Geriatric Psychiatry Division at the University of California, San Diego, and V.A. San Diego Healthcare System.