February 5, 1999

The APA Council on Aging is making substantial progress toward the overriding goal of turning the council into a major resource for APA members seeking advice on geriatric psychiatry, according to Christopher Colenda, M.D., who became chair of the council in May 1997.

"I had set the agenda for twin missions," said Colenda. "I think the council's best service is to assure that the principles and practice of geriatric psychiatry are accessible to the generalist psychiatrist. In a similar vein, the general psychiatrist, when issues about geriatric psychiatry arise, should be able to turn to the council."

The council is "well on the way to accomplishing those goals," Colenda added.

Colenda, who has been involved with the Council on Aging for a decade, said he "came up through the ranks." As someone involved for so long, "I am concerned with continuity in the Council on Aging," he said. At a time when there is talk of eliminating some APA components, it is important that members understand the role of the council, he explained.

"It's the only venue for APA to have a national voice on geriatrics. I think there's a place for a component dedicated to aging" despite the existence of subspecialty societies devoted to geriatric psychiatry, he said. The council gives geriatric psychiatry a stronger voice in APA.

One of the committees under the council, the Committee on Long-Term Care, is in the process of publishing a how-to manual for general psychiatrists on nursing home care, said Colenda. Publication by the American Psychiatric Press Inc. of A Manual of Nursing Home Care for the Psychiatrist is slated for later this year. It will be a practical guide to the delivery of psychiatric care to elderly patients residing in nursing facilities, according to Colenda.

Those concerned about geriatric care should welcome the long-term care initiative that President Clinton unveiled on January 4, said Colenda. The heart of the proposed $6.2 billion, five-year package is an annual $1,000 tax credit for the elderly and caregivers to assist with long-term care. The tax credit would cost an estimated $5.5 billion and help approximately two million people from 2000 to 2004, according to the White House. The flat $1,000 credit would be provided on the basis of "a certified need for long-term care rather than expenses for long-term care," according to a fact sheet from the Department of Health and Human Services Administration on Aging (AOA). Families and people with long-term care needs would not have to collect and submit receipts for paid home health or respite care, according to AOA. Informal, family caregiving would also be recognized. The eligible would include taxpayers with long-term care needs, taxpayers whose spouses have long-term care needs, and taxpayers with dependents with long-term care needs. Included in the definition of those with long-term care needs are people with severe cognitive impairments.

"Historically Medicare has avoided payment of long-term care by design because of its high cost," Colenda commented. "Long-term care has historically been funded through Medicaid, a blended state-federal program, and out of pocket by patients and families. There's been little market viability for long-term-care insurance, in part because premiums are so expensive and the policy benefits are limited. What Clinton's done with his initiative is he has begun to recognize the need and recognize the caregiver burden that exists for families with elderly or disabled individuals needing long-term care. He has also stimulated the private sector to look at developing insurance products that may guard against the risk of excessive out-of-pocket expenses by individuals or their families who require long-term care. The key issues will still be cost and quality."

"Cost plus quality equals value," said Colenda. Clinton is "beginning to address the cost of the issue," he observed, but it is also important that society examine the quality of services that are delivered, and "quality services must include psychiatric coverage in order to have maximum value," he added.

The council has been involved in shaping federal policy, according to Colenda. It provided testimony to the Institute of Medicine in March 1998 for its Committee on Improving Quality in Long-Term Care, he noted. That testimony focused on a variety of topics, including "adequate assessment of patients by a psychiatrist, appropriate utilization of psychotropic medication, and the whole issue of increasing accessibility to mental health services for nursing home residents and appropriate payment for those services." The testimony will be published in the winter issue of the American Journal of Geriatric Psychiatry, he noted.

Colenda discussed some of the major issues confronting geriatric psychiatrists.

Two-thirds of nursing home residents suffer from some form of dementia, and one-fourth have clinically significant symptoms of depression, Colenda noted. Of those with dementia, about 80 percent suffer from Alzheimer's disease.

The use of restraints is another controversial issue. "There's a tension between the legitimate use of [restraints], and their overuse in nursing facilities," said Colenda. "What we want to do is enhance physicians' clinical decision making about appropriate use of [restraints] and not resort to dogmatic or formula-driven approaches."

At present restraints and chemical sedation are overused, but it is equally important that physicians not be prevented from exercising their own best judgment, Colenda said. "Psychiatrists, by virtue of their specialized knowledge, should be key participants in the decision-making process."

The Council on Aging as a whole and its members individually have worked with Bayer Pharmaceutical to develop a slide set and speaker's kit on Alzheimer's disease titled "Alzheimer's Disease: Strategies for the Practicing Psychiatrist." The council took the lead in developing the speaker's pack and slides as part of a pilot program, with Bayer and APA providing selected district branches with materials and funding. Bayer provided a $50,000 grant to APA for the pilot project.

The Council on Aging consists of five committees. These are the Committee on Access and Effectiveness of Psychiatric Services to the Elderly, Committee on Ethnic Minority Elderly, Committee on Long-Term Care, Committee on the Senior Psychiatrist, and the Jack Weinberg Award Committee. The Committee on Ethnic Minority Elderly is planning a consensus development conference for the year 2000 on the effects of psychopharmacologic agents on cognition in ethnic minority elderly, according to Colenda. The conference is the outgrowth of two component workshops held at the 1997 and 1998 APA annual meetings.