She sits in the recliner, sometimes for hours on end, staring off into space. She could be your mother, your neighbor, your friend. “She’s just getting old,” you tell yourself. But is it really old age? She could have Alzheimer’s disease--5 percent of those over age 65 have it--or another type of dementia. Or it could be depression, a condition affecting perhaps 10 percent of the older population, that is too often never diagnosed. The symptoms--fatigue, lack of appetite, confusion, irritability--may just be chalked up to “old age” by relatives, friends, and even the family physician.

There is growing recognition of the prevalence of problems like substance abuse and depression in the elderly. An estimated 2-10 percent of those over age 65 are alcoholic or abuse alcohol. Depression is a serious concern, as reflected by the high rate of suicides among older individuals, particularly white males. In 1993 the overall rate of suicide in Virginia across all ages was 12.1 per 100,000. For white males aged 75 and older, the figure leaps to 79.1 per 100,000. Unfortunately, the depression underlying many cases is often not recognized. Studies show that 35-47 percent of elderly suicide victims were seen by their primary physician within the seven days prior to the suicide, and 70-75 percent within 30 days. Educating the primary physician could make a difference; major depressive disorders in later life are often treatable. Nearly 60 percent will respond to appropriate antidepressant therapy, and another 10-20 percent will improve with the addition of psychotherapy. The costs of treatment are relatively small compared to the costs, if untreated, in increased morbidity, mortality, and related physical health care and hospitalizations.

An estimated 15-25 percent of older people living in the community have clinically significant psychiatric symptoms, with a prevalence as high as 50-70 percent among nursing home residents. The number of elderly persons with schizophrenia is projected to double over the next 30 years. As these individuals have been institutionalized much less than in the past, they have housing needs and periodically reenter the health-care system, which may be unprepared to manage the complications this disease can develop by later life.

While there are many issues swirling around this troubled population, there are two primary foci: the need for community-based care and support for nursing homes. Concerns are evident in all areas about being able to meet the growing needs as our population ages. Pressure is mounting in part due to the rise in HMOs. Managed care is designed to pay less than fee for service. This trend necessitates an emphasis on disease management and preventive care in order to maintain individuals in the least costly environment. Current trends at the national level are also pushing toward a lesser Medicare/federal role, leaving more and more responsibilities on the states. There are grave concerns that the states will not have enough money to meet the needs.

Sadly, the mentally compromised elderly have a hard time “competing” for dollars when budgets are tight. Spending money on these elderly may be seen as a poor investment. But many of the kinds of services they require are needed by adults of all ages who are dealing with these problems.

COMMUNITY-BASED ISSUES

Deinstitutionalization of the mentally ill in the 1970s poured a rush of unstable individuals into the community. Their care was to have been supported by funneling government dollars into the community to develop services. However, full funding was never appropriated.

The need for stronger and more comprehensive development of community services continues as a major issue today. In the spring of 1996, a study commission was formed by Virginia House Joint Resolution 240 to examine the future delivery of publicly funded mental health, mental retardation, and substance abuse services. While the study is still in the early stages, the need for community-based support is already becoming apparent.

Greater availability of residential homes, especially small ones, would help many adults, including those with Alzheimer’s disease and developmental disabilities. Small home-like situations, if well run, can work well for such individuals, providing the structured routine, friendly supervision, and medication management that they need. However, some state oversight would help ensure that certain minimum standards are met.

Correct diagnosis and treatment of the elderly in the community presents another challenge. The current generation of elderly does not readily admit a need for mental health services and only reluctantly seeks out help. Those who are now in their 70s and older lived through the Great Depression and have a strong regard for doing for themselves and not asking others for help. Therefore, anything that can be done to make it easy for the elderly client to talk with mental health professionals, when the need arises, should be pursued.

One way to make needed care more accessible is through psychiatric home health visits (already covered by Medicare under certain conditions). Being able to take the service to the elderly in their homes would lessen any stigma issues and allow care to reach the homebound and those who otherwise might have to go to the hospital.

Another innovative idea is to provide counseling on site in the physician’s office. The behavioral health service line of Carilion Health System in Roanoke has begun a pilot program in which a clinical nurse specialist spends several days a week seeing patients in a family practice clinic. On-site arrangements like these can be a win-win situation for everyone. When a physician has a concern about a patient, she or he can suggest the patient walk down the hall and talk with a counselor, making it easy for patients to get the help they need. The counselor can listen to the patient and make recommendations to the physician, giving the physician better insight into the patient’s condition from a holistic viewpoint.

Many other services could help the elderly stay in the community. Provision of adult day care and other forms of respite can help family caregivers struggling with the stressful job of caring for a disoriented elder. Failure to provide such support takes a toll in our society, reflected by the growing incidence of abuse and neglect of the elderly. It is estimated that as many as 1.5-2 million Americans over age 60 are abused annually, with perhaps as many as 26 new cases per 1,000 over age 65.

Often, the problems of an older person can be managed by the family and family physician, with a little support as needed. However, complex situations may call for geriatric expertise. Geriatric assessment clinics, like those at Carilion Roanoke Memorial Hospital and Saint Mary’s Hospital in Richmond, serve the frail, medically complex elderly who may be experiencing loss or change in functional ability, changes in mental status, recent bereavement, high fall risk, multiple chronic illnesses, incontinence, caretaker stress, and threatened institutionalization. They can also help with medication management. Maryland has a nurse/social worker team from the Agency on Aging conducting home assessments, a program that combines the above suggestions. All of these programs need to become more widely available.

MENTAL HEALTH ISSUES IN NURSING HOMES

If an older individual crosses the threshold to become a resident of a nursing facility, chances are good--50-70 percent--that they have some type of psychiatric symptoms. “Nursing homes have replaced state mental hospitals as the locus of institutionalized care for older mentally ill and demented people,” say Chester Jakubiak, Jr., and James Callahan, with Mental Health Services Research at Brandeis University. They cite data indicating that of all elderly with mental disorders who are institutionalized, 94 percent are in nursing facilities.

Unfortunately, nursing homes are not prepared to manage these individuals; nor do they receive adequate support from mental health professionals. According to a recent Institute of Medicine study, eight years after major federal nursing home standards were passed, some advances have been made, but problems with quality of care continue in some facilities. The advances that have been made are threatened by the current movements toward decreasing funding. Even the Long-Term Care Ombudsman program, one of the main consumer advocacy avenues available to residents and their families, is at risk.

These trends run counter to the realities: problems are worsening since long-term care residents are sicker now than they used to be, and the numbers in need will only continue to grow. Admissions criteria are stiffer, keeping out all but the most frail and disoriented, making the staff’s jobs even more challenging. Staff are paid the very lowest wages for what is already one of the most difficult jobs: taking care of the intimate personal bodily needs of former strangers, who may be cranky and combative.

And who wouldn’t be cranky and combative? Imagine, after living an independent life, ending up in a nursing home, sharing a room with someone you have never seen before. You are allowed to keep only a few of your belongings with you. In even the best facility, with the most caring staff, it is only natural that residents may rebel.

Other things can cause agitation as well. Medications; physical conditions such as infections and malnutrition; and illnesses like diabetes, congestive heart failure, and pain can produce symptoms of delirium and behavior problems if left untreated. Better recognition and screening of possible common causes before the patient is transferred to an acute-care hospital would help tremendously. While the mental health needs of residents overall are great, such screening would help target professional help and costly hospitalizations to the patients who most need it and can benefit from it. Inappropriate admissions of disoriented elderly patients, with the consequent health-care costs, are a nationwide problem. Unfortunately, the state ombudsman office sees all too many cases of patients who are labeled when they exhibit problematic behaviors. The nursing home may give a mental health diagnosis and get the resident transferred to an acute-care hospital when perhaps the problems could have been dealt with there. Then they do not seem to have a bed available when it is time for the individual to be discharged--the hospital becomes a dumping ground.

But the nursing homes cannot do it all alone, and they cannot seem to get the support they need. They get very little help from mental health professionals. They may rely too readily on inappropriate use of medications and physical restraints. Caregivers everywhere--from nursing homes to community settings--need to be trained to understand what is natural in the aging process and how to constructively manage patients who are experiencing dementia and other problems.

CONCLUSIONS

What should Virginia’s public policymakers do? Initiating support for or adding support to the following programs would help the commonwealth meet present and coming needs:

• Programs to raise awareness of appropriate diagnoses;
• Funding and oversight of residential facilities;
• Offering psychiatric services in the home and primary physician’s office to increase accessibility;
• Increasing availability of adult day-care and other forms of respite;
• Geriatric assessment services across the continuum of care, from home to nursing facility;
• Training of formal and informal caregivers in all settings to improve their understanding and management of problem behaviors;
• Continued support for the Long-Term Care Ombudsman program, and making a similar advocacy service available for individuals in assisted living/residential settings; and
• Better screening of patients before transfers for costly inappropriate hospitalizations.

States face ever increasing demands for their attention and support. In all the clamor, the voices of the elderly suffering from depression, dementias, and other mental disorders may not be heard. However, money spent wisely in appropriate interventions can save money spent less effectively if their conditions go untreated. Even more importantly, when so much of their pain--and the suffering rippling out across their family and friends--can be eased, it becomes imperative to try.

Anne Howard Pyles Glass is a strategy specialist with Carilion Health System in Roanoke; a consultant and educator specializing in long-term care and quality improvement; and an adjunct faculty member at Virginia Tech, teaching, among other courses, adult development and aging, and rural gerontology. She has been director of quality for Saint Albans Psychiatric Hospital in Radford and for the Carilion Psychiatric Service Line. Glass has written articles for professional journals on nursing home quality, nursing resident assessments, and how to improve the quality of care and life in nursing homes.

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