SECTION: HEALTH

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HEADLINE: k230 TODAY'S HEALTH

 Geriatric psychiatrists see looming crisis ahead

BYLINE: Scott LaFee Copley News Service

BODY:

There's an old Indian adage, says Dr. Dilip Jeste, that goes something like this: "If we are lucky, we will not be poor; if we are lucky, we will not be disabled; but if we are lucky, we will live to be old."

But is old enough? In the United States, most people live to be old. The average American life span is now 76 years, up from just 47 years in 1900. One in 8 Americans today is at least 65 years old, a ratio expected to grow to 1 in 5 by 2030. The very old - people over the age of 85 - are the fastest growing population group in the country. There are 120,000 Americans over the age of 100.

But what's a long life if you can't fully enjoy it, if you suffer from depression, dementia or some other form of mental illness? Among the elderly, mental illness is a crisis coming of age.

There's no disputing that the nation is turning gray. The first baby boomers will hit 65 in just six years. That means health care can only become an ever-larger issue. This is especially true when it comes to mental illness, says Jeste, a geriatric psychiatrist at the Veteran Affairs Medical Center in San Diego and director of University of California San Diego's Stein Institute for Research on Aging.

Not only are more people living long enough to develop late-onset mental disorders, but the chronically mentally ill are living longer, too. And existing care for elderly psychiatric patients is almost uniformly inadequate.

"Health care for the elderly mentally ill in this country is very poor," said Jeste. "It's a crisis, and something needs to happen. We're all getting older. Some of us are going to become depressed. Some of us will suffer from other mental illness. That number will be greater than in the past."

TICKING TIME BOMB

A survey by the National Institute of Mental Health, published earlier this year, estimates that roughly half of all Americans will develop one or more mental disorders in their lifetimes. Most will be mild, but most will also go untreated for years, if they're treated at all.

By the age of 65, according to epidemiological studies, 18 percent to 28 percent of the elderly in the United States suffer significant symptoms of mental illness. The most common psychiatric problems of older people are dementias such as Alzheimer's disease, anxiety disorders such as panic and phobias, depression, and cognitive or mood disorders caused by physical problems, such as heart disease or poor nutrition.

Yet less than half of all older Americans who currently acknowledge a mental health problem receive treatment from any health care provider, and only 3 percent receive care from geriatric psychiatrists - medical doctors with extended, specialized training in the mental health of the elderly.

The suicide rate among the elderly is higher than any other age group in the nation. "People who are seriously mentally ill are simply less likely to reach very old age," Jeste said.

Dilip Jeste, 60, is among the nation's premier authorities on elderly mental illness, though he didn't start out to make that his specialty. Born in Pimpalgaon, a small town near Bombay, India, and educated there and in the United States at Cornell and George Washington, Jeste originally pursued a career in general psychiatry, focusing on schizophrenia research - a diverse group of often-severe psychotic disorders most commonly associated with youth and middle age.

"I had the usual notions about the elderly," he said, "that working with them was not fun, there wasn't much you could do, that geriatric work was a 'career-buster.' "

But his research showed that schizophrenia can sometimes debut or remit late in life. It was a startling finding. Then came what Jeste calls a "a bit of serendipity."

In 1986, he had decided to move to San Diego and take a research and teaching job at UCSD. That year, the VA coincidentally opened one of the first fellowship programs in geriatric psychiatry and invited him to head it. Jeste leaped at the chance.

"The more I got into geriatric research, the more exciting it was," he said. "One of the things I used to think was that as people got older, they got more similar. Like the way spouses supposedly start to look alike after awhile.

"But in reality, people become more different as they age. They acquire different life stories and experiences. Even their organs age at different rates. An elderly individual can have the liver of a 70-year-old, but the brain of a 40-year-old.

"It's actually hard to say if there's a prototypical elderly psychiatric patient. Some conditions are more common - 15 percent of people over the age of 65 have dementias such as Alzheimer's - but there are many, many other disorders and degrees of disorder."

But what virtually all mentally ill elderly have in common, said Jeste, is their generally dire circumstances: "These people are the most disenfranchised of all. They suffer the double bias of being both old and mentally ill."

Sitting in his VA office - a relatively sterile space featuring utilitarian bookshelves and furniture - Jeste smiled politely. He is a slight man, with thick, dark hair and an engaging, accommodating manner. His words are precise, the lilt and cadence of his Indian accent clear.

Prejudice against aging and the aged, he said with a sigh, is profound and universal.

"Even older people buy into it. It's something seemingly ingrained from childhood: When we get old, we become disabled, less useful to society. The best we can hope for is to just get by. If you want to compliment an old person, tell them how young they look."

The medical profession is part of the reason why care is lacking, Jeste and others contend. They say primary care doctors often dismiss psychiatric ailments like depression as simply part and parcel of becoming old.

"There's a perception that depression/forgetfulness/confusion/delusions are normal in old age," said Dr. Judith Crossett, director of geriatric psychiatry at the University of Iowa College of Medicine. "Some loss of function is normal, but depression, dementia and associated symptoms are not. It's ageism: 'Of course, he's depressed, he lost a spouse, had to give up driving, had to move into a nursing home.' Balderdash."

Older patients don't always help their cause. Mental illness carries a stigma, especially among those born before World War II, said Dr. Judah Ronch, vice president of mental health services for the Erickson Health System, a national network of retirement communities.

Baby boomers, he said, are more inclined to seek and expect medical services. Older generations are not. They grew up in a different time, with fewer resources and lower expectations.

"They don't necessarily expect help or know even how to seek it," said Ronch, "especially if it concerns a semi-taboo subject like their mental health."

The problem is frequently compounded by family issues.

"In some ways, geriatric psychiatry is analogous to child and adolescent practice," said Dr. Charles Ettari, a geriatric psychiatrist in Scripps Mercy Hospital's Behavioral Health Unit in San Diego. "With geriatric patients, it's almost back to treating adolescents, you deal with the patient and family members. Sometimes they're supportive, sometimes they are not.

"The vast majority of the elderly are doing just fine, but those who aren't very often have problems related to their families. Maybe they're depressed because the family isn't visiting enough. Or that they're being unwittingly negative, treating them as if they were useless or just trouble.

"There might be unresolved conflicts in the family. The patient might not want to be dependent, or the family might not know how to take care of an elderly member. As the psychiatrist, you tend to get much more into the whole family dynamic."

And then there is the fundamental complication of simply being old. An elderly patient with psychiatric problems is likely to have physical ailments, too.

"Most mentally ill elderly patients are seen by primary care doctors, if they're seen at all," said Jeste. "For the most part, these physicians likely do not have any specific training (on treating mental illness) beyond what they learned in medical school.

"That deficiency is compounded by the fact that they may have only 15 minutes or less for each patient. So what are they going to do when an elderly patient comes in with, say, seven problems, including mental illness. They're going to treat what they understand."

Contrary to what the French philosopher Rene Descartes once opined, the mind and body are not distinctly separate; each intersects, influences and complicates the other.

Numerous elderly, for example, are undernourished, resulting in reduced amounts of body fat and albumin, a protein made in the liver that helps maintain blood volume in arteries and veins. Less body fat means some fat-soluble drugs may circulate at higher than intended levels. Reduced albumin means drugs that must bind with the protein to work are less effective.

Problems also arise from simply being unable to read or understand prescriptions or doctor's instructions, something that's hard enough at times for younger patients, let alone those with failing sight or diminished cognitive abilities.

"There's so much complexity," said Crossett at the University of Iowa. "So many older patients have multiple medical conditions, multiple life situations or stressors, so many pills to take."

HOLES IN THE SAFETY NET

Studies suggest the majority of elderly mentally ill are long-suffering. Their psychiatric problems tend to be chronic, perhaps dating to youth. In some cases, says Jeste, they were able to cope with or get adequate treatment for them when they were younger. In other cases, the problem was ignored or unrecognized, as is often the case in alcoholism and substance abuse.

But advancing age changed the equation. As physical problems increased, as family or friends drifted or passed away, as finances declined or other stresses appeared, mental health problems became more apparent and more overwhelming.

Many mentally ill elderly confront this reality alone, said Ronch. They live in relative isolation. They may be widowed or live apart from other family members. Their lifestyles have diminished over time. They may be poor. Infirmities have exacerbated things: Perhaps they can no longer drive. And all around them, their neighborhood and world are different, strange, frightening.

Even when patients seek help, it might be hard to find.

In writings, Jeste has noted that of 39,000 licensed psychiatrists in the United States in 2001, only 5,000 listed treating the elderly as a primary interest and less than half were certified in that subspecialty.

"There are far too few geriatric psychiatrists currently trained and not enough entering training," agreed Dr. Ken Brummel-Smith, chairman of the geriatrics department at the Florida State University College of Medicine.

"The reason why is complicated: negative attitudes in psychiatry toward the elderly in general and mental health problems in the elderly specifically; bad images of older people being demented as a normal part of aging; poor respect of geriatric psychiatry by other members of the profession; poor Medicare reimbursement; a lack of governmental support for training programs."

AGE-OLD SECRETS

Treating old people with mental health issues is indisputably hard work. It can be frustrating and depressing.

"You cannot be a robot and do this job," said Jeste, who sees patients in clinical research and supervises clinical care provided by junior doctors. "You need to feel for and have a feel for both the patient and family. But you also need to keep some distance. You can't let emotion affect your rational thinking of how best to help."

That help tends to be focused more on the here and now, said Ronch.

"These people are in the latter half of their lives. You don't know how long they will live, so you want to help them reach a sense of maturation and fulfillment with their present life and situation.

"You're not going to do an in-depth exploration of their personality structure. They're past that. Rather, the challenge is how to optimize their quality of life, access the wisdom they have but which is considered obsolete by society."

Jeste finds it all rather self-therapeutic. Psychiatrists, he said, have a tendency, especially in medical school, to learn about new disorders and then discover those symptoms in themselves. Usually, they get over it.

But we all get old, at least hope to, according to that old Indian saying. And many of us will develop mental illnesses with age. But the notion that the elderly are emptied vessels, that they do nothing but cost money and take up space, is egregiously antiquated, said Jeste.

In his research at UCSD's Stein Institute, Jeste has studied hundreds of cases of "successfully aging" elderly who carry some or all of the expected burdens of advanced age.

"They've got arthritis, failing organs, cancer. But when you ask them how they are doing, they say fine. They're enjoying life.

"The idea that the brain stops growing is false. Studies show that on the psychosocial side, older people are capable of learning new things. They have more wisdom. Despite their illnesses and disability, many are generally happier than young people."

An America turning more gray by the day needs to learn how to age successfully, he said.

"As we grow old, we want to be functional old. The challenge is how to get there. I think that's exciting. Not just for other people, but for myself."

BY THE NUMBERS

35 million: Elderly Americans, ages 65 and older, in United States

70 million: In 2030

18 to 28: Estimated percentage of elderly Americans who suffer from significant psychiatric symptoms

275: Estimated percentage growth of mentally ill elderly over next 25 years

2 million: Elderly estimated to suffer from depressive illness

5 million: Elderly estimated to have symptoms of depressive illness, but not full-fledged disease

1 in 100: Chances of an American adult developing Alzheimer's disease

4 million: Elderly suffering from Alzheimer's disease or related condition

20: Percentage of elderly who meet criteria for alcohol abuse or at-risk drinking

17.6: Percentage of all suicides committed in 2003 by elderly (highest rate of all age groups in nation)

39,000: Number of licensed psychiatrists in United States in 2001

5,000: Number who list geriatric psychiatry among their three primary interests

2,360: Number who are actually certified in that subspecialty

4: Percentage of patients in community mental health centers who are elderly

2: Percentage of patients undergoing private psychiatric treatment who are elderly

8.5: Percentage of National Institutes of Health's aging research devoted to mental health

30: Percentage devoted to alternative medicine

Sources: National Institutes of Mental Health; American Psychology Foundation; American Journal of Psychiatry; National Center for Health Statistics; American Association for Geriatric Psychiatry

SIDEBAR

Big 3: dementia, anxiety, depression

Copley News Service

Aside from the physical ailments of old age, three psychiatric conditions dominate the lives of the mentally ill elderly.

-Dementia

This condition is characterized by confusion, memory loss and disorientation. It is not an inevitable part of growing old - only 15 percent of older Americans suffer from the condition - but it is devastating.

The most common and notorious form of dementia is Alzheimer's disease, which progressively destroys the parts of the brain controlling thought, memory and language.

Alzheimer's usually appears after age 60; the number of people afflicted doubles every five years beyond age 65, from about 5 percent of men and women ages 65 to 74 to nearly half for those 85 and older. Up to 4.5 million Americans suffer from it, and 1 million are severely affected. The cause is unknown; there is no cure. Alzheimer's is the fourth leading cause of death in the United States.

Initial symptoms, such as forgetfulness or trouble solving simple math problems, are mild. They worsen slowly, progressively. Late-stage Alzheimer's typically involves the inability to think or communicate coherently. Patients eventually lose the ability to take care of themselves.

Other than Alzheimer's, dementia may be caused by complications of chronic high blood pressure, blood vessel disease or a previous stroke. Deterioration occurs in steps rather than as a steady progression. Some diseases may include dementia as a consequence, such as Parkinson's disease, Huntington's disease and Creutzfeldt-Jakob disease.

Pseudodementias mimic the symptoms of dementia but can be quickly reversed with appropriate diagnosis and treatment. They may be caused by conflicting medications, poor nutrition or diseases that impinge oxygen supply to the brain.

- Anxiety

Until recently, it was widely believed that anxiety disorders decline with age. New research indicates otherwise, that psychiatric problems related to anxiety are just as common in the elderly as the young, though how and when they appear may be distinctly different.

Roughly 11 percent of adults ages 55 years and older suffer from anxiety, the symptoms of which include overwhelming feelings of panic and fear; uncontrollable obsessive thoughts; painful, intrusive memories; recurring nightmares; and nausea, sweating, muscle tension and other uncomfortable physical reactions.

Phobias are the most common anxiety ailment appearing late in life. There are three basic types:

1. Specific phobias are irrational, persistent fears of a specific object or situation.

2. Social anxiety disorder is the fear of being embarrassed or scorned in a public situation.

3. Agoraphobia is the fear of experiencing an anxiety attack in a place or situation where escape is difficult or embarrassing. In severe cases, agoraphobics may refuse to leave their homes.

Other anxiety disorders range from obsessive-compulsive behaviors to post-traumatic stress disorder.

- Depression

Depression in varying degrees affects up to 5 percent of all elderly. Some researchers believe the percentage is greater, that some elderly patients diagnosed with dementia may actually suffer from depression that, if treated, is reversible.

Depression in the elderly is frequently dismissed as simply "part of growing old." It is not, and in serious cases it can pose a significant health hazard in the elderly by exacerbating existing physical problems or boosting the risk of suicide.

Symptoms are diverse:

- Chronic feelings of worthlessness, hopelessness, inappropriate guilt, unexplained crying spells, jumpiness, irritability

- Loss of interest in formerly enjoyable activities, family, friends, sex or work

- Inexplicable memory loss; inability to concentrate; confusion; disorientation

- Thoughts of death or suicide; suicide attempts

- Loss of appetite or noticeable increase in appetite; insomnia or noticeable increase in sleep time; aches, pains, constipation or other physical ailments that cannot be explained

- Scott LaFee

SIDEBAR

Resources and aid on mental illness

Copley News Service

For more information on mental illness and the elderly, and where to find help, contact these sources:

- American Association for Geriatric Psychiatry

Geriatric Mental Health Foundation

7910 Woodmont Ave., Suite 1050

Bethesda, MD 20814

(301) 654-7850

www.gmhfonline.org

www.aagpgpa.org

- American Psychiatric Association

1000 Wilson Blvd.

Arlington, VA 22209-3901

(202) 682-6000

www.psych.org

- National Alliance for the Mentally Ill

200 N. Glebe Road, Suite 1015

Arlington, VA 22203-3754

(800) 950-6264

www.nami.org

-National Institutes of Mental Health

Information Resources and Inquiries Branch

5600 Fishers Lane, Room 7C-02

Rockville, MD 20857

FACTS ON DEMAND: (301) 443-5158

www.nimh.nih.gov

- National Mental Health Association

1021 Prince St.

Alexandria, VA 22314-2971

(800) 969-6642

www.nmha.org

-National Self-Help Clearinghouse

25 W. 43rd St.

New York, NY 10036

(212) 354-8525

www.selfhelpweb.org

Visit Copley News Service at www.copleynews.com.

LOAD-DATE: September 26, 2005