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GERIATRIC MENTAL HEALTH 101 A Presentation By Michael B. Friedman, LMSW Chairperson The Geriatric Mental Health Alliance of New York Why Geriatric Mental Health Is Important Mental Disorders Are a Major Impediment to Living Well in Old Age.

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geriatric mental health 101


A Presentation


Michael B. Friedman, LMSW


The Geriatric Mental Health Alliance of

New York

why geriatric mental health is important
Why Geriatric Mental Health Is Important
  • Mental Disorders Are a Major Impediment to Living Well in Old Age.
    • “Losing one’s mind” or getting Alzheimer’s disease is a major fear about aging
    • Mental illness has a terrible impact on health
    • Depression and anxiety are major contributors to social isolation and high suicide rates
importance of geriatric mental health cont
Importance of Geriatric Mental Health (Cont.)
  • Mental and behavioral disorders of older adults and/or family caregivers are major contributors to unnecessary placement in institutions.
  • Most mental disorders are treatable.
why geriatric mental health is often neglected in practice and in policy
Why Geriatric Mental Health is Often Neglected in Practice and in Policy
  • Ageism
    • Belief that mental illness — especially depression — is normal in old age
  • Stigma
    • Shame about being mentally ill
  • Ignorance
    • About mental illness
    • About effectiveness of treatment
    • About where to get help

The Population of People 65 + In The US Will Double from 35-70 Million Over the Next 25 Years

Source: U.S. Bureau of the Census. (2000). Population projections of the United States by age, sex, race and hispanic origin: 1995- 2050, Current Population Reports, P25-1130.



  • Increase from 13-20% of the population
  • 5% decline of working age adults
  • Adults age 85 and over will more than double
  • Majority of older adults will be ages 65-74
  • Minority population of elderly population will grow from 16% to 25%


  • Disproportionate increase in ages 80+


Sources: U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General (Rockville, MD: 1999).

U.S. Bureau of the Census. (2000). Population projections of the United States by age, sex, race and hispanic origin: 1995-2050, Current Population Reports, P25-1130.


Prevalence Varies By Age

Adults 18-54

Older Adults 55+

* This does not include minor depression. 25-30% of older adults have symptoms of depression.

NOTE: These figures represent the prevalence of mental disorders in a 1-year period.

NOTE: The percentages do not add up to 100% due to co-occurring disorders.

Source: U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General (Rockville, MD: 1999).

heterogeneous population
Heterogeneous Population
  • Long-term psychiatric disabilities
  • Late life psychotic conditions
  • Dementia
  • Severe anxiety, depressive, and paranoia
  • Less severe anxiety and mood disorders
  • Addictive disorders: lifelong and late life
  • Emotional problems related to aging

Long-Term Psychiatric Disabilities

  • Usually develop prior to 30; some in late life
  • Diagnoses include:
    • Schizophrenia
    • Treatment refractory mood disorders
  • Involve severe functional impairment
  • Some people experience recovery over time
  • High risk for obesity, hypertension, diabetes, heart and pulmonary conditions
  • High rates of suicide and accidents
  • Premature mortality: 10 TO 25 YEARS
treatment of long term psychiatric disabilities
Treatment of Long-Term Psychiatric Disabilities
  • Service Needs
    • Atypical Anti-Psychotic Medications
      • Effective but
      • Side effects include obesity and diabetes
    • Stable housing
    • Rehabilitation
    • “Wellness” and Healthcare

Late Life Psychotic Conditions

  • Major thought and/or perceptual disorders such as hallucinations and/or delusions
  • Difficulty grasping reality
  • Functional impairment
  • Transient, recurrent, or long-term
  • SPMI Look-alikes
treatment of psychotic disorders
Treatment Of Psychotic Disorders
  • Inpatient and Outpatient Treatment
  • Medication
  • Supportive Psychotherapy
  • Day Programs
  • Social Supports: in-home care, case management, housing/residential care, relationships, and activities


  • Alzheimer’s disease: most common form (70%)
  • Memory loss + reduced cognitive functioning
  • Progressive decline
  • Depression and/or anxiety are common during early and mid phases

Prevalence of Dementia Doubles Every 5 Years Beginning at 60

Sources: U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General (Rockville, MD: 1999).

Cummings, Jeffrey L. and Jeste, Dilip V. (1999) Alzheimer’s Disease and Its Management in the Year 2010. Psychiatric Services.

50:9, 1173-1177

treatment of dementia
Treatment of Dementia
  • Early and differential diagnosis is critical.
  • New medications slow deterioration due to dementia.
  • Anxiety and/or depression are commonplace in early and mid stages.
  • Effective treatment of depression can improve cognitive functioning.
  • Support for family caregivers helps them and delays nursing home placement.

Major Depression

  • Not just sadness
  • Cardinal symptoms: Deep sadness with sense of hopelessness or loss of interest and pleasure in life
  • Other symptoms:
    • Changes in patterns of sleep, eating, or activity,
    • Difficulty concentrating
    • Frequent thoughts of death or suicide,
    • Low sense of self-worth
  • Need 5 in total
prevalence of depression
Prevalence of Depression
  • Major depression: 5%
  • Minor depression: 10%
  • Symptoms of depression: 25-30%
  • Higher rates of major depression among younger cohorts: 7%



treatment of depression
Treatment of Depression

Strong evidence-base for

  • Screening, such as PHQ-9
  • Anti-Depressant Medications
  • Psychotherapy
    • Cognitive-behavioral
    • Problem-solving
    • Interpersonal
  • Psychosocial Interventions, e.g. care management, exercise, activity, relationships, dealing with real life problems such as finding appropriate housing

Older Adults Complete Suicide Nearly 50% More Than the General Population

Source:Mortality Reports. National Center for Injury Prevention and Control. Centers for Disease Control and Prevention.


White Males 85+ Complete Suicide

Nearly 6x the General Population

Note: Suicide among Am Indian/AK Native population at 80 years and above is virtually non-existent.

Source: “Mortality Reports.” National Center for Injury Prevention and Control. Centers for Disease Control and Prevention,


Suicide Prevention

  • Identification of risk by “Gatekeepers”
    • Primary care physicians
    • Home health providers
    • Social service workers
    • People in the neighborhood
  • Outreach to those at risk
  • Depression treatment and care management
  • Public education


  • Prevalence: 11-12% (most common mental disorder)
  • Ranges from extreme “worry-warts” to extreme suspiciousness to those too frightened to leave home
  • Consensus regarding effectiveness of:
    • Medications
    • Psychotherapy
      • Cognitive-behavioral therapy
      • Problem-solving therapy
    • Psychosocial Interventions
addictive disorders
Addictive disorders
  • 17% have substance use problems
  • Lifelong vs. Late life
  • Very few heavy, lifelong alcohol or illegal drug abusers survive into old age
  • Methadone
  • Gambling
treatment of addictive disorders
Treatment of Addictive Disorders
  • Screening, esp. in primary care
  • Brief motivational or cognitive-behavioral therapies: non-confrontational
  • Medications: e.g. naltrexone, acamprosate, buprenorphine
  • Detoxification: Outpatient/Inpatient
  • Rehabilitation: Community-based or residential
  • Mutual aid/self-help: e.g. AA
emotional challenges adjusting to old age
Emotional Challenges: Adjusting to Old Age
  • Role changes: e.g. retirement
  • Loss of status
  • Diminished (but not lost) physical and mental skills
  • Losses of family and friends
  • Confronting death

Coping With Transition

  • Planning for retirement
  • Meaningful activities (paid or volunteer work, physical or creative activities)
  • Relationships (family, friends, intimate—including sexual—relationships)
  • Spiritual matters
  • Get help when needed
    • Homecare
    • Elder care
    • Assisted living and lifecare communities

Behavioral Problems Often Lead to Institutionalization

  • Distrust/paranoia,
  • Rejection of help
  • Non-adherence to treatment
  • Belligerence/abusiveness,
  • Dangerous Behaviors: e.g. Leaving stove on, smoking in bed
  • Hoarding
  • Wandering
  • Annoying behavior: e.g. frequent complaints, repetitive questions
treatment of behavior problems
Treatment of Behavior Problems
  • Very careful use of psychotropic medications
  • Skilled, humane interaction
  • Respect for clients as human beings
  • Effort to understand client’s motivation
  • Careful listening
  • Time and patience
  • Design of living settings to encourage alternatives to wandering or to doing nothing
only 40 45 of older adults with a mental or substance use disorder get treatment
Only 40-45% of older adults with a mental or substance use disorder get treatment
  • More than 20% of older adults have a diagnosable mental or substance abuse disorder
  • 40-45% get treatment

Treatment of Mental Illness

  • Among Older Adults

Source: U.S. Department of Health and Human Services, Older Adults and Mental Health: Issues and Opportunities (Rockville, MD: 2001).

low utilization of mental health professionals
Low Utilization of Mental Health Professionals
  • More than half of those who get treatment get it from primary care physicians: 12.7% minimally adequate treatment
  • Fewer than 25% get treatment from mental health professionals: 48.3% minimally adequate treatment

Vast shortage of geriatric mental health professionals, now and in the future.

Sources: Halpain, Maureen al. (1999). Training in Geriatric Mental Health: Needs and Strategies. Psychiatric Services. 50:9, 1205-1208.

Jeste, Dilip V. et al. (1999). Consensus Statement on the Upcoming Crisis in Geriatric Mental Health. Archives of General Psychiatry, 56, 848-853.

thanks to family caregivers the vast majority of older adults live in the community
Thanks to Family Caregivers The Vast Majority of Older Adults Live in the Community
  • 92% of geriatric patients/older adults live in the community
    • Most are not disabled
  • 80% of disabled older adults are cared for by family caregivers
    • High risk of stress, depression, anxiety and physical illness
  • The national economic value of informal caregiving was $196 billion in 1997. ($360 billion in current dollars)
  • Family as workforce

Support of Family Caregivers Reduces Their Mental and Physical Problems and Delays Placement in Nursing Homes

  • Mittelman Model
    • Counseling
    • Family Counseling
    • Support Groups
    • Responsiveness to CRISIS
  • Respite
  • Psycho-education for caregivers
  • Elder care managers
  • Financial support such as tax relief
co morbidities are virtually universal
Co-Morbidities Are Virtually Universal
  • Most older adults have chronic physical conditions, including those with mental disorders.
  • People with serious mental illness are:
    • At high risk of obesity, hypertension, diabetes, cardiac, and respiratory problems
    • Have 10-25 years lower life expectancy.
co morbidities are virtually universal cont
Co-Morbidities are Virtually Universal (cont.)
  • People with serious chronic health conditions (such as diabetes, heart disease, and neuromuscular disorders) are at high risk of anxiety and/or depression which increase disability, mortality, and health care costs.

Integrating Mental Health into Primary Care

  • Well-trained primary care providers
  • Co-location
  • Integrated teams
  • Disease/care management (e.g. Impact, Prism-E, Prospect, and Respect-D.)
  • Telepsychiatry (using telephone or video conferencing for consultation, assessment, or treatment)

Integrating Health Into Mental Health

  • Health care in mental health clinics
  • Health satellites in mental health programs
  • Special health clinics for people with mental illness and/or substance abuse disorders
  • Formal or informal networks
  • Disease management
  • Wellness and self-management
integrating mental health into long term care
Integrating Mental Health into Long-Term Care
  • Specialized home health care
  • Specialized adult medical day care
  • Improved mental health services in adult homes and nursing homes

Integrating Mental Health And Aging Services

  • Community Gatekeepers
  • Screening in senior centers, NORCs, social adult day programs, and case management
  • Neighborhood-based networks (formal or informal)
  • On-site treatment services in community settings
  • Activity and socialization promote mental health
how you can help direct service
How YOU Can Help: Direct Service
  • Get trained
  • Provide outreach and public education
  • Use screening, assessment, and treatment model
  • Provide home and community-based services
  • Develop working relationships across systems—especially informally
  • Learn how to get the most out of current funding streams (especially Medicare)
how you can help local systems
How YOU Can Help: Local Systems
  • Develop cross-system “coalitions” or “alliances”
    • Local planning
    • Collaborative program development
  • Establish cross-systems networks to handle tough cases, especially with APS
  • Develop initiative to optimize funding




(212) 614-5751