There can be little argument that the population of the United States is getting older. The United States Census Bureau (2012) reported 40.3 million people age 65 and older in the latest census of 2010. This represents 13% of the total population. This was up from 35 million in the 2000 census and 31.2 million in the 1990 census. Also in this same report was a projection of 88.5 million people age 65 and older by 2050.
This tremendous increase in “senior” Americans reflects the Baby Boomer generation aging. In fact, Baby Boomers are reaching their 65th birthday at the rate of 10,000 per day (Pew Research Center, 2010). Not only today, but every day for the next 19 years.
This increase becomes even more impactful when considering this is one Baby Boomer reaching age 65 every 10 seconds!
By the middle of the century, 2050, people age 65 and older will make up more than a fifth of the population of the U.S. (Williams, 2014). This is more than double the number in that age group today.
As would be expected, this population is in need of medical intervention more than the general population. Aging and its effects on the body lead to this need. Some researchers (Larsen & Martin, 1999) report people in the age range of 65 and older consume an average of two to six prescription and one to four non-prescription medications regularly. Possibly as many as two out of three of this population has at least one chronic illness. The Centers for Disease Control and Prevention (2012) provided a higher estimate than this. The CDC estimated 80% of older adults to have at least one chronic health condition and 50% to have two or more.
Not only are body functions affected by aging. Cognitive and emotional functions also fall prey to the aging process. The later years often bring on mental health problems for the first time in older people. According to Rollins (2008), Baby Boomers will largely ignore the past stigma associated with seeking help for emotional problems and will seek the therapy services they need to deal with the emotional aspects of aging.
But is the profession responsible for supplying the emotional therapy services this population needs? There is significant concern.
Prevalence of Mental Health Problems in Older Adults
There may be as many as 20% of adults age 65 and older in need of either mental health or substance abuse treatment or both. According to a report for the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2005 (Bartels, Blow, Brockmann, & Van Citters, 2005), the total number of older adults needing substance abuse treatment will more than double to 4.4 million in 2020. This same report estimated the number of older adults needing treatment for major psychiatric illnesses to also more than double to 15 million in the same time period.
According to Bartels and Naslund (2013), 5.6 million to 8 million older adults have mental health and/or substance abuse disorders. An estimate as high as 14.4 million has been made by the Institute of Medicine (2012).
The American Psychological Association reported approximately 20.4% of older adults had some type of mental disorder including dementia in 2011 (Karel, Gatz, & Smyer, 2012).
It is easy to see the impact of these types of problems in the elderly population. And this may be a conservative estimate.
Common Mental Health Problems and Symptoms in Older Adults
Many people unfortunately hold the opinion that getting older automatically means suffering from a mental health problem of some kind. But mental health disorders are not the norm in older adults. However, due to a number of factors, older adults do experience one or more of several mental health disorders.
The most common mental health problem among older adults is depression. According to the American Psychological Association (n.d.), up to 20% of older adults in the U.S. have reported depression. One of the major issues of importance in depression is its effect on other health issues that impact older adults. Depression can lower immune functioning and limit an older adult’s ability to fight off infection. Chronic illnesses and depression work in a negative cycle, each making the other more difficult for the elderly to handle. For example, older adults with heart disease have a higher incidence of depression. And depression affects the outcome of heart disease negatively.
What are the common symptoms of depression in older adults? In general, any of the following that persist for two weeks or more may indicate significant depression.
· Feelings of sadness or emptiness
· Continuing worries about finances, family, or physical health
· Difficulty sleeping or sleeping more than usual
· Inability to concentrate or becoming confused
· Difficulty eating or eating more than usual
· Increasing number of physical complaints
· Thoughts of self-harm or attempts to harm self
A very significant issue related to depression is the last of the indicators mentioned above. Depression is a major risk factor in suicide. Suicide deaths among those age 65 and older was 14.22 per 100,000 in 2006 (CDC, 2006). White men age 85 and older had a rate of 49.8 deaths by suicide that same year. This group is at the highest risk of suicide. In addition, the fatality rate for suicide attempts by older adults is greater than that of the general population by a great amount. One in four attempts by older adults is successful compared to one in twenty attempts for all other age groups.
Anxiety is frequently diagnosed in older adults, as well. It is the second most diagnosed mental health condition in older adults. The Geriatric Mental Health Foundation (2009) reported 10% to 20% of older adults are diagnosed with some form of anxiety disorder. The most commonly diagnosed anxiety disorders are:
· Phobias – an irrational fear of some place, thing, or event
· Social anxiety disorder – feeling overwhelming fear in social situations
· Generalized anxiety disorder – constant, irrational worry
· Post-traumatic stress disorder – a set of behaviors and fears resulting from trauma
· Obsessive-compulsive disorder – persistent, unwanted thoughts leading to self-imposed rituals to relieve anxiety
· Panic disorder – sudden attacks of terror
Alzheimer’s disease and dementia are also common disorders among older adults that fall into the category of mental health issues. These cognitive disorders may be changes that occur due to physical problems, but can manifest themselves in disordered behavior as well as a decrease in memory functions and difficulty in thinking clearly.
At the present time, estimates of 1 in 8 adults over the age of 65 have Alzheimer’s (Alzheimer’s Association, 2012). As the population continues to age, this number will of course increase.
Dementia patients often suffer from accompanying depression, anxiety, and paranoia. Possibly 10% of the population age 65 and older can be diagnosed with dementia (Jeste, Alexopoulos, Bartels, et al., 1999).
Barriers to Treatment
Perhaps the most significant barrier to treatment of the above mental health disorders and the added substance abuse disorders in older adults is the very significant lack of trained professionals (IOM, 2010). This lack of professionals is made more significant in that there are only 10-15 training programs offering specialty training in geropsychology. Certainly, this shortage will become more severe as the population continues aging.
The vast majority of adults age 65 and older with substance abuse and/or mental health problems don’t receive needed treatment (Bartels, Blow, Brockmann, & Van Citters, 2005). Reportedly, only about one-third of these adults living in the community receive needed mental health services. Those in nursing homes receive needed treatment even less frequently.
Another barrier to treatment for this population is the fact that older adults typically depend on their primary care physicians for help with the typical mental health problems. These very busy medical professionals do not have the time needed for adequate diagnosis and treatment of these issues. Unfortunately, there are quite a number of health care professionals who view older adults’ symptoms of depression as a normal part of aging (CDC, 2012). Thus, these health care professionals don’t see this depression as a condition in need of treatment.
Other barriers to treatment include inadequate insurance coverage. For example, Medicare and other insurance carriers may not cover treatment for mental health and substance abuse problems at the same rate as physical health problems. Fortunately, this disparity may be disappearing with current legislation.
Transportation problems may also play a part in the lack of sufficient health care. Many older adults no longer drive, so they depend on public transportation which may be sporadic, if it exists, in some rural areas. Or they depend on relatives to provide transportation to appointments. If there are multiple appointments over closely-spaced periods of time, this may become problematic.
Lack of coordination among health care professionals can also become a barrier. Communication among all those providers giving needed care to older adults is necessary. Especially in the case of these adults taking multiple medications from various providers. The interaction of these medications may have a very detrimental effect on older adults’ mental and physical health.
Denial is yet another barrier to obtaining needed services. Some older adults still hold on to the idea of weakness being behind mental health problems. Seeking professional help for these issues thus becomes mortifying. This becomes even more problematic when substance abuse issues become the focus of treatment.
Even with the overwhelming evidence behind the significant impact of substance abuse and mental health problems on older adults, these problems remain “invisible” to the majority of Americans.
In the general population, the prevailing myth seems to be that growing older and developing mental health problems is the norm. Such is not the normal state of older adults. In fact, many of those over 65 develop these kinds of problems for the first time because of other factors that come with the aging process. Many of those factors are physical. Considering up to 80% of older adults have at least one chronic health condition (CDC, 2012), this seems logical.
Unfortunately, part of the “invisible” nature of mental health problems in older adults also occurs with health professionals. Because older adults most often visit their primary care physicians for their physical and emotional care, and because these professionals do not have the time required for a thorough evaluation, seniors do not receive the care needed.
Also, there are too few trained professionals to provide the care for the increasing numbers of older adults needing it. The American Psychological Association (n.d.) reported only 4.2% of practicing psychologists claiming expertise in geropsychology as their primary focus of practice. Thirty-nine percent report treating senior adults.
Clearly, the ability to provide needed treatment for the growing population of senior adults is woefully lacking. A concerted effort to close the gap is desperately needed.
Alzheimer’s Association. (2012). Alzheimer’s Disease Facts and Figures. Retrieved from http://www.alz.org/utah/documents/2012_facts_and_figures.pdf.
American Psychological Association. (n.d.). Mental and behavioral health and older Americans. Retrieved from http://www.apa.org/about/gr/aging/mental-health.aspx.
Bartels, S.J., Blow, F.C., Brockmann, L.M., & Van Citters, A.D. (2005). Substance abuse and mental health among older Americans: the state of the knowledge and future directions. Substance Abuse and Mental Health Services Administration, Rockville, MD.
Bartels, S.J. & Naslund, J.A. (2013). The underside of the silver tsunami -- older adults and mental health care. N Engl J Med, 368: 493-496. doi:10.1056/NEJMp1211456.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2006). Web-based injury statistics query and reporting system. Retrieved from http://www.cdc.gov/ncipc/wisqars.
Centers for Disease Control and Prevention. (2012). Depression is not a normal part of growing older. Retrieved from http://www.ced.gov/aging/mentalhealth/depression.htm.
Geriatric Mental Health Foundation. (2009). Anxiety and older adults. Retrieved from http://www.gmhfonline.org/gmhf/consumer/factsheets/anxietyoldradult.html.
Institute of Medicine. (2012). The mental health and substance use workforce for older adults: in whose hands? Retrieved from http://www.iom.edu/Reports/2012/The-Mental-Health-and-Substance-Use-Workforce-for-Older-Adults.
Jeste, D.V., Alexopoulos, G.S., Bartels, S.J., et al. (1999). Consensus statement on the upcoming crisis in geriatric mental health: research agenda for the next 2 decades. Archives of General Psychiatry, 56(9),848-853.
Karel, M.J., Gatz, M., & Smyer, M.A. (2012). Aging and mental health in the decade ahead: what psychologists need to know. Am Psychol, 67(3):184-198. doi:10.1037/a0025393.
Larsen, P.D. & Martin, J.L. (1999). Polypharmacy and elderly patients. Retrieved from http://www.highbeam.com/doc/1G1-54216921.html.
Pew Research Center. (2010). Baby boomers retire. Retrieved from http://www.pewresearch.org/daily-number/baby-boomers-retire/
Rollins, J. (2008). The graying of the baby boomers. Retrieved from http://ct.counseling.org/2008/10/the-graying-of-the-baby-boomers/.
United States Census Bureau. (2012). Older Americans Month: May 2012. Retrieved from http://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/
Williams, T. (2014). Graying of America is speeding, report says. New York Times, May 6, 2014.