Uses of Psychology in the Healthcare of Older Adults

 

By Paula Hartman-Stein, Ph.D.

Congressional Briefing

May 18, 2000

 

Introduction

The year 2000 began the Decade of Behavior, following the Decade of the Brain, according to over 40 scientific societies (Gatz and Smyer, in press). Why? Because increasing evidence demonstrates conditions such as heart disease, stroke, chronic lung disease, obesity, diabetes, and unintentional injuries have a large proportion of their prevalence due to our behavior, not just our genetics. Behaviors make a major difference in our health and the cost of our healthcare. Examples are whether we smoke, eat a low fat diet, floss our teeth, adhere to medication directions, get flu shots, wear seat belts when driving, wear helmets when bicycling, and engage in any exercise at all.

How well we manage our anger, also a behavior over which we have control, is a major risk factor in heart diseases as well as "road-rage" related car accidents. How effectively we shrug off grudges and cope with the inevitable stress in our lives are among the most important factors in successful aging for those who reach the status of centenarian (Perls and Silver, 1999). The ability to self-quiet is essential for good mental health across the life span. Such behaviors not only influence our longevity but also the quality of our life in older age. Emotional hardiness is as important as physical hardiness in the prevention of disease.

My presentation today, on the uses of psychology in healthcare of older adults, will illustrate ways that behavioral health professionals help to change behavior and thereby reduce misery in the lives of older Americans, positively impact health and quality of life, and reduce healthcare costs.

 

Older Americans often need behavioral health services but do not receive them.

Most older adults who live independently in the community maintain social circles, have supportive friends and family, stay active, and have lower rates of most mental disorders than young adults (Cohen, 1992, Haley, in press). There are several recent books on successful aging (Rowe and Kahn, 1998), maximizing potential through age 100 (Perls and Silver, 1999), and learning how to become a sage as we age (Schachter-Shalomi and Miller, 1995). Such writings stress the possibilities of living vital, fulfilling lives through and beyond the ninth decade of life.

In spite of the fact that many older Americans lead vigorous lives, undiagnosed and untreated late life depression is a public health problem. For example, research shows that depression in people aged 65 years and older causes undue suffering to those who are undiagnosed and to their families (Lebowitz et al, 1997). Untreated depression is associated with excess disability in the older adult with chronic illness by impairing rehabilitation efforts that can lead to premature institutionalization (Lichtenberg, 1998).

On average 20 to 22% of older Americans meet the criteria for mental disorders (Gatz & Smyer, in press). Analysis of 1994 data reveals that 10.3% of older Americans who received healthcare services under Medicare had a mental disorder as a primary diagnosis with another 5% of claimants with mental health or substance abuse as secondary diagnoses (Larson et al, 1998).This would suggest that a substantial number of older Americans with psychological disorders/behavioral health problems are untreated.

 

Psychological problems are often missed in the general medical sector

 

Older adults who are treated for depression and other behavioral health disorders are likely to obtain this care through their primary care physician in the general medical sector (Gatz and Smyer, in press). Managed-Medicare plans stress the role of primary care physician as gatekeeper. The trend of the future is that psychologists and other mental health specialists need to work in the primary care setting in order to make a major impact on the mental health needs of larger numbers of older Americans.

Perhaps because depression may be a co-occurring condition with another chronic illness, physicians often miss signs of depression and even suicidal intent. Estimates are that between 70 to 75% of older adults who commit suicide had seen their physician within the past month, and a segment of these patient were seen in the last 24 hours (Carney, Rich, Burke, and Fowler, 1994).

 

Likewise, dementia is often missed, with one study indicating the absence of documentation in more than 75% of patients with moderate to severe impairment (Callahan, Hendric, and Tierney, 1995).

 

A public health goal for the future: Better detection of psychological problems

An increase of misery and lack of planning for future care needs are not the only reasons that undetected and untreated behavioral health problems are a public health concern. Untreated depression also raises medical costs. For example, a 1997 study (Unutzer et al) demonstrated that older adults with significant depressive symptoms use more medical services in managed care settings, after controlling for the severity of their chronic illnesses.

Other mental health problems such as anxiety and substance abuse impact older Americans’ ability to cope with chronic conditions common in older age such as arthritis, cardiac disease, Parkinson’s disease, cognitive impairment, and stroke.

 

How can behavioral interventions prevent medical problems and keep costs down?

Providing psychotherapy in a traditional way of weekly to 1 hour sessions is not likely to keep costs down. Resources are limited. In 1997 I attempted to get a collection of ideas together regarding innovative programs, approaches that are targeted toward meeting psychosocial needs of older Americans yet keeping costs down

 

  1. PACE (Program for All-inclusive Care of the Elderly (Miller, Miller, Mauser, and O’Malley, 1998). This is a Congressionally authorized demonstration program that has become a permanent part of the Medicare and Medicaid programs. This program is geared to keep indigent elderly out of nursing homes. Key features of PACE are the use of interdisciplinary teams and the interactions of primary care with center-based and in-home services. The PACE model began in 1971 with concern about the frail elderly in San Francisco’s China town. After 10 years of developing services under federal and state grants, On Lok associated with HCFA in 1983. The OBRA (1986) authorized the replication of this model. The program has grown over the years to 25 sites nationally. The program has been evaluated using outcome measures of use of health services, health and functional status, quality of life, and satisfaction of services.
  2.  

  3. Biodyne Bereavement Outreach & Counseling Program (Cummings, 1998)

Surviving spouses were contacted within 2-3 weeks of loss of a spouse. An outreach worker attempted to enroll the newly bereaved spouse into a psychosocial program consisting of 14 group sessions over 6 months. The program emphasized self-efficacy, defeating learned helplessness, and restoring a sense of coherence and meaning to actions and life in general.

The medical care utilization of participants vs a wait list control revealed that the contrast group’s medical care use was double that of the Bereavement program group for the first year after the spouse’s death. In the second year after the death, the contrast group’s use of medical services remained 40% higher. For the 2 years, the amount saved was $1400 per patient. This translates to several million dollars when extrapolated to the older adult population covered by that health plan.

 

 

Do psychological interventions work with older Americans?

 

Case studies

  1. Cognitive evaluation and one couples’ therapy session for an 81 year old man with memory loss and alcohol abuse.
  2. Alexandra, a 74 year old woman of Hungarian descent, with severe depression following knee replacement and open heart surgery. Her Primary care physician pushed her to consider psychotherapy because anti-depression medication had proven ineffective. She was non-compliant with physical therapy efforts and had gained 50 pounds since the surgery. She voiced self-deprecatory thoughts and feelings of complete worthlessness. Her life had no meaning. Her depression was significantly reduced after 7 treatment sessions over six months(Hartman-Stein, 1999).
  3. Sonya, an 82 year old woman with multiple somatic complaints and excessive utilization of medical services responded well to group therapy (10 sessions), 2 sessions with her daughter, and 4 individual treatment sessions (Hartman-Stein, 2000).

 

 

Solutions:

  1. More training for primary care medical staff and mental health professionals to aid in detection and treatment of behavioral disorders of older Americans in the primary care setting, wellness programs, and in senior centers.
  2. We need money for demonstration research so that mental health professionals can learn what are the most cost-effective strategies. There is a proposal whereby the House Subcommittee wants to cut the Title IV program of Research and Training by $22 million. If that occurs, there will be significantly less effort into learning what the most effective/efficient strategies are for different segments of older adults.
  3. Development of innovative approaches for delivering behavioral health services and preventive programs.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REFERENCES

Callahan, C.M., Hendric, H.C., and Tierney, W.M, (1995) Documentation and evaluation of cognitive impairment in elderly primary care patients. Annals of Internal Medicine, 122, (6) 422-429.

Carney, S.S., Rich, C.L., Burke, P.A., Fowler, R.C. (1994, February) Suicide over 60: the San Diego study. Journal of the American Geriatrics Society, 42, (2) 174-80.

Cummings, N.A. (1998). Approaches to preventive care. In P.E. Hartman-Stein (Ed.), Innovative Behavioral Healthcare for Older Adults: A Guidebook for Changing Times (pp. 1-17). San Francisco, CA: Jossey-Bass.

Gatz, M., and Smyer, M.A. (in press). Mental health and aging at the outset of the twenty-first century. In J.E Birren and K.W. Schaie (Eds.) Handbook of Psychology and Aging: 5th Edition. San Diego: Academic Press.

Haley, W.E., (in press) Serving the elderly: psychology in primary care. In R. Frank, S. McDaniel, J.Bray, & M. Heldring (Eds.), Psychology in Primary Care, Washington, D.C.: American Psychological Association Press.

 

Hartman-Stein, P.E. (1999). Adapting to managed behavioral healthcare for older adults: A practitioner’s perspective. Journal of Geriatric Psychiatry, 22, 43-61.

Hartman-Stein, P.E. (2000). Medicare: The case of Sonya. In N. Cummings and J. Cummings (Eds.) The Essence of Psychotherapy: Reinventing the Art in the Era of Data, New York: Harcourt Brace.

Hartman-Stein, P.E. (Ed.)(1998). Innovative Behavioral Healthcare for Older Adults: A Guidebook for Changing Times. San Francisco, CA: Jossey-Bass Inc., Publishers

 

Larson, M.J., Farrelly, M.C., Hodgkin, D., Miller, K., Lubalin, J.S., Witt, E., McQuay, L., Simpson, J., Pepitone, A., Keme, A., and Manderscheid, R.W. (1998 ). Payments and use of services for mental health, alcohol, and other drug abuse disorders: Estimates from Medicare, Medicaid, and private health plans. In R.W. Manderscheid. and M.J. Henderson, (Eds.) Mental Health, United States, 1998. Rockville, MD: U.S. Department of Health and Human Services, Center for Mental Health Services.

Lebowitz, B.D., Pearson, J.L., Schneider, L.S., Reynolds, C.F., Alexopoulos, G.S., Bruce, M.L., Conwell, Y., Katz, I.R., Meyers, B.S., Morrison, M.F., Mossey, J., Niederhe, G., and Parmelee, P. (1997, October) Diagnosis and treatment of depression in late life. Journal of the American Medical Association, 278, (14) 1186-1190.

Lichtenberg, P.A. (1998). Mental Health Practice in Geriatric Health Care Settings. New York: Haworth Press.

Miller, S.N., Miller, N.A., Mauser, E., & O’Malley, K. (1998). PACE: Innovative care for the frail older adult. In P.E. Hartman-Stein (Ed.), Innovative Behavioral Healthcare for Older Adults: A Guidebook for Changing Times (p 13-39). San Francisco CA: Jossey-Bass.

Perls, T. T. & Silver, M. H. (1999). Living to 100: Lessons in living to your maximum potential at any age. New York: Basic Books.

Reynolds, C. F., Frank, E., Perel, J.M., Imber, S.D., Cornes, C., Miller, M.D., Mazumdar, S., Houck, P.R., Dew, M.A., Stack, J.A., Pollock, B.G., & Kupfer, D.J. (1999). Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: A randomized controlled trial in patients older than 59 years. Journal of the American Medical Association, 281, 39-45.

Schachter-Shalomi, Z., and Miller, R.S. (1995). From Age-ing to Sage-ing. New York NY: Warner Books, Inc.

Unutzer, J., Patrick, D.L., Simon, G., Grembowski, D., Walker, E., Rutter, C., and Katon, W. (1997). Depressive symptoms and the cost of health services in HMO patients aged 65 years and older: a 4-year prospective study. Journal of the American Medical Association, 277, 1618-1623.

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