The Changing Tide of Geriatric Mental Healthcare

In an introduction to September/October 2015 issue of Harvard Review of Psychiatry, James Ellison, MD, MPH, the Swank Foundation Endowed Chair in Memory Care and Geriatrics at Christiana Care Health Systems and Brent Forester, MD, MSc, Chief of the Division of Geriatric Psychiatry and Director of the Geriatric Mood Disorders Research Program at McLean Hospital, write that changes in mental health care are being driven by the increasingly aging United States population, new diagnostic criteria, and novel healthcare policy initiatives, among other factors.

“Both workforce shortages and fiscal pressures have presented obstacles to caring for the behavioral needs of our elderly,” wrote Drs. Ellison and Forester, in the special issue of Harvard Review of Psychiatry, which provides an update on the trends and developments that are leading to new directions in mental healthcare for older patients.

With older adults now making up 13% of the US population, geriatric psychiatry has transformed drastically as a field in recent years. The Affordable Care Act has also affected the field, with the introduction of measures meant to integrate behavioral health treatment into primary care settings in the hopes of increasing the availability and effectiveness of mental healthcare.

Seven papers makes up the special September/October issue of the journal, written by noted experts who discuss these policy changes, new diagnostic classifications, and the latest research behind recent changes in the mental healthcare of the elderly. The topics discussed are:

• Changes in the healthcare landscape, including nine key initiatives— (1) accountable care organizations, (2) patient-centered medical homes, (3) Medicaid-financed specialty health homes, (4) hospital readmission and health care transitions initiatives, (5) the Medicare annual wellness visit, (6) quality standards and associated incentives, (7) support for health information technology and telehealth, (8) Independence at Home and the 1915(i) State Plan Home and Community-Based Services program, and (9) the Medicare-Medicaid Coordination Office, Center for Medicare and Medicaid Innovation, and Patient-Centered Outcomes Research Institute—that represent opportunities for assessing and treating older adults with mental health disorders, as well as for funding outcomes-based research. Emerging technologies such as telehealth, smartphone health apps, and social media may provide new approaches to improving outcomes while reducing costs.
• New diagnostic criteria, based on the recently revised DSM-5. These include the new diagnosis of hoarding disorder; a newly defined category of neurocognitive disorders that includes major neurocognitive disorder (replacing the term dementia), mild neurocognitive disorder, (replacing mild cognitive impairment), and delirium; and other diagnostic criteria changes that will increase the accuracy of assessment of common mood disorders.
• Age-related differences in the prevalence and characteristics of anxiety disorders. These symptom differences—along with the effects of accompanying medical disorders—may contribute to the challenges of assessing anxiety in older adults.
• New approaches to the problem of depression in later life. A palliative care approach has gained increasing support among caregivers who treat terminal disorders in the elderly. Instead of emphasizing the aggressive search for curative treatments, palliative care prioritizes quality of life, a change in focus that often leads to longer survival as well as greater comfort.
• The many and varied causes of psychosis—often related to underlying medical or neurological conditions. New evidence on the appropriate use of antipsychotic medications in older patients with neurocognitive, psychotic, or mood disorders is summarized as well.
• An in-depth focus on the new DSM-5 category of mild neurocognitive disorder. While more research is needed to clarify this new diagnostic category, it reflects the growing emphasis on early recognition and treatment of cognitive impairment.
• Management of behavior changes and neuropsychiatric symptoms in older adults with Alzheimer’s disease or other neurocognitive disorders. Alternatives to antipsychotic medications, including nondrug approaches, may provide urgently needed new treatments.