There are a variety of behavioral health issues that negatively impact the quality of life of the elderly population in this country. Issues such as depression and anxiety were exacerbated by the isolation and stress caused by the COVID-19 pandemic. Diagnosis can also prove to be challenging because the elderly generation is less likely to seek help when help is needed. They tend to suffer in silence. Add to that a critical shortage of medical providers who specialize in elder patient care, or providers that are not well-trained to the unique needs of an older person, and it becomes clear that there is a desperate need for more investment, training and awareness.
“Access to behavioral health services for older adults is difficult to come by,” said Lynette Killen, the Executive Director of The Sarah Ralston Foundation, a non-profit foundation that funds organizations that serve the aging population in Philadelphia County. “The supply of geriatric-trained and educated providers is woefully low,” she said. “This has been an ongoing problem for this field. Not many people are drawn to caring for the elderly.” The lack of access to care and the shortage of properly trained providers means that behavioral health issues will continue to plague the elder population. When left untreated, symptoms may worsen, lead to medical issues, poor decision making, and diminished quality of life.
The medical community agrees and many mental health providers currently working in the field have been sounding the warning bell. Dr. Jerry Skillings is the Chief Services Officer of Behavioral Health and Homeless Services of Horizon House, a behavioral healthcare center in Philadelphia. Dr. Skillings noted how difficult it is to retain qualified providers: “The exit of licensed staff for more money offered by for-profits is an issue for non-profit providers who cannot afford higher salaries,” he said. Dr. Daniel Weintraub, MD, is Professor of Psychiatry and a geriatric psychiatrist at the University of Pennsylvania School of Medicine and specializes in psychiatry for individuals diagnosed with Parkinson’s disease. He accurately summed up the issue: “Relatively lower pay in a field less popular than other medical specialties tells the story of why there is a dearth of geriatric psychiatrists.”
In addition to a shortage of qualified providers, many who currently operate in the field lack proper training and experience. They are well-intentioned, but inadequate training frequently results in underdiagnosis/misdiagnosis, along with under-researched and ineffective medication treatments. Geriatric psychiatrist Dr. Jenny Paola Rodriquez Alzate, Assistant Professor of Psychiatry, University of Pennsylvania noted that general psychiatrists and primary care physicians who treat the younger population also treat older adults with a one-size-fits-all approach. “Medication management, for both OTC and prescription drugs is difficult for providers who are not educated about the metabolic differences in an older adult,” she said. Dr. Rodriquez’s point speaks to another underlying issue. Providers are only as good as the information that they’re privy to, and the drugs that are prescribed oftentimes have limited research backing them up. Drug companies wary of risk will sometimes avoid testing pipeline drugs on elders. Or worse, they simply ignore the category altogether and don’t target this segment of the population. Participation for older adults in clinical trials is only just starting to open up as a more accepted practice.
The challenges in diagnosing elder-specific mental health issues make treating the underlying problem more difficult. For instance, diagnosing co-occurring issues can be especially complicated. “In addition to depression and anxiety, substance abuse is also a problem in the population,” said Dr. Rodriquez. Dr. Weintraub commented that, “Some patients who are dealing with issues such as confusion might also be suffering from anxiety and/or depression.” Increased longevity means we have an expanding elderly population, which has produced a startling increase in neurodegenerative diseases that have both physical and cognitive implications.
There are other contributing factors that make diagnosis and treatment a challenge. “Elders, especially in the Greatest Generation (born 1901-1927) and the upper age of the Baby Boomers, often do not seek help – ever – or only when in an acute crisis,” Killen said. Behavioral health care has not historically been offered to elders as an important part of their treatment package, so many are unaware of it. “Some elders are of the mind that they must pull themselves up by their bootstraps, or fear being labeled as ‘crazy’,” Killen pointed out. It can sometimes be a simple transportation issue or a more serious issue of neighborhood violence that stands in the way of treatment.
Robin Goldberg-Glen, Associate Professor, Ph.D., AM, of Widener University, Center for Social Work Education, commented on how older adults’ vulnerability during the pandemic exacerbated their fear and anxiety. She noted that these reactions have not abated. “For numerous older adults, COVID served as an incubator for loss, anxiety, and fear that increased their experience of isolation and loneliness, which has continued into the post-pandemic stage. Loss of loved ones and a reluctance to resume their outdoor routines due to concerns about contracting the virus have furthered the experience of isolation and loneliness. In contrast, other older adults have recognized their resilience and ability to handle the stressors of a national health problem independently.” She stressed the importance of addressing concerns, strengths and providing continued support.
Dr. Jerry Skillings noted, “One unexpected but welcome COVID outcome was the boom of telehealth medicine as a permanent model.” He also noted that some government funded programs targeted to help with this issue that stopped running during COVID are starting up once again.
The situation is admittedly grim, but there are solutions being proposed that offer hope. Multi-pronged treatments that combine pharmacological interventions, talk therapy and socialization can be highly effective. “Having a case manager and access to socialization – such as senior/community centers, can improve quality of life,” Dr. Rodriguez said. For many older adults in Philadelphia, their connection to their church or synagogue can be a lifeline. A priest, pastor or rabbi can serve a de facto counselor role by simply listening, or sometimes encouraging older members of their congregation to take action and seek treatment when necessary.
“My hope is that organizations that treat our elders hire and/or train staff around the behavioral health issues, so they are better equipped to treat those who are in need of help,” Killen said. “Hopefully they can then offer services and treatments that don’t play into the old stereotype that it’s taboo to seek help. We need more free or reduced care, because insurance companies often don’t reimburse 100% or at all for these services. Because it’s often private pay/out-of-pocket, it would be ideal if services could be offered at a rate that’s affordable for the low-income portion of our elderly population,” she said.
Addressing behavioral issues is a focus area of the Sarah Ralston Foundation. “Our hope is to support organizations that offer behavioral and mental health services for the elderly,” said Killen. Information about The Sarah Ralston Foundation and the grants they provide can be found on their website at www.sarahralstonfoundation.org.