Our nation’s population is rapidly aging. According to the U.S. Census Bureau, by 2030 all members of the Baby Boom generation will have reached or surpassed 65 years of age, and the population of older adults will outnumber children for the first time in our nation’s history (United States Census Bureau, 2018). It is commonly known the “Golden Years” pose unique social, medical, financial and environmental challenges to those who have been fortunate enough to achieve such longevity. These challenges are often compounded for individuals with serious mental illness (SMI) and related behavioral health concerns for whom the aging process is anything but golden. Those with SMI between the ages of 55 and 64 are four times more likely to die as individuals without SMI (Olfson, Gerhard, Huang, Crystal & Stroup, 2015). This fact, as much as any other, illustrates the plight of these individuals. It should also serve as a clarion call to health and behavioral healthcare providers who aim to alleviate suffering and to improve the quality of life for members of this population.
A comprehensive analysis of integrated care for older adults with SMI revealed deficiencies within our existing systems of care along with potential opportunities for improvement that must be explored lest we fail to address a looming mental health crisis among our aging citizens. Comorbid physical health conditions are common among individuals with SMI, and the incidence of comorbidity rises rapidly during the aging process (Divo, Martinez & Mannino, 2014). Nevertheless, authors of the aforementioned analysis found most Evidenced-Based Practices (EBPs) applicable to older adults to address components of their mental or physical health, but few address both in a concurrent or coordinated fashion (Bartels, DiMilia, Fortuna & Naslund, 2017). Aging individuals – and especially those with SMI – frequently experience potentially preventable Emergency Department (ED) and inpatient hospital encounters, and a dearth of coordinated, whole-health interventions is bound to perpetuate this unfortunate trend. Nevertheless, various healthcare reform initiatives of the past decade have recognized integrated and coordinated care are integral to the achievement of desired outcomes among vulnerable populations, and Bartels et al. (2017) have identified some promising approaches specifically targeted to older individuals with SMI.
The Health and Recovery Peer (HARP) program (not to be confused with a Medicaid Managed Care product line of the same acronym) is an illness self-management program derived from the Chronic Disease Self-Management Program (CDSMP) and calibrated to the needs of older individuals with SMI (Druss et al., 2010). This program deploys peer specialists to guide participants through sessions that incorporate elements of exercise and physical activity, symptom management, nutrition, medication management and principles of effective collaboration with primary care physicians. Participants proceed in stepwise fashion and are encouraged to develop short-term goals related to positive behavioral change. This program has produced favorable outcomes among its participants who reported greater perceived ability to manage their illnesses, improved medication adherence and use of primary care services, and enhanced quality of life (Druss et al., 2010). The Targeted Training in Illness Management (TTIM) program is another peer-facilitated initiative designed specifically for adults with SMI and comorbid diabetes (Sajatovic et al., 2017). Diabetes Mellitus is a chronic condition that afflicts approximately 6% of the population, but its incidence is considerably greater among individuals with SMI (Medved, Jovanovic & Knapic, 2009). Thus, interventions that target this comorbidity are of special importance to this cohort. TTIM bears some resemblance to the HARP program inasmuch as it addresses medication management, nutrition, exercise, substance use, socialization and the development of problem-solving and personal empowerment skills, among others. It, too, has produced favorable results among participants who evidenced overall improvements in their psychiatric symptoms and enhanced knowledge of diabetes (Sajatovic et al., 2017). Other approaches that have demonstrated promise for older individuals with SMI incorporate elements of the Collaborative Care Model (CCM) through which primary and behavioral healthcare services are delivered in the same setting(s) (Pallavi et al., 2017). These approaches promote both service coordination and access for their recipients, and the latter benefit is especially important to older adults with SMI, many of whom cannot navigate the logistical challenge of coordinating multiple appointments with both primary and behavioral healthcare providers. Technological innovations such as Telehealth (and Telemental health), biometrics and social media, among others, have enabled many individuals, especially older adults of limited mobility, to access health and social services from the relative comfort of their homes (Bartels et al., 2017). These advances may permit seniors to enjoy longer periods of independence and community tenure than would otherwise be possible for them.
Notwithstanding the potential of the foregoing practices to improve the health of their beneficiaries, few of them address Social Determinants of Health (SDoH) in a systematic or comprehensive manner. SDoH include such constituents of health as safe and stable housing, food and income security, and access to social and emotional supports, among many others (Centers for Disease Control and Prevention, 2019). These constituents often elude individuals with SMI for whom widespread unemployment and other significant life challenges lead to chronic poverty and its attendant ills. These challenges are especially pronounced for many older adults whose diminishing social networks and increasing reliance on fixed (and limited) incomes produce heightened stress and dissatisfaction. In addition, older adults, including those with SMI, are vulnerable to the existential crises that afflict other generations and must be successfully navigated in order to achieve optimal health and fulfillment. In other words, these crises are not the sole province of the aggrieved adolescent or the middle-aged man. Older adults who cultivate a sense of meaning that locates their lives in a broader context and transcends their daily challenges are more likely to experience enduring health and fulfillment (Graham, 2017). This is not to suggest we must become practitioners of logotherapy in the tradition of Viktor Frankl, nor should we expect our seniors to divine a definitive meaning of life in order to find happiness. We must simply recognize they, like most of us, aspire to something more than an absence of infirmity. They desire the presence of purpose and all it entails.
Interventions that aim to promote health and to mitigate suffering among older adults with SMI must effectively address chronic and comorbid conditions unique to this cohort. They must also address other impediments to enduring health and satisfaction common to all. Comprehensive, whole-health orientations that explore the medical, emotional, psychosocial, environmental and spiritual underpinnings of wellness are essential to the welfare of their beneficiaries. Our seniors deserve nothing less.
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