Time to Confront the Challenges of an Aging America

America is aging rapidly.¹ Over the next few decades, the proportion of adults 65 and older will come to exceed the proportion of children under 18 – an historic first.² And as the number of older adults grows from approximately 56 million at the beginning of this decade to 85 million in 2050,³ so will the number of older adults with cognitive impairment, mental and/or substance use disorders, and autism or other developmental disabilities.^* Unless there are long hoped for breakthroughs in treatment and prevention, the number of older people with diagnosable mental disorders in the United States will grow from about 11 million in 2020 to about 17 million in 2050.⁴ The number of older people who misuse alcohol and other drugs will grow from a bit over 2 million to 3.5 million.⁵ And the number of older people with dementia will grow from about 7 million today to 13 million in 2050,⁶ most of whom will have co-occurring behavioral health conditions during the time that they have dementia.⁷

Despite decades of demographic and epidemiological warnings and some efforts to respond, America is still not adequately prepared to meet the challenges of supporting mental well-being in older adults. Current services are dysfunctionally fragmented. Many older people are not able to live where they would like to live, whether in a family home or a retirement community. People with cognitive impairment living in the community have a range of unmet needs, including “neuropsychiatric behavior management and caregiver support.⁸ Those living in nursing homes and assisted living facilities often get inadequate treatment for cognitive and behavioral health disorders.⁹ Fewer than half of older adults with mental or substance use disorders get any treatment at all¹⁰ because of limited-service capacity and access. As a result, treatment for mental illnesses is too often provided by primary care physicians without adequate training or by mental health professionals without geriatric expertise.¹¹ Only about 1 in 3 people who get treatment get even “minimally adequate treatment.”¹²

And very importantly, our systems of care are plagued by racial and economic disparities.

Some Basic Facts

• About 1 in 10 people 65 and older have some form of dementia, most likely Alzheimer’s disease. At 90 and over, it’s approaching about 35%.¹³
• Virtually all people with dementia develop behavioral health conditions (aka “neuro-psychiatric symptoms”), such as depression, anxiety, psychosis, etc., at some point while living with dementia.¹⁴
• About 1 in 7¹⁵ (the NIMH estimate) or perhaps 1 in 5¹⁶ (the CDC estimate) of older adults have mental illnesses such as anxiety disorders, mood disorders, or psychosis.
• About 1 in 25 suffer from addiction,¹⁷ and as many as 1 in 5 dangerously misuse alcohol and medications.¹⁸
• Many older adults experience emotional distress in response to challenging life circumstances such as the pandemic, social isolation, economic instability, racism, disasters, poor health, and the changes that are part and parcel of aging in America.

For example, emotional distress – including grief, loneliness, hopelessness, anxiety, and more – unquestionably increased during the pandemic for older as well as younger people.¹⁹

All of this contributes to personal and familial dysfunction, premature disability and death, avoidable institutionalization, high rates of suicide, and very high costs of care.

• Dementia was the 7^th leading cause of death in the United States in 2022.²⁰
• Behavioral health conditions, i.e., mental and substance use disorders, contribute to premature death. For example, people with serious mental illness die 10-25 years younger than the general population.²¹ And people with co-occurring depression and cardiac conditions are far more likely to experience premature disability and death.²²
• Depression contributes to high suicide rates among older adults, and in 2021, suicide was the 11^th leading cause of death in the United States.²³ Suicide rates are especially high among older adults.²⁴
• Anxiety disorders contribute to social isolation and rejection of help.
• “Neuropsychiatric” disorders are the leading cause of disability in the United States, accounting for nearly 20% of all years of life lost to disability and premature mortality.²⁵
• Misuse of alcohol often leads to illnesses and accidental injuries, especially falls and automobile accidents, which can result in premature disability or death. Between 2015 and 2019, there were about 140,000 alcohol-related deaths per year in the United States.²⁶
• Misuse of illegal substances contributes to overdose deaths (over 100,000 in the US in the last year), homelessness, the over-population of prisons, the spread of contagious diseases, disruption of work and family life, and violence in the home and in the community – especially in poor communities of color – and more.
• In addition, cognitive and behavioral health conditions are major drivers of high healthcare costs in America. This includes the costs of long stays in hospitals, the high use of emergency rooms, and long-term residential care.

It is important to note that while the risks to mental health are great in old age, the opportunities to experience mental well-being are also great.

For all of these reasons, it is very important to address the needs of those people who experience mental problems in old age.

Currently, for example, many states are developing “master plans” to address aging in America. They have various names, such as “multi-sector plans,” “longevity-ready plans,” etc.

What should these plans include regarding cognitive and behavioral health? Here are 15 key goals:

1. Enable older adults with cognitive or behavioral health conditions to live where they prefer, generally not in institutions.
2. Improve long-term care, including nursing homes, assisted living, and home and community-based services.
3. Enhance support for family caregivers.
4. Increase cognitive and behavioral health service capacity to keep pace with the growth of the older population and to address current shortfalls.
5. Enhance access to care, particularly with extensive use of telehealth and increased outreach and engagement.
6. Improve quality of care and treatment, emphasizing clinical, cultural, and geriatric competence.
7. Increase and improve the professional and paraprofessional workforce in primary care, long-term care, behavioral health, and aging services in America. And develop alternatives to current service models using peers and others.
8. Enhance integration of care within and between service systems – dementia care, behavioral health care, primary care, long-term care, and aging social services. And enhance collaboration between service programs and community organizations, especially faith communities.
9. Address social “drivers” of behavioral health, such as racism, poverty, and social isolation.
10. Address racial and economic disparities.
11. Increase “preventive” interventions so as to reduce the incidence of cognitive and behavioral disorders, relapse, institutionalization, and suicide.
12. Promote mental well-being in old age.
13. Improve public and professional education.
14. Increase and redesign funding to meet the needs of older adults.
15. Compile epidemiological, services, and financial data and create a publicly accessible data dashboard.

A daunting agenda, no doubt. However, it is well past time to address the consequences of the elder boom. We knew it was coming decades ago. Now, we are halfway through the boom and just beginning to confront the challenges. No More Delay!

^*People with developmental disabilities, who used to have a life expectancy no greater than 40, now have a life expectancy just a bit lower than those without developmental disabilities.

Michael B. Friedman, LMSW

Michael B. Friedman is the Honorary Chair of the Geriatric Mental Health Alliance of New York and Co-Chair of the Ad Hoc Group of Experts on Geriatric Cognitive and Behavioral Health of Maryland. He has published over 250 articles, op-eds, and book chapters, most of which can be found at www.michaelbfriedman.com. He welcomes comments at mbfriedman@aol.com.

Footnotes

1. US Census Bureau (2017) National Population Projections Datasets.
2. Ibid.
3. Ibid.
4. National Institute of Mental Health. “Any Mental Illness.”
5. Lehmann, S. W., & Fingerhood, M. (2018, December). Substance-Use Disorders in Later Life.
6. Alzheimer’s Facts and Figures Report | Alzheimer’s Association
7. Phan, S. V., Osae, S., Morgan, J. C., Inyang, M., & Fagan, S. C. (2019, June). Neuropsychiatric Symptoms in Dementia
8. Black BS, et al. (2019) “Unmet needs in community-living persons with dementia are common, often non-medical and related to patient and caregiver characteristics” in International Psychogeriatrics. February 2019
9. Institute of Medicine (2012). The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? | The National Academies Press (nap.edu).
10. Byers, A. et al (2012). “Low Use of Mental Health Services Among Older Adults With Mood and Anxiety Disorders” in Psychiatric Services, January 2012.
11. Klap, R. et al (2003). “Caring For Mental Illness In The United States: A Focus On Older Adults.” The American Journal Of Geriatric Psychiatry. September-October 2003.
12. Wang, P.S. et al. (2005). “Twelve-Month Use Of Mental Health Services In The U.S.” Archives of General Psychiatry.
13. One in 10 Older Americans Has Dementia | Columbia University Irving Medical Center
14. Phan Op. Cit. Neuropsychiatric Symptoms in Dementia
15. National Institute of Mental Health (2019) Mental Health Information, Prevalence of Any Mental Illness. (2019).
16. Centers For Disease Control (2006). “The State of Mental Health and Aging in America.”
17. Reynolds, K., et al. (2015). Prevalence of psychiatric disorders in U.S. older adults: findings from a nationally representative survey. National Center for Biotechnology Information
18. Lehmann S. and Fingerhood M. (2018). Substance-Use Disorders in Later Life | NEJM
19. The Implications of COVID-19 for Mental Health and Substance Use | KFF
20. Products – Data Briefs – Number 492 – March 2024 (cdc.gov)
21. Mortality Associated With Mental Disorders and Comorbid General Medical Conditions | Psychiatry and Behavioral Health | JAMA Psychiatry | JAMA Network
22. Association of Symptoms of Depression With Cardiovascular Disease and Mortality in Low-, Middle-, and High-Income Countries | Cardiology | JAMA Psychiatry | JAMA Network
23. Suicide rises to 11th leading cause of death in the US in 2021, reversing two years of decline | CNN
24. Fatal Injury Reports. (2022).
25. US Burden of Disease Collaborators (2013). The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA.
26. Deaths from Excessive Alcohol Use in the United States | CDC

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