As of this writing, the healthcare and behavioral health systems are facing unprecedented threats from proposed legislation to significantly roll back the gains achieved through the Affordable Care Act (ACA). Medicaid is also under threat, as the current legislative proposal attempts to alter its funding structure to block grants or “per capita” funding to the states without the proportional federal funding match. The proposed changes not only threaten to severely restrict, if not eliminate, some people’s ability to access behavioral health care, and are particularly likely to affect older adults. For example, while the ACA requires behavioral health care to be an “essential” covered service by all insurance carriers, such a requirement is not guaranteed under the current legislative proposal. In addition, “younger” older adults (for example, those aged 55-64 who are not yet eligible for Medicare) who may have gained behavioral health care either by becoming eligible for Medicaid under the ACA, or who purchased insurance through a state or the federal exchange, may not be able to access care if they are unable to afford to buy insurance with the proposed tax credits, which are significantly less generous than ACA subsidies. Inability to access care may also result if older adults live in states that have to curtail eligibility for Medicaid or reduce covered benefits as they struggle under decreased overall funding for services.
While these proposed system changes have been widely acknowledged as generally disastrous for many, including older adults, there has been relatively little acknowledgement of the particular risks to older adults with behavioral health needs. This is problematic, as the population of older adults continues to expand rapidly, with the number of older adults who have a diagnosable psychiatric disorder expected to reach 14 million by 2030. Despite this, however, older adults with behavioral health challenges continue to be an afterthought for policy makers and for mainstream providers. Going forward, it will be especially important for behavioral health advocates to understand the unique challenges of older adults who need behavioral health services and supports to ensure that they are not left behind.
This article provides a brief overview of the needs of this population in order to illustrate the necessity of coordinated, integrated services that address the dynamic interplay between physical and behavioral health in older age. This group of individuals is heterogeneous, ranging from people living with long-standing psychiatric disabilities to those who have acquired symptoms of behavioral health challenges in later life. Regardless of the age of acquisition or degree of functional disability, most older adults with behavioral health issues also need to manage co-morbid physical health problems and require services and supports that reflect their physical, psychological, developmental and social needs.
Older adults with chronic physical and mental disorders have different needs and challenges than younger populations with complex conditions. Normal physical age-related changes, such as sleep problems, declines in vision and/or hearing and/or mobility may require older adults to modify their activities and/or environment to adapt to these changes. Modest environmental modifications may be needed to help older adults remain at home independently. Vision, cognitive, and physical changes increase the risk of falls among older adults, which are often due to hazards that are easy to overlook. The risk of medical illnesses, particularly chronic conditions, increases with age, therefore requiring effective and integrated medical management. Good nutrition and exercise become particularly important for older adults to reduce their risk of chronic disease, lower their body weight, and improve their overall quality of life.
Dementia, which doubles every five years after the age of 60, , leads to memory loss as well as loss of executive and other functioning that interferes with the ability to manage activities of daily living. In addition, it is important to note that people with histories of clinically significant behavioral health challenges may also acquire a dementia-causing illness in later life. Therefore, they experience additional cognitive impairment, which can make it increasingly difficult to manage activities of daily living. Both conditions will need to be managed carefully by health care and behavioral health care providers.
Depression and Anxiety: While depressive and anxiety disorders are somewhat less common among older adults than in the general population, depression frequently co-occurs in older adults with dementia, with long-term psychiatric disabilities, with chronic physical conditions, with reduced social networks, or with reduced quality of life. Both depressive and anxiety disorders are associated with increased health care utilization, poorer health outcomes, and increased functional disability; however, a majority of older adults who experience depressive and anxiety disorders do not receive mental health services in traditional settings, so it is imperative that older adults are able to access services where they need to receive them, such as in primary care, aging services programs, and in long-term care; the current proposed changes to the health care delivery system do not take into account the need for providing services in non-traditional settings.
Suicide is a major concern among older adults. They are 50% more likely to take their own lives than the general population, particularly white men of over the age of 85. Suicide is also part – though by no means all – of the reason for the lower life expectancy of people with long-term psychiatric illness, as some adults living with psychiatric disabilities complete suicide before achieving older age. A number of factors increase the risk of suicide for older adults, including depression and other mental disorders, co-morbid physical illness, social isolation, and feeling a lack of meaning or purpose in life, among other risk factors.
Recovery, a core value in the mental health care delivery system, is as relevant and possible for older adults as it is for younger populations. Unfortunately, ageism leads to the false perception that older adults cannot recover and/or learn new skills. The concept of recovery for older adults can and should focus on achieving integrity, which is centered around increased acceptance of one’s life and history, a sense of meaning and purpose in one’s current life, which can be influenced by engagement in valued relationships and activities and interest in guiding future generations, in addition to what might be achieved in the current moment. Recovery for older adults should also include the goal of living in a setting, often in the community, that promotes optimal functioning and independence.
Older adults experience a number of normal developmental transitions as they age. How these transitions are experienced and managed are critical to successful aging, which we define as older adults’ ability to feel good about their lives, even as they live with physical, emotional and social challenges. Typical developmental transitions may include voluntary and non-voluntary retirement from employment; loss of family and/or friends; shifting social and familial roles; diminished cognitive and/or physical abilities; spiritual concerns; and confronting end-of-life. Dealing with these transitions as part of programming will help support older adults’ physical and mental wellness. Death and dying, a reality for older adults, unfortunately is rarely dealt with openly but requires careful end of life planning to prepare for properly. Preparation includes helping older adults manage their needs and wishes for end of life care, but also for helping them meet the developmental task of addressing mortality in the first place. Grief is a common problem for older adults because they are more likely to experience the deaths of family and friends as they get older. Grief, while not a mental disorder, often leads to additional mental and emotional challenges.
As people age, staying connected with family and friends and avoiding isolation is also important for well-being. Some older adults with long-term psychiatric disabilities may have close family relationships, while others have been estranged from their family and may want to reconnect. Many adults with long-term psychiatric illnesses often rely on their family members, especially parents and siblings, for support throughout their lives. Therefore, they risk losing this primary support as they get older and their family members have less ability to provide care or die. Helping older adults with long-term psychiatric disabilities connect to community supports and develop additional relationships – or strengthen existing relationships, where possible – can be particularly critical as they enter older age.
Recreational activities, which are often associated with retirement, may be particularly important for those older adults who are no longer employed. They include various activities such as the arts, cooking, gardening, exercise, religious practices, education, and more. Some older adults want to participate in volunteer work as opposed to paid employment. Volunteer work can be formal, such as within an organization, or informal, such as time spent helping a neighbor or friend. Some older adults want to engage in programming offered for their age cohort. Additionally, older adults are more likely than younger adults to be concerned with religion and spiritual issues. Being a part of a religious community is a way for older adults to stay connected and explore the meaning, value, and purpose of their life.
Social and Economic Needs
Older adults often face financial problems because the traditional sources of income, such as pensions or public assistance are generally not enough to live on. Also, there are housing issues related to the possibility of aging in the community rather than in institutions. While there is specialized housing for adults living with psychiatric disabilities, such as supported housing and community residences, these are not typically designed to meet the needs of an aging population. Conversely, housing designed for older adults, such as senior housing, supportive housing and assisted living, are not typically designed to address behavioral health. As older adults with behavioral health needs increasingly live in the community, issues of cost, safety and accessibility, among other concerns, will need to be considered.
The population of older adults with behavioral health challenges will to continue to grow at a time when access to the services and supports that help them to achieve and sustain recovery are increasingly at risk. It is imperative that we in the behavioral health community work hard to ensure that essential services are not limited or stripped away. The specific issues facing older adults with mental health and substance abuse problems deserve careful attention and planning, and we must not allow them to be neglected as we advocate to preserve the ACA, Medicaid and any other entitlements upon which this vulnerable population depends. If we do not address the needs of older adults with behavioral health conditions, we not only risk diminishing their quality of life, but we also continue to promote an ageist society that fails to care and support the most vulnerable among us.
Kimberly Williams is President of the Mental Health Association of New York City. She is also the co-founder of the Geriatric Mental Health Alliance (GMHA) and Chairs the National Coalition on Mental Health and Aging. Lisa Furst is the Director of the GMHA and the Assistant Vice President of the Center for Policy, Advocacy and Education of the Mental Health Association of New York City. Michael B. Friedman is the Co-founder and Honorary Chair of the GMHA. He is on the adjunct faculty of Columbia University School of Social Work.