AAGP Position Statement: Mental Health and Medical Care of Older Adults
Adopted by the AAGP Board of Directors, June 2002
Position 1: Mental status evaluation is an integral part of the evaluation of geriatric patients. When patients or caregivers present with cognitive, emotional, or behavioral complaints, there should be reimbursement for initial and for follow-up care of these problems by primary care providers.
Rationale: Epidemiologic studies have demonstrated that 5-8% of adults age 65 and older have dementing illnesses, and the prevalence of Alzheimer's disease in adults over age 85 has been found to be between 22 and 48%. Clinically significant symptoms of depression are evident in approximately 15% of community dwelling elders, with higher rates in medical settings; and adults over age 65 have the highest rate of suicide of any age group. A substantial proportion—up to 75% of older adults who commit suicide have visited their primary care physician within the last month of life. Anxiety disorders, alcohol and substance abuse, and disturbances of sleep and sexual function are also common among the mental health problems of late life. Most of the elderly patients with these conditions do not seek out, or find it difficult to gain access to specialty mental health services. This makes it crucial for primary care services and health care coverage for those services to include evaluation for the mental disorders of late life.
Rationale: The mental disorders that are highly prevalent in late life cause: (1) significant distress and suffering for patients and family, (2) increased medical morbidity, (3) excess disability, (4) interference with medical, nursing, and rehabilitative care, and (5) increased mortality. These complex interactions of mental disorders with medical illnesses and disabilities that occur commonly in geriatric populations require that care be highly coordinated, with provisions for mental health care as an intrinsic component of comprehensive geriatric health care. The ability of geriatric patients to benefit from health care services also depends on the acceptability of those services, which must therefore be physically accessible, affordable, and culturally appropriate. Health care organizations and payers must design systems for health care delivery and coverage of services that facilitate rather than create barriers to provision of high quality mental health care. This should include the adoption of appropriate incentives for referral to geriatric psychiatry and other geriatric mental health services. Payment policies that provide reduced mental health care coverage, compared to coverage for treatment of general medical conditions, discriminate against the many older adults who suffer from mental disorders of late-life. Mental health services should therefore be covered on par with general medical care. Furthermore, evaluation and treatment of mental disorders must be available across the array of settings in which health care is delivered to geriatric patients, including but not limited to hospital, outpatient clinic, subacute care units, partial hospital programs, nursing homes, assisted living facilities, hospice and home care programs.
Position 3: Managed care and Medicare carrier advisory boards would benefit from inclusion of at least one geriatrician and one geriatric psychiatrist to help ensure adequate, non-discriminatory coverage for needed mental health services.
Rationale: Geriatric medicine and psychiatry are both medical subspecialties formally recognized by accreditation of geriatric fellowship training programs and board certification. These subspecialties have a foundation of scientific knowledge regarding the normative phenomena of aging and the relationship of aging to medical and psychiatric illnesses and associated disabilities. The health problems that commonly occur in late life reflect the complex interactions of aging and mental and physical functioning; and, therefore, the coverage and reimbursement of health services for geriatric patients must accommodate the special needs of this population. Geriatricians and geriatric psychiatrists are the subspecialists most qualified to provide guidance to carrier advisory boards on the provision of medically necessary, coordinated mental health services.
Positon 4: Training in geriatric mental health must be expanded and incorporated into geriatric curricula at all levels of health care professional education, particularly for physicians, nurses, psychologists, social workers, pharmacists and rehabilitation specialists.
Rationale: Geriatric psychiatrists are the medical subspecialists with expertise in evaluation and treatment of mental disorders of late life. However, it is acknowledged that the number of fellowship-trained geriatric psychiatrists in the United States will not be sufficient to provide all of the mental health care needed by the older adult population. It is therefore necessary to ensure that primary care providers are competent to recognize, and in many cases to assess and manage, common mental health problems in older adults; and that they know when to refer patients for further evaluation and treatment by a geriatric psychiatrist or other geriatric mental health specialist.
Full funding, including direct medical expenses and indirect medical expenses, for graduate medical education in geriatric psychiatry at the PGY-5 level must be preserved. However, training in geriatric mental health must also be part of medical school curricula on aging and primary care residency programs (e.g., internal medicine, family practice, obstetrics and gynecology, neurology, and psychiatry). Practitioners in the fields of medicine and psychiatry should be encouraged to participate in continuing medical education programs that include training in basic aspects of geriatric psychiatry, with emphasis on recognition of common mental disorders of late life, and guidelines for referral to geriatric mental health specialists. In addition, the ABIM recertification examination in internal medicine, the ABFP recertification examination in family practice, and the ABPN recertification examination in psychiatry should include material that tests basic competency in the area of geriatric mental health.
Position 5: Increased support for research on late-life mental disorders is needed. Geriatric health professional organizations and advocacy groups for older Americans must work together to preserve and expand federal funding for research on the etiology and treatment of mental disorders of late life.
Rationale: Given the continued growth of the geriatric population and the substantial prevalence of mental disorders of late-life, funding agencies such as the NIMH should encourage more research on the effectiveness of treatment for the mental disorders of late life, and should support health services research that examines the effectiveness and efficiency of models for delivery of mental health care to older adults from various ethnic backgrounds and in the different settings where geriatric patients reside and receive their health care. Pharmaceutical companies and the NIH should include older patients in clinical trials.
Most research on the efficacy and safety of treatments for mental disorders has been conducted in young or middle aged adults without medical comorbidity or physical disability. Such studies do not establish the effectiveness or tolerability of treatment in geriatric patients, especially in the oldest old patients with comorbidity from interacting medical and psychiatric illnesses and related disabilities. Funding agencies therefore need to encourage and support more research on effectiveness of treatment in older populations with complex health problems. Effectiveness research should also examine mental health services delivery models across the wide range of settings in which geriatric patients now reside and receive their health care, including but not limited to hospital, outpatient clinic, subacute care units, partial hospital programs, nursing homes, assisted living facilities, hospice and home care programs.