Health Services For Older Adults Research Articles

Characteristics of Older Adults With Serious Mental Illness Enrolled in a Publicly Funded In-Home Mental Health Treatment Program

In-home mental health services for older adults will likely become increasingly utilized as the population ages. Little is known about older adults with serious mental illness who receive in-home services through the public mental health system. This study examined the demographic and clinical characteristics of this population. A total of 148 clients were included. Mood disorders were present in 75.7% and schizophrenia spectrum disorders were present in 23.6%. A history of problematic substance use was documented in 47.3% of clients and 31.8% reported suicidal ideation prior to enrollment. A total of 25% of clients utilized psychiatric emergency services during the year prior to enrollment and 15.5% of clients were hospitalized for psychiatric treatment. Older adults who receive in-home mental health services are vulnerable and have complex treatment needs.

Inequitable Access to Health Services for Older Adults with Diabetes: Potential Solutions on a State Level

Diabetes is a serious global public health challenge. The cost for health services for diabetes care has increased 41% over the past 5 years. Despite escalating health expenditure, the United States continues to have higher rates of diabetes than many other developed countries. There is a need for health care reform in the United States not only in reducing health care costs but also in improving the quality of preventative care. This study presents the testing of a multilevel model investigating variables on the individual and state levels to develop a better understanding of the most important contextual pathways that can lead to providing older adults (50+) with type 2 diabetes with the recommended preventative quality care they require. The model was tested using a three-level repeated cross-sectional design with data from various existing data sources, using a national sample of 181,870 individuals aged 50 years and older. Results showed that differences in state health care systems contributed to inequitable access. Specifically, in a state where there was a higher percentage of adults 65 and older coupled with a shortage of health care professionals, the likelihood of receiving the recommended preventative quality care decreased. Also, older adults living in states with a higher percentage of people with diagnosed diabetes but with a lower-than-average annual per capita health care expenditure fared worse in receiving quality preventative care. Last, older adults in wealthy states with higher percentages of uninsured people had the lowest odds of receiving quality preventative care. Health care reform, similar to what is currently promoted by the Patient Protection and Affordable Care Act of 2010, is recommended to improve the performance of all health care systems in all states.

Shared medical appointments to screen for geriatric syndromes: preliminary data from a quality improvement initiative.

Older adults are at greater risk of developing conditions that affect health outcomes, quality of life, and costs of care. Screening for geriatric conditions such as memory loss, fall risk, and depression may contribute to the prevention of adverse physical and mental comorbidities, unnecessary hospitalizations, and premature nursing home admissions. Because screening is not consistently performed in primary care settings, a shared medical appointment (SMA) program was developed to fill this gap in care. The goals of the program were to improve early identification of at-risk individuals and ensure appropriate follow-up for memory loss, fall risk, and depression; facilitate discussion about prevention, diagnosis, and treatment of these conditions; implement strategies to reduce risks for these conditions; and increase access to screening and expand preventive health services for older adults. Between August 2011 and May 2013, 136 individuals aged 60 and older participated in the program. Three case studies highlighting the psychosocial and physiological findings of participation in the program are presented. Preliminary data suggest that SMAs are an effective model of regularly screening at-risk older adults that augments primary care practice by facilitating early detection and referral for syndromes that may otherwise be missed or delayed.

Research Update One: Cognitive Analytic Therapy and a specialist mental health service for older adults: Relationship-centred care

Research Update One: Cognitive Analytic Therapy and a specialist mental health service for older adults: Relationship-centred care

Does a Structured Gardening Programme Improve Well-Being in Young-Onset Dementia? A Preliminary Study

Introduction: Young-onset dementia affects about 1 in 1500 people aged under 65 years in the United Kingdom (UK). It is associated with loss of employment, independence and an increase in psychological distress. This project set out to identify the benefits of a 2 hours per week structured activity programme of gardening for people with young-onset dementia. Method: A mixed methods (qualitative and quantitative) study of therapeutic gardening for people with young-onset dementia, measuring outcomes for both participants with young-onset dementia and their carers, was used. Twelve participants were recruited from a county-wide mental health service for older adults, based on onset of dementia being before the age of 65 years (range 43–65 years). Of these, two participants dropped out and one died during the project. Measures included the Mini Mental State Examination (MMSE), Bradford Well-Being Profile, Large Allen Cognitive Level Screen (LACLS) and Pool Activity Level (PAL). Findings: Over a 1-year period the carers of the people with young-onset dementia found that the project had given participants a renewed sense of purpose and increased well-being, despite cognitive functioning continuing to decline during this period. Conclusion: This study suggests that a meaningful guided activity programme can maintain or improve well-being in the presence of cognitive deterioration.

Mental health care Monitor Older adults (MEMO): monitoring patient characteristics and outcome in Dutch mental health services for older adults

Information on which older adults attend mental health care and whether they profit from the care they receive is important for policy-makers. To assess this information in daily practice, the "Mental health care Monitor Older adults" (MEMO) was developed in the Netherlands. The aim of this paper is to describe MEMO and the older adults who attend outpatient mental health care regarding their predisposing and enabling characteristics and need for care. In MEMO all patients referred to the division of old age psychiatry of the participating mental health care organisations are assessed at baseline and monitored at 4, 8 and 12-month follow-up. Primary outcomes are mental and social functioning, consumer satisfaction, and type of treatment provided (MEMO Basic). Over the years, MEMO Basic is repeated. In each cycle, additional information on specific patient groups is added (e.g. mood disorders). Data collection is supported by a web-based system for clinicians, including direct feedback to monitor patients throughout treatment. First results at baseline showed that the majority of patients that entered the division of old age psychiatry was female (69%), had low education (83%), lived alone (53%), was depressed (42%) and had a comorbid condition (82%). It seemed that older immigrants were not sufficiently reached. The current study is the first in the Netherlands to evaluate patient characteristics and outcome in mental health care provided for older adults in day-to-day practice. If MEMO works out successfully, the method should be extended to other target groups.

Primary Care Psychology: An Opportunity for Closing the Gap in Mental Health Services for Older Adults

Older adults, particularly in minority and lower income communities, continue to receive less mental health care relative to the general population. Concurrently, there has been increasing emphasis on the need to integrate mental health services into primary care settings. This push toward integration presents a unique opportunity to help close the gap in mental health services to underserved populations, including older adults. We discuss factors that have influenced this trend and specifically address the role of primary care–based psychologists in treating psychological disorders in older adults. A primary care psychology service at an urban training clinic is described and data are presented on 134 consecutive older adult patients who received services. Finally, two cases are presented to illustrate how integrated care can reach older adults who may not otherwise seek services or would get services only after psychological issues had become more acute. These cases support the view that integrated primary care can serve as a vital, flexible tool for enhancing timely mental health care for older adults, particularly within underserved populations. This population-based approach to providing brief services to a wide range of patients does not eliminate the need for more intensive services provided in mental health care settings but, rather, serves as a complement to those services.

A method for identifying research priorities for health systems research on health and aging

A rapid and feasible priority-setting method conducted within a limited budget was used to identify research topics that would have an influence on health services for older adults. Health and aging researchers, policy makers, and caregivers were recruited to complete Delphi surveys that generated and ranked topics and identified other potential researchers. An interdisciplinary team of researchers was selected to produce and submit a proposal to a peer-review-granting agency. This method can be adapted by organizations to determine the focus of their research agenda and to engage individuals for collaboration on future research projects.

Home-Based Mental Health Services for Older Adults: A Review of Ten Model Programs

The objective is to provide information on successful programs providing home-based services to mentally ill elderly in order to assist other communities wishing to establish such programs. The ten programs described in this article were selected by peer review from applications for an award given by the American Association for Geriatric Psychiatry and were participants in an invitational conference. Eight of the programs were components of a community agency and two were components of a medical school department of psychiatry. Six of the programs focused primarily on individuals with anxiety and depression and utilized a range of individual psychotherapies. The other four accepted patients with any psychiatric diagnosis including dementia and included medication management as part of their services. The numbers served by the ten programs ranged from about 50 to 300 new cases per year, and the staffing ranged from 2 to 13 often with a combination of full and part time. The annual budget for the ten programs ranged from $30,000 to $1,250,000. Budget sources usually included some combination of public funds, philanthropy, and fee-for-service income. Despite the logistic and fiscal challenges of providing home-based services to mentally ill older adults there are many long-standing successful programs that can serve as models for communities wishing to establish similar programs. A great opportunity exists for a unified outcome research endeavor as well as expansion into many more communities.

The Barriers to Mental Health Services Scale Revised: Reliability, Validity, and Underlying Structure

Introduction: It is understood that older adults underutilize mental health services; however, it is unclear which factors create the biggest barriers. The purpose of this study was to revise the Barriers to Mental Health Services Scale (BMHSS), previously developed and validated by these authors (Pepin, Segal, & Coolidge, 2009). We developed this scale to address a gap in the literature; although barriers had been measured separately no comprehensive measure had been developed. The BMHSS addressed this by concurrently measuring a number of barriers making it possible to examine them in relationship to each other. The BMHSS is a self-report scale comprised of 10 possible barriers to mental health service use, including transportation, finding a psychotherapist, physician referral, psychotherapists’ qualifications, ageism, help seeking, stigma, and insurance/ payment concerns. The BMHSS’s primary strength is providing a comprehensive tool measuring a number of barriers potentially instrumental in preventing geriatric mental health service use. However, the instrument has several limitations. Weaknesses include: a) an inconsistent distribution of items across subscales, with some subscales comprised of 12 items and others only containing 3; b) Cronbach’s alpha values below the acceptable level (.7) for 4 subscales (finding a psychotherapist [.32], belief that depressive symptoms are normal [.48], physician referral [.61], and ageism [.63]); c) a lack of convergent validity analyses; and d) the absence of analyses examining the underlying scale structure. Methods: In the present study, we revised the BMHSS, resulting in the Barriers to Mental Health Services Scale Revised (BMHSS-R). The BMHSS-R is an improved, shorter, and more user-friendly instrument, which was achieved by changing the response format, adding new items, eliminating some existing items, and balancing the number of items on each subscale in the original measure. Younger (n 1⁄4 499, M 1⁄4 22.03 years) and community-dwelling older (n 1⁄4 100, M 1⁄4 72.09 years) adults completed the BMHSS-R. Results: Internal consistency ranged between .55 and .85, with 7 of the 10 subscales’ alphas being over .70. The subscales of stigma and help seeking were moderately correlated with existing measures. The stigma subscale was significantly and positively correlated with The Beliefs Toward Mental Illness Scale (Hirai & Clum, 2000), r(589) 1⁄4 .42 p < .001. The help seeking subscale was significantly and negatively correlated with the Willingness to Seek Help Questionnaire (Cohen, 1999), r(588) 1⁄4 -.44, p < .001. We used principal component analysis to explore the underlying structure of the measure. Ten components with eigenvalues above 1 comprise the underlying structure. These explained the following percent of variance, respectively: 29.14%, 6.60%, 5.25%, 4.13%, 3.37%, 3.09%, 2.77%, 2.55%, 2.43%, and 2.40%. Items for the subscales were all supported through PCA. However, some subscales (i.e., confidence in psychotherapists’ qualifications and ageism; stigma and knowledge and fear of therapy) were not well represented as independent components, instead having one underlying component whereas another subscale (i.e., transportation) was split into two components. Conclusions: Revisions to the BMHSS resulted in improved reliability and validity. This study provides a needed contribution to the field by expanding and improving tools available to assess barriers to mental health services for older adults. Valid measurement of barriers may be helpful in identifying improvements that could lead to improved design and delivery of services, facilitating more appropriate use of services. Also, such a scale could be used in intervention studies to illuminate previously unmeasured variables responsible for participant differences in engagement and intervention use patterns.

Multidisciplinary Team Perspectives on Older Adult Hoarding and Mental Illness

This qualitative study examined multidisciplinary team members' perspectives of their involvement in older adult hoarding cases. Fifteen informants, as representatives of four hoarding teams, described cases in which teams did or did not work well together. Specifically, informants described their (a) team characteristics, (b) awareness of hoarding as a mental health illness, (c) barriers to providing mental health services for older adults who hoard, and (d) components of successful teamwork within the team and with the older adult as hoarder. Implications include research to better guide interventions, team training to develop common perspectives, and policy development that supports mental health representation on teams and in-home mental health treatment.

The Patient Protection and Affordable Care Act: What Does it Mean for Mental Health Services for Older Adults?

The U.S. Supreme Court recently upheld the constitutionality of the Patient Protection and Affordable Care Act (PPACA). It is important to think about how this act will affect mental health services for older adults. The act has the potential to improve health outcomes across all income and age groups. There are specific provisions that are expected to improve care for individuals with mental illness, but there is little information about how these provisions will affect older adults with mental illness. As we move toward implementation of the PPACA, psychiatric nurses need to be aware of myths surrounding the act and to think about changes in the health care system, such as collaborative models of care, that may help identify and overcome barriers to treatment of older adults with mental illness.

Nurse-led liaison mental health service for older adults: Service development using lean thinking methodology

ObjectivesLiaison Psychiatric Services for Older Adults in the UK have been established over the last decade, with rather divergent team composition and involvement. The latest documents (National Dementia Strategy, Who Cares Wins) set the gold standard for liaison services for older adults in England, requiring a proactive approach to services and integrating assessment and treatment of mental disorder into routine general hospital practice. This requires a physical presence of liaison services in the hospital, with collaboration with medical colleagues. MethodsWe have adopted the above strategy in a nurse-led liaison service working in a General District Hospital, and used the Toyota Production System. ResultsIn the current study we reflect on the 5day rapid progress improvement workshops event for the liaison branch of the project, and describe the process of identifying real situation problems for the care of the medically ill, the involvement of the liaison team in their clinical care, and a feedback on the change in practice. ConclusionThe novel approach of identifying areas for change in an ongoing nurse-led Liaison service for Older Adults resulted in improving access to mental health services for elderly medically ill inpatients and improved quality of their overall care.

Guest Editorial: The future of Old Age Psychiatry in Africa

It is a popular belief that mental disorders in the elderly in Africa are less prevalent, less expensive to treat and not an important health care issue. Health problems facing African authorities are diverse. In South Africa where 32% of the population is in the 0-14 year age group, a high percentage of health resources have been shifted to maternal and child care. Primary health care priorities address needs such as human immunodeficiency virus (HIV),tuberculosis and other infectious diseases. Thus, resources for mental health care are limited. Human resources for mental health care in Nigeria are dismal, with virtually all mental health personnel concentrated in urban areas where far less Nigerians reside. There are no specially separated mental health services for older adults in rural or urban Nigerian communities.

Substance Abuse in Older Adults: Policy Issues

By 2020, it is projected that the number of older adults needing treatment for drug and alcohol addictions will increase dramatically. Although Medicare covers treatment for mental health issues, copayments can be prohibitive for those with lower incomes. The Positive Aging Act, an amendment to the Public Health Service Act, is a policy alternative that could address substance abuse in the older adult population by (a) demonstrating ways of integrating mental health services for older adults into primary care settings, and (b) supporting the establishment and maintenance of interdisciplinary geriatric mental health outreach teams in community settings where older adults reside or receive social services. Increasing funding to states to emphasize primary care provider education on the detection, evaluation, and treatment of substance abuse problems of older adults has the potential to better meet the substance abuse needs of this population. Educating primary care providers, including gerontological nurses, to recognize signs of substance abuse in this population and providing age-appropriate treatment options is critically important but will require funding beyond what is currently available.

Chronic Physical Conditions in Older Adults with Mental Illness and/ or Substance Use Disorders

To examine the association between mental illness and chronic physical conditions in older adults and investigate whether co-occurring substance use disorders (SUDs) are associated with greater risk of chronic physical conditions beyond mental illness alone. A retrospective cross-sectional study. Medicare and Medicaid programs in Massachusetts. Massachusetts Medicare and Medicaid members aged 65 and older as of January 1, 2005 (N=679,182). Diagnoses recorded on Medicare and Medicaid claims were used to identify mental illness, SUDs, and 15 selected chronic physical conditions. Community-dwelling older adults with mental illness or SUDs had higher adjusted risk for 14 of the 15 selected chronic physical conditions than those without these disorders; the only exception was eye diseases. Moreover, those with co-occurring SUDs and mental illness had the highest adjusted risk for 11 of these chronic conditions. For residents of long-term care facilities, mental illness and SUDs were only moderately associated with the risk of chronic physical conditions. Community-dwelling older adults with mental illness or SUDs, particularly when they co-occurred, had substantially greater medical comorbidity than those without these disorders. For residents of long-term care facilities, the generally uniformly high medical comorbidity may have moderated this relationship, although their high prevalence of mental illness and SUDs signified greater healthcare needs. These findings strongly suggest the imminent need for integrating general medical care, mental health services, and addiction health services for older adults with mental illness or SUDs.

P01-498 - Smell identification test as a progression marker in Alzheimer's disease

IntroductionFactors influencing or predicting progression in Alzheimer's disease (AD) is not well understood. Olfactory dysfunction, impaired smell identification in particular, is known to occur in AD. Mesial temporal lobe, important for memory function is also critical for the processing of olfactory information. In view of the common anatomical substrate, we hypothesized that olfaction dysfunction worsens faster in people with AD with rapid cognitive decline compared to those with slower cognitive decline.AimsTo test whether smell identification test can be used as a predictor for illness progression in AD patients.MethodsForty one participants with late onset mild to moderate AD were recruited from mental health services for older adults. Subjects were classified as ‘Rapid Progressors’ defined on ‘a-priori’ with a loss of 2 or more points in Mini-Mental State Examination (MMSE) within six months. Assessments included MMSE, Neuropsychiatric Inventory, Bristol Activities of Daily Living, and the University of Pennsylvania Smell Identification Test (UPSIT), at baseline and after 3 months.ResultsTwenty subjects were ‘Rapid Progressors’, and had lower UPSIT scores compared to ‘Non-Rapid Progressors’ both at the baseline (p = 0.02) and at follow up after 3 months (p = 0.05). Baseline UPSIT correlated with follow up UPSIT (r = 0.5, p &lt; 0.01) and MMSE (r = 0.4, p = 0.04). Also it was the baseline UPSIT score that best predicted (p &lt; 0.05) the follow up smell and cognitive function on linear regression analysis.ConclusionsSmell identification function could be useful as a clinical measure to assess and predict progression in AD.

Public's View of Mental Health Services for the Elderly: Responses to Dear Abby

The need for adequate mental health services for older adults is an increasingly urgent issue as the life expectancy of Americans continues to extend; yet there are unresolved questions regarding the public's perception of service needs. The Group for the Advancement of Psychiatry collaborated with advice columnist Jeannie Phillips of "Dear Abby" to invite public feedback on mental health services for the elderly. Feedback was invited on access to services as well as perceived need for improvement in the quality or quantity of those services. The effort resulted in 800 responses that identified three primary issues: problems in accessing care, inadequate detection of mental health conditions by general practitioners, and a need for more psychotherapy services. It is hoped that this Open Forum will stimulate discussion throughout the country for the benefit of older persons with mental health needs as the country grapples with changes to come after the passage of health care reform.

Access Barriers to Mental Health Services for Older Adults from Diverse Populations: Perspectives of Leaders in Mental Health and Aging

This project is based on the results of telephone surveys with 52 local, state, and national informed respondents including policymakers, county leaders, planners, and advocates in mental health and aging with a particular focus on the states of California and Florida. This article addresses challenges to access to mental health services for diverse older adults including barriers related to race and ethnicity, socioeconomic status, location, age, gender, immigrant status, language, sexual orientation, and diagnosis. The article also highlights broad themes that emerged including (1) the importance of outreach and transportation tailored to diverse elders, and (2) recruitment of diverse staff and training related to diversity. The article concludes with policy and practice recommendations to reduce these disparities in access to mental health services for diverse populations of older adults.

Developing a family-inclusive mental health service for older adults

Developing a family-inclusive mental health service for older adults