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Preparing for the Elder Boom

An Opinion by Michael B. Friedman, CSW
First Published in Mental Health News, Winter 2004

The mental health system, which currently does not serve most older adults with mental illnesses at all, let alone serve them well, is in no way ready for the elder boom, which will hit in full force beginning in 2011. Perhaps it’s not surprising that there has been so little preparation despite more than a decade of warnings. The big hit will come outside the ordinary five-year planning horizon. But the boom will be so large and will require such extensive restructuring, as well as growth that preparation cannot responsibly be put off any longer.

Facts

Here are the facts:

From 2000 to 2030 the population 65 or over in the United States will grow from 35 million to 70 million and from roughly 13% of Americans to 20%.
From 2010 to 2020 the growth will be 35%, from approximately 40 million to 54 million.
Based on current prevalence estimates, from 2000 to 2030 the number of older adults with mental illnesses will grow from approximately 7 million to approximately 14 million.
Between 2010 and 2020 alone the number of older adults with mental illnesses will grow from approximately 8 million to approximately 11 million.
During these same periods there will also be a significant increase in the proportion of minority older adults in the United States, rising from 16.5% of the elderly population in 2000 to 25.6% in 2030. (Estimates are from the U.S. Census Bureau)

Diverse Population means Diverse Illnesses and Issues

Of course, older adults with mental illnesses are a diverse population.

Anxiety and mood disorders are the most prevalent mental illnesses.
Dementia becomes increasingly common as people age.
Schizophrenia may occur less frequently among older adults than younger adults. (Surgeon General’s Report on Mental Health)

In addition, older adults with mental illnesses exhibit a wide range of abilities and disabilities.

Some work, have significant personal relationships, and participate in community activities.
Some are unable to manage without substantial supports and/or are extremely isolated.

Common Issues Affecting Most Older Adults with Mental Illnesses

Despite the heterogeneity of the population, there are a number of common issues affecting virtually all older adults with mental illnesses.

There is a vast shortage of mental health professionals with expertise serving older adults.
Funding for mental health services is inadequate and discriminatory. For example Medicare reimburses less for mental illnesses than physical illnesses, does not cover prescription drugs, pays for very limited home-based services, and does not cover the kinds of outreach and “wraparound” services that are vital to many people with severe psychiatric disabilities.
The current service system is, for the most part, structured and financed in ways that assume that people are able to leave home to go for services in specialized settings despite the fact that virtually all providers and researchers report a widespread need for mobile services.
Most older adults with mental illnesses also have chronic physical illnesses. In part this reflects the fact that older adults are more likely to have chronic illnesses, but in part it reflects an apparent correlation between mental and physical illness. An adequate system must, therefore, address issues of co-morbidity.
For all older adults activity and social involvement appear to be essential to maintaining and/or improving mental health. It is, therefore, critical to promote access to the social mainstream and to integrate mental health services with services provided through the “aging” system.
Families increasingly regard institutions for older adults as an undesirable last resort. Therefore, in addition to improving services in institutions, it is essential to conceptualize and create community- based support systems for older adults who need them.
Because families provide most of the supports which older, disabled adults need, it is critical to address the needs of family caregivers as well as the needs of those for whom they provide care.
The rise in the numbers of minority older adults makes it more and more important to develop culturally competent services.
Research has not yet produced ultimate insights or cures for mental illnesses among older adults. More research is critical.

Must Change the Way We Provide Mental Health Services

These are not easy issues to address, and they cannot be addressed without substantial shifts in the way in which we think about the provision of mental health services. It is not just a matter of doing more; it requires doing things differently. It requires understanding that the needs of older adults are as different from those of adults as adult needs are from children’s needs.

So it is not as simple as training a large number of geriatric mental health professionals, pressing for more funding to expand services, and expanding research. Finance, research, and the development of a well-trained, highly skilled workforce are all essential of course, but it will also be essential:

To craft a new vision of service and support, a vision which weaves together the clinical, the rehabilitative, the medical, the social, and the familial,
To address the fissures in the current structure of serving older adults and to bring together mental health, health, and aging systems

Must Act Now or Face a Vast Crisis

Given the magnitude of other issues confronting the mental health system, it is easy to understand why little work has been done to begin to shape a system of care of older adults with mental health problems. But the march of demography is ineluctable. We must act now or face a vast crisis in the not too distant future.

(Michael B. Friedman is the Director of the Center for Policy and Advocacy of The Mental Health Associations of New York City and of Westchester and is their Public Policy Consultant. The opinions expressed in this column are his own and not necessarily the positions of the Mental Health Associations.)

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