GENE

26.

Dodd

J: A retrospective

of treatment 151:75-84,

27.

Frank

JD:

pectations

BY GENE

ofvariables

psychiatric

related clinic.

to duration

J Nerv

Ment

The

influence

of

outcome

Health D. COHEN,

patients’

and

of psychotherapy.

Services

therapists’ Br J Med

and

exPsychol

the

of a paper Psychiatric

LC, Covi

rotic

patients’

closed.

29.

Corner

L: Nonblind responses

placebo to placebo

Arch Gen Psychiatry JP: The need is now.

Needs

and

trial: when

12:336-345, Ment Hyg

an exploration its inert 1965 57(I):3-6,

content

of neuis dis-

1973

Options

M.D.

IN 1512 the Spanish explorer Ponce de Leon embarked on a voyage to discover a spring whose waters had the power to restore youth. More than four centuries later, the quest for rejuvenating agents continues (1). Curiosity about potential wonder drugs on dramatically innovative techniques often dominates discussions about the psychiatric treatment of olden people, and more time is devoted to speculation than to delineating what is actually known about treating the elderly. Attention to iatrogenic problems in olden people defers to fascination with the effects of vitamin E on rats and the possible ramifications of such studies for the elderly. At this time, however, the likelihood of breakthroughs or progress in the treatment of the aged nests more in the areas of seriice delivery and implementation of current knowledge than in unknown pharmacology or

Revised version American 1975.

Park

Elderly:

The author examines mental health issues related to the elderlvfrom the perspective ofthe options for immediate impact on treatment. He stresses the potentialfor creative collaboration between public andprivate mental health care systems. Myths, stereotypes, and misinformation about the aged are discussed, as are the positive, rewarding aspects of working with elderly patients. The author also describes an innovative model ofservice delivery in the treatment ofolder individuals.

the

28.

COHEN

1968

41:349-356, Dis

1970 on the

Mental

analysis

in a university

D.

presented Association,

at the I 28th Anaheim,

annual Calif.

,

meeting of May 5-9,

Dr. Cohen is Chief. Center for Studies of the Mental Health Aging, Division of Special Mental Health Programs, National tute of Mental Health, Parklawn Bldg. , Rm. 18-95, 5600 Lane, Rockville, Md. 20852.

of the InstiFishers

novel procedures. I do not mean to disparage creative research focusing on the latter areas. Such research is necessary, commendable, and should be encouraged. What I am suggesting is an additional approach-a pragmatic one addressing the present situation and offening the potential for immediate impact. Perhaps the need for this type of approach can best be appreciated from another perspective. Fewer than 4 percent of all psychiatric outpatients seen in private practice on at community mental health centers are 65 years of age or olden, despite the fact that the elderly constitute more than 10 percent of the population and have a higher incidence of mental health problems than other age groups. Clearly, the issue of service delivery is a major one. What use is treatment expertise if patient and practitioner do not have access to one another? If patient-practitioner access were better, existing services were more readily available, and cane of proven quality were provided, the beneficial results for the elderly would undoubtedly surprise many people.

THE

PROBLEM

OF

ACCESSIBILITY

Why does the problem of accessibility exist? What has interfered with access between patient and practitioner? There are six major categories of causes. 1 The Group for the Advancement of Psychiatry (2) described six attitudes that affect therapists’ desire or willingness to work with the elderly. a. The aged stimulate the therapist’s fears about his own old age. b. Elderly patients arouse the therapist’s conflicts about his relationships with parental figures. c. The therapist thinks he has nothing to offer old people because he believes that they cannot change .

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their behavior or that their problems are all due to untreatable organic brain disease. d. The therapist believes that his psychodynamic skills will be wasted with the aged because they are near death and not really deserving of attention. e. The patient might die while in treatment, which could challenge the therapist’s sense of importance. f. The therapist’s colleagues may be contemptuous of his efforts on behalf of aged patients. One often hears the remark that gerontologists on geriatric specialists have a morbid preoccupation with death; their interest in the elderly is considered “sick” or suspect (3). 2. A therapist’s myths, stereotypes, and misinformation regarding olden people interfere with the recognition of their problems and may preclude a decision to provide treatment (4). 3. Economic concerns, both real and exaggerated, have provided explanations and excuses for not treating the elderly. 4. The therapist may be uneasy about the possibility of being overwhelmed by the diversity of the problems an older individual might present. 5. The elderly patient may have problems getting to the therapist (e.g. physical limitations and transportation difficulties). 6. Cultural insensitivity has slowed community and societal responsiveness to the aged. It was not that long ago that one heard the phrase, “You can’t trust anyone over 30. Butler and Lewis have elaborated on ‘ageism’ and its effect in creating obstacles to treatment of elderly patients (3). I would like to elaborate on some of these problem areas, particularly item number 2 above.

aging per se, as opposed to underlying disease, plays in effecting intellectual changes has become increasingly open to question. As a result, functional on acute organic processes should always be considered when there are intellectual changes-particularly those of recent onset. Thompson (5) reviewed a number of studies focusing on intellect and performance as they vary with age. He referred to studies in which Army Alpha Tests revealed a significant gain in total scores from the freshman year in college to an age of about 5 1 Although testing at about age 62 showed a slight decline, the differences were not significant. Thompson also cited studies in which the Wechsler Adult Intelligence Scale was used to test a group of respondents over a 10-year period beginning in their 60s; little change was found. .

those

with

enties,

For

there

was

statistically

decline.

A

16-year

follow-up

revealed

only

dents. only

That slightly

their

seventies,

of survivors

whom

a minimal is,

testing

was

of decline

their

in the 60-70

scores

age

but

survivors for

scores for survivors lower than their scores and

begun

significant

were

range.

in

in this

both in

groups their when

the

sev-

unimpressive study of eighties they

comparable

has

responwere were to

in

those

(5. p. 57)

,

‘ ‘





MYTHS,

STEREOTYPES,

AND

MISINFORMATION

Myths. stereotypes, and misinformation about olden persons can prevent physicians from even referring them for evaluation. Treatable problems are too often seen as inevitable, irreversible concomitants ofthe aging process, and symptoms that elicit concern in younger people are frequently ignored in older ones. Such symptoms as mental status changes in olden persons often receive only casual attention. Two millenia ago, Cicero remarked that “intelligence and reflection and judgment reside in old men, and if there had been none of them, no states could exist at all.” Now, after innumerable major medical and technological advances, we often dismiss impaired intellect, disturbed reflection, and altered judgment in the elderly as natural concomitants of their age. This happens in spite of our knowledge that problems ranging from depression to acute brain syndrome-many of which are treatable and reversible-can cause identical symptoms. The fact is that changes in intellectual performance should never be taken lightly, even in people over 80. Moreover, the basic issue of what part

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These findings, like any statistical data, apply in a general sense to broad groups and not to any given individual who might reveal no discernible change. Another classic misinterpretation involves sleep patterns. Ifone believes that old people sleep less or need less sleep and accepts this as an age-specific fact, questions that a younger person would be asked will not follow. Ordinarily, changes in sleep patterns are immediately suspected of signaling underlying difficulties. Sleep problems are hallmark symptoms, and questions relating to sleep pattern changes offer the therapist one of the most objective opportunities for diagnostic assessment (6). Is the patient sleeping more or less? Does he have trouble falling asleep? Does he awaken early? How often does he get up in the middle of the night? These questions and others provide easy, direct, and important basic information about an individual’s health status but are perhaps less likely to be asked ofolden persons, as ifthe replies would be irnelevant. The facts, however, indicate that old people do not sleep less. Feinbeng (7) traced a curve of total sleep time pen 24 hours as a function of age and found no significant change from age 20 to past 80. Kahn and Fishen (8), in a study of normal elderly men (average age=80), evaluated sleep patterns from several perspectives. They found that these men were in bed an average of8 hours at night, slept more than 6 ofthese 8 hours, took 25 minutes to fall asleep, and awoke fewer than 2 times a night. This represents only nighttime sleep, not total sleep time (which would include naps). Certainly, this type ofinformation provides a more objective basis for evaluating olden people in terms of undenlying psychiatric disturbance.

GENE

Another major area of myth and misinformation concerns sexuality in the elderly. When changes occur in urge and performance, for example, they are too often readily discounted as inevitable, irreversible aspects of aging. The abrupt onset and rate of changes are genenally ignored. Underlying anxiety or depression is commonly overlooked. The potential for sexual desire and fulfillment is frequently denied or misunderstood, as Masters and Johnson have pointed out (9).

SERVICE

DELIVERY

Service delivery can be examined from several perspectives, although I will discuss only two here-comprehensiveness and actual delivery of services. Community mental health centers (CMHCs) have focused on these areas and have defined a charge to provide older persons with a complete range of services, including diagnosis, treatment, liaison, and follow-up. The change is not a simple one, for it is difficult to find another group with such salient interplay among the biomedical, psychological, and social determinants of illness (10, 11). Practically speaking, this might mean referring the psychiatric patient for a medical evaluation-handly a revolutionary idea, but it could be costly for a CMHC. It might be argued that performing a physical examination on elderly patients would drain too much ofthe center’s resources. However, this explanation should not be accepted too readily, since the elderly have access to a type of third-party insurance coverage available to no other group, i.e., Medicare. Medicare creates opportunities for comprehensive medical evaluation of patients with mental symptoms who need a differential wonkup. Medicare also provides opportunities for interesting collaboration and communication between CMHCs and the private secton. For example, the CMHC could establish relationships whereby psychiatrists, internists, neurologists, and others would come to the center to evaluate a numben of olden persons, or the center could arrange for the patients to have workups done at physicians’ offices or clinics. The physicians would then be reimbursed through Medicare. Obviously, there are many variations ofthis theme, which could also include dinics as well as psychiatric and/or internal medicine residents doing the evaluations of older people. The patient would gain a more comprehensive service; the CMHC would gain by being able to offer more with minimal extra cost; and the private sector would gain an opportunity to be involved in geriatric care with the appropriate support of other systems. Because of the scarcity of physicians in certain geographic areas, implementation of this approach could require some effort. In many geographic areas, however, the failure to adopt this approach could represent reluctance or resistance to working with olden patients. Another aspect of service delivery that confronts the practitioner in treating older people is the problem of the elderly getting to the services and, conversely,

D.

COHEN

getting the services to the elderly. The first part of the problem often involves attention to the elderly patient’s perception of a facility-how appealing or threatening it may seem to him. Also involved are factons of physical access (e.g. the necessity for wheelchain ramps). Transportation can be another problem. Volunteer services, Department of Transportation grants, and special contracts can be helpful. The second pant of the problem is the area of outreach and home visits-in other words, leaving our offices to treat the elderly. These words almost immediately raise red flags of skepticism and remarks about impracticality. If the elderly population is regarded as a whole, then it is indeed difficult to present one solution for service delivery. If instead a range of target groups within this population can be identified, the service delivery issues become approachable. The target groups can be defined, for example, by clinical problem or living arrangement. I will describe in some detail an example of the latter approach. ,

An

Innovative

Approach

to Service

Delis’erv

So-called senior citizen buildings are increasing in number. This living arrangement provides certain unique opportunities for service delivery. For the past 3 years, I have worked I afternoon each week at such a building. This building, which is sponsored by the Department of Housing and Urban Development, is like most apartments, except that its population is predominantly over 65. Selection of tenants is primarily on the basis of economic status, with an emphasis on lower income individuals. There is also a part-time medical clinic in the building, with an internist available I afternoon a week. In addition, a relationship has been established with the area CMHC for appropniate back-up support (such as partial hospitalization if necessary). Most inhabitants of the building have both Medicaid and Medicare coverage, which pays for the bulk of their services. Although private practitioners may have a little extra paper work with Medicaid and Medicare, and this coverage may not always be equal to private coverage, reimbursement can nonetheless be respectable, with no financial loss for the practitioner. More importantly, this arrangement presents a rewarding opportunity to work with olden persons within a reasonable time frame and with reasonable back-up. Again, the practitioner can be a CMHC staff member, private psychiatnist, psychiatric resident, or other mental health worker. In this setting, people can be seen in the building’s clinic or in their apartments, with only 3 minutes of travel time via the elevator. Ofparticulan interest is the similarity of presenting problems in this setting to those seen in general psychiatric practice, i.e. depression, anxiety, paranoia, and situational reactions to loss. Equally important is the extent to which these problems respond to the traditional approaches of talking therapy and judicidus use of medication. Obvious,

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ly these are not the only problems, but a psychiatrist can have significant impact in addressing these difficulties alone. Another appealing facet has been the effectiveness with which consultation to the clinic and management personnel within the building can be carned out. Because of well-defined boundaries (i.e. the building itself), feedback on the effects of consultative discussions is rapid, which facilitates necessary modifications ofapproach. In my case. this has been an expenience in which I have essentially become the psychiatnc general practitioner for a community of nearly 300 persons, although I only have to spend one half day each week there.

with and cycle.

trying

to understand

the

later

stages

ofthe

life

CONCLUSIONS

,

WHY

WORK

WITH

ELDERLY

Problems of accessibility, compounded by myths, stereotypes, and misinformation about the elderly have interfered with mental health service delivery to this population. However, the necessary knowledge for working with olden persons is available and the rewards to be gained from treating the elderly are many and varied.

REFERENCES

PATIENTS? 1.

My experience in the service delivery model I have described has led me to believe that there are indeed many identifiable satisfactions to be gained from working with elderly patients. There can be a new frontier’ quality about working with an age group that is generally on the periphery of mental health care. This can lead to the exploration of new techniques, particularly in innovative service delivery. There is probably no other group in which the interplay of the psychological, social, and biomedical factors influencing mental health is so obvious. The psychiatnist has unique opportunities in this regard to creatively interact with other medical specialties and various support systems. If he so desires, the psychiatnist can make practical and rewarding use of his medical background. There are also appealing opportunities to combine consultation with direct service, especially in systems with well-defined boundaries (e.g.. senior citizen buildings and nursing homes). Working with olden persons, even fonjust a half day every week or two, offers important diversity to one’s regular routine. in addition, there can be both intellectual curiosity and human satisfaction in dealing ‘ ‘

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Busse

EW:

Hope

for

rejuvenation.

in Drug

chiatry. Edited by Fann WE. Maddox GL. & Wilkins Co. 1974, pp 113-115 2. Group for the Advancement of Psychiatry: rnunity

Mental

8, series 3. Butler 4.

Mosby Zeman age. N

81. New

7.

9. 10.

II.

LW:

ness

in Later

ton,

York,

GAP,

to

DC,

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Edited

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9:138-147.

Aged

and Corn-

Development.

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1971 Mental

Health.

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Detre TP. Jareki HG: Modern Psychiatric delphia, JB Lippincott Co. 1971, pp 32-48 Feinberg I: The ontogenesis ofhurnan sleep of sleep variables to intellectual function

Psychiatry 8.

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RN. Lewis MI: Aging & Co, 1973 FD: Myth and stereotype EngI J Med 272:1104-1106,

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Kahn E, Fisher C: The sleep characteristics of the normal aged male. J Nerv Ment Dis 148:477-494, 1969 Masters WH, Johnson VE: Human Sexual Inadequacy. Boston, Little, Brown, and Co. 1970 Birren JE. Butler RN (eds): Human Aging I: A Biological and Behavioral Study. Department of Health, Education, and Welfare publication ADM-74-l22. Washington. DC, US Government Printing Office. 1974 Granick S. Patterson RD (eds): Human Aging II: An ElevenYear Followup Biomedical and Behavioral Study. Department of Health, Education, and Welfare publication HSM-71-9037. Washington. DC, US Government Printing Office. 1971

Mental health services and the elderly: needs and options.

The author examines mental health issues related to the elderly from the perspective of the options for immediate impact on treatment. He stresses the...
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