DILEMMAS IN GERIATRIC PSYCHIATRY:
A Critical Exploration of Health Care Delivery for the Elderly
By Mickey Skidmore, ACSW
Demographics: The Graying of America
The increasing interest in the elderly, both in terms of healthcare delivery, and as a political power group is in large part stimulated by the new phenomenon of our increasingly aging population. The baby-boomers as they pass through life together have exerted a certain influence on the rest of society over their lifespan thusfar. The current age cohort of persons 65 years and over — 30 million strong — comprises 13% of the total population. By 2040, it is estimated that there will be 55 million elderly Americans representing 21% of the nations population. Due to the baby-boom generation, there will be an increasing proportion of elderly in this advance age category.
The Looming Medicare Crisis
One of many consequences of our aging population structure is the problems the swelling ranks pose for younger generations. For example, one of the most pressing problems is the dependency ratio (or the ratio of persons in the dependent ages to those in the “economically active” ages). In 1985, there were about 19 persons age 65 and over for every 100 working-age Americans. Estimates are expected to increase to 21 by 2000; and by 2050, the elderly dependency ratio is expected to reach 38, double the 1985 level.
In large part due to these numbers, many experts and pundits alike have predicted the insolvency, bankruptcy of the hospital insurance trust fund, and ultimate demise of the Medicare program as early as the year 2001. It doesn’t require a Ph.D. in economics to crunch the numbers and discover that these trends contribute significantly to Medicare going broke. And if this weren’t alarming enough, The General Accounting Office recently estimated that Medicare fraud represents between $6 billion and $20 billion of the $197 billion spent last year on the program, further compounding the problem.
So . . . what exactly is Geriatric Psychiatry?
I confess, I am extremely ambivalent about the term “Geriatric Psychiatry”. At face value, one might assume this term to be defined as relating to the curing or healing of psychiatric disorders of old age. Realistically however, in my own professional experience, I have found this to be ambiguous at best. There are many factors which contribute to this ambiguity. Consider the following:
*There are numerous physical and/or medical conditions which exacerbate or mimic psychiatric symptoms. I have witnessed on many occasions an ER doctor call for a psych consult for what appears to be a “psychiatric problem” in an elderly patient, without even running basic blood work or other evaluation protocols which might have revealed or ruled out an organic etiology. It would be a compelling research project to ascertain just how many “psychiatric” symptoms of the elderly are actually secondary to primary medical/physical conditions or ailments.
*The most common psychiatric disorders in later years are the affective disturbances, especially depression. Many older people experience episodes of sadness, lack of interest, and feeling of listlessness, or more serious depressions as a result of especially stressful life situations or in response to more significant losses. (If your body were gradually decompensating, and you were increasingly losing your loved ones, and/or various abilites, wouldn’t you be depressed?) It is worth noting that suicide among the elderly occurs at a rate over triple that of the general population. While younger people may often attempt suicide without succeeding, older people who attempt it rarely fail, having decided fully to die.
*Dementia(s), (previously referred to as organic brain disease) is a particularly fearsome mental condition that is typified by mental confusion, loss of memory, incoherent speech, poor orientation to the environment, and is often accompanied by poor motor coordination as well. Furthermore, this gradual deterioration of mental functioning may sometimes bring agitated behavior, depression, or delirium. Perhaps due to this older term many people today frequently refer to Alzheimer’s as a disease. However, by today’s standards Alzheimer’s actually is more accurately defined as one of several classification types or categories of dementia. Unfortunately, there is no known or recognized treatment to cure or heal these conditions. While there is some minimal success of reducing some of the symptoms with medications, most treatment interventions are behavioral and environmentally focused. Lastly, while dementia is listed in the DSM-IV (the accepted manual for psychiatric disorders) the causation of several dementia’s is due to other medical conditions. Thus, perhaps the question should be: is this geriatric psychiatry or geriatric medicine?
Emerging Psychiatric Programming for Geriatrics: Treatment or Smoke & Mirrors?
There is no doubt in my mind that with the growing elderly population base, that specialized psychiatric healthcare delivery programs are necessary. In fact, the potential for psychological change may even be greater in later years than in any other period, one motive for such change being the proximity to death. At this stage individuals have their entire past life as a backdrop against which to appraise their successes and failures. Yet historically, elderly people do not receive their share of benefits from the mental health system. Many mental health professionals tend to avoid dealing with elderly people, possibly because of their own unresolved conflicts with parental images and a need to deny their own mortality. In part at least, this contributes to a general “attitude of futility” that surrounds psychotherapy administered to the elderly, which may have been inadvertently reinforced by the trend to reduce treatments predominantly to medications. As a last refuge then, geriatrics have been subjected increasingly towards “custodialism”; that is, the aged are simply (being) placed in nursing homes.
Shrewd (and large) business entities have recognized these trends as well, and have moved to capitalize with the fundamental economic principal of filling this need. However, I have serious concerns that they are more interested in getting there hands in the Medicare cookie jar, than they are in providing sorely needed specialized treatment for this population.
While it may be encouraging to see new programs and healthcare delivery systems emerging for the elderly, closure examination may lead ultimately to further discouragement and cynicism. Having few models to base specialized service delivery to this target population, many large corporations modeled their programs on previous ones already in place. Given the unique aspects of geriatric psychiatry, this may be tantamount to forcing a circle into a square slot. I can only speak of my own professional experiences and hope they are not an accurate reflection of the industry as a whole. However, my fears are that these experiences reflect more of the norm than the exception. For example:
*I know of an inpatient hospital program that was intended to provide “acute care” for geriatric psychiatric patients. Specifically, they set up their programming loosely based on adult acute care units which had been previously successful in other hospitals. When the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reviewed the program, the hospital staff informed them of the program’s admission criteria, the program’s multi-disciplinary approaches to individual and group therapies, activity therapy, etc. However, this plan was quickly abandoned. No sooner was JCAHO out the door, than this program began accepting patients. Once the program had been accredited, the unofficial admission criteria became: if a Nursing Home had a patient they no longer wished to deal with, and the patient was breathing — they were admitted! (I swear, this is not an exaggeration). Never mind that the bulk of the staff was inadequately educated or trained to deal with predominantly demented geriatrics… Forget the fact that this program regularly accepted patients in direct violation of the program’s own and the hospital’s policy regarding patients with predominantly medical conditions… Disregard that over 90% of these patients were inappropriate for traditional group or individual psychotherapy approaches… Forget altogether, that there was little realistic hope of improving the patient’s condition. What mattered first and foremost was the bottom line — all these patients had Medicare and/or Medicaid — which would reimburse the hospital and the company managing this program for “treatment” of any psychiatric disorder listed in the DSM-IV. From my perspective, this was not an acute care geriatric psychiatric program. It was nothing short of a fraudulent scam — raping the Medicare benefits of Nursing Home patients ostensibly under the guise of treating psychiatric conditions. All the good intentioned staff members who struggled to make a small difference in their daily interactions, could not change this reality.
*Likewise, other businesses are emerging, targeting their services specifically to Skilled Nursing Facilities (SNF’s)/Nursing Homes directly. They recruit psychotherapists (all Medicare eligible) to go into SNF’s to do evaluations and subsequent follow-up treatment/interventions. While this seems reasonable at face value, and may indeed prove beneficial to the small percentage of SNF patients who could adequately respond to psychotherapy approaches, the overwhelming majority of geriatrics in SNF’s typically suffer from varying classifications of dementia or other serious medical conditions which makes them inappropriate candidates for traditional psychotherapies. Imagine if you will, a group of 8-10 Alzheimer’s patients in a Nursing Home receiving “group psychotherapy”. Your tax Medicare dollars hard at work . . .
*As if these examples weren’t bad enough, South Carolina has a much deeper quagmire of convoluted governmental policies to deal with the elderly in their nursing homes. Consider that the predominant treatment interventions for dementia focuses primarily on medications. (In fact, changing medications is one of the few tangible justifications for inpatient admission of “acute care” geriatric psychiatric patients, considering that most other treatment interventions can be provided in the SNF). Yet, South Carolina law requires SNF’s to discontinue psychotropic medications within 10 days of their return to the Nursing Home (even if this was the only discernible treatment offered showing any signs of symptom reduction). While this law was likely intended to ensure that psychotic patients were not “dumped” in Nursing Homes, in effect for the patient experiencing psychiatric afflictions (even if may be dementia), this becomes little more than a revolving door between agencies — all receiving Medicare payments. Moreover, South Carolina’s governmental policies and structure is simply not sufficient to adequately address geriatric patients who genuinely suffer with psychiatric difficulties. Although South Carolina professes to have Level II facilities for these patients (regular SNF patients would be considered Level I), the reality is they essentially do not have the tangible facilities or resources to meet the needs of these patients. Even expressing concern or outrage through the appropriate governmental channels yields few if any results. Ultimately, it may require a class action law suit to force South Carolina to meet its responsibilities regarding this issue.
No-one is debating the need for specialized programming and services to meet the unique needs of genuine geriatric patients with psychiatric conditions. Furthermore, it is abundantly clear that specialized programming and healthcare delivery is also desperately needed for the demented geriatric patient, considering traditional psychotherapeutic approaches are generally both inadequate and often inappropriate, and medications offer only minimal results. However, in our desperation to meet these increasing programming needs, we must be vigilant to the greedy and unethical practices of corporations and unscrupulous individuals who’s primary motivation is predominantly mercenary in nature, disregarding ethical and professional integrity.
Perhaps because of some of the concerns raised in this article, the newest trend in geriatric psychiatry is the emergence of Partial/Day Care Programs, which are beginning to become increasingly prevalent. They may very well be a more a appropriate service program for the geriatric psychiatric patient and well worth Medicare reimbursement. Yet, we should carefully scrutinize the ethical and professional viability of such programs. Beyond this, Home Health Care — already the fastest growing segment of healthcare (also paid for in large part with Medicare funds), will no doubt position itself to contribute to these service needs as well.
Solving the approaching Medicare crisis is already a complex issue. And with all these various companies, organizations, programs, and agencies getting their hands in the Medicare cookie jar, we had better make sure we ask some hard and serious questions — clearing any ambiguity or doubts about whether these programs are actually yielding the results they are intended to do. This is something we can do. This is something we must do.
Atchley, Robert C. Aging: Continuity and Change. Wadsworth Publishing Company, Belmont, CA, 1983.
Butler, Stuart M. How To Fix Medicare. CNN/Time Counterpoint, July 12, 1996. http://allpolitics.com/1996/counterpt/9607/12/.
DSM-IV: Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) American Psychiatric Association, Washington, DC, 1994.
Moon, Marilyn. Facing Up To Medicare’s Future. CNN/Time Counterpoint, July 12, 1996. http://allpolitics.com/1996/counterpt/9607/12/.
Rogers, Dorothy. Life-Span Human Development. Brooks/Cole Publishing Co.
(A Division of Wadsworth, Inc.), Belmont, CA, 1982.
Clinton Tightens Medicare Rules.http://allpolitics.com/1997/03/25/clinton.medicare.
“Remember Me” — Kenneth Chafin
When you forget your own address and find yourself on strange streets we’ll sell your car, and I’ll drive youto all the places you need to go, like you did for mewhen I was a child.
When you forget how to dressand end up with three sweaters, two sets of panty hose, and a slip on over your dress, I’ll help you look properwhen you go out, like you did for mewhen I was a child.
When the words on the menudon’t match the pictures in your mind, and you keep ordering things you won’t eat, then I’ll order the foodthat I know you’ll enjoy, like you did for mewhen I was a child.
When finding your way at church is frightening, I’ll take you to your class and pick you upand let you sit with me in big church. If the sermon seems long and you get sleepy, I’ll let you put your head on my shoulder, like you did for me when I was a child.
When hot and cold faucets confuse you, I’ll put you in a tub of warm water and give you a bath like you did for mewhen I was a child.
When you forget who people are and can’t tell your family from total strangers, I’ll be your memory and tell you their names, like you did for mewhen I was a child.
When they’re having a party for all the residents, and you want to go but don’t know what to wear, I’ll make you a costume that everyone will envy, like you did for me when I was a child.
When you forget who I am, not just my name or my birthday, but that you ever had children, then there isn’t much I can do but go somewhere and cry, like I sometimes did when I was a child.