Brian Draper, MD

The world is rapidly aging. In 2013, the global population aged 65 years and older was nearly 579 million (8.2% of the total population), and by 2050 it is projected to be over 1.45 billion (15.6%).

 This demographic transition is occurring much more rapidly in low- and middle-income countries compared with high-income countries, particularly for those aged 80 years and older. This poses the challenge of how low economic development will influence the management of population aging so that the dignity and rights of older persons are respected and protected, particularly those who are vulnerable because of mental illness, social isolation, or physical debility.

Dementia is the most prominent mental disorder in late life: worldwide in 2010, 4.7% of those aged 60 years and older were affected, and the prevalence has increased exponentially with age to between 29% (East Asia) and 64% (Latin America) of those aged 90 and older. There were an estimated 35.6 million people with dementia worldwide in 2010, and the numbers are projected to double every 20 years to 65.

 million in 2030 and 115.4 million in 2050. In 2010, 58% of all people with dementia lived in low- and middle-income countries; this percentage is projected to increase to 71% by 2050.

About 30% of persons with dementia experience behavioral and psychological symptoms at a level that would benefit from the involvement of geriatric psychiatry.

 Common behaviors that prompt referral include agitation, aggression, sleep disturbance, depression, and psychosis. The challenge for the clinician is to establish causal factors in an individual case to inform the management plan. A typical referral for an 80-year-old nursing home resident with moderate Alzheimer disease complicated by severe restlessness and vocal disruption might result in the identification of a range of possible causal factors, including arthritic pain, discomfort from a urinary tract infection, social isolation, and boredom. [[{"type":"media","view_mode":"media_crop","fid":"22893","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2358907605948","media_crop_h":"307","media_crop_image_style":"-1","media_crop_instance":"1702","media_crop_rotate":"0","media_crop_scale_h":"178","media_crop_scale_w":"160","media_crop_w":"276","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]Each of these factors needs to be addressed in the management plan for the behavior to improve. It is this type of intellectual challenge in working through complex comorbidities that contributes to the high job satisfaction among geriatric psychiatrists.

Depression is the other major mental disorder of late life: nearly 20% of older people have a depressive disorder and more than 3% have major depression. The latter is more common in those over age 75, in whom the prevalence appears to be about 7%.

 Confounding issues such as physical illness, cognitive impairment, and residence in a long-term care facility result in marked heterogeneity in the published prevalence of late-life depression.

 Understandably, these factors pose challenges to clinicians in their assessment and management of older persons with affective symptoms. An example is a 78-year-old single woman who lives alone. She has a 3-month history of depressive symptoms in the context of a stroke in the previous year that led to mild cognitive deficits, apathy, and gait disturbance. She requires medical assistance for hypertension, diabetes, and ischemic heart disease. The geriatric psychiatrist frequently faces this type of challenge to determine the extent to which this patient’s symptoms result from a post-stroke depressive disorder, an evolving vascular dementia, or perhaps a medication-induced depression-with the different implications each differential diagnosis has for management and prognosis.

Care coordination with the primary care physician, pharmacist, nurses, and others in the multidisciplinary team is essential. Open communication and collaboration are key, whether by electronic medical records, shared written reports (hard copy or electronic), case conferences (face to face, phone, or video), or joint rounds.

Meeting the needs of the elderly population

Data from a recent meta-analysis from Europe and North America in adults aged 50 years and older are summarized in 

 The prevalence of anxiety disorders, substance use disorders, and psychoses is generally lower than in younger adults.

 There are concerns that the baby boomer generation, whose oldest members turned 65 in 2011, will herald an increase in substance use and mood disorders in late life.

I am not aware of any country that has adequately addressed the challenges of establishing and training a workforce to meet the current and future mental health needs of older adults. Despite the aging population, many countries lack adequate geriatric psychiatry service development and some countries are seeing a decline from previous levels,

 even though prominent professional organizations, such as the International Psychogeriatric Association (IPA), are providing international leadership in this area and are increasing research into late-life mental disorders.

 What are the reasons for the workforce deficiencies around the world? And what needs to be done to address the gaps that are readily apparent?

The key issues that contribute to the challenges facing geriatric psychiatry workforce development are listed in 

. These issues affect low- and middle-income countries differently than they do high-income countries.

India, China, Brazil, and Nigeria are examples of low- and middle-income countries. Over a third of the older people in the world currently live in India and China. According to Vinod Gangolli, an IPA board member from Mumbai, India, and Shuiyuan Xiao from the School of Public Health, Central South University, Changsha, China, similar challenges are present in each country (personal communications, September 2013). There is inadequate government focus on issues of aging with a lack of social security and very limited geriatric psychiatry services. These countries have few hospitals for geriatric mental disorders (fewer than 100 in China in 2004); most are located in cities, and community mental health resources are scarce.

For the 125 million people currently aged 65 years and older in China, there are about 100 geriatric psychiatrists-or 1.25 million older adults per geriatric psychiatrist! The number of general psychiatrists and mental health nurses with even minimal training about late-life mental disorders is limited, and primary care providers (formerly “barefoot doctors”) have even less training; hence, there is a huge gap in service delivery.

 Little is known about what happens because of this lack of expertise and services. Much is attributed to normal aging, and high levels of stigma about mental disorders in both countries result in avoidance of help-seeking. Referrals are often delayed until symptoms are quite severe. These challenges are amplified by demographic changes with the migration of young adults from rural to urban areas, leaving older adults in rural areas with few family supports.

Nigeria, which has the largest population of older people in Africa, faces similar challenges: policy makers pay little attention to the aging population. There are pockets of specialist services for older people in the major cities but little rural development. Olusegun Baiyewu, an IPA board member from Ibadan, Nigeria, noted that psychiatrists at 4 university teaching hospitals and 3 psychiatric hospitals have developed geriatric psychiatry clinics. An important event took place in Ibadan in November 2012, when Nigeria’s first geriatric assessment unit was opened (personal communication, September 2013).

Brazil, which has the largest population of older people in South America, has made some headway. Geriatric psychiatry became a certificated branch of psychiatry in 2008, although there are still few geriatric psychiatrists. According to Cassio Bottino, an IPA board member from Sao Paulo University in Brazil, the most challenging issues facing the country in the next few years are the need for more training programs around the country and increased emphasis on screening for mental disorders in primary care (personal communication, September 2013).

In high-income areas of the world, such as North America, Western Europe, Japan, and Australasia, service developments in geriatric psychiatry have stalled and in some ways are in retreat. Subspecialty training in geriatric psychiatry remains limited to a few countries. More European countries are developing training programs, although their qualifications tend not to be recognized outside of their own country. In the US, the 2012 Institute of Medicine (IOM) report on the mental health and substance use workforce for older adults identified numerous barriers to workforce development.

 The number of geriatric psychiatrists in the US is waning: fewer than half of the available geriatric psychiatry fellowships are being taken up.

 To a lesser extent, the number of geriatric psychiatry trainees has also decreased in the UK, Australia, and New Zealand, while in Canada there are insufficient training posts (Dallas Seitz, Queen’s University, Kingston, Canada, personal communication, September 2013).

Systemic deficiencies were identified in the IOM report with 3 key findings

• The old age mental health workforce lacks clear definition

• There is an absence of accurate data on workforce supply and demand

• Financial disincentives and limited opportunities hamper recruitment

These findings are not unique to the US and suggest a low prioritization of aging mental health issues by policy makers. Only a few countries such as the UK, Australia, New Zealand, Netherlands, Norway, and Switzerland have comprehensive integrated geriatric psychiatry services with reasonable geographic coverage.

Demographic imperative alone is not enough to influence policy makers to support the development of geriatric psychiatry services. Evidence of effectiveness is also needed for specific mental health interventions and service delivery configuration.

In the past decade an increasing number of countries have developed national dementia strategies, but I am not aware of any country that has a comprehensive geriatric mental health strategy. The low prioritization of aging mental health by policy makers of high-income countries is demonstrated by a failure to address fragmented service structures that are poorly resourced. In the US, it is hoped that the Affordable Care Act might provide the impetus to give geriatric mental health higher priority in service development (Jeffrey Lyness, past President, American Association of Geriatric Psychiatry, personal communication, September 2013).

The economic downturn since 2008 has stalled service developments in countries such as Ireland and New Zealand that otherwise have reasonable service frameworks (personal communications, Greg Swanwick, Dean of Education, College of Psychiatrists of Ireland, and Chris Perkins, old age psychiatrist, Auckland, New Zealand, September 2013). In Australia, which also has relatively well-developed services, aging mental health issues are split between different federal and state government departments, but a cohesive national policy or service structure is still lacking. Furthermore, policy makers have overtly prioritized youth mental health over aging mental health.

The relatively successful campaigns of dementia advocacy groups, such as Alzheimer Disease International, are also inadvertently contributing to fragmentation of policy and service delivery. In the UK, there is mounting concern that demands for early dementia diagnosis and services are occurring at the expense of other mental disorders; these concerns have been echoed in New Zealand and Australia (personal communications, Susan Mary Benbow, IPA board member, UK; Dave Anderson, past Chair, Old Age Psychiatry Faculty, Royal College of Psychiatrists; Chris Perkins; Rod Mckay, past Chair, Faculty of Psychiatry of Old Age, Royal Australian & New Zealand College of Psychiatrists, September 2013).

The absence of comparable advocacy groups for other late-life mental disorders has resulted in a relative dearth of policy-relevant information on the needs of older people. In the UK, there is pressure, because of the recently enacted Equality Act, to dissolve old age psychiatry services and replace them with general adult services with the misguided notion that this prevents age discrimination (personal communications, Susan Mary Benbow and Dave Anderson, September 2013).

Despite these challenges, there are some positive developments. At a policy level, apart from investing greater effort to combat ageism and stigma, it is essential that each country develops a geriatric mental health policy and strategy. Organizations such as the IPA can play a key role in promoting and easing international collaborations between high-income countries and low- and middle-income countries. Other organizations can also become involved: for example, the Worldwide University Network recently sponsored a meeting in Hangzhou, China, with representatives from the US, Australia, Taiwan, and Hong Kong to plan research on improving dementia care in rural China.

In geriatric psychiatry, collaborations with colleagues (psychologists, nurses, social workers, occupational therapists) in multidisciplinary and interdisciplinary teams as well as partnerships with primary care, geriatric medicine, and long-term residential and community care providers are fundamental for successful service delivery systems. Indeed, how well geriatric psychiatrists are able to forge innovative collaborations and partnerships may determine the quality of old age mental health services in the future; and this will in part relate to whether service delivery systems achieve reasonable integration. Inadequate care integration will increase the challenges and risks of geriatric psychiatry practice. Empowerment of older people with mental disorders and their caregivers so that a more overt recovery focus is achieved is likely to be the key to this process.

 Then older people with mental disorders will become their own effective advocates to improve geriatric mental health care.

Dr Draper is Conjoint Professor in the School of Psychiatry at the University of New South Wales in Sydney, Australia. He reports that he is a board member of the International Psychogeriatric Association and author of the book, Understanding Alzheimer’s and Other Dementias.

 United Nations Department of Economic and Social Affairs. World Population Ageing: 1950-2050. http://www.un.org/esa/population/publications/worldageing19502050/index.htm. Accessed January 2, 2014.

 Central Intelligence Agency. The World Factbook. https://www.cia.gov/library/publications/the-world-factbook/geos/xx.html. Accessed January 2, 2014.

 Prince M, Jackson J, eds. World Alzheimer Report 2009. http://www.alz.co.uk/research/files/WorldAlzheimerReport.pdf. Accessed January 2, 2014.

 Brodaty H, Draper BM, Low L-F. Behavioural and psychological symptoms of dementia: a seven-tiered model of service delivery. 

 Draper B, Reutens S, Subau D. Workforce and advanced training survey of the RANZCP Faculty of Psychiatry of Old Age: issues and challenges for the field. 

 Luppa M, Sikorski C, Luck T, et al. Age- and gender-specific prevalence of depression in latest-life: systematic review and meta-analysis. 

 Volkert J, Schulz H, HÃ¤rter M, et al. The prevalence of mental disorders in older people in Western countries: a meta-analysis. 

 Kessler RC, Aguilar-Gaxiola S, Alonso J, et al. Prevalence of mental disorders in the world mental health survey initiative. In: Kessler RC, Ustun TB, eds. 

The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders. 

New York: Cambridge University Press; 2008:534-540.

 Jeste DV, Palmer BW. A call for a new positive psychiatry of ageing. 

 Draper B, Anderson D. The baby boomers are nearly here-but do we have sufficient workforce in old age psychiatry? 

 De MendonÃ§a Lima CA, Draper B, Benbow SM. Old age psychiatry: challenges for the development of the specialty. http://www.ipa-online.org/ipaonlinev4/main/homepagearticles/oap.html. Accessed January 3, 2014.

 Wang H, Fernandes L, Oster S, et al. The state of psychogeriatrics in different regions of the world: challenges and opportunities. 

 Wang H, Xie H, Ma L, Yu X. The psychogeriatric workforce in China: challenges for the future. http://www.ipa-online.net/ipaonlinev4/main/homepagearticles/pwc.html. Accessed January 3, 2014.

The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?

 Washington, DC: The National Academies Press; 2012.

What Is the Effectiveness of Old Age Mental Health Services?

 Copenhagen, Denmark: World Health Organization Regional Office for Europe Health Evidence Network; 2004.

 McKay R, Draper B. Is it too late to prevent a decline in mental health care for older Australians? 

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Brian Draper, MD

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