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The ranks of the elderly are swelling, yet fewer and fewer physicians are choosing to practice geriatric psychiatry. What will be the impact on older patients who receive their mental health care from primary care physicians?
Much has been written about the unprecedented increase in the number of elderly people in the United States, which can be attributed to the aging of the baby-boom generation as well as to changes in mortality rates. What has not been noted as often is the pending parallel explosion in the number of older adults with behavioral disorders. With more effective treatments for psychiatric illnesses, the high mortality in mentally ill young adults should begin to decrease, resulting in a greater number of those who will reach old age. Furthermore, with the overall growth in the elderly cohorts, there will be more elderly individuals who will have the chance of developing late-onset psychiatric disorders, often associated with underlying medical or neurological diseases (Jeste et al., 1999).
This country is also facing an extreme shortage of health care professionals skilled in treating elderly people with behavioral disorders. Presently there are 2,360 board-certified psychiatrists who have passed the American Board of Psychiatry and Neurology examination for added qualifications in geriatric psychiatry (Jeste et al., 1999). A total of 49 accredited geriatric psychiatry fellowship programs exist in the United States, and they train less than 100 psychiatrists each year. It has been estimated that 4,000 to 5,000 geriatric psychiatrists who are active in patient care will be needed by the year 2010. In addition, 400 to 500 academic geriatric psychiatrists will be needed (Halpain et al., 1999).
Primary care physicians provide much of the mental health care for older adults, but numerous studies have demonstrated that these physicians receive little training in geriatric psychiatry and are often unprepared to accurately diagnose and effectively treat behavioral problems in the elderly. A survey of primary care physicians found that 20% considered themselves "not very knowledgeable" about geriatric mental health care issues, and only 66% of the physicians regarded themselves as "somewhat knowledgeable" (Droge and Billig, 1992, as cited in Halpain et al., 1999). It should also be noted, however, that nearly 90% of these physicians stated that they would be interested in increasing their knowledge of geriatric psychiatry.
How might this shortage of geriatric psychiatrists impact the outcome of an illness typically seen in the elderly, such as Alzheimer's disease (AD)? During the past decade, numerous advances in the comprehensive treatment of this disease have been documented. Cholinesterase inhibitors (such as tacrine [Cognex], donepezil [Aricept] and rivastigmine [Exelon]) have been shown to provide symptomatic treatment of the cognitive deficits for a period of time (Small et al., 1997). Long-term studies with tacrine have demonstrated the benefit of a delay in nursing home placement by approximately one year. Due to the increasing number of patients with AD, the need to delay institutionalization is imperative (Knopman et al., 1996).
This leads one to wonder about the differential outcome of patients with AD treated solely by their primary care physicians versus those also treated by a geriatric psychiatrist. Are there differences in the cognitive outcomes of patients from each cohort? Do generalists differ from specialists in the prescription of cognitive enhancers? How about the utilization of health services or placement into a long-term care facility?
The purpose of the pilot study by Aupperle and Coyne (2000) was to examine a cohort of patients with AD and their caregivers at one-year intervals. After a comprehensive university-based neuro-psychiatric evaluation (including neuropsychological testing), the use of health services of those patients who had been treated only by their primary care physicians was compared with those who had also received treatment by a geriatric psychiatrist. Clinical outcome and the prescribing patterns of donepezil were also examined.
All dementia patients who were diagnosed with AD (n=80) and their caregivers were surveyed after initial assessment. Data collected at baseline and at follow-up included assessments of cognition using the Clinical Dementia Rating (CDR) Scale, physician practices, caregiver distress and utilization of health services by the patient.
Fifty-eight patients were contacted for a one-year follow-up. Of those, 31 patients were seen only by their primary care physicians (MED), who received a detailed consultation letter, while 27 patients were receiving additional treatment from a geriatric psychiatry faculty (GERO) member in collaboration with a case manager (e.g., geriatric social worker or geriatric nurse). Case management involved AD education, a detailed review of caregiver coping skills, behavioral management, community resources, long-term care planning, and legal and financial planning.
At the two-year follow-up, 39 patients -- 22 MED patients and 17 GERO patients -- were contacted (Aupperle and Coyne, unpublished data). Several significant issues surfaced in the treatment of AD by primary care physicians versus geriatric psychiatrists. While hospitalization rates (38.7% MED versus 14.8% GERO) and use of home health aides (45.2% versus 18.5%) were significantly different in the pilot study (Aupperle and Coyne, 2000), there was no significant difference between the groups at the two year follow-up. An important issue that was not investigated in the pilot study, however, was institutionalization. MED patients had a significantly higher institutionalization rate in the two-year follow-up study (30% versus 4.6%) (Aupperle and Coyne, unpublished data).
With the cohort of patients treated only by a primary care physician, there was decreased use of donepezil (45.5% versus 76.5%). This is consistent with the results from the one-year follow-up, which also revealed a significant difference in the prescription of donepezil (35% versus 64%). This may reflect an incomplete understanding of reasonable expectations of the medication by either the primary care physician or the caregiver. The percentage of GERO patients receiving donepezil may reflect continual reinforcement by the physician and case manager.
In addition, the CDR of the MED patients had deteriorated significantly more than the CDR of the GERO patients at the one-year mark. The differential decline in the CDR could be the result of the differing prescribing patterns. Greater cognitive decline has also been associated with increased hospitalization (Weiler et al., 1991). The increased utilization of home health aides by the MED patients may also be a function of greater global impairment compared to the GERO patients.
Although clinical practice guidelines are disseminated to standardize and improve the care of patients, their benefit is variable. Solely disseminating practice guidelines may not be the most effective way of changing physician practices. Instead, a comprehensive intervention for enhanced treatment in the primary care setting may be indicated. There also exists a need to analyze physician knowledge, attitudes and behaviors regarding the diagnosis and treatment of AD.
Significant differences in institutionalization, cognition and donepezil prescriptions emerged during the two-year follow-up in this comparison of two different models of care (Aupperle and Coyne, unpublished data). Primary care intervention trials would be useful in assessing differences in outcomes after an educational intervention, in order to determine if a collaborative care model is efficacious. This would need to be assessed in a large-scale prospective study. Additionally, the assessment of the cost/benefit implications (both direct and indirect) of such an intervention would be necessary. Such a study has been recently initiated at Robert Wood Johnson Medical School as a collaboration between geriatric psychiatry and several primary care sites.
In summary, our country is facing an extreme shortage of health care professionals skilled to treat elderly people with behavioral disorders. Currently, there are approximately 4 million Americans with AD -- roughly 10% of the population over the age of 65 -- and most of these individuals have behavioral complications such as depression or psychosis during the course of their illness (Small et al., 1997). The aforementioned research demonstrates the advantage of having a geriatric psychiatrist treat this illness, in terms of both clinical outcomes and the use of health services.
The cost of caring for a person with dementia is twice as high as the cost of caring for the average Medicare patient. In addition, patients with dementia account for 10% to 30% of nursing home admissions, at a cost of nearly $100 billion annually (Small et al., 1997; Weiler et al., 1991). It is imperative that this shortage of geriatric mental health care professionals be addressed. This will likely involve both educational and financial incentives to enhance the "pipeline" of individuals who are exposed to geriatrics early in their training and professional development.
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5. Small GW, Rabins PV, Barry PP et al. (1997), Diagnosis and treatment of Alzheimer disease and related disorders. Consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society. JAMA 278(16):1363-1371 [see comment].
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