By Karen Stephen, Ph. D., Mental Health Clinical Director, Partnership HealthPlan of California

ISSUES:

As a Medi-Cal MCP, we don’t often think about serving elderly or 65+ Members, but October 2017 Medi-Cal eligibility tables indicate that 45,145 Medi-Cal eligible 65+ Members reside in PHC’s 14-county service area. When divided by Aid Group, 323 of those are listed under Parent/Caregiver Relative & Child (let’s give a shout out to those grandparents who are raising grand- or great-grandchildren!), 524 are Undocumented, and 36,562 fall within the SPD (Seniors and Persons with Disabilities) category. Nearly all of 65+ Members (40,137) are listed as dual eligible (meaning Medicare would be the primary insurer for mental health care instead of Beacon Health Options).

Isn’t it interesting that once you’re over 65 (speaking as a person who is 74), that you automatically get lumped in with those with a disability. Perhaps as a nation, we do see age simply as the “final” disability instead of seeing aging as our golden passport into the “venerable elder” category.

According to the World Health Organization, the most common mental health problems in this age group and the percentage affected world-wide are dementia (5%) and depression (7%). Anxiety is seen in 3.8%, and substance use disorders in 1%. Remarkably, one-quarter of all deaths from self-harm are among people 60 and above. In addition, one in ten are vulnerable to elder abuse (physical, verbal, financial, sexual, or abandonment/neglect). Reduced mobility, chronic pain, and frailty combine to require long term care. Other factors such as bereavement, drop in socioeconomic status lead to isolation and loneliness.

And here are some startling statistics: There are currently 50 million people with dementia (60% residing in low to middle income countries). There will be 82 million in 2030 and 152 million in 2050. Calculate for a moment how old you will be 12 or 32 years from now—and think about what chances you will have of receiving treatment and resources for possible dementia at that age!

Two other important issues cited by WHO:

• Elders with depression have POORER functioning than those with chronic medical conditions such as lung disease, hypertension, and diabetes.
• Depression increases the PERCEPTION of poor health and thus increases utilization of healthcare services and costs.

The CDC cites some other important issues:

• Depression is more common in those who have other illnesses and whose function is limited
• Older adults are underdiagnosed—symptoms of depression are seen as just a natural reaction to illness or life changes and, therefore, not to be treated. And, even worse, older adults share this belief.
• Estimates of occurrence of depression is 13.5% in those who require home health care, and 11.5% in those hospitalized.

Here is a FACT SHEET for Depression in Older Persons distributed by NAMI, for an in depth discussion of the topic.

TREATMENT:

In treating patients 65+ for mental health disorders (because the majority are duals), they will not be eligible for Beacon services even though their condition may fall within the mild to moderate range. If you do not have resources within your clinic to treat these patients under Medicare (pamphlet on Medicare Mental Health Services), then two resources for finding mental health professionals in your community who accept Medicare is the Medicare Physician Compare page or the Psychology Today website.

But the old adage applies. You can lead a horse…etc. The main referral issue is that, as cited above, seniors are not likely to see the need for mental health care and are even more sensitive to the stigma issue because of their generation. A recently published major study of 240,000 patients receiving a diagnosis of depression in the PRIMARY CARE setting, indicated that only 37.5% start treatment, that those 60+ were half as likely to start treatment than those under 44, and that 80% chose medication over psychotherapy (with only 7% of those over 75 choosing therapy). Here are some tips to increase odds of the elderly accepting psychotherapy as a treatment option for depression:

• Do use the PHQ-9 to diagnose their depression. But in discussing the results, use a TRAUMA INFORMED approach. Focus not on what is WRONG with the patient but WHAT THEY ARE GOING THROUGH. For example:

• DON’T SAY: Our screening indicates you are suffering from depression and I recommend [medication and psychotherapy options].

• DO SAY: Seniors your age who have gone through so much [cite their specific chronic illnesses, losses, changes in economic status, falls, and isolation] that they often suffer from depression. I can prescribe medication but you can also learn coping skills and get needed support from a therapist or counselor. Can I help you find someone you can talk to about your life situation and needs at this time?

• Of course, if there are risk factors present (age, in and of itself, being one of them), be sure to use County crisis services or law enforcement as needed for crisis intervention.

MEDICATION:

As a psychologist I cannot make recommendations regarding medication in the treatment of mental health problems in the 65+ population, but I will pass along some general recommendations from sources available online.

From an article on Pharmacologic treatment of depression in the elderly (2014):

• Motto: START LOW and GO SLOW!
• Initial dosing should be half of the usual adult starting dose and be titrated regularly until the patient responds, until the maximum dose is reached, or until side effects limit further increases.
• Common side effects of medications include falls, nausea, dizziness, headaches, and, less commonly, hyponatremia and QT interval changes.

And on the risks of using antidepressants and benzodiazepines for depression and anxiety in the elderly from an article on Geriatric pharmacotherapy (2015)

• Antidepressants.For the elderly, the most significant risks include anticholinergic, sedative, cognitive, cardiovascular (blood pressure and conduction), falls and increased bleeding (made worse for the elderly already receiving anticoagulant medication).
• The problems with using benzodiazepines in the elderly include a reduced capacity to metabolize the drugs in the elderly (increasing their t_1/2 and increasing the risk for toxicity); active metabolites in some of the medications (essentially creating an extended release function); the side effects of cognitive (executive function), memory and attentional deficits (functions which may already be impaired in the elderly); decreased reaction time; and increased risk for falls. Add to this that benzodiazepines may cause paradoxical reactions (i.e., increase agitation) in the elderly; can produce carryover effects next day; and can produce tolerance, dependence and respiratory depression. Also, once started, benzodiazepines are notoriously difficult to withdraw.

An important resource for prescribing to the elderly is the American Geriatrics Society (AGS) Beers Criteria (2015) providing information on medications that are either ineffective or high risk when used to treat elderly patients.

A LAST PERSONAL NOTE on FALLS AND DEPRESSION:

As a senior who had a recent fall when on vacation and sustained a head injury, I have become well aware of the risks of falling and its connection to depression. The trauma and subsequent mobility limitations and social isolation almost immediately triggered depressive and anxiety feelings—even while I was still in “paradise” (kudos, by the way, to the marvelous staff at Kaiser Moanalua in Oahu during my 2-day stay). And this occurred in someone not compromised by chronic illness, mobility or balance issues, not under the adverse effects of any substance or medication, and not cognitively impaired (at least not before the accident!). How much more significant a fall is in terms of personal and societal costs for seniors who have these comorbid conditions.

The U.S. Centers for Disease Control and Prevention cite that:

• One in four Americans aged 65+ falls each year.
• Every 11 seconds, an older adult is treated in the emergency room for a fall; every 19 minutes, an older adult dies from a fall.
• Falls are the leading cause of fatal injury and the most common cause of nonfatal trauma-related hospital admissions among older adults.
• Falls result in more than 2.8 million injuries treated in emergency departments annually, including over 800,000 hospitalizations and more than 27,000 deaths.
• In 2014, the total cost of fall injuries was $31 billion.
• The financial toll for older adult falls is expected to increase as the population ages and may reach $67.7 billion by 2020.
• Falls, with or without injury, also carry a heavy quality of life impact. A growing number of older adults fear falling and, as a result, limit their activities and social engagements. This can result in further physical decline, depression, social isolation, and feelings of helplessness.

Seniors can find evidence-based fall prevention and balance programs through their Area Agency on the Aging or their Public Library. Members assigned to Kaiser Permanente can register for Fall Prevention classes there. Some counties have fall prevention services that can assess homes for risks of fall and provide advice and night lights.