Restoring the Inner Self
By: Source: AARP Bulletin Today Date Posted: 2003-07-29 08:28:18
Over the next 25 years, as the nation's baby boomers age, the number of Americans with late-life mental or emotional problems is expected to climb to 15 million—a surge of epidemic proportion.
Millions of Americans over 65 already struggle with the changes, losses and stresses of growing older, but their numbers are increasing sharply as the nation's population ages.
Fortunately, the past decade has seen the emergence of a full-fledged specialty in medicine—geriatric psychiatry—that's aimed at the diagnosis and treatment of mental and emotional problems that affect older people. But the need for geriatric psychiatrists still dramatically outstrips the supply. Nationwide, there are fewer than 2,600 board-certified geriatric psychiatrists—only about one for every 14,000 Americans age 65 and over.
"We're still a long way from having what is really needed within our schools of medicine—a cadre of first-rate teachers with experience in geriatric psychiatry," Robert Butler, M.D., a psychiatrist who was the founding director of the National Institute on Aging, told the AARP Bulletin. "Pretty soon 60 percent or more of all routine doctor-patient contact is going to be a reflection of the graying of America."
Consider just a few cases in which the experience and expertise of geriatric psychiatrists can be critical:
- By spotting the earliest signs of Alzheimer's disease and differentiating them from those of other dementias or drug interactions, geriatric psychiatrists can prescribe drugs to improve brain function soon enough to slow the progression of the disease.
- Experts say that substance abuse among older Americans, including the abuse of alcohol and prescription and over-the-counter drugs, is underdiagnosed and undertreated; geriatric psychiatrists can often see warning signs that primary care physicians miss.
- Americans 65 and older have the highest suicide rate of any age group; they account for about 13 percent of the population but nearly 19 percent of all suicides. Half of all older people who commit suicide had seen their doctor in the month before their death. Geriatric psychiatrists may be able to spot hidden suicidal tendencies that elude other doctors.
"Excellent care of older people with multiple physical and mental problems is complex," says Judith Salerno, M.D., deputy director of the National Institute on Aging. "It requires a comprehensive approach and often requires a specialist—such as a geriatric psychiatrist—to recognize and assess the complexities of their care."
Nathan Billig, M.D., a former director of the geriatric psychiatry program at Georgetown University Medical Center and author of "Growing Older & Wiser" (Lexington Books, 1995) emphasizes that older adults have special—often urgent—physical, emotional and psychological needs. Aging, he says, brings with it all kinds of changes: physical decline; life-threatening illness in some cases; contemplation of death in the not-too-distant future; loss of friends and possibly a spouse; retirement from a longtime job and familiar workplace; and relocation to a new home or even a new geographical area.
"Most of our medical textbooks are written about 45-year-olds, not 80-year-olds," Billig told the Bulletin. "I think geriatric psychiatrists have an increased understanding of the developmental changes in aging as well as the biology of aging."
That's especially important, Billig and other experts say, because the developmental changes that accompany aging often result in acute loneliness, anxiety, depression, confusion or other mental disorders—conditions that geriatric psychiatrists are trained to recognize and treat.
BIRTH OF A SPECIALTY
In his landmark 1975 book, "Why Survive? Being Old in America," Butler rendered a blunt verdict about his own profession.
In a section titled "Psychiatry Fails the Elderly," Butler observed: "Psychiatry as a whole—in private practice, state institutions, community mental health centers, education, training and research—shares a sense of futility and therapeutic nihilism about old age."
Butler, who was awarded a Pulitzer Prize for his groundbreaking book, joined with some of his colleagues to press for the creation and recognition of a new specialty: geriatric psychiatry.
"We thought it was essential to have such a field," Butler told the Bulletin, recalling a talk he gave in the late 1970s to a meeting of the American Psychiatric Association. "The reason was that so many of the diseases related to aging are associated with the central nervous system—from Alzheimer's disease to depression."
Butler, now president of the International Longevity Center in New York City, also argued that people with the hearing and vision losses common in aging are likelier to have such problems as depression, anxiety and paranoia (feeling persecuted and overly suspicious).
But it wasn't until 1991 that the American Board of Psychiatry and Neurology designated geriatric psychiatry as a separate specialty.
Geriatric psychiatrists complete four years of medical school, four years of postgraduate residency psychiatry training and then a one- or two-year intensive fellowship in geriatric psychiatry. They must pass a certification exam in geriatric psychiatry as well as one in general psychiatry.
BALANCING ACT
Nearly 20 percent of people age 55 years or older experience mental problems—such as depression, anxiety and dementia—that are not part of normal aging, according to the American Association for Geriatric Psychiatry (AAGP) in Bethesda, Md.
"We've had a revolution in our understanding of the brain," says Richard K. Nakamura, the deputy director of the National Institute of Mental Health. "We now know that the brain is constantly rebuilding itself throughout life." With this revolution has come what the surgeon general's 1999 report on mental health calls "a plethora of new pharmacologic agents and psychotherapies for mental disorders."
MANAGING TRICKY MEDICINES
A key reason why geriatric psychiatrists are needed today, in fact, is the increasing complexity of managing older people's medicines, says Jonathan D. Lieff, M.D., the medical director of a Massachusetts network that provides geriatric mental health services to nursing homes and hospitals. "The medications are very, very tricky," Lieff told the Bulletin. "Depression is an enormous problem; depression with medical illness is an enormous problem. You're giving medications on top of other medications. It's really a full-time job keeping up with it all."
Geriatric psychiatrists also specialize in dealing with family members—and their intertwined relationships—as well as with the patient, Lieff points out. "When you deal with an elderly person, you deal with the family," he says. "It's like a system."
A case in point: In caring for her mother, a depressed widow with Alzheimer's disease, Betty Bruen of Hoboken, N.J., sought the help of Gary J. Kennedy, M.D., director of the division of geriatric psychiatry at Montefiore Medical Center in New York City and a past AAGP president.
"Being a psychiatrist instead of a therapist or counselor, he's looking at the whole woman—body and mind together—and her independence," Bruen told the Bulletin.
In addition to prescribing medications, Bruen says, Kennedy met with family members to talk over key issues, medical and nonmedical (her mother's will, for example).
"Along the way," she says, "he's stayed available with coping advice and assistance on an as-needed basis to me and my siblings."
SUCCESS STORIES
Many geriatric psychiatrists seem to thrive on challenges that might be daunting to other doctors.
One tells the story of a recently widowed woman of 77 who had trouble sleeping (as do half of all older people). The woman's doctor had prescribed a sedative-hypnotic (sleeping pill), but it made her so dizzy and confused that she almost fell when she got up at night to go to the bathroom.
The geriatric psychiatrist immediately took the woman off the sedative-hypnotic, which can be habit-forming, and suggested that she change her daily routine to get more exercise (by walking), reduce her nap time, use her bed only for sleep and go to bed and get up at the same time every day. He also suggested that she write down her feelings of grief in a journal and come in to meet with him for counseling sessions. The woman's sleep soon improved with no medication.
Stories like these are the rule, rather than the exception, in geriatric psychiatry. Some practitioners, in fact, say that's precisely why they chose the field.
"In the course of my workweek, I couldn't possibly get bored," says AAGP president Joel E. Streim, M.D., associate professor of psychiatry at the University of Pennsylvania School of Medicine. "It's every bit as intellectually challenging and exciting as intensive care medicine."
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