The Pew Research Center estimates that 22 percent of the U.S. population in 2050 will consist of adults 65 and older. As adults age, they face specific risk factors that increase their chances of behavioral health challenges. For example, older adults experience changes in their physical and mental health capacities and functioning. They are also more prone to living alone, either due to death or divorce. More than 25 percent of women ages 65 or older live alone and older adults experience higher divorce rates. From 1980 to 2018 divorce rates among older women and men increased from three to 14 percent and four to 11 percent respectively. These factors may lead to increased loneliness and isolation contributing to a greater risk of behavioral health concerns.
According to an America’s Health Rankings analysis of the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System, nearly 15 percent of older adults in 2019 reported having depression, which can rise up to 35 percent among individuals in long-term care. The National Council on Aging reported that older adults comprised up 18 percent of suicides that same year, and are more likely to successfully complete a suicide attempt. They also found that men ages 65 and older have the highest suicide rate compared to other age brackets.
Physical health concerns such as chronic pain or conditions and physical disabilities can become high-risk factors for substance use disorder (SUD) in older adults. Between 1999 and 2019, almost 80,000 adults ages 55 or older died due to an overdose. The number of adults ages 65 and older with a SUD has increased and average admissions for SUD has increased over this time as well. Alcohol use disorder is one of the eight leading causes of death for older adults.
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Three main factors are contributing to a growing behavioral health crisis among this population: a historically strong focus on physical health needs, limited resources to identify and treat behavioral health needs, and a stigma that depression is inherent in old age. Risk factors and barriers to care vary across race and ethnicity as well. There are several policy, care delivery, and patient engagement solutions that could help meet the critical needs of this population.
First, enhance Medicare benefits that currently inhibit behavioral health care and restructure coverage and reimbursement of services that provide social care to improves the quality of life and prevent behavioral health conditions (e.g, transportation, community center activities). A study by Morning Consult found seniors with one or more chronic conditions cited the most common obstacles for seeking mental health care is the cost of ongoing therapy (32 percent), the cost of seeing a health care provider (20 percent), and the cost of prescription medication (17 percent). Currently, Medicare does not reimburse for some behavioral health interventions such as peer support services or assertive community treatment or for services provided by certain mental health professionals such as clinical psychologist students or licensed professional counselors. Medicare also does not cover non-emergent medical transportation leaving many seniors without a way to attend doctor appointments. Furthermore, outpatient behavioral health services covered under Medicare Part B require patients to meet a deductible and pay 20 percent coinsurance for each visit exposing patients to cost concerns.
Second, increase screening and assessment at various non-health-care settings (e.g., places of worship, community centers, independent livings, mobile clinics). Innovation in Aging reported older adults are more likely to be seen by primary care providers for behavioral health issues, and less likely to be screened for mental illness in these settings. While 80 percent of physicians felt responsible to diagnose depression, only 55 percent felt confident doing so. Other barriers include lack of time during the visit, and patient clinical complexity.
Third, incentivize and promote career paths in geriatric behavioral health to address the physician workforce shortage. The American Psychiatric Association (APA) stated the U.S. will need more than 5,700 geropsychiatry physicians to meet the needs of patients. The demand for older adult psychologists is expected to grow by 40 percent for patients ages 65 to 74 years and 71 percent for patients 75 and older. The APA also found in 2019, the National Provider Identifiers Register identified fewer than 1 percent (660) of all doctor-level licensed psychologists are in the geriatric psychology field.
Fourth, integrate behavioral health care specialists into long term care settings. The American Journal of Geriatric Psychology published the prevalence of serious mental illness in assisted living facilities increased 54 percent from 2007 to 2017. Generally, long-term care direct staff have limited knowledge and skills to address behavioral health challenges leaving patients’ conditions often go unmanaged and unrecognized leading to significantly poor health outcomes and decreased quality of life.
Lastly, provide increased family and social support, education, and engagement tools such as Mental Health First Aid. The Family Caregiver Alliance cites that family members are often unprepared and have little or no support when they take on the role of caregiver. Family caregivers consistently report higher levels of their own mental health challenges including depression and chronic anxiety.
Behavioral health conditions are not a side effect of old age and are certainly not inevitable. A set of complementary policy and care delivery reforms are required to address the behavioral health crisis among older adults. For instance, an enhancement to Medicare benefits without adequate workforce capacity to fulfill newly covered services would not support an improvement to the quality of care. Policymakers, practitioners, patients, and caregivers must collaborate to evaluate the key drivers of this crisis and develop holistic, sustainable, high-quality solutions that fill the current system gaps today.