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By Kristen Heitkamp and Mary Louise Bussabarger*

Background

Missouri’s senior population is increasing at an unprecedented rate. This trend is projected to continue until growth in the senior population, as well as seniors as a proportion of Missouri’s population, peaks around 2020—when the largest annual baby boom cohorts reach age 65. These demographic changes will affect some state regions more than others: for some time, trends have indicated that the “most significant increases in the 55-64 age cohort during the 1990s occurred in suburban, small city and retirement recreation counties.” These increases “tends to confirm the pattern of retiree in-migration.”¹ Along with a growing population of retired baby boomers, Missouri’s seniors are living longer lives. Both factors will contribute to increased demands on health care delivery, especially in rural areas. Coupled with health problems, mental health needs present a growing concern for the state’s health delivery system. Missouri seniors, their families, policy makers, and service providers will face particular challenges related to senior mental health.

Challenges

Depression

Depression continues to be the leading mental health concern for older adults, as noted by Senior Report 2006. Depression and associated disorders, particularly dysthymia (mild depression), are generally underreported by older adults, and consequently untreated. Many older adults develop depression in response to grief, social and familial losses, and chronic physical diseases. “Clinically significant depression in older adults results in greater risk of suicide, poorer outcomes on medical conditions, such as diabetes and heart disease, as well as an overall shortened lifespan and increased mortality rates.”²

Alzheimer’s disease and dementia

Alzheimer’s disease (AD) and associated dementias are irreversible, debilitating conditions, which increase the burden on health care services as individuals with these diseases age. The 2005 estimates of the prevalence of AD vary from 110,000³ to 125,000⁴, or approximately 14%, of Missourians over the age of 65. The costs associated with dementia health care are significantly higher than caring for those without dementia. Reporting in 2000, annual Medicare spending in nursing homes, for a person over 65 in with dementia was $13,207, while the cost for a person without dementia was $4,454.³

Of the 75,103 Missourians in long term care in 2005, an estimated 42% had severe cognitive impairments, and 29% had “very mild” to “mild” impairment. ³

According to the Alzheimer’s Association, “Medicare beneficiaries with Alzheimer’s and other dementias had 3.4 times more hospital stays than the average for other beneficiaries, and the costs for hospital care were 3.2 times higher than the average ($7,704 versus $2,204). Ninety-five percent of Medicare beneficiaries age 65 and over with Alzheimer’s and other dementias have at least one other chronic condition, including congestive heart failure, coronary heart disease, diabetes and/or chronic obstructive pulmonary disease. Among beneficiaries of these relatively costly conditions … Medicare costs are more than double when dementia is present.”³

Persons with Alzheimer’s and other dementias make slightly more visits to a doctor (1.3 times), but the availability of appropriate care is an issue. “The greatest barriers to screening and treatment exist in rural areas. Approximately one third of Missourians with dementia live in rural counties. Changing demographics suggest that a substantial portion of these live alone and thus may face even greater healthcare challenges.”⁴ Further, rural caretakers have fewer respite and support services than those in urban areas.⁶

Long-term medical complications of psychiatric drugs

As the baby boom cohort ages, an increasing number of persons taking “new generation” psychiatric drugs will require health care services for related chronic diseases. Recent research compares patients with bipolar disorder receiving conventional treatment, such as lithium, with patients receiving newer antipsychotic drugs, such as clozapine, risperidone, olanzapine and quetiapine.⁷ Findings show that the development or exacerbation of diabetes mellitus is associated with antipsychotic use in bipolar patients, particularly the use of novel antipsychotics.⁸ The treatment of bipolar disorders places these seniors at “risk for developing diabetes … associated with weight gain, hypertension and substance abuse.” ^7,8

Substance Abuse

Federal studies estimate that abuse of alcohol and legal drugs affects as many as 17% of adults aged 60 and older. “Prescription drug misuse and abuse are prevalent among older adults, not solely because more drugs are prescribed, but because aging affects vulnerability to drugs.” Moreover, the aging baby boomer cohort will increase not only the number of substance abusers, but also the demands on the substance abuse treatment system.⁹

Suicide

The suicide rate of those 65 years and older is the highest rate of any age group, while the rate for Missourians 85 years and older is twice the national average (CDC 1999). Missouri’s age-adjusted rate of suicide is 22% higher than the national average. “The suicide rates among adolescents and elderly males are of particular concern.”¹⁰ Compared with non-veterans in the general population, male veterans are more likely to die of suicide. Research indicates that veterans over the age of 65 “commit suicide slightly more often (40.39%) than veterans aged 45-64 (37.23%).” Disability and access to firearms increase the likelihood of mortality from suicide.¹¹

Building a Safer System of Care for Seniors

In its August 2006 report, Bulding a Safer System, the Missouri Mental Health Commission urged the Department of Mental Health (DMH) to “develop a comprehensive plan, including adequate staffing, for addressing the unique mental health needs of aging DMH clients.”¹²

The 2006 Governor’s Task Force on Mental Health noted the strong need for elder mental health services, recommending that the Department of Mental Health “work with the Department of Health and Senior Services to establish formal ties to its adult abuse hotline, and with the Department of Social Services for formal ties to its child abuse hotline, so that reporters of abuse and neglect of DMH consumers fully utilize those hotlines as another means of reporting abuse and neglect. The Department shall then rigorously promote the use of these hotlines.”¹³

Recognizing the potential public health risk, the Missouri Department of Mental Health cites “research in eight states, including Missouri” that found “persons with serious mental illnesses (SMI), on average, will die 25 years earlier than the average American. DMH can no longer be content to focus solely on a psychiatric illness without attending to the individual’s broader physical health needs.”¹⁴

Conclusion

While effective treatments exist for many late-life mental health problems, there is a gap between current mental health services and the infrastructure necessary to meet the coming demand. This substantial under-investment in research, knowledge dissemination, and service development could lead to a public health crisis. (Bartels) ¹⁵

The challenges presented here comprise trends following the baby boom cohort as it ages. In response to these trends, Missouri’s public and private health care providers must face the challenge of skyrocketing medical costs, within the context of decreasing budgets. As the recent task force reports suggest, a coordinated interagency plan, adequate funding, strategic service delivery, and educational efforts to dispel the stigma associated with mental illness will all be essential elements to protecting Missouri’s seniors.

* Kristen Heitkamp, OSEDA, former Director of Information, Project LIFE Publications. Mary Louise Bussabarger, former Missouri Mental Health Commissioner.

References

1. Elder, William. Observations about Pattern of Change in the 55-64 Age Cohort. Office of Social and Economic Data Analysis. http://oseda.missouri.edu/regional_profiles/babyboom_1990_2000.shtml
2. Eisenhart, Meredith, Jaime Goldberg et al. (2006) Mental Health and Seniors. Missouri Senior Report 2006.
3. Alzheimer’s Association. (2007) Alzheimer’s Disease Facts and Figures.
4. U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Cognitive Impairment in Nursing Home Residents by State, 2005. Nursing Home Data Compendium 2005 Edition. (These figures include all individuals who spent any time in a nursing home in 2005.)
5. ARDC, Washington University. Aging, Healthcare and Dementia in Rural Missouri factsheet. Online at http://alzheimer.wustl.edu/Rural/default.htm
6. Lester, Jessica. (2006) ADRC and the Memory & Aging Project (MAP). Horizons Newsletter, 13(2), Fall 2006.
7. Guo, JJ, PE Keck Jr, et al. (2007) Risk of diabetes mellitus associated with atypical antipsychotic use among Medicaid patients with bipolar disorder: a nested case-control study. Pharmacotherapy. 2007 Jan;27(1):27-35.
8. Guo, JJ, PE Keck Jr, et al. (2006) Risk of diabetes mellitus associated with atypical antipsychotic use among patients with bipolar disorder: A retrospective, population-based, case-control study. J Clin Psychiatry. 2006 Jul;67(7):1055-61.
9. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Chapter 1. The Impact of Substance Use and Abuse by the Elderly: The Next 20 to 30 Years. Substance Use by Older Adults: Estimates of Future Impact on the Treatment System. OAS Analytic Series #A-21, DHHS Publication No. (SMA) 03-3763, Rockville, MD, 2002.
10. Missouri Department of Mental Health. (2002) Missouri State Suicide Prevention Plan.
11. Kaplan, Mark S., Nathalie Huguet, et al. (2007) Suicide among male veterans: a prospective population-based study. J. Epidemiol. Community Health 2007;61;619-624
12. Missouri Mental Health Commission (August, 2006) Report to the Governor: Building a Safer Mental Health System, Recommendation 22.
13. Missouri Governor’s Task Force on Mental Health. (Nov. 29, 2006) Findings and Recommendations. Final Report.
14. Missouri Department of Mental Health. State Fiscal Year (SFY) 2009 Budget Development Cycle. (July 16, 2007, Page 7) at http://www.dmh.missouri.gov/admin/budget/FY09buddevel.pdf.
15. Bartles, Stephen J. & Michael A. Smyer, guest editors. (2002) “Mental disorders of aging: An emerging public health crisis?” Generations: Journal of the American Society of Aging, Volume XXVI, Number 1. Pages 14-20.

Missouri Senior Report is published by the State of Missouri’s Department of Health and Senior Services (DHSS), MU’s Office of Social and Economic Data Analysis (OSEDA) and University of Missouri Extension.

 
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