Has the Silver Tsunami Begun?

Increased ED Visits May Herald Geriatric Mental Health Crisis

Caroline Cassels

May 24, 2011

May 24, 2011 (Honolulu, Hawaii) — An increase in emergency department (ED) visits by elderly patients in Hawaii is a strong indicator that a national geriatric mental health crisis is brewing, new research suggests.

A study presented here at the American Psychiatric Association (APA) 2011 Annual Meeting shows a 30% increase over 1 year in geriatric psychiatric visits that included longer length of stays.

"Our findings are consistent with the notion that elderly patients with psychiatric symptoms are being underserved … due to various shortages including cuts in community services, provider shortages of those specializing in geriatric mental health as well as limited research funding earmarked for the geriatric population and limited reimbursement for [mental health] providers," principal investigator Brett Y. Lu, MD, PhD, medical director of psychiatric emergency services and director of community geriatric psychiatry, Queen's Medical Center, Honolulu, Hawaii, told reporters attending a press briefing.

Dr. Brett Y. Lu

Driving this trend, said Dr. Lu, is the aging baby boomer population. It is expected that by 2030 the number of Americans aged 65 or older will double to 70 million. Of these, 30% will develop dementia, which is frequently accompanied by severe behavioral and psychiatric symptoms, including hallucinations, wandering, paranoia, and combative and dangerous behavior.

Given the demographics, "there is bound to be a disproportionate increase in the number of elderly requiring psychiatric services. With resources lagging, it is expected there is going to be a crisis in geriatric mental health as early as 2011 specifically, because that is the year when the oldest baby boomers will hit age 65," said Dr. Lu.

Caregiver Burnout

Typical scenarios that are becoming more common in the psychiatric ED include elderly patients being dropped off by exhausted or "desperate" caregivers or family members who need respite and nursing home patients who have been discharged because of dangerous or combative behavior, said Dr. Lu. In addition, in Hawaii there is a growing problem of homeless elderly, who often end up in the psychiatric ED because they exhibit socially inappropriate behavior.

Furthermore, police often bring delusional or violent elderly patients to the ED after a 911 call. Dr. Lu noted that between 2009 and 2010, there was a 2-fold increase in such calls made to the Honolulu police due to elderly patients attacking their caregivers.

Many health care organizations, most notably the Alzheimer's Association, have begun to warn that this wave of aging baby boomers, often described as the "Silver Tsunami," along with the concomitant surge in dementia cases, is threatening to overwhelm healthcare resources.

On the basis of their clinical experience, which suggested increased utilization of psychiatric ED services by seniors, Dr. Lu and his fellow investigators suspected this disturbing trend may have already begun and set out to determine whether their suspicions would be borne out by objective data.

For the study, the researchers sampled all visits to the Queen's Medical Center ED from 2007 to 2011. This ED is the largest and has the highest volume in Hawaii. It is also the only ED in Honolulu staffed by psychiatrists 24 hours per day, 7 days a week, and has the acute capacity of geriatric psychiatric admissions.

Growing Need

Over the 4-year study period, the researchers tracked the number of visits triaged to the psychiatry section of the ED. They also tracked length of stay according to age. In total there were 14,402 visits; of these, 787 were for individuals aged 65 or older.

Year-by-year analysis showed an increasing percentage of psychiatric ED visits by older patients (P = .01). The largest increases (30%) occurred from 2008 to 2009. In addition, length of stay for older patients was significantly longer (P < .01), with a median of 403 minutes vs a median of 357 minutes for younger patients.

Mental health resources, Dr. Lu said, have not kept pace with the growing psychiatric needs of this population, and, as a result, the ED has become the de facto point of care.

"There need to be policy changes including increased awareness of the plight of the geriatric population with psychiatric needs. This will include changes in the implementation of community resources, increasing incentives for residents considering a career in geriatric psychiatry, and pharmacological as well as nonpharmacological ways of decreasing behavioral symptoms," said Dr. Lu.

"Given that there is no FDA [Food and Drug Administration]-approved medication for any dementia-related [behavioral] symptoms, a lot of primary care physicians are reluctant to prescribe any medications and the outcome for that is that patients can get even worse," he said.

Provider Shortage

Asked by Medscape Medical News to comment on the study, Iqbal "Ike" Ahmed, MD, a geriatric psychiatrist and board member of the American Association of Geriatric Psychiatry (AAGP) said the study's findings are cause for major concern.

Although Dr. Ahmed was not involved in the research, he said he has worked in the ED at Queen's Medical Center and has experienced this issue first-hand.

"The fact is there is not an adequate number of mental health providers for the elderly — psychiatric or otherwise — so what happens is family members and caregivers and even institutions like nursing homes don't know who to turn to get help and out of desperation they bring people to the emergency department. We can't do anything about the demographics but we can do something about the availability of services, not only in Hawaii, but nationally," said Dr. Ahmed.

Dr. Ahmed said the AAGP is working to address the issue at multiple levels. At the federal level, he said, the AAGP is lobbying to increase reimbursement for geriatric psychiatry. It is also initiating several programs to make the subspecialty more attractive by establishing scholarships for medical students and residents.

"We are also working to make medical students and psychiatric trainees more aware of geriatric psychiatry as an interesting and worthwhile field. There is a lot of gratification in taking care of our seniors. It is also an intellectually stimulating field because it is an interface of psychiatry, medicine, and neurology so it can be very intellectually challenging," he said.

The association is also working to improve the educational curriculum for geriatric psychiatry by increasing the amount of time residents spend in training, he added.

Importantly, said Dr. Ahmed, the issue is now officially on the national radar. He noted that the Institute of Medicine is conducting a consensus study to determine the mental and behavioral health care needs of Americans over age 65.

Dr. Lu and Dr. Ahmed have disclosed no relevant financial relationships.

American Psychiatric Association (APA) 2011 Annual Meeting. NR08-42. Presented May 17, 2011.


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