By Phyllis Hanlon
The World Health Organization (WHO) reported that between 2015 and 2050 the global population of individuals over the age of 60 is expected to jump from 12% to 22%; in actual numbers that means an increase from 900 million to 2 billion people.
Aging may mean a decline in physical and/or mental health. In a 2010 article, then-U.S. Surgeon General David Satcher, M.D., Ph.D., asserted that mental and physical health in older adults is inextricably linked, but that some providers fail to recognize symptoms.
So before an effective treatment plan can be initiated, health care professionals must clarify the diagnosis, often a difficult task, according to an article in the American Medical Association Journal of Ethics. The author reported that medical comorbidities frequently complicate the ability to identify a diagnosis accurately. For instance, depressive disorders are often associated with physical illnesses, such as Parkinson’s disease, stroke, cancer, coronary artery disease and other conditions. Furthermore, delirium is under-recognized and sometime presents with an underlying medical diagnosis or may be related to medication.
When signs of mental health conditions in older adults are missed and subsequently untreated, physical symptoms, such as immune system and cardiac dysfunction, susceptibility to infection, pain and other illnesses, could develop, according to the APA.
While dementia and Alzheimer’s disease are typically associated with advanced age, other behavioral issues, such as depression and anxiety, may commonly occur and can negatively impact physical health. In 2014, 15% of women age 65 and older reported depressive symptoms, while 10% of men reported such symptoms, according to “The Older Americans 2016: Key Indicators of Well-Being,” a report from the Administration for Community Living.
Another study, out of Georgetown University, found that depression might lead to suicide; in 2014, 8,255 Americans over the age of 85 died by suicide.
Scarcity and under-utilized services
In 2010, the American Psychological Association (APA) created a specialty focused on treating behavioral health issues in older adults – geropsychology. However, the number of specialists is limited because of an insufficient number of training programs and established paths to gain valuable hands-on experience. So, although this group comprises the fastest growing population in the country, mental health services and support for older adults with behavioral issues continues to be lacking. A 2015 article in Health Affairs cited several other reasons for the dearth of professional care:
- physicians untrained in recognizing mental illness in older adults;
- patients reluctant to discuss emotional challenges;
- self-blame for failure to be happy;
- stigma attached to the admission of behavioral health issues.
Additionally, the American Psychological Association (APA) reported that fewer than 3% of older Americans seek professional help for mental health problems. This under-utilization is because of:
- inadequate funding for mental health services;
- lack of collaboration and coordination among primary care, mental health and geriatric providers;
- lack of access to appropriate providers;
- shortage of trained professionals to provide geriatric mental health services.
Substance use in older adults
Older adults are also just as susceptible to substance abuse as their younger counterparts, but for varying reasons. The Office of Alcoholism and Substance Abuse reports that health-related issues or life-changing events could impose a psychological toll, leading to the abuse of a substance. And identifying a substance abuse problem is just as challenging as distinguishing a mental illness from a physical condition. Prescribing habits contribute to the problem. The Addiction Center notes that older adults are often prescribed highly addictive benzodiazepines for anxiety, pain or insomnia.
To further complicate the situation, alcohol abuse has become one of the eight leading causes of death for older adults; in addition to reducing cognitive functioning, alcohol addiction can lead to numerous of physical conditions, such as malnutrition, cirrhosis of the liver and osteomalacia, according to an APA study.
Call for more geriatric specialists
To address growing recognition of the mental health problems facing older adults, a 2012 report from the Institute of Medicine (IOM) called for training more geriatric specialists as well as direct care workers and peer support providers.
In response to this appeal, the Substance Abuse and Mental Health Services Administration (SAMHSA) created the Certified Older Adult Peer Specialist (COAPS) training program with a Grant to the Pennsylvania Office of Mental Health and Substance Abuse in partnership with the University of Pennsylvania in 2004. The purpose of the program is to train older adults to act as behavioral health specialists and wellness coaches. These peer specialists learn to work with older adults who have physical and mental health problems that might include normal aging, cultural competence, anxiety, depression trauma, substance use and others.
The three-day COAPS training provides important background on older adult demographics, defines normal aging, examines special considerations when working with older adults and addresses cultural competence. Day two sessions review clinical issues, including depression, anxiety, addictive disorders, trauma and suicide. The last day focuses on implementation and teaching the stages of change, motivational interviewing, planning and legal issues, an introduction to positive psychology and how to work with the behavioral health and aging systems.
To become a COAPS, individuals must be at least 50 years old, be a Certified Peer Specialist or Recovery Coach, demonstrate a commitment to working with older adults and complete an application. Peer specialists must also have undergone their own personal journey from an addiction or mental illness to recovery.
Peer specialists for older adults practice in a variety of settings, including the patient’s home; state hospitals and other inpatient settings; psychiatric rehabilitation centers; intensive outpatient programs; consumer run and advocacy organizations; with Assertive Community Treatment (ACT) teams; and with case managers.
Funding mechanism
Funding for COAPS comes from different sources, including Medicaid and state and local funds. In Pennsylvania, during the pilot phase of the program, the National Research Institute Transformation Transfer Initiative (TTI) grant program provided financial support. Subsequent funding came from the Pennsylvania Department of Aging, the Pennsylvania Office of Mental Health and Substance Abuse and the Pennsylvania Department of Vocational Rehabilitation.
Rob Walker from the Massachusetts Department of Mental Health, Office of Recovery and Empowerment, reported that the Commonwealth received approval from the federal government to reimburse COAPS for older adults through the Frail Elder Waiver, which covers additional home care services for individuals who meet income guidelines and who would otherwise be in nursing homes.
Benefits for specialists and those they serve
Although still in its infancy, COAPS is showing some positive results. Mental Health America collected data from several peer support programs across the country and released research findings that support the value of these programs:
- reduced re-hospitalization rates;
- reduced inpatient days;
- lower overall cost of services;
- increased use of outpatient services;
- increased quality of life outcomes;
- increased engagement with provider and social supports;
- increased whole health.
While research has shown that older adults who receive support from certified peer specialists experience physical and mental health benefits, the peer specialists who provide support also derive some perks. One study (under Additional Resources) found that individuals working as a certified peer specialist developed skills related to their own life and recovery. Their work also instilled hope and self-confidence and provided financial and psychological benefits.
Mental Health America reported that as of May 2018, 45 states and the District of Columbia had established or are in the process of developing training and certification programs for COAPS; some states are working with the National Association of State Mental Health Program Directors (NASMHPD) to bring the program to their state.
May 20 has been designated National Older Adult Mental Health Awareness Day; Health and Human Services (HHS) will be holding a panel in Washington, DC to discuss issues related to older adults, including older adult peer specialists. The panel will be webcast on the Internet.
Story ideas
If your state/geographic region has a peer specialist program for older adults, when and why was it started? If your state does not have a peer specialist program, do they plan to create one? Does the data on older adults suggest a need for such a program?
What other interventions does a peer specialist replace? What other healthcare professionals does a peer specialist work with?
Why would an individual decide to become certified as a peer specialist for older adults? Perhaps a COAPS would be willing to describe his or her personal journey and reasons for helping others.
For a personal interest story, interview an older adult receiving support from a peer specialist for an intimate look at how this service is affecting him/her.
A technical story could focus on the data: statistics on the number of certified peer specialists in a certain city/town, state or region; number of older adults supported; cost savings to the older adult regarding prescriptions and medical services; financial impact due to the older adult’s ability to engage successfully in the workplace.
What challenges are involved in creating a peer support program/training peer specialists/ finding clients/getting reimbursement?
Peer specialists work in a variety of settings. How does one venue differ from another in the way support is provided? For instance, what are the benefits/challenges in seeing a patient in his/her home versus at a rehab program or in the hospital?
An in-depth look at how peer specialists benefit from providing support for older adults who have behavioral difficulties might inspire others to become certified.
After receiving a year of support from a peer specialist what is the mental health status of the older adult?
Associations/organizations
AARP Health – Provides information on Medicare, brain health, health conditions and treatment and prescription drugs for adults age 50 and older.
Administration on Aging – Designated agency to carry out the provisions of the Older Americans Act (OAA) of 1965.
Administration for Community Living – Responsible for increasing access to community supports for older Americans.
American Association for Geriatric Psychiatry – Provides a search tool for finding a geriatric psychiatrist as well as resources for educators, clinicians and researchers specializing in geriatric psychiatry.
American Geriatric Society – Provides clinical guidelines and recommendations for health care professionals to build clinical competence in serving a variety of needs of older adults.
National Association of State Mental Health Program Directors – Only national association to represent state mental health commissioners/directors and their agencies.
National Council on Aging – Provides resources for health care professionals, caregivers and advocates on benefits, healthy aging and public policies impacting older adults.
National Institute on Aging – Part of the National Institutes of Health, the NIA conducts research on the nature of aging and is the primary federal agency conducting Alzheimer’s research.
Veterans Geriatrics and Extended Care Services – Offers information for older veterans on health care and benefits, home and community based services and shared decision-making.
Additional resources/studies
- Older Americans Behavioral Health, Issue Brief: Series Overview
- Study on the benefits for peer support providers
- Overview on the value of peer support specialists
- National Certified Peer Specialist white paper provides background on the creation of the program; requirements; established competencies and performance domains; and process to become certified.
- Webinar sponsored by SAMHSA and the National Association of State Mental Health Program Directors (NASMHPD) on older adult peer specialists
- Depression in older adults: Key issues
Phyllis Hanlon is an independent journalist based in Massachusetts, specializing in health care – alternative, medical, mental – and business; features, profiles and news briefs.
