"Meeting the mental health needs of older Iowans".

Our society is ill prepared to care for the number of older persons with mental disorders currently and in the future. The President's New Freedom Commission on Mental Health (2005) to transform mental health care in the U.S., responded in part to a U.S. Surgeon General (1999) report that the mental health of older adults is a critical public health issue for the 21st Century. Severe shortages, however, of physicians, psychologists, nurses, and social workers exist now and are expected to worsen in subsequent decades. The need to prepare more nurses, psychiatrists, primary care physicians and nurse practitioners, psychologists, and social workers for geropsychiatric practice and academic roles is unmistakable, as is the need for additional training of assisting nursing personnel who provide much of the direct care of older persons with mental disorders in their homes and in institutions. Nowhere is this need more urgent than in rural areas such as Iowa where workforce shortages are most acute.

This critical shortage of healthcare providers with training in psychiatry and gerontology to care for older persons is compounded by the continuing growth in psychiatric and co-occurring disabilities, such as those that accompany dementia and chronic physical illness.

The Iowa Context

Iowa essentially mirrors the nation in terms of its rapidly aging population and the shortage of geropsychiatric healthcare providers. As in the nation, the incidence and prevalence of mental illness among older Iowans is increasing with the number at risk for mental illness estimated to grow by 1/3, reaching 140,000 by 2020. Iowa ranks 6th among states with the largest proportion of persons 65 and older and 1st in the proportion of elders who are 85 years and older. Because the incidence and prevalence of mental illness among a high and increasing proportion of older Iowans is rising, the importance of training programs in geropsychiatry is recognized and considered a priority. There is mounting appreciation of the need for more services for persons with severe mental disabilities as they age. Yet, as elsewhere in the nation, the vast majority of older Iowans with mental illnesses still do not get appropriate mental health services. Most continue to seek care from primary care physicians who frequently misdiagnose and under-treat older persons with mental illness.

Mental Health Services Access and Use

There are some data that indicate that access and use of mental health services by elderly Iowans may be worse than for older persons nationwide. For example, the rate of use of publically funded inpatient specialty mental health services is much lower (40 per 100,000 older citizens) than the national average and is decreasing (Kessler, Berglund, Demler, Jin, et.al., 2005). The use rate of publicly funded outpatient services is also lower than in the rest of the country and has been decreasing since 1990. Older Iowans comprised only 16% of all publicly funded adult inpatients and just 10% of all adult outpatients, rates that are lower than expected given the number of older Iowans and prevalence rates of mental illness in this population (Iowa Department of Human Services, 1998). Furthermore, one survey indicated that the prevalence of mental illnesses among older Iowans living in nursing homes has steadily increased since the mid 1990s (Cowles, 2004). Slightly more than 46% of elders in all Iowa nursing facilities (skilled and intermediate) suffered with Alzheimer disease and related dementias. An additional 14.5% of nursing home residents suffered some form of mental illness, such as depression. Based on these and other prevalence data, nearly 20,000 older persons in nursing homes are estimated to have a mental disorder.

Service Efforts

There have been some targeted service efforts for older persons with mental disorders. The Iowa Rural Elderly Outreach Project (Buckwalter, Smith, Zevenbergen, & Russell, 1991) was one of the first. A collaborative program with a community mental health center modeled after a community gatekeeper program in Spokane, Washington, community gatekeepers (e.g., mental health specialists, postal carriers, professionals who worked with older adults) were recruited and trained to identify rural older Iowans at-risk for mental illnesses. Those thought to be at-risk were referred to an interdisciplinary team for evaluation and treatment. The program served nearly 1000 older Iowans during a nearly 10 year period. The Eyerly-Ball community mental health center in Des Moines replicated the project and continues to provide outreach to older persons who are at-risk for mental illnesses.

In 2002, the Iowa Department of Human Services, Division of Behavioral, Developmental, and Protective Services for Families, Adults, and Children (the State Mental Health Authority) sponsored a series of statewide educational programs focusing on older adults with mental illnesses. As follow-up, the BDPS provided pilot grants to local community mental health centers to develop innovative service programs. Mental health centers in Clinton, Des Moines, and Clarinda are considering how to provide specialty care to older persons with mental illness who use primary health care settings. In 2005, the Iowa Coalition of Mental Health and Aging (ICMHA) was formed to expand and improve the delivery of specialty mental health to older Iowans. Members of the coalition represent primary care, hospital care and specialty mental health providers; aging health and mental health administrators; policy leaders from the Legislature, the Governor's office and departments such as Elder Affairs and Human Services; and researchers. Coalition membership also includes older consumers, their caregivers, and representatives of advocacy organizations. Goals of the coalition include: 1) to improve public education and professional training that focuses on identifying and treating older persons with mental illnesses, 2) to establish a formal, evidence-based approach to identifying and treating older persons with mental illnesses, 3) to establish formal, sustainable linkages between qualified mental health providers and the usual places older persons with mental illnesses receive care: primary health care offices, nursing homes, and other community based programs, 4) to enlist federal agencies, state policy makers, and private organizations to support the coalition's efforts to expand and improve the care provided to older Iowans with mental illnesses.

Dr. Buckwalter is the Director of the John A. Hartford Center of Geriatric Nursing Excellence, Associate Director of the Gerontological Nursing Interventions Research Center, Co-Director of the University's Center on Aging, and holds joint appointments in the University of Iowa College of Medicine Departments of Psychiatry and Internal Medicine.

Dr. Buckwalter's work and research focuses on improving mental health services and providing community-based care for chronically ill older persons. She has written extensively in the field of gerontology, authoring over 250 articles and 80 chapters, and has edited eight books.

Dr. Maas' areas of scholarship and teaching are Nursing Administration and Gerontological Nursing. She is Co-Director of the John A. Hartford Center for Geriatric Nursing Excellence, Co-Principal Investigator of the Iowa Geriatric Education Center, Co-Director of the Gerontological Nursing Interventions Research Center (GNIRC) and Director of its Regional Research Training Core. She currently serves on four editorial boards and is a reviewer for five journals, has numerous peer reviewed journal articles and book chapters in print, and has authored or edited several books.

In recent years, Dr. Maas and colleague Dr. Janet Specht have developed entrepreneurial projects to provide needed nurse managed LTC options for elders.

By Kathleen C. Buckwalter, PhD, RN, FAAN Sally Mathis Hartwig Distinguished Professor of Gerontological Nursing

and

Meridean Maas, PhD, RN, FAAN Professor Emeritus