Our aging global population has the potential to enrich our communities, strengthen intergenerational relationships, and help preserve our cultural heritage. However, to realize this promise, our aging population needs a group of professionals such as geriatric psychiatrists who are trained to care for older adults with mental health, addiction, and other neuropsychiatric problems. Such geriatric mental health specialists can help provide crucial expertise and support to primary care providers and allied health professionals, but are currently an underutilized resource. Here, we present a set of recommendations for primary care providers seeking specialist support for older adult patients with neuropsychiatric symptoms or disorders.
Current patterns of referral to geriatric psychiatry do not align with the high burden of neuropsychiatric disorders
The proportion of older adults is projected to increase from 12 percent to 22 percent of the world’s population by 2050. Given that neuropsychiatric disorders affect over 20 percent of older adults, contributing to 6.6 percent of total disability worldwide, there is a strong case for improving access to geriatric psychiatry. While the overall burden of neuropsychiatric disease in older adults is high, epidemiological studies show variable prevalence of specific mental health disorders. For example, Volkert et al.’s 2013 study of the early 2000s reported rates of 33 percent for anxiety disorders, 17 percent for affective disorders, 12 percent for substance use disorders, and 5 percent for psychosis for older adults in Europe and North America.
Despite high rates of psychiatric disorders among older people, studies show disproportionately low use of mental health specialty care, such as geriatric psychiatry, in this population. This was true in the early 2000s, when Garrido et al. investigated mental health care (MHC) utilization among community-dwelling older adults in the U.S. and found that just 6.5 percent of them received MHC per year, with the majority of patients with major depressive disorders or anxiety disorders going without any MHC. Notably, 17 percent of respondents did not receive MHC but felt they needed it, especially those with lower self-care ability. Similarly, the most recent results of a Substance Abuse and Mental Health Services Administration (SAMHSA) national survey estimated that only 46.3 percent of older adults with any mental illness received mental health treatment.
Receipt of mental health care by a mental health specialist typically depends on referrals from another provider. In one small study in New York, the majority of referrals to geriatric psychiatry were from primary care physicians, and the most cited reasons for referral were problem behaviors, psychosis, depression, anxiety, or a loss of function due to cognitive impairment. The majority of patients referred to geriatric psychiatrists had a diagnosis of a neurocognitive disorder. A larger national study found that patients with established mental health diagnoses and patients with psychotic disorders were more likely to be referred to psychiatry by their primary care physicians than to be treated within primary care. Depressive or anxiety disorders did not affect the likelihood of referral significantly. Another review of data from a nursing home population found that agitation, disinhibition, and aberrant motor behavior were the most common neuropsychiatric symptoms among patients referred. At this point, it appears that psychosis and neuropsychiatric symptoms of dementia are the most common reasons for referral to geriatric psychiatry.
Guidelines for Referring to Geriatric Psychiatry
Greater awareness of the expertise of geriatric psychiatrists may help increase appropriate referrals and improve access to effective care for the growing number of older adults whose quality of life is impaired by mental health, neurocognitive, and addiction problems.
Navigating the complexities of geriatric mental health care can be challenging, with numerous factors influencing the decision-making process for a referral to geriatric psychiatry. Below are guidelines for clinicians considering a referral.
- What patients would benefit from a geriatric psychiatry referral?
Most referral criteria consider adults age 65 or older, but there are exceptions for individuals with early-onset dementia, developmental disabilities, or late-onset psychiatric disorders. Common clinical syndromes that benefit from the expertise of a geriatric psychiatrist include late-onset psychiatric disorders, cognitive impairment with neuropsychiatric symptoms, dementia-related behavioral disturbances, and psychiatric manifestations of neurological disorders. Geriatric psychiatrists are also skilled in treating complex co-occurring psychiatric, acute, and chronic medical disorders, which often involve the use of complex medication management. - How often should patients see a geriatric psychiatrist?
In some cases, a one-time geriatric psychiatry consultation can be sufficient. In other cases with more complex or difficult-to-treat conditions, ongoing follow-up by a geriatric psychiatrist or a hybrid model of collaborative care – in which a geriatric psychiatrist consults with the primary care team caring for older adults with mental health disorders – is effective. - Who else should be part of the care team for older adults with neuropsychiatric disorders?
For most older adults, primary care providers are the key figures in recognizing and treating common mental health problems and also in making effective referrals to geriatric psychiatry. Such referrals may be regarding specific diagnostic or management questions, but occasionally, psychiatric care is needed continuously and indefinitely. Many types of health care professionals can contribute to the care of older adults with mental health and other neuropsychiatric problems, and Figure 1 and Figure 2 outline overlapping and complementary skills of geriatric psychiatrists and primary care providers. Coordination is important not only due to practical constraints regarding specialty access, but potentially also to improve patient outcomes for common mental health conditions including depression, anxiety, suicidal ideation, and at-risk alcohol use. A 2004 study found that substantially more (71 percent) of older adults engaged in treatment for these conditions when mental health services were provided in primary care settings than when they were offered in traditional psychiatry clinics (49 percent), highlighting the value of collaborative care and home-based primary care programs in providing mental health care for older adults. Effective collaboration between primary care providers and specialists, such as geriatric psychiatrists, is also key in meeting the needs of older adults who often have not only mental health but also acute and chronic medical problems.
Figure 3 outlines suggestions for managing dementia, one of the most common reasons for referral to geriatric psychiatry. Such an outline can help busy primary care providers and consulting geriatric psychiatrists keep track of key steps in the assessment, work-up, and treatment of such patients. - How can I educate family members and caregivers about when to advocate for geriatric psychiatry referral?
Understanding when and how to seek specialized care from a geriatric psychiatrist can also be valuable for family members and caregivers. It may empower them to seek expert help for their loved one from a skilled geriatric mental health professional. This knowledge may also help prevent or address burnout and mental health crises that are common amongst caregivers of older adults living with serious mental health challenges. Figure 4 summarizes several warning signs experienced by both older adults and caregivers who would benefit from seeing a geriatric psychiatrist. It also lists emergency resources, credible online resources for pertinent self-education, and an overview of the initial geriatric psychiatric assessment process. This information can help to alleviate apprehension, address stigma related to getting help from a geriatric psychiatrist, and set expectations for the visit.
Conclusion
Family members, caregivers, and primary care providers have a key role in the process of recognizing when an older person is struggling with a mental health, neurocognitive, or addiction problem and helping them get effective care. A variety of consulting specialists can help, including general psychiatrists, consultation-liaison and collaborative care psychiatrists, home-based primary care programs, geriatricians, neurologists, neuropsychologists, clinical psychologists, social workers, occupational therapists, geriatric pharmacists, chaplains, and palliative care providers. Referrals to geriatric psychiatrists – specialists who are uniquely qualified to care for older individuals with mental health problems – may be particularly useful but can be challenging. In the setting of a national shortage of psychiatrists – and an even more critical shortage of geriatric psychiatrists and other geriatric mental health professionals – primary care providers remain on the front lines of identifying, managing, and coordinating care for older adults with mental health needs. The tools provided in this brief overview are designed to support this essential work.
The authors would like to acknowledge support from the Archstone Foundation Learning Collaborative in Geriatric Psychiatry in the development of this article.
About the authors
Dr. Koblova is an acting assistant professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington and is a fellowship-trained geriatric psychiatrist. She currently works at the Center for Behavioral Health and Learning at the University of Washington, providing inpatient psychiatric care to individuals living with serious mental illness, including older adults.
Dr. Unützer is a geriatric psychiatrist and health services researcher whose work focuses on the integration of mental health services and general medical care. He chairs the Department of Psychiatry and Behavioral Sciences and serves as director of the Garvey Institute for Brain Health Solutions at the University of Washington. He is the recipient of numerous federal and foundation grants and awards for his research on integrated behavioral health care and he has served as an advisor to national and international organizations dedicated to improving behavioral health care for diverse populations.
**Feature photo obtained with a standard license on Shutterstock.
