The Advantage of Psychiatric Involvement in Geriatric Care
So much has been published about the substantial increase in the number of Senior Citizens in the United States. This increase is greatly attributed to the aging of the baby boom generation and the change in the mortality rate. There has also been a rise in the number of elderly persons with behavioral disorders. Due to underlying medical and neurological disease, there will be older adults developing late-onset psychiatric disorders. There is an extreme shortage of health care professionals who are skilled in treating these types of behavioral disorders. Numerous studies have shown that the primary care physicians, who provide the elderly much of their mental health care, have received very little training in geriatric psychiatry. Because of this, elderly people are not being accurately diagnosed or treated effectively.
According to a primary care physicians survey, 20% of primary care physicians admitted to be not very knowledgeable about mental health care issues in the elderly, and another 66% felt they were somewhat knowledgeable. How does this shortage of Geriatric psychiatrists impact the treatment of an illness seen typically in the elderly such as Alzheimers Disease (AD)? Because numerous advances in the treatment of this disease have been documented, Cholinesterase inhibitors (e.g., tacrine [Cognex], donepezil [Aricept], and rivastigmine [Exelon]) showed to have symptomatic treatment of the cognitive deficits for a period of time. There has been an approximately one-year delay in nursing home patients, according to long term studies with tacrine.
The need to delay institutionalization is imperative due to the rise in the number of patients with Alzheimers Disease. What is the differential outcome of patients with Alzheitners Disease being treated solely by a primary care physician versus those also being treated by a geriatric psychiatrist? What are the differences in the cognitive outcome of patients from each cohort? Are generalists different than specialists in the prescription of cognitive enhancers or in the utilization of health care services and placement into long-term treatment facilities? Significant issues have surfaced in the treatment of Alzheimers Disease by primary care physicians versus geriatric psychiatrists. While hospitalization rates (38.7% primary care patient versus 14.8% psychiatric patients) and use of home health aides (45.2% versus 18.5%) were significantly different in the pilot study. Primary care patients had a substantially higher institutionalization rate in the two-year follow up study (30% versus 4.6%). In patients treated only by a primary care physician, there was decreased use of donepezil (45.5% versus 76.5%). A significant difference was revealed in the prescription of donepezil (35% versus 64%). This may reflect an incomplete understanding of reasonable expectations of the medication by either the primary care physician or the caregiver.
The percentage of psychiatric patients receiving donepezil may reflect continuous reinforcement by the physician and case manager. The CDR, clinical dementia rating, of the primary care patients had deteriorated significantly more than the CDR of the psychiatric patients at the one-year mark. Greater cognitive decline has also been associated with increased hospitalization. The rise in utilization of home health aides by the primary care patients may also be a fimction of greater global impairment compared to the psychiatric patients. A comprehensive intervention for enhanced treatment in the primary care setting may be indicated.
There also exists a need to analyze physician knowledge, attitudes and behaviors regarding the diagnosis and treatment of Alzheimers Disease. Significant differences in institutionalization, cognition and donepezil prescriptions emerged during the two-year follow up in this comparison of two different models of care. Primary Care intervention trials can be useful in assessing differences in outcomes after an educational intervention, in order to see if a collaborative care model is efficacious. Additionally, the assessment of the positive implications (both direct and indirect) of this type of intervention would be necessary. A similar study has been initiated recently at Robert Wood Johnson Medical School. It is a study of collaborations between geriatric psychiatry and several primary care sites. Most of the individuals with AD have behavioral complications such as depression or psychosis throughout the course of their illness.
The cost of caring for a person with dementia is twice as high as the cost of caring for the average Medicare patient. Patients with dementia are 10% to 30% of nursing home admissions. To address this shortage of geriatric specialists, it will likely involve both educational and financial incentives to enhance the pipeline of individuals who are exposed to geriatrics early in their training and professional development.