In collaboration with The Geriatric Mental Health Alliance of New York, Vibrant Emotional Health provided a summary of their most recently published (August 2022) Data Book, Cognitive and Behavioral Health in Later Life: New York State Demographic and Epidemiological Information.

This resource was written for policymakers, advocates, journalists, and others who are concerned about the mental well-being of older adults in New York State during the "elder boom", but could also be helpful to others elsewhere in the U.S. 

Lisa Furst, LMSW, MPH, Director of The Geriatric Mental Health Alliance of New York and Chief Program Officer at Vibrant Emotional Health, is one of the co-authors and explained that the book has been in publication for many years and is updated regularly.

People 65 years of age and older are living longer than ever, and as this population ages, they have encountered service shortages, limited access to services that exist, uneven quality of care, limited integration of services, limited continuity of care, workforce shortages, and more. This results in deeply rooted inequities for older adults living with behavioral health conditions, or avoidable and unjust differences in their behavioral and physical health outcomes. Additionally, many older New Yorkers live in environments that do not promote their safety and increase the likelihood of social isolation rather than social connection.

Keeping the pace and improving their care will depend on data availability to inform planning and policy development. This document is a step toward gathering the needed data.

Below are the "Top Ten Important Things to Know", which summarizes the highlights which would be most helpful for the book's audience. 

1.  DEMOGRAPHICS

• In New York state over the next 20 years:
  • The 65 and up population will grow by 1 million, nearly 30%, from 17% to 22% of the total population.
  • The proportion of adults 65 and up will increase by 5% while the proportion of working-age adults will decline by 4%.
  • Older adults will outnumber children.
  • Males will outnumber females by almost 2:1.

• Black, Indigenous, and People of Color in the US will increase from about 25% to about 45% of the older population over the next 40 years.

• In the population of older adults (65+):
  • 28% live alone in communities
    • Some older adults experience social isolation and/or loneliness, which can contribute to physical and mental disorders, disability, and premature mortality.

• 80% of older adults in the community with long-term care support service needs receive care from unpaid caregivers.
  • Older adults who require services and support in the home are at greater risk for mental health challenges.
  • Their caregivers are also at greater risk for mental health challenges, such as anxiety or depression.

• 10 to 15% of older adults in the US are victims of mistreatment, leading to early death, harm to physical and psychological health, substance misuse, ruptured social and family ties, social isolation, and/or devastating financial loss.

• 51% of New York State veterans are 65 +.

2.  COGNITIVE AND BEHAVIORAL HEALTH PROBLEMS OF LATER LIFE

• Cognitive and behavioral health conditions are highly prevalent in older adults.

• Dementia prevalence increases as people age: 
  • From ages 60 to 74, the prevalence is 3%
  • From 75 to 84, it increases to 17%
  • At age 85, it is more than double that, at 38%

• 98% of people with dementia have co-occurring mental and/or substance use disorders.

3.  BEHAVIORAL HEALTH CONDITIONS

• 50% of American adults experience a mental or substance use disorder in their lifetime.

• Annually, approximately 20% of older adults 55 + have a mental disorder such as:
  • anxiety disorders
  • depression and other mood disorders
  • psychotic disorders
  • substance misuse and other addictions such as alcohol overuse and dependence
  • medication misuse
  • misuse of illegal substances
  • problem gambling

• Among older adults:
  • 11.4% have anxiety disorders
  • 15% have minor subsyndromal depression
  • 4 to 5.6% have major depressive disorder

• These lead to:
  •  increased risk of dementia
  •  increased risk of disability and premature death due to physical illnesses
  •  high rates of suicide
  •  problems in relationships, loneliness, and isolation
  •  reduced productivity
  •  reduced engagement in pleasurable and/or meaningful activities
  •  high rates of substance use disorders
  •  higher rates of nursing home admissions for those with co-occurring cognitive and behavioral health disorders than those with dementia alone 

• From 2016 to 2020, the rate of suicide in New York varied with age, peaking with men over 85, who are more than twice as high as men aged 15 to 24 and ten times higher than women over 85 in completing suicide.

•  In 2019, 50% of all completed suicides in the United States involved firearms, but of older adults who died by suicide, 70% used guns. 

• People with severe mental illness are at high risk of serious physical health conditions and low life expectancy due to:
  • high rates of smoking, obesity, diabetes, and heart disease
  • high rates of substance abuse (about 50% during their lifetime)
  • lingering effects of homelessness and crime victimization
  • poor access to adequate physical health care
  • behaviors and lifestyles that increase health risk
  • high suicide rates (8.5 times the general population)

• They are also at elevated risk for dementia.

• People with severe mental illness often rely on special housing and public income support to live in the community. 

• Nearly 1 million adults aged 65 and older live with substance use disorders as reported in 2018 data.
  • Approximately 14.5% of older adults consume more alcohol than is recommended by health authorities, with high risks of falls and other accidents as well as physical illnesses.
  • An estimated 3.6% to 7.2% of older adults aged 50+ used illegal drugs between 2002-2012, including heroin, cocaine, methamphetamine, and cannabis.
  • The drug overdose epidemic has impacted every one of all ages and has not left the older adult population untouched. 
  • The use of cannabis, the most commonly used “illegal” substance, is expected to rise due to relatively higher use by the baby boomer population and the legalization of cannabis for medical and recreational purposes.
  • Prescription opioids sometimes result in addiction, overdoses, and later heroin use.
  • The misuse of prescription and/or over-the-counter medications by older adults can result in injury, addiction, or death.

• The incidence of traumatic brain injury is increasing.
  • Traumatic brain injuries contribute to the early development of dementia and other neurodegenerative disorders.
  • Traumatic brain injuries contribute to the development of mood and anxiety disorders, including PTSD.

• Historically, people with developmental disabilities died at younger ages, but are now surviving into older age.
  • The average life expectancy for people with a developmental disability was 22 years in 1931, compared to 62 years for the general population. Now, their average life expectancy is 70, which is approaching that of the general population, about 79 years in 2018.

• Emotional reactions to adverse life circumstances, including social “determinants” of health and behavioral health and personal trauma, including
  • grief
  • fear for self or loved ones
  • loneliness/sense of isolation
  • economic distress
  • loss of a sense of control
  • sense of uncertainty
  • sense of helplessness
  • sadness and hopelessness
  • demoralization
  • apathy
  • anger

4.  DEVELOPMENTAL EMOTIONAL CHALLENGES OF OLD AGE

• Retirement and other role changes
  • Finding meaningful activities
• Decreasing social connections and increasing social isolation as friends and family move away or die
  • Developing new relationships, including intimate relationships
• Dealing with loss and grief
• Living with declining physical and mental capabilities, chronic health conditions, and pain
• Tolerating the increasing risk of dependency
• Reconciliation with one’s past despite regrets and disappointments
• Coming to terms with the inevitability of death

• Co-occurring disorders are highly prevalent among older adults, contributing to higher rates of disability, premature death, and high medical costs.
  • Co-occurring dementia and neuropsychiatric symptoms including depression and anxiety
  • Co-occurring types of mental disorders, e.g., depression and anxiety
  • Co-occurring mental and substance use disorders
  • Co-occurring acute/chronic physical and behavioral health conditions

• Older adults with co-occurring disorders are at high risk for premature disability and death.
• Older adults with co-occurring disorders require more care, leading to high healthcare costs.

5.  WHAT IS HELPFUL?

• Despite common emotional challenges in old age, psychological well-being is the norm and older adults are often a resource to their communities rather than a burden.
• Personality traits that support well-being include a positive attitude, optimism, adaptability, and resilience.
• Satisfying social relationships are a key element of well-being.
• Engaging in activities that provide pleasure and/or meaning is also key to well-being:
  • grandparenting
  • volunteering or working for pay
  • civic/political activity
  • creative arts
  • self-improvement: education, hobbies, including sports
• A sense of self-worth is a key element of psychological well-being.
• Self-care: exercise, eating well, sleeping well
• Yoga, meditation, and other complementary practices can contribute to well-being.

6.  POPULATIONS AT HIGH RISK OF COGNITIVE AND BEHAVIORAL HEALTH CONDITIONS

• The COVID-19 pandemic highlighted the psychological vulnerability of many older people.
• Although fewer older adults report emotional distress in response to the pandemic than younger adults, nearly ½ report significant levels of distress, and ¼ report symptoms of depression or anxiety disorders.
• Especially vulnerable older adults include but are not limited to:
  • those with dementia and/or other disabilities
  • those in long-term residential care
  • those with pre-existing serious and persistent mental illness
  • those with substance use disorders
  • those confronting severe illness or death
  • those in social isolation
  • older adults who are Black, Indigenous, and/or People of Color
  • people living in economic instability
  • informal caregivers 

• Loneliness and social isolation increase the risks of physical, cognitive, and behavioral disorders.
  • Social isolation significantly increases a person’s risk of premature death from all causes, a risk that may rival those of smoking, obesity, and physical inactivity.
  • Social isolation is associated with about a 50% percent increased risk of dementia.
  • Loneliness is associated with higher rates of depression, anxiety, and suicide.
  • Poor social relationships are associated with a 29% increased risk of heart disease and a 32% increased risk of stroke.
  • Loneliness among heart failure patients is associated with a nearly 4 times increased risk of death, 68% increased risk of hospitalization, and 57% increased risk of emergency department visits.

• Family caregivers of people with mental disabilities are at high risk for anxiety disorders, depression, and burnout.
• Family members and friends provide the most basic care for people with
  • Dementia
  • Psychiatric disabilities due to severe mental disorders
  • Autism and other developmental disabilities

• Informal caregivers are at high risk for depression, anxiety disorders, physical ailments, and burnout, resulting in premature institutionalization.
• Informal caregivers’ ability to provide care may diminish as they age, particularly if they develop disabilities themselves.

• Cognitive and behavioral health disorders are highly prevalent in nursing homes and assisted living facilities.
  • About 2/3 of nursing home residents live with cognitive impairment.
  • Most of those living with cognitive impairment also have neuropsychiatric symptoms.
  • Many nursing home residents have a primary diagnosis of serious mental illness.
  • About 2/3 of those in assisted living have some dementia, most with co-occurring neuro-psychiatric symptoms.
  • Over 20% have a psychiatric disorder other than dementia or cognitive impairment. 

• Black older adults are about two times, and Latinx older adults are about one and one-half times, more likely than Whites to have Alzheimer’s and other dementias.
• They also have more limited access to behavioral health services.
• Although the rate of Alzheimer’s and other dementias among Black and Latinx older adults is higher than among Whites, they are less likely than Whites to have a diagnosis of the condition.
• Physical conditions, such as high blood pressure and diabetes, rather than genetic factors, appear to account for the greater prevalence of Alzheimer’s among Black and Latinx older adults.
• Improved access to high-quality health care could likely reduce the prevalence of dementia among Black and Latinx older adults.
• Rates of mental illness among Black Americans are similar to those of the general population. Rates for Latinx Americans are somewhat lower. However, both Latinx and Black older adults generally receive poorer quality of care than White non-Hispanic older adults and lack access to culturally competent care.
• Rates of substance use disorders among these populations are about the same as White non-Hispanic older adults. Studies of disparities in the use of public behavioral health services reveal complex patterns of use and completion of services that vary by race, ethnicity, and socioeconomic status.

• Poverty is associated with an increased risk of dementia, mental illness, and suicide.
  • Poverty is associated with an increased risk of dementia. There may be intervening variables such as poor diet and loss of control of finances due to dementia.
  • People living in poverty are at higher risk of developing mental illness, and people with mental illness are at higher risk of becoming impoverished - a “vicious cycle”.
  • People living in neighborhoods with high rates of poverty have less access to physical and behavioral health care.
  • Mental illness is associated with lower levels of household income.
  • Suicide rates in the U.S. are closely correlated to poverty rates.

• Women are at higher risk than men for some (but not all) cognitive and behavioral health disorders.
  • As they age, women become more at risk of social isolation than men.
  • Women are at higher risk of dementia than men & at risk of faster decline after diagnosis.
  • Women are at higher risk than men of anxiety and depression but lower risk of substance use disorders.
  • Women are 1.75 times more likely than men to attempt suicide.
  • Older men are almost 5 times more likely to complete suicide than women.

• Older adults are at high risk for trauma, which increases the risks of dementia and mental disorders.
  • 10-15% of older adults are victims of elder abuse.
  • Many older adults experience other forms of trauma, such as injuries from falls and the deaths of loved ones.
  • Traumatic experiences in old age can result in PTSD and other anxiety or mood disorders.
  • PTSD contributes to the development of dementia and vice versa.
  • People with dementia are at increased risk of elder abuse.

• Veterans are at significant risk of complex, co-occurring physical, cognitive, and behavioral disorders.
  • Older veterans have co-occurring medical, mental health, and substance use disorders, and cognitive impairments more frequently than younger veterans. 
  • Rates of post-traumatic stress disorder (PTSD) are highest among Vietnam-era veterans. 
  • In 2018, the rate of suicide among veterans was 32.0 per 100,000, compared with 17.2 per 100,000 for nonveterans.
  • Alcohol and substance use disorders are more common among veterans than non-veterans and frequently co-occur with mental disorders, especially PTSD.
  • Despite higher rates of PTSD, older veterans are less likely to seek mental health services than younger veterans.
  • This willingness to seek services will likely continue as this cohort ages and will require a system designed to support the increased care needs of the aging veteran population. 

There are 2.7 million LGBTQ+ adults over the age of 50 in the US.

• Older LGBTQ+ individuals 
  • are less likely to be diagnosed and treated for cognitive impairment and are at higher risk for behavioral health disorders.
  • are less likely to get adequate cognitive and behavioral health care, including culturally competent diagnosis and treatment.
  • are less likely to receive informal caregiving due to being less likely to have children and having smaller social support networks.
  • are more likely to experience emotional distress leading to anxiety, depression, and substance use due to lifetime exposure to stigma and discrimination.

• Outcomes vary greatly depending on geography, race, economic status, education, and specific sexual and gender identities.

7.  PROJECTED GROWTH OF OLDER ADULTS WITH COGNITIVE AND/OR BEHAVIORAL HEALTH CONDITIONS

• In the next decade in NYS:
  • The number of people 65+ with dementia will increase by 100,000 (over 25%).
  • The number of adults 65+ with a mental health condition will increase by about 175,000 (25%).
  • The number of older adults with anxiety disorders will grow by 120,000 (25%).
  • The population 65+ with major or minor depression will grow by 25%.
  • The population of older adults 65+ with psychotic conditions will increase by 25,000 (nearly 25%).
  • The number of people 65+ with substance-use disorders or who misuse alcohol, medications, or illegal substances will grow by 25%.

• In NYS from 2011 to 2019, the rate of overdose deaths among older adults (65+) rose 236%.

8.  ACCESS TO QUALITY CARE AND TREATMENTS REMAINS INADEQUATE

• Older adults with cognitive impairment have extensive unmet needs.
• People with cognitive impairment and their family caregivers have high rates of anxiety disorders, depressive disorders, as well as physical disorders.
• Recommendations  for people with dementia living in the community and their caregivers include 
  • More extensive screening for functional abilities, neuropsychiatric symptoms, misuse of substances, safety, and pain
  • Early disclosure of diagnosis to people with dementia and their family to enable advanced care planning
  • Education, support, and behavioral health care for family caregivers
  • Training for primary care physicians and gerontologists in diagnosis, treatment (including more cautious use of medications), and the use of motivational techniques to promote healthy aging.
  • Neuropsychiatric behavior management
  • Daily/meaningful activities
  • Home and personal safety provisions
  • Medical condition management

• Most (about 2/3) of older adults with mental disorders do not get treatment.

• Older adults are half as likely to be served in NYS’s public mental health system as children or adults.

• Most older adults with mental illnesses do not get even minimally adequate mental health services.
• Treatment by primary care physicians is not minimally adequate 87.3% of the time.
• Treatment by mental health professionals is not minimally adequate 51.7% of the time.
• Older adults are less likely to get health care in mental health specialty settings than other age groups.
• In-home service providers, such as home health aides, are rarely trained to identify or treat mental disorders.
• Community service providers in senior centers, adult day care, etc. are rarely trained in identification or treatment.
• Mental health care in nursing and adult homes is also uneven. Overuse of antipsychotic medications is common and dangerous. 

9.  BARRIERS TO CARE AND TREATMENT 

• Barriers to care and treatment of older adults with behavioral health conditions
• Shortages of clinically, culturally, and geriatrically competent providers
• Over-reliance on primary care providers without adequate training
• High out-of-pocket cost
• Inadequate public information about where and how to get services
• Transportation problems with reaching service sites
• Shortages of services in rural areas
• Shortages of in-home services
• Shortages of outreach and engagement services
• Shortages of bi-lingual providers
• Low perceived need
• Stigma
• Lack of culturally and linguistically competent services and support 
• The use of telehealth services during the pandemic has significantly improved access, but such services are less available to older adults than younger ones due to issues of broadband access, ownership of needed equipment, and the ability to use it.

• The workforce for geriatric cognitive and behavioral health is too small and not keeping pace with population growth.

• Actions needed to address workforce shortages
  • Increase and improve the geriatric workforce with financial and other incentives to work with older adults as well as by providing increased training.
  • Because it is not possible to train enough geriatric cognitive and behavioral health specialists, it is necessary to change the workforce paradigm and to train primary care clinicians, social service providers, paraprofessionals, peers, volunteers, etc. to identify needs and provide care to older adults.
  • Increase the use of the internet and related technology.
  • Provide increased support for family caregivers, who are the primary de facto workforce for people with mental disabilities.

10.  AN AGENDA FOR IMPROVED COGNITIVE AND BEHAVIORAL HEALTH POLICY

• Provide services to support community integration (“aging in place”).
• Improve long-term care—nursing homes, assisted living, and home and community-based services.
• Increase cognitive and behavioral health service capacity to keep pace with the growth of the older population and to address current shortfalls.
• Enhance access to care, particularly with extensive use of telehealth.
• Improve the quality of care, emphasizing clinical, cultural, dementia, and geriatric competence in service design and delivery.
• Increase and improve the professional and paraprofessional workforce and change the workforce paradigm to create clinical, cultural, and geriatric competence in the primary care, long-term care, behavioral health, and social service workforces.
• Enhance integration of care within and between separate service “systems”—dementia care, behavioral health care, long-term health care, and aging social services.
• Enhance support for family caregivers.
• Address social “determinants” of behavioral health, such as racism, poverty, and isolation.
• Improve public and professional education.
• Increase and redesign funding to meet the needs of older adults.
• Develop a publicly accessible data dashboard for planning purposes.