Practical Geriatrics: Mental Health Services for Older Veterans in the VA System

In the United Sates, the number of people aged 65 years and over grew from about 4 percent of the population in 1900 to 12 percent in 1994 (1). It has been estimated that by 2010 about 13.3 percent of the population will be over 65 (2). Veterans in this age group accounted for 38 percent of the total veteran population in 1999 (3) and are expected to number between 7.8 million and 9 million until 2020. As in the general population, veterans over 80 years of age are the fastest-growing cohort of veterans. Between 1995 and 1996 the number of veterans 80 to 84 years old and 85 years or older increased by 15 percent and 13 percent, respectively (4). With a greater probability of having multiple comorbidities and with fewer social and economic resources, individuals in these age categories, who require more medical and social services than younger individuals, may be particularly vulnerable.

Although the reported prevalence of mental illness among elderly persons varies, conservative estimates for those aged 65 years or older suggest a minimum of 10 percent with Alzheimer's disease or other dementias and an additional 15 to 30 percent with other psychiatric illnesses. Thus it can be expected that at any time during the period of 1999 to 2020, between 2.3 and 2.7 million veterans will need psychogeriatric care (5).

Mental health professionals have generally responded to the clinical and social needs arising from these significant demographic changes by actively advocating and developing specialized clinical settings, research centers, and training programs (6). Toward this effort, the U.S. Department of Veterans Affairs (VA) has assumed a leadership role in developing the field of geriatrics for more than two decades.

The Veterans Health Administration, the medical branch of the VA, is the nation's largest integrated medical system. Its mission is to serve the needs of America's veterans by providing specialized care, primary care, and related medical and support services. Older veterans can receive medical and psychiatric care in the national VA network of 172 medical centers, 551 outpatient clinics, 132 nursing home care units, and 40 domiciliaries. The VA also contributes financially to the cost of care for veterans in long-term-care facilities—93 state veterans homes operated by 42 individual states (7).

Mental health programs

In addition to addressing significant demographic changes, VA mental health services have found themselves caring for growing numbers of challenging older veterans who cannot be effectively managed in traditional medical or psychiatric settings. These patients typically suffer from a combination of chronic medical and mental disorders. Additionally, they are often homeless and have already exhausted community resources for various reasons such as substance abuse, problematic behavior, and aggression.

These veterans also require a broad array of services. Although such services are often available, they tend to be fragmented throughout the system. In contrast with mental health services, the VA geriatrics and extended care program has responded to changing demographics by focusing on increasing geriatric services through the establishment of hospital-based home care teams, palliative care hospice units, adult health care programs, geriatric evaluation and management programs, and geriatric research, education, and clinical centers (8). A survey of all VA medical centers in 1992 revealed 87 VA medical centers reporting 192 psychogeriatric programs, including 19 outreach and consultation teams, 41 clinics, 18 home health and day care teams, 40 brief and 43 long-term inpatient programs, and 11 substance abuse programs for older veterans (9).

The following are brief descriptions of clinical programs relevant to mental health services for older persons in the VA system (5). Note that each VA medical center uses a different format and different definitions for its clinical programs.

Psychogeriatric team care

The aim of the psychogeriatric team care program is to bridge levels of care and work within and among existing clinical services rather than being attached to a particular unit or clinic. This approach can be effective in providing diagnostic evaluation, treatment recommendations, and case management on a direct or consultative basis, especially when resources are limited.

There are two types of psychogeriatric team care programs. The psychogeriatric integrated care team primarily serves psychogeriatric patients at the medical center at all levels of care and monitors discharged inpatients with active case management, education of caregivers, and consultation in the community through a primary care approach. Another program is the specialized psychogeriatric outreach treatment team, which provides services to eligible elderly veterans with specifically targeted disorders, such as substance abuse, posttraumatic stress disorder, and chronic mental illness complicated by homelessness.

Psychogeriatric outpatient program

There are two types of psychogeriatric outpatient programs. The psychogeriatric primary care clinic serves elderly patients who require active psychiatric treatment but are basically medically stable. This program can be a part of mental health clinics, specialty clinics for patients with dementia, or geriatric primary care clinic programs. There are also integrated medical psychogeriatric clinics, which provide clinical services to elderly persons who have major complex medical and psychiatric conditions. These individuals may have medical problems of a more severe nature, such as acute oxygen-dependent chronic obstructive pulmonary disease and congestive heart failure.

Psychogeriatric day and partial hospitalization programs

The psychogeriatric day and partial hospitalization programs serve psychogeriatric patients who need more intensive services than those provided by traditional outpatient clinics, yet do not require 24-hour care. The programs also provide a locus for ongoing health maintenance activities and a mechanism for sharing the burden of care of the chronically ill with their families. They can be a cost-effective alternative to repeated or prolonged hospitalizations and can shorten the length of stay in the medical center or nursing home.

Psychogeriatric inpatient programs

There are various types of inpatient programs for older veterans who require different levels of care. The focus of the psychogeriatric brief-stay unit is on the evaluation and stabilization of patients whose primary treatment needs are psychiatric. The average length of stay on this unit is less than 30 days.

The medical-psychogeriatric brief-stay unit serves older veterans who require acute medical and psychiatric care—for example, the aging veteran with chronic schizophrenia who is experiencing a psychotic exacerbation and who has coexisting chronic pulmonary disease.

The psychogeriatric intermediate-stay unit serves older veterans who have been stabilized in a brief-stay unit, who continue to require inpatient treatment at a lower level of intensity, and who are expected to achieve improved status or rehabilitation.

The medical-psychogeriatric sustained treatment and rehabilitation unit provides care in a secure setting for older veterans with various combinations of psychiatric and medical illnesses who, after 30 to 90 days, have failed to recover sufficiently to be discharged to a lower level of available VA or community services.

The skilled psychogeriatric nursing unit provides long-term care in a secure and therapeutic environment for patients with chronic, treatment-refractory illnesses. The expectation for discharge from this program is low. The program places emphasis on skilled psychiatric nursing and maintenance of optimal functioning in a supported environment.

Finally, within each VA nursing home care unit, a section of beds is specifically designated for psychogeriatric patients. This section is authorized for patients who require physical care and who also manifest behavioral disturbances that are manageable within the context of a nursing home. Care is provided by staff who are skilled in psychogeriatric interventions. The program is supervised by the nursing home care unit.

Because of the complex needs of older veterans, the patient populations for whom psychogeriatric programs are appropriate overlap considerably with existing geriatrics and extended care programs, such as the Alzheimer's disease and dementia program, the domiciliary care program, and the home-based primary care program. Older veterans can be more effectively served through collaboration rather than through mutually exclusive programs.

Recent developments

Since the mid-1990s, the VA has undergone a dramatic transformation during which it has added important new programs to those described and has moved to integrate all of its programs into one system of care. This move can be seen at various organizational levels and in various local and national initiatives. One of the key issues in VA mental health services for older veterans has been how to integrate primary care, geriatrics, and mental health.

Unified biopsychosocial evaluation and treatment

The Unified Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT) program is a six-year demonstration project that was developed to test whether psychogeriatric intervention that targets acute medical and surgical inpatients will improve health care and reduce excess hospitalizations in older veteran patients. The UPBEAT program is a new and cost-effective approach to identifying and caring for medically ill veterans with previously unrecognized depression, anxiety, or alcohol abuse. These patients often have higher rates of hospitalization and prolonged hospital stays. The UPBEAT program serves these patients with outreach screening, mental health care coordination, and treatment adapted to their needs. Operating at nine VA medical centers nationwide since 1995, the program has proved to be cost-effective (10).

SAMHSA primary care project

The VA has joined the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) in cosponsoring a collaborative, interdisciplinary multisite program that will assess which of two service-delivery models—integrated or referral based—is most effective in terms of access, treatment adherence, consumer outcomes, system outcomes, and cost in providing mental health and substance abuse services to older veterans through primary care. The VA is funding five VA study sites, and SAMHSA and HRSA are funding six sites as well as a national coordinating center (11).

The VA Primary Care Multidisciplinary Education Committee is a VA headquarters initiative cosponsored by primary care, mental health, and geriatrics and extended care programs, with support from the VA employee education system. The committee's primary goal is to facilitate integrated services of primary care, mental health, geriatrics, and extended care. The committee selected several VA sites to serve as program models. These selected programs are to be involved in various educational activities (12).

Other developments

The VA has responded to the diverse needs of the veteran population. Since the establishment of the Center for Women Veterans, the VA has established eight comprehensive women veterans' health centers, a national counseling program for victims of sexual trauma, and many other programs specific to women veterans, ranging from mammography to treatment of posttraumatic stress disorder. All VA health care facilities have a women veterans' coordinator to help women veterans of all ages to access VA health care.

The VA is also addressing the growing challenges of the homeless veteran population. Since the first round of homeless provider grants and per diem funding in 1994, a total of 127 grants have been awarded to 101 public or private nonprofit groups in 39 states and the District of Columbia. When all projects are completed, some 2,700 new community-based beds will be available for homeless veterans. In 1998 nearly 3,600 homeless veterans completed specialized programs in VA domiciliary facilities. The Domiciliary Care for Homeless Veterans program provides health care, psychosocial rehabilitation, and residential treatment to homeless veterans who are medically and psychiatrically ill. The program is currently available at 35 VA medical centers across the country and provides more than 1,600 beds. While receiving services through this program, older veterans are encouraged to become involved with programs in the community, such as senior centers and foster grandparent programs.

The Committee on Care of Severely Chronically Mentally Ill veterans was established in 1996 to monitor the care of veterans in the VA system who are seriously medically and mentally ill. In 1998 the committee submitted its second annual report, which addressed the issues of capacity, compliance with treatment, community-based outpatient clinics, intensive community case management, use of new antipsychotic medications, the transition from inpatient to community-based care, services for posttraumatic stress disorder, and the mental health of women veterans.

The committee also assessed the VA's support of mental health research and recommended a greater investment in such research as well as the funding of additional Mental Illness Research, Education, and Clinical Centers (7,10). More recently, on the basis of the Veterans Millennium Health Care and Benefits Act, the geriatrics and extended care strategic health care group developed specific recommendations that will affect the current provision of health care to older persons in the VA system.

The program at the Salem VA medical center

Traditionally, much of the impetus for developing psychogeriatric programs has come from individual medical centers. Given the increasing number of older veterans and the fact that resources are limited, most VA medical centers mightily attempt to serve this patient population according to Veterans Health Administration guidelines. This effort requires innovative ideas and full support from the administrative offices of medical centers. Two of the authors (K.Y.K. and E.J.) are affiliated with the VA medical center in Salem, Virginia.

The Salem VA medical center has a fellowship-trained geriatric psychiatrist who runs two 29-bed sustained-treatment and rehabilitation units as well as the memory disorders clinic. One ward treats mainly older patients with major psychiatric disorders. Some of the patients on this unit are less than 65 years old, but they suffer from various major psychiatric disorders, such as schizophrenia and bipolar disorder. The other ward treats older veterans who have various dementias with psychiatric symptoms. Three beds on this ward are designated for respite care to support patients in the community. These patients are referred primarily from the memory disorders clinic.

A built-in grief support group is an integral part of this program. The two wards receive patients on referral from the acute psychiatry unit, the medical and surgical units, and the extended care rehabilitation center. When the patients are stabilized, they are placed in the less restrictive facilities in the community.

The center has a primary care psychiatry consultation and liaison team, which is run by a psychiatrist with extensive experience in psychogeriatrics. This team is actively involved in a variety of psychiatric issues in the primary care clinics, the medical and surgical units, and the extended care rehabilitation center. The team refers its patients to the mental health clinic, the memory disorders clinic, inpatient psychiatric programs, or the day treatment center as needed.

Outreach programs are available for patients in the community via the mental health clinic and the community residential care program. The mental health clinic operates the primary psychiatric care clinic that cares for medically and psychiatrically ill outpatients who have no primary care physician. Many of these individuals are psychogeriatric patients.

The complex medical and psychiatric needs of elderly veterans are also served by other components of the existing programs at the Salem VA medical center. We believe that the interaction and integration of these multiple elements of the continuum of care in the VA medical center will serve the psychogeriatric needs of our veteran population.

Conclusion

The increasing number of older veterans has posed substantial challenges for the VA system. However, the Veterans Health Administration has effectively responded to these challenges by actively advocating various specialized clinical settings, training programs, and research centers. Although it addresses general mental health concerns with veterans, it also focuses on more VA-specific issues, such as homelessness, addiction, and posttraumatic stress disorder. Because there is no VA funding category specific to geriatric mental health, the mental health needs of older veterans are addressed through existing mental health, medical, and extended care programs. Future consideration of specific funding for geriatric mental health may further enhance the advancement of mental health care for older persons in the VA system.

Acknowledgments

The authors thank Susan Cooley, Ph.D., and William Van Stone, M.D., for their valuable advice in the preparation of this paper.

Dr. Kim and Dr. Jones are assistant professors in clinical psychiatric medicine at the School of Medicine of the University of Virginia and Salem Veterans Affairs Medical Center. Dr. Goldstein, who is editor of this column, is associate professor of psychiatry and director of the division of geriatric psychiatry at the School of Medicine and Behavioral Sciences of the State University of New York at Buffalo. Send correspondence to Dr. Kim at Psychiatry Service, VA Medical Center, Salem, Virginia 24153 (e-mail, [email protected]).