A groundbreaking outreach program for frail elderly who need psychiatric services in their homes - believed to be the first of its kind in the United States -- is being launched by the Department of Psychiatry and Behavioral Medicine at Wake Forest University Baptist Medical Center.

"The highest prevalence of mental illness is in those aged 65 and older, but people in this age group are poor users of mental health services," said Deirdre M. Johnston, M.D., the psychiatrist who is medical director of the new program.

The biggest problem may be an inability to leave the house to get care, she said, either because of physical illness or disability or because of the psychiatric illness itself. So instead, members of the new team will visit homebound patients at home.

The new program, modeled after successful programs in the United Kingdom and Canada, is being funded by an endowment established by Arnold H. Snider of Princeton, N.J., and his wife, Katherine M. Snider. Snider grew up in Salisbury, where his mother, Kate Mills Snider, still resides.

The Sniders established the Kate Mills Snider Geriatric Psychiatry Outreach Program -- GO for short -- both to honor Snider's mother, who received care from Johnston, and to create a model of patient-centered mental health care for the elderly.

"The Sniders' gift will make it possible to provide mental health care while respecting the autonomy of the older patient, and should serve as a model of how mental health services could be best delivered in our country," said W. Vaughn McCall, M.D., professor and chairman of the Department of Psychiatry and Behavioral Medicine.

Visiting homebound psychiatric patients in their homes may prevent hospitalization or premature placement in a nursing home.

Constantine G. Lyketsos, M.D., M.P.H., co-director of the Division of Geriatric Psychiatry and Neuropsychiatry at Johns Hopkins Hospital in Baltimore, said there is "an enormous need for such programs." He cited the rapidly growing number of seniors, especially those who are over 80 years old.

In that age group, he said, "there is a very high rate of psychiatric problems, often occurring in people who are otherwise frail or have other medical problems and who therefore can't easily make it into a health care setting to get treatment."

In addition to "late life psychiatric illness, these patients might have heart failure, cancer, or bad arthritis, and therefore getting to and from appointments is difficult. For many it is difficult for them to spend time sitting waiting in a waiting room," Lyketsos said.

Johnston said, "The GO program has been established to develop a model of care that provides outreach mental health services to frail elderly in their homes. The GO team will accomplish this by partnering with local community agencies working with this population."

She hopes to involve agencies such as Senior Services, community mental health agencies, the Area Agency on Aging, Hospice, primary care physicians and the local home health agencies.

Johnston said the effectiveness of the program would be assessed at regular intervals, using standardized psychological and psychiatric tests to measure mood, cognition, functional capacity, quality of life, caregiver burden, and health services utilization.

The Sniders' gift will provide salary support for the medical director, a clinical nurse specialist, a clinical social worker, and a project manager.

The team will create treatment plans to prevent crises and improve the quality of life and mobilize the community agencies.

Johnston said Martha Bruce, Ph.D., M.P.H. of Cornell University studied 539 frail elderly patients who were enrolled in home care programs and found that 73 of them, or 15 percent, had major depression, a specific psychiatric diagnosis.

Major depression often leads to additional medical problems, reports of unexplained pain and inability to perform such tasks as cooking, managing money and doing household chores, known collectively as instrumental activities of daily living.

"This group is also at greatest risk of suicide, particularly in the presence of chronic illness and/or social isolation," said Johnston.

The number of people 65 and older is expected to double by the year 2030, growing from 969,000 in 2000 to 2.2 million in 2030. At present, she said, about 45.7 percent of N.C. adults in this age group have a disability.

Alzheimer's disease is one disability that will affect increasing numbers of people as baby boomers age. Currently, there are 4.5 million cases in America and the numbers is expected to increase to at least 11.3 million cases by 2050.

"Alzheimer's is frequently associated with a range of behavioural symptoms," Johnston said. "These behavioral symptoms are the main reason for hospitalization or institutionalization of Alzheimer's disease sufferers.

Caregivers also are at increased risk for depression so caregivers may benefit from the GO program directly, through recognition of stress and treatment of associated depression."

Wake Forest University Baptist Medical Center
www1.wfubmc.edu