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Megan Brooks November 20, 2013

Aging adults with mental illness have significantly higher rates of healthcare utilization than their mentally healthy peers, new research shows.

An analysis of comorbidity levels and healthcare utilization in older adults with lifelong, serious mental illness shows that these patients have higher rates of emergency care, longer hospital stays, are more likely to fall, and have alcohol and substance abuse problems compared with mentally healthy control individuals.

"Our study illustrates the continuing vulnerability of seriously mentally ill patients as they grow older," Hugh C. Hendrie, MB, ChB, DSc, geriatric psychiatrist and health services researcher from the Regenstrief Institute and Indiana University School of Medicine and Center for Aging Research, both in Indianapolis, told Medscape Medical News.

"An integrated healthcare system that addresses both their medical and psychosocial needs will be required to care for these patients whose numbers are increasing by the year," Dr. Hendrie added.

Iqbal "Ike" Ahmed, MD, geriatric psychiatrist from University of Hawaii and Tripler Army Medical Center in Honolulu, who was not involved in the study, agrees. "The older, and younger, mentally ill populations who often have comorbid medical and psychiatric illnesses beg for integrated care."

The study was published in the December issue of the American Journal of Geriatric Psychiatry.

Survivor Cohort

Just as in the general population, patients with serious mental illness are living longer. Despite this, few studies have focused on healthcare utilization and its relationship with comorbidities in aging mentally ill patients.  

hugh hendrie Dr. Hugh Hendrie

Dr. Hugh Hendrie Dr. Hendrie and colleagues compared the comorbidity profile and healthcare utilization of 255 adults (mean age, 72 years) who had lifelong serious mental illness and who were attending a mental health clinic with a representative sample of 533 adults of similar age who were without serious mental health illness or dementia and who were being seen in primary care. In the mentally ill group, 119 patients (46.7%) had major recurrent depression, 100 (39.2%) had schizophrenia, and 36 (14.1%) had bipolar disorder.

Compared with the primary care control patients, the seriously mentally ill patients were more likely to have diagnoses of substance abuse (P = .02) and alcoholism (P = .0016) than the primary care control group, mirroring prior several studies. However, they were no more likely to have comorbid medical conditions, including diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, thyroid disease, and cancer.

The researchers note that this is in contrast to the current literature among younger patients that suggests that the prevalence of several comorbid medical conditions, including obesity, diabetes, and symptoms of cardiovascular disease and respiratory disease, is at least twice as high in seriously mentally ill patients than in the general population.

These findings suggest that these elderly mentally ill patients represent a "survivor cohort." Dr. Ahmed agreed. "The authors are right on point that these patients are actually in some ways a survivor cohort.

They are a hardier bunch than the average chronic mentally ill patient because as a rule, chronically mentally ill patients tend to live 20 to 25 years less than the general population, so the fact that they made it this long suggests that they are a hardier group," said Dr. Ahmed.

Reform to the Rescue?

The mentally ill patients in the cohort had significantly lower rates of hypertension (83% vs 93%), and their greater use of antipsychotic medications, which can have hypotensive effects, may be a factor, the researchers say. The researchers also found that falls were significantly more common in the mentally ill group (32.2% vs 18.6%, P < .0001).

It may be that this "survivor cohort of mentally ill patients will now have to face the consequences of aging, such as falls, which represent a major contributor to morbidity in the older adults," Dr. Hendrie and colleagues write.

Even after adjusting for demographics and alcohol and substance use, the seriously mentally ill were significantly more likely to fall (odds ratio, 2.16; 95% confidence interval [CI], 1.52 - 3.08; P < .002).

"These are people who probably have neurological consequences of long-term substance use, including alcoholism and psychotropic drug use," which may help explain the higher rate of falls, Dr. Ahmed said.

In adjusted analyses, patients with serious mental illness also had significantly higher rates of medical emergency department visits (P = .0027) and significantly longer lengths of medical hospitalizations (P < .0001) than did the primary care control group.

Dr. Ahmed said a similar pattern is seen in younger mentally ill patients. "They too have a longer length of stay and use the ER more than primary care clinics. They aren't integrated into the primary care health system.

These patients are often not comfortable going to medical clinics, and also medical doctors may not necessarily feel comfortable taking care of a patient who has severe mental illness," he said.

Overall, the researchers note that the findings suggest that the aging mentally ill represent a "vulnerable elderly population that deserve more intensive studies, leading hopefully to a better integrated model of medical and psychiatric care including consideration of psychosocial factors."

"Health reform, insofar as it addresses the requirement of coverage of treatment for mental disorders, will certainly help, as would the final implementation of the Mental Health Parity Act," said Dr. Hendrie.

The study was supported by the National Institutes of Mental Health. The authors and Dr. Ahmed report no relevant financial relationships. Am J Geriatr Psychiatry. 2013;21:1267-1276. Abstract

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