Welcome. Last session of the meeting. Thank you for coming. You're finishing strong. I'm Dan Dahl. I'm a psychiatrist in Birmingham, Alabama. And today, a topic that is of growing importance. By 2050, there'll be 1.6 billion seniors in the world. As I get older, I certainly get more and more interested in the topic. We have a distinguished panel today of rising stars in geriatric psychiatry. I'll go ahead and introduce them for you. First is Dr. Bhadra Rakhnakaran, a geriatric psychiatrist and medical director of Connect at Carilion Clinic, Virginia Tech Carilion School of Medicine. He's the president-elect of the Psychiatric Society of Virginia and also serves as a member of the APA Council on Geriatric Psychiatry. So, Bhadra, on the end. Then we have Dr. Wang. She's a geriatric psychiatry fellow at the University of Washington. She received her medical degree from the University of Chicago and completed her residency in the research track at UT Southwestern. She's going to stay at Washington as a health services research fellow following her geriatrics fellowship. And last but not least, Dr. Karen Dionisotis. She's a fourth year psychiatry resident and soon to be geriatric psychiatry fellow at Johns Hopkins in Baltimore, Maryland. She's an APA leadership fellow and is the APA resident and fellow delegate to the AMA House of Delegates. All right. None of us today have any financial disclosures. The objectives to describe various theories of origin of ageism in our society, to identify the occurrence of ageism in mental health care of older adults, summarize the consequences of ageism in mental health care of older adults, appraise the interventions to reduce ageism among older adults and improve mental health care of older adults, and recommend potential solutions in improving gaps in mental health care of older adults and creating an anti-ageist health care system. All right. Dr. Ratnakar. All right. We will start our session talking about what it means by ageism in our society. It's something that's very evident in our society, but nobody talks about it in depth. And in our session, we'll be focusing more on ageism against older adults. There's something called reverse ageism that younger adults and even adults in social phase based on their younger age. But broadly, ageism deals with how we think, how we feel, and how we act based on ourselves on our biases against age. And this is basically age-based stereotypes, prejudice, and discrimination. This term was coined by Robert Butler in 1969. It's been almost 60, 70 years. But it only gained in prominence 30 years ago at the UN's Madrid International Plan of Action on Aging. And it was considered a problem again by the UN in 2016, only six or seven years ago, when their expert panel on enjoyment of all human rights by older persons said ageism is a big concern for older adults. And the last two, three years during the COVID-19 pandemic, older adults faced a lot of challenges during that period. Their age made them vulnerable to infections. There was a huge rise in elder abuse and neglect. They could not be employed. They faced poverty. They faced loneliness. And residents in long-term care facilities could not see their loved ones. It was not easy. Much worse was when our society was telling, oh, this COVID virus is going to decimate older adults and give us more opportunities. There was terms like the boomer remover circulating around social media saying this virus is going to take away all the older adults. We also saw politicians asking older adults to come out from their homes and work in society and be productive because they're in the last laps of their lives. What is there for them to lose if they die? So that whatever efforts they had in the society could be used for the benefits of older adults. It was shocking those statements were made. And even shocking when we had to triage our resources based on age. And somebody who was older was sometimes not given a ventilator based on the reason, saying what more or how much more life in years can they gain if you put them on the ventilator? So a lot of older adults' lives could not be saved because of triage. And this is not a new problem. The University of Michigan conducted a national poll on healthy aging over 2,000 adults. And they said, people who are above 50 years of age, they said around 82% of people experience ageism every day. 65% reported they would be exposed to ageist messages. And 45% reported that they had interpersonal experiences that had age-based context to it. But this is not universally true. There's an east and west divide. People who are from Asian or eastern culture, their views of aging is very different from the western world. I'm from India. For us, taking care of older adults is considered an honor. When I got my admission to medical school, my mom would say to me, your job is to make somebody who's dying or growing old, to make them comfortable. If you have the opportunity to give them the last drop of water when they're dying, if you have the opportunity to clean their stools or urine, you should consider that as an honor. That was something that was ingrained in me. But when I came to the USA in residency and my first year I was in medicine, I would see how much reluctance my colleagues had in treating older adults. It was a culture shock for me that you didn't see a dying older adult as something, as a calling, as a big reason for you to have a calling to join medicine. It's to take care of the submarine who's passing through the last stages of their life. People in eastern culture tend to be more dependent on each other. They give relationships and social harmonization more importance, whereas in western culture, there's more emphasis on independence, youth orientation, personal control, and innovation. But however, I would say there are news and literature coming out. Since the pandemic, people in the eastern culture, the older adults are struggling for many reasons. One, the COVID-19 pandemic also brought in a lot of the messages from the western world about ageism. Second, because things are very difficult in lower and middle income countries, a lot of the young adults, younger populations are migrating to other places, leaving the older adults alone in their homes. This causes issues like loneliness, poor social support, and in that way society is also slowly, slowly growing ageism against them. But it's all around us. You look for job vacancies. Last one or two years, people are talking about people not coming and working in grocery stores or in retail. But I had my patients who are 65 years old who are still productive, who want to work in grocery stores and supermarkets or retail stores. They're not given the job because people thought that they were too old to work, when in reality that's not true. They were working and being productive and they were smart. They have a lot of resilience and wisdom. And they're not given the opportunities. Technology is going so fast. Even our telehealth, when we implemented it, how many of us took into consideration whether our older patients knew how to use a computer or a smartphone properly to do a video teleconferencing with you? Things go so fast that they're not included in it. You go to, my wife and I, she's the lady wearing the red dress over there. We were just passing by the mall nearby and we were looking at all the beauty products and how they use your wrinkles, your gray hair, to shame you to say you're going old, better cover it up. Society has a lot of ageist messages. And this is a hot topic, sexuality. Our society sees older adults as non-sexual human beings, they're incapable of romance or emotions, where they themselves have their own physical and emotional needs. If an older adult expresses their sexuality, especially in long-term care facilities, seen as a taboo, immoral or perverted, where they're also human beings who are very active young adults. So ageism is a hindrance of their sexual expression. Or even romantic expression, love for somebody else in the long-term care facility too. So ageism is all over. It can be your own personal biases, your institutions might have their own ageism, your retirement age, somebody lost their retirement age to 60 or 55. Does that mean when you're 65 years old or 75 years old, you still cannot care for patients? One of my senior psychiatrists, two senior psychiatrists are 73 and 74 years old. And one of the 74-year-old psychiatrists is the first blind psychiatrist in America. He's Dr. Hartman. And he's still doing all the groups three, four times a day and seeing more patients than us. When he, during the COVID, since he cannot see, he always relied on his hearing to assess patients. It put him at an advantage during the COVID season because we were all trained to look at patients and assess patients and general appearance. He had always been trained to use his other senses to assess patients and put him at an advantage. He's still very strong and going strong. I don't think he'll retire anytime soon. So institutions saying that you're not worthless, you're worthless at age of 65 doesn't make any sense. You still can be productive. It can be intentional ageism to pursue your needs. If you are looking for a position, you can say this guy's an older adult. I'm eligible for this position. It can be unintentional biases that you learned all through the years that brief society has taught you, saying growing old means bad. You're worthless and things like that. And we ourselves, when we grow old, we might have our own ageist attitude saying I'm growing old. I'm not up for this. I don't have to do exercise. I don't have pain. There's no treatment for it. Those are all ingrained ageist attitudes. And that's where self-ageism can be a lot of times a problem in the medical system. Like I said, pain, low mood, isolation. They see that as a part of their old age. They're less likely to seek medical needs. They have low expectations of getting help as their age advances. And negative age stereotypes has been associated with poor health outcomes including cardiovascular events, increase in Alzheimer's disease, biomarkers, and gay disturbances. And it's less likely for older adults with self-ageist attitudes to embrace positive health behaviors including exercising every day, taking your medicines on time, having health checkups regularly. But if you have a positive self-ageist attitude, studies, there was a meta-analysis saying that studies have shown that patients who have positive ageist attitudes have better quality of life less likely to feel they have a disability or physical illness. It's related to less medical events and hospitalizations and increased longevity. So as you grow old, don't limit yourself to what you want. You can do things and it will help your life. But overall, our society sees getting old as part of degeneration of the brain. It's decline. It's disability. It's associated with diseases. It's associated with dementia and depression and even eventually death. Everything's negative. And there's a lot of theories for this at a macro and micro level. There's a functional approach theory saying human beings ourselves like to stereotype. And stereotyping based on cognitive function or age can help us in making decisions. And we use our negative biases against older adults as a way of grouping people or stereotyping against them. A very common theory is called the terror management theory where when you see an older adult, you're reminded of your impending death in years. You try to take all measures to be reminded of that impending death, your own mortality. And that way you take measures to shun away older adults. You have a social identity theory where we all try to group people or be with people based on personal characteristics, race, sex, et cetera. But we also tend to find ways to be in a group that gives us a positive identity. We tend to be with our own peers of our age or somebody who's higher functioning. And you tend to shun away people or older adults because they're not productive and they don't look good and it's associated with a lot of negative connotations. And age can be one way of that group identification. You can have stereotype content theory where you tend to be close to people who are warm and competent. And older adults are seen as warm but seen by many people as incompetent, not worth of any productivity in a society. And because of this, you will have a lot of pity, sympathy. Has anybody heard of elder speak? So a lot of times if you're noticing your hospital, you might see medical students or nurses talking to older adults in a very patronizing way. Oh honey, it's okay, it's fine. And the older adults are like, why are you talking to me like that? I need some respect in my talk. Unless you don't feel envious to an older adult, you only have a lot of sympathy for them. And that's because of the stereotype content theory. There's a stereotype embodiment theory that because of your lifelong exposure to negative stereotypes to age getting older, when you get older, you imbibe yourself with those negative stereotypes and you start having self-ageist attitudes. I know we are a small crowd. This is a small group. This is the end of the day. I have a question for the audience and I would like to hear your answers. Have you experienced or witnessed ageism based on older age in your personal or professional life? Could you share your experience? If anyone would like to talk, we would like you to talk on the mic because this is a recorded session. We would like to hear your question. Sharon Harvey from Barbados. It's not a very profound experience, but I am myself, I'm 69, about to be 70. But I dance, I do ballroom dance and line dance. I don't kind of think of myself as an older age person. But I'm always brought down to earth when I go to the Barbados Association of Retired Practitioners. I think we have AARP here. We have a card where we can get discounts when we go to certain stores. And I'm always shocked. I come and I'm paying, right? I'm paying and I'm going and they say, this is a Barb card. And I think, what? Did they just look at me and decide that I'm Barb age? I mean, I'm willing to pay the non-discounted price. So, I don't know. So, it's those things that you were suddenly sort of presented with. Yeah, the assumptions that you weren't really thinking about at the time. Yes. Hi, my name is Shell. I'm from Illinois and I practice mental health. I've been dealing with older Americans since I first went into my first career, which was nursing. And so, I can relate to what you're saying about the way older people are being treated. My mother is in a nursing home because we cannot care for her at home because she's immobile. So, I see the biases there, very much so because she is immobile and they tend to think, well, she's not all with it. So, they will kind of dismiss her complaints. And if we weren't there advocating for her, then she would not get the care that she deserves. So, I see that from both spectrums. It's seen as that, you know, the children have to advocate for the older adults, you know, because sometimes they think the younger generation, they dismiss them, they feel, oh, well, they're not all with it. But they are with it, you know. Even if you're diagnosed with a dementia, which is a new diagnosis for her, she still can recall certain things and she still knows, well, I'm in pain, I should ask for something for pain, but I'm afraid because they will dismiss me and not take my complaint seriously. So, we have experienced that as a family and have to advocate for her on a continuous basis. How do you want to address that? Are you talking about the nursing home? Oh, yeah. That kind of leads into our next section. Yeah, so Karen will be, that would be a good way to transition to the next section. And we are covering that topic, too. Perfect. Thank you. Great. That was a perfect lead into our next section where we're going to be talking about ageism and how that is seen in the healthcare system, as well as in, specifically in the mental healthcare system and how we provide mental healthcare to older adults. So I think just kind of giving us a preface of where we begin, I think we all know that the population is aging, but I think some of these numbers are really staggering that by the year 2030, the number of older adults are supposed to have doubled in this country, and by the year 2034, the percentage of the population that is going to be older adults will actually bypass for the first time those of children under the age of 18. So that is really staggering how our population is gonna be shifting pretty drastically and what that means for the healthcare, the mental healthcare of this population. The data shows that about 20% of adults over 65, and I'll be utilizing the term older adults kind of throughout the rest of this presentation, will experience some sort of mental health issue, but those same people are 40% less likely to seek or receive mental healthcare than younger individuals, which is really substantial. We know that 10 to 20% of older adults experience symptoms of anxiety, so whether that's an anxiety disorder or just symptoms of kind of everyday life anxiety, and we know that that often goes undertreated. We know that one to 5% of older adults in the community experience major depressive disorder, but this can actually rate be up to about 15% when you're looking at the population that's either in long-term care or getting home healthcare services, or who are hospitalized. We know rates of depression are much higher in that population. I think one of the most staggering statistics that I think that we don't talk about enough is that about 18% of all deaths by suicide are by adults above the age of 65. The statistic that I saw when I was going through the literature is that one in every four older adults who attempt suicide will complete suicide, and that actually is, as opposed to younger adults, so under the age of 18, one in every 200 who attempt suicide will complete suicide. So what we know is that older adults are tending to plan suicide more carefully, and they're utilizing more lethal methods. They're less likely to be kind of found in the middle, and then if they do attempt but not complete suicide, we know that older adults are less likely to recover than their younger counterparts. In terms of substance use disorders and substance misuse, so about 2% of older adults have a substance misuse or substance use disorder, but of the population that has a disorder, only 27% with substance misuse or substance use disorders are receiving treatment. And I think kind of these big statistics, right, that X amount of people have these problems but only a very small number are actually receiving treatment really begs the question as to why that is. And I think kind of up here, what we really believe is that a lot of ageism is impacting who is getting treatment and who isn't. So another kind of staggering and terrifying statistic is that the AGP, the American Association for Geriatric Psychiatry, reports that there will be 2,600 or so geriatric psychiatrists trained by 2030, but the demand will actually, given this change in population that I mentioned, will necessitate 4,000 to 5,000 geriatric psychiatrists. So we're going into a time where there is a huge health workforce shortage, right? And we've been saying this all along, for as long as I can remember in my training and in advocacy work, that there has been a shortage of physicians overall and specifically a primary care shortage. But I think we really need to considerably look at who is gonna be treating these older adults. Okay. So what are some of these barriers to care that we are assuming that people are having and why they're not getting the care, the untreated care that they potentially need? So I think that these are a number of reasons, financial insecurity or insufficient insurance coverage to support mental health care. I know for Medicare Part D, not everybody has access to that. And so prescription medications can really take a lot out of somebody's pocket. And also then with Medicare, you're talking about what is on the formulary, what medications do they cover, if at all. So I think that that is something that we need to be looking at. We do know that anybody living in a rural area likely has decreased access to care. And so I think that this is likely more difficult or a greater issue for older adults living in rural areas. I think one of the biggest things that we've seen from the COVID pandemic is lack of social connection, right? This social isolation or lack of people who have family caregivers. I think in my outpatients, I think about, those who have family, are they're advocating for them at every step of the way? And I do think that those people probably receive better care, right? Because they are getting kind of pushed and pushed to look for other options or getting symptoms brought to their attention that family or caregivers may notice that someone might not notice themselves. I think social isolation and social connectedness is actually one of the biggest things that is going on right now with, so the Surgeon General Vivek Murthy just released a really big report on social connection and how important that is for flourishing and continued life. And so I think this is gonna be a part that we see kind of being integrated into healthcare in the future. We also see, as I had mentioned, lack of specialists informed on and specializing in geriatric care. So I know that same exact cap that I mentioned, that lack of access to geriatric psychiatrists, geriatricians have the same exact issue. So in general, it's just people in the healthcare system with not specialized knowledge in treating older adults. I do think there is still a significant amount of mistrust in the healthcare system. I work in Baltimore, Maryland, and I know in my institution, Johns Hopkins, there is a really significant history of just really egregious things that have been done to people, right? That has continued to further the mistrust in the healthcare system in general. And so I think acknowledging and being present and saying that that is what happened, right? And being able to work with the community to be there to support and to make amends is really important. Internal stigma or shame. So, I mean, I can't tell you how many older adults that I take care of that. Like the thought of having any sort of depression, any sort of anxiety is seen as a weakness, right? Is seen as a personal character flaw and being raised in that culture of, well, you just pick yourself up with your bootstraps and like you just put your head down and get work done, right? So any sort of mental health treatment being seen as a weakness, I think can also lead to lacking care. Lack of culturally competent care. I think that that also is really difficult. Lack of access to transportation or if somebody has a disability with impaired mobility. I know, again, in Baltimore, the mobility buses that we have are often running three to four hours late or are unable to get people to their appointments on time. And so that's a really big issue, even in a big city with actually pretty well-funded like behavioral health system. Having a shortage of services and long-term care facilities and in-home services. And then as Badr mentioned earlier, this poor technology literacy. I do have a lot of older adults that I Zoom with regularly, but I have also had patients that I've taken advantage of the telehealth expansion and doing phone call visits with. And I find that a lot of people for phone calls have been a lot easier. But again, you don't get as much information on a phone call as you do when you're seeing a person either face-to-face in your office or even over Zoom. And then again, I think that there are a lot of discriminatory beliefs in healthcare settings in general. So I think if you think about where you're working with the different types of healthcare workers that you have around, somebody likely has some sort of disbelief, right? That older adults automatically have a poorer prognosis. And so kind of, you know, why bother give them standard of care? Older adults are helpless or unable to care for themselves or can be seen as senile. Older adults will not accept treatment recommendations, are dependent or burdensome, are frail, are unable to make their own decisions about treatment or are less competent than other adults or memory issues or behavioral health concerns like depression are normal parts of aging and there's nothing that can be done. When I think about like a healthcare setting, right? I think about the people who talk to somebody's family members before they talk to the patient about the treatment that they'd like to implement, right? Or even talk to family members before talking about discharge planning and kind of what the plan will be to set the stage as opposed to having a conversation with the person themselves. Can anybody think of any experience that they've seen? I know, I feel like a few of the things you mentioned about your mom and where she's at kind of fits into these that if someone's in pain or someone reports being pain, they're not really in pain, right? I just gave you some Tylenol. Those sorts of beliefs lead to substandard care to this population. What about ageist beliefs in mental health professionals in general? And so the data and the studies on the side there show that psychiatrists can view older adults as having perceptual disorders when maybe they have a UTI and are delirious, right? That they're fragile or vulnerable or senile instead of, again, maybe just being delirious and often require polypharmacy, which we know can actually really be harmful to our patients. Psychiatrists are less likely to recommend treatment for sexual dysfunction. Oftentimes, that's just kind of written off and not even really described as a side effect for things like antidepressants, right? Maybe you'll say, you'll talk about the GI side effects, but you'll leave the sexual side effects out because, I mean, who really cares? This person probably isn't sexually active anyways, which is a really ageist belief. Psychiatrists are also less interested in treating older adults with suicidal ideation. Psychologists and counselors may view older adults as being less appropriate for therapy, as depression in late life, as being a consequence of old age, or being less able to create proper therapeutic relationships. I think being on a consult service in a major hospital where a lot of the teaching that I have to do is about delirium, unless otherwise assumed, with all sorts of interesting consults that I get. Older adult, aged 87, been in the hospital for three days, broken femur, new onset visual hallucinations, new onset schizophrenia. That is, we get that consult five times a day, right? And we kind of chuckle, but then it's also really terrifying to think about that is kind of the care that's occurring for older adults in a hospital setting, right? Or the lack of knowledge that people have in caring for this population, and assuming that any sort of neuropsychiatric symptom automatically means a psychiatric diagnosis, right? I think there's a lack of curiosity that happens about what the etiology is behind someone's symptoms. And that's something that I think as a healthcare workforce, we really, really need to address. We know that taking care of older adults is challenging, right? There's so many different factors that can be contributing to one symptom, let alone one illness. So things that we may think are visual hallucinations, and people automatically think about depression with psychosis, or people automatically think about a psychotic illness, right? We are more thoughtful in thinking about delirium, or even thinking about changes in hearing or vision, or vitamin deficiencies, right? And so I think it's really important that we're, or even pain, right? We know pain can cause delirium. And so I think we as the workforce caring for this population are doing our best to educate the rest of the workforce as well about these things that make caring for this population very nuanced. There are some biases in psychiatric diagnoses then for when we go about diagnosing older adults. And so we do know that a lot of older adults have a more unique or atypical aspect of the disease and of their presentation, or variations in symptoms. And this can lead to missed or delayed diagnoses, decreased or delayed access to care, inadequate or inappropriate treatment. And older adults are maybe less likely to report a symptom of a disorder. So all of this can lead to decreased survival, increased disability, poor quality of life, worsening mental illness, increased cognitive and functional impairment, and increased in hospitalization and ED visits. I think one of the things I think about the most is that a lot of people will just say to themselves, like, this is a normal part of aging, right? And I know I've said that a few times in this presentation so far, but, you know, or we'll assume that, well, of course, I'm feeling sad and depressed. Like all of my friends are dying and I'm losing mobility and I'm not able to do the things that I used to do, right? We as physicians and as healthcare workers know that there's a distinct difference, right, between demoralization and a depression, a major depressive disorder. And so it's very likely that people who are undergoing a major depressive illness and are not likely to report those symptoms or we as healthcare workers are likely to say, oh, well, you know, of course, this person is having a hard time, right? It's a hard time in life at times. And I think that that's something that I hope that we begin to shift. So looking at these kind of three types of symptoms, what are things that can be seen? So specifically for psychosis, so these symptoms can be concordant with conditions such as delirium, dementia, medication side effects, medical illnesses, and all of which can be relatively common in later life as opposed to, say, new onset visual hallucinations at age 87, right? There is an ageist assumption regarding older adults. So, you know, that disturbed thinking in an older person automatically means they have dementia or a misdiagnosis of psychotic syndromes by attributing those symptoms to a dementia-like process. For depression, older adults may be less likely to endorse sadness or low mood, or they may be present with, they may present with instead apathy or somatic symptoms. I have a patient that I'm taking care of right now that every morning he wakes up with just feeling of dread and this ball of feeling uncomfortable in his gut. And he has been hospitalized in the past for depression, but there's no part of him that would ever identify with having depression, right? And so that oftentimes we see older adults presenting with these somatic symptoms as opposed to presenting with what we typically see as the typical symptoms of depression. So the phenomenon known as depression without sadness or mass depression may lead to misdiagnosis and in some cases to over-diagnosis of depression. And then in the case of pseudodementia, the presentation of cognitive deterioration may reflect an ageist assumption of dementia in older adults, as opposed to treating the depression that is actually causing the cognitive changes. Regards to anxiety, so ageism may be linked with a tendency to interpret anxiety and avoidance behaviors in late life as adaptive or realistic reactions to age-related physical illnesses or to life events. So what are some ageist attitudes that we see in mental health treatment in general? So in nursing homes, oftentimes, right, unfortunately there are shortages of staff, there's reduced evening and weekend staffing patterns and increased time pressure on each personnel, which typically results in increased use of medication to address problem behaviors, right? Which could be anything from actually delirium, right? To any sort of other symptom. We do see an increase in prescriptions for said problem behaviors, including use of benzodiazepines, antipsychotic medications and sleep medications, which we know cause adverse outcomes and typically have a lot of side effects, especially for older adults. Frequent use of medications to treat mental disorders may be related to the belief of, so utilizing medication instead of also utilizing psychotherapy because of the thought that older adults don't want psychotherapy or won't get psychotherapy. So in cognitive behavioral therapy, maybe a psychotherapist doesn't assign as much homework to an older adult to complete between therapy sessions because they don't think they're capable of keeping up with the work. Also, some therapists may have stereotypical and subconscious beliefs about the elderly, which may lead to a challenge in the psychotherapist identifying a patient's maladaptive thoughts and then also engaging the patient in correcting them. So this is just a few of the things that we see and I think it's important for us to identify so that we can begin to correct. And with that, I'll turn it over to Dr. Wang to talk about some interventions. Thank you. So we all have some beliefs about old age. So let's take just 30 seconds to write down one to two statements about old age. You can do it on your phone. There's no right or wrong answer to this. So looking at, sorry, looking at ageism just starts with ourselves. We all have beliefs about ageism, about becoming older. And some of the common ones that people have about turning older include that there's a physical decline that happens. Our bodies will break down, there's a cognitive decline that mentally will be not as sharp, that we won't be as happy, that we'll have dementia, that there's this sense of degeneration. So we can just look and see how well those beliefs hold up to the data. So although dementia is a common mental issue that happens in old age, there's a 90% chance that your thinking abilities will be just fine. Dementia affects one in ten older adults, but it also includes a lot of modifiable risk factors for most people like education, diet, and exercise. What about if you don't have dementia? We think of old age as the time where our cognitive abilities decline, and childhood as the part where our brain develops. But the formation of synapses and the pruning of synapses that occurs in early adulthood also continues throughout life, and it's the balance of the two that leads to the maturation of the brain. And so our mental and physical abilities might begin to decline around age 30. But when we break down intelligence into crystallized and fluid intelligence, we see that crystallized intelligence are actually better than what we had when we were younger. And those include things like vocabulary, knowledge, reasoning. Whereas our fluid intelligence starts to go down, things like processing speed, short-term memory, and solving skills. But not to the point where they're so bad, maybe to about the age of 20. And the belief that as we age, we'll just become more lonely and sad is actually not true for people in high-income Western countries. And this has been replicated across the world in other high-income countries, where the point of most unhappiness is around mid-age, where people have a lot of responsibilities for the generation above and the generation below. But that actually life satisfaction increases as we age. This U-shaped relationship between age and well-being across the adult lifespan is well-documented. And this is what is shown in the United States, that here we are the most unhappy in mid-age. But as we age, that our well-being actually increases. So furthermore, the prevalence of psychiatric disorders in older adults actually is less than you would see in younger adults. The rates of depression is about one to five, anxiety is about ten, except for dementia. So successful aging is a sense of well-being that includes the attainment of goals, positive attitudes towards oneself and the future, social connectedness and adaptation. And it showed that mental well-being actually improved in a linear fashion from age 20 to the 90s, and that most people felt that they were aging successfully despite having physical function that worsen or social stress. This phenomenon of successful aging, despite physical functioning and social stresses, were found in older adults who were also being treated for serious mental and physical illnesses. And people could attribute this to the resilience and wisdom that we develop throughout aging. We especially saw this during the COVID-19 pandemic, where although the mental health of older adults was higher than at baseline, compared to other age groups, they were lower for PTSD symptoms, depression, anxiety, and older adults were more resilient and less fearful of dying than younger ones. So we also wanna just make the point that aging successfully is not just something that is driven by biology. The perception of ability is also influenced by culture and by policy. So where we are, we don't necessarily have a lot of social structure for older adults to be able to age and exercise. But in other parts of the world, for example, like in China, there's a lot of activities and things in the communities for older adults that I would like to show you. Okay. Okay, so we don't have to watch all of it. But it just makes the point that when there are social structures in place, it's easier for people to age well, too. So it's not an uncommon sight where you see grandparents exercising and having a community in the neighborhood. Okay, so why does even addressing ageism matter? Studies show that individuals with a positive outlook towards aging lived on average seven and a half years longer, even when adjusted for health and socioeconomic status. And it also affects patient care. We all bring parts of ourselves when we care for our patients in any patient encounter. And so these are real cases we wanna share with you. So this was a case of ageism in patient care. A 60-year-old female with psychosis and disorganization that occurred over months was brought to the ED involuntarily for bizarre behaviors and was then hospitalized. She didn't have any prior psychiatric history and there was no substance use. So the team decided to get a BRING MRI cuz they suspected dementia. BRING MRI showed chronic microvascular disease. She didn't have any cardiovascular risk factors. So her primary team and the consult liaison team diagnosed her neuropsychiatric symptoms due to vascular dementia based on the MRI reading. And the team was planning to discharge her to an adult family home. So just how confident would you be about not missing something and to give somebody a serious diagnosis like dementia if she was 20 years old, 40 years old, or even 50 years old? And so on the day of discharge, this consult liaison team is asked to see the patient again for documentation purposes before discharging them to an adult family home. So the psychiatric, geriatric psychiatry fellow was rotating on the service and review the MRI, review the history, didn't find any early family history of any dementia, didn't see any pathological findings of any sort of dementia. Administered a mocha and the patient scored a 30 out of 30. And so the CL attending was notified of the findings and reexamined the patient. And then coordinated with the primary team to transfer the patient to inpatient psychiatry for treatment of late onset schizophrenia. So what have organizations say about addressing ageism? The World Health Organization recommends having policies and law in place, such as monitoring mechanisms, as ombudsmen, courts, human rights agencies to reduce ageism and discrimination. Also to increase education activities and to have intergenerational contact. So in the US, we have a couple of employment laws that prohibits age discrimination in the hiring process and the compensation process. So people cannot just not promote someone or push them towards early retirement based on age. And this is particularly true for those that receive federal funding. However, this law can be strengthened. Currently, the maximum damages that you can collect for a company of 100 workers is about 100K. And this law has been applied to the compensation process, but not so much the hiring process. There's also been argument for having intersectionality between other dimensions such as LGBTQ or older women, other minorities, and older adults. And that perhaps for companies or agencies that receive some sort of federal state funding, there should be an affirmative action in the hiring process. And what are some ways that we can address ageism in healthcare? Some recommendations include having oversight committees or transition of care processes. When we know that older adults are more complex and are more likely to fall through our safety nets and have adverse outcomes during care transitions. Some ways to address medical care include wraparound services that can include things that older adults commonly face such as providing transportation, doing home calls, sharing medication costs, or care coordination burden. There could be better reimbursement for providers that take care of older adults, such as when you do family discussions, caretaking prevention, coordinating with the nursing home, and also to increase the participation of older adults in clinical trials for adults to raise the age cap over 60. There are several ways that researchers have tried to increase access to mental health care, and this is particularly important in subspecialties like geriatrics. So integrative care have been shown to improve outcomes in physical and common mental illnesses, especially when co-managed. And for things like the neuropsychiatric symptoms of depression, even having an MP to give psychoeducation to coordinate has been shown to lower the neuropsychiatric symptoms of dementia and also the caregiver distress and depression levels. Collaborative care models in primary care has been shown to show increased satisfaction in improved medication adherence and increased caregiver satisfaction, as well as decreased wait time to see a specialist if something does go wrong. Other ways to increase the workforce include training peer providers to deliver psychotherapy. And this has been shown to prevent and also treat mild to moderate depression and anxiety well in older adults. So macro-level interventions compared education intergenerational contact, which means connecting with somebody who's an older adult or combining the interventions on youth in 63 studies. And it showed that this combined intervention had the greatest effect on reducing ageism. A lack of knowledge was correlated with more negative attitude towards working with older adults, but increased clinical curriculum in medical schools and increased patient exposures to older adults reduced those attitudes. In addition, stimulating the sensory deficits that older adults might face improved empathy and attitudes in trainees. So just some food for thought. A lot of us, most of us would probably supervise trainees. So on a consult liaison rotation, a resident is reluctant to see older adults presenting with delirium, depression, anxiety, or behavioral or psychological symptoms of dementia. His notes about older adults are not as thorough or detailed in clinical reasoning and treatment plans as his other patients. He comments that there's no point in treating delirium or dementia as patients are at the end of life. And outcomes will be always poor due to medical comorbidities. So faculty have noticed that residents who plan to pursue fellowships such as child comment they're not just interested in treating older adults. So this is something that we can discuss as a group. Is this a professionalism issue? And how would you help the resident to reflect on these ageist attitudes in clinical care? Who would you suggest to the faculty? And how would you supervise residents not interested in this patient population? So maybe if you guys can talk for maybe five minutes and then we can just share what we, what our thoughts are. Okay, so one of the things that they've done with people who work with individuals who are aging is to kind of do a role reversal. And when I first went into nursing, I was working in a nursing facility. And they had us to sit down and they put these thick glasses on us. And they didn't clean them. They put Vaseline on them so we couldn't see. And so we were told, you know, to do certain things in a certain order. And of course we couldn't see so we were disoriented and we really felt the role reversal. We really felt how that individual must feel when certain individuals are coming to them, telling them to do things. And their perception is off because maybe they can't see, their glasses are dirty, and they need a new prescription. But we don't see ourselves as that individual. So it would help if we could see ourselves and put ourselves in their role. And it would help us to take better care of them. Thanks for sharing. Thoughts from any of the other groups? Hello, my name is Musa. I am a psychiatrist from the Emirates. So just my experience with the geriatric population, I mean my own experience as well, I mean my team, that we always look at them as complicated, complex, you know, medically, as well socially. So one of my, he's really very experienced psychiatrist, consultant psychiatrist. Whenever a geriatric case come under his care, usually as an inpatient, get admitted, I found him very much anxious. And he ask most of the time from the geriatric psychiatrist to come and see the patient. Sometimes he doesn't even give much of, you know, he will anticipate a complexity even before taking a full history. And we always have this assumption that probably this patient might end up with us for quite long time. Maybe the family will not be interested to take the patient back home whenever you decide to discharge the patient. So this is the perception. I'm not sure if it is an ageism. For me, I feel comfortable dealing with geriatric patients. I actually work in a community home care service. So I feel comfortable because there is a lot of exposure. And I feel comfortable also, I mean, referring complex cases to our geriatric psychiatrist. So yeah, I mean, the ageism is there, but the more the exposure, you get better and you feel more confident and comfortable dealing with the geriatric population. Actually, working with them is really fun. But still, I mean, it is complex and you have to keep it in mind. Thank you. Hi, I'm Donna. I'm a rising fourth year at Michigan State University, interested in geriatric psychiatry. So to answer this question from a trainee perspective, I think that it would be a disservice. And I'm assuming the best from my co-residents, right, my co-trainees, that it's not like a malicious intent or a negative viewpoint on not wanting to care for patients, right? Cuz we're all physicians, that's the point of going into this field. But giving them kind of like a gentle nudge on reminding them that even if they are interested in the pediatric population or even adults, these children, these adults eventually become older adults, right? And so to be able to understand the scope of the care and the holistic view of caring for patients from cradle to grave, I think is very important. So even if I am interested in geriatrics, I would still love to see pediatric patients, adult patients, to understand how their health evolves over time, right? Cuz health and mental health and even their physical health is a dynamic situation throughout a whole lifetime. It's not just like a stagnant one point in time. Even older adults in different age ranges has different health needs as well. So that's like, if I was their co-resident, that's kinda how I would try to explain it to them. And then hopefully they'll perk up and wanna treat older adults a little bit more sincerely. Thank you. Any other thoughts? Did you wanna share? Hello, I'm a geriatric psychiatrist from the Netherlands, working around Amsterdam. And usually what we also say when residents or interns are a bit reluctant to help the elderly, we say, what if it was your own grandmother or grandfather? How would you like them to be treated? And if it's more like anxiety of how to handle the elderly patient, because they're frail, we try to encourage them to see the patient and to get supervision and to learn while they still are in residency. And in our country, it's also mandatory to do a geriatric psychiatry rotation for the residents. So we hope that they get more comfortable seeing the elderly. That should be at least six months long, right? Yeah, it's six months. No, is it? Yeah. Wow. Yeah, so at this point, we'll open it up to any other thoughts or questions. Bar, I am glad you brought up differences in cultures. In the United States, people move throughout the country, so I think things are more difficult here. And I don't know if anybody has thoughts about how to improve the sense of community and care as we get older, or if you have thoughts on other issues. So I had a question about that schizophrenia diagnosis for the 60-year-old, the late onset. Was she experiencing positive or negative symptoms? Was she kind of tonic in any way? No, she was not. She didn't have any negative symptoms. She was just psychotic. But I mean, I think the diagnosis of dementia was very too much, because her brain was healthy. Chronic microvascular changes is just something that happens normally with aging. And usually, if you have most types of dementia, don't get to that point of psychosis until it's like years later. Yeah. So I was concerned with that. I had an experience with an elderly woman in a nursing home, and we just thought she was combative. She smacked her hand away, and this, that, and the other. And I didn't realize, one of the other nurses told me, she says, you know, she was sexually abused early in her development. And it just changed everything, you know, to understand why she was always clinging to a baby, didn't want people touching her things and everything. So it was the psychosocial that we were missing to help her to go forward. And I think a lot of times we miss that. There's a, it's like a disconnect. We'll look for medication, we'll look for dementia, schizophrenia, and everything. But there's some type of trauma that we haven't addressed and we're not looking for, and it goes missed until they say something. And then we think, wait a minute, who did what, when, you know? And it's like it comes back to us that we missed a step, so. Thank you. Other thoughts? I'm a senior, and I want you to know that I've totally gone pro bono as a psychiatrist and an advocate, and I did primary care first, and now I've been doing both primary care and psychiatry. This isn't data-driven, this is just fact. I've lost 15 friends. I used to come to primary care meetings, and I knew geriatric psychiatry, I went to Stanford, and I didn't become an academician, and they accepted me, all my peers. They're now retired, a number of them are chairmen of departments, and my professors would be 80s and 90s and 100, I learned geriatric psychiatry, and I took a long time learning about that. The problem is, even in medicine, the year sexually transmitted diseases, and the reason I know this is, I asked the presenter, were 16 billion, he said, they would deliberately miseducate the next generation of doctors. This was down, prime ed, I've been going to those meetings for a number of years, a long time, I can't tell you how long, and they had thousands of doctors, because it was in San Diego, you know, a lot of people want to come over, nurses, physician assistants, psychiatry, I mean, everybody. They said they would deliberately miseducate to save money for the government, and there would be deaths, and I went up to this young man, and I said, so where are you making, he was the head of internal medicine at the time, it was sexually transmitted diseases. So I know that that decision, it was nuanced before. I didn't have white hair, 20% of the people say, you can't change the guidelines. So we have a group of people now, not only did I used to love hearing the chairman of Duke who was the head of diagnostic three, and all the way up to four, who wrote Saving Normal, there have been people that have been disrespected, we have content in psychiatry, and in medicine, and they're acting like the elephant's not in the room. And I've lost friends to incompetency. And the miracle for me is my dad was mad I didn't become a pediatrician, and I liked all ages, so I did primary care, and the hospital he started founding had mismanaged him, and he would have died. This is a reality, and all the people that are grieving the loss, it needs to be out in the open. The psychiatrists in geriatric psychiatry need to know that. I heard a wonderful talk on geriatric psychiatry on Saturday night. They talked about what you need to do before you do any other kind of meds, and it was really good, the one that was at the Hilton. It was content, and they were, they knew, and they knew geriatric psychiatry. And it wasn't, it was just, it's really important that we don't disrespect and assume that. I look down what happened before the shutdown, because you know it's about money. And I've been doing, talking at the law school, I've gone to financial conferences that Forbes have been at. A lot of this is a misappropriation of funds, and not letting young people know that these decisions were made. No, I want to say this before you go. So please look, there's another area that elderly people are not aware of, and when their families are using technologies, there's a new environmental exposure that my husband and I as electrical engineers did not put this content, but we used to try to tell people. Okay, I think we're going to. You need to know, look at a Massachusetts for safe technology. It's another thing that can be inflammatory, stimulate atrial fibrillation, suppress all of us, all ages, suppress melatonin, increase norepinephrine, and decrease voltagated calcium channels. And I had one success. I did a dementia, I mean a risk management for dementia talk. A guy from Harvard finally put it in the chat in the last month, and he said, oh, the communal of exposure of both marijuana and the communal exposure of electromagnetic radiation. Thank you very much. Yeah. So this website for CME, you need to tell people. For the comments. Wait, wait. Before you go, please let me tell you, it's going to expire. 20 hours of CME, Massachusetts for safe tech has it for doctors, nurses, nurse practitioners, physicians and assistants, and EMTs. It will expire in June. It's the EMF Medical Conference, Massachusetts for safe tech. I didn't put it together. I just was aware for a year. Thank you. And you got to do the truth, right? Because elderly people, they deserve that. And everyone deserves their grandma, and everyone deserves their parent, and they got a lot of wisdom. Thank you. Thanks so much. All right. We have another question at the mic. Hi. Thank you to each of the panelists for your presentations. So I work in a federal prison, so we have a lot of aging adults there. And as you can imagine, it's not conducive to respectful aging in some ways, because officers come by every half an hour, even through the evening, and do checks. Sometimes they put a light in the room. There's not a lot of engagement with elders as far as recreational things and just opportunities to do social activities. So I'm just wondering if you have any ideas about how to make an environment where it's very regimented and structured, more appropriate and friendly to older adults? Any thoughts on the panel? It's a rising topic. I remember reading it during my fellowship last year. I read a lot of this older adults were young or middle-aged when they were in jail for small offenses like drugs or something like that. The system and law then were not very kind to them, and they were kind of like aging in their age. So there was a lot of what I saw. This is what I'm remembering. I'm not very well versed with the forensic system, but what I read, there should be an ongoing assessment about the cognition, depression, and how to engage them in the prison system. You can do activities for them inside the prison system and also being respectful about their aging. One of the problems I see is like within the prison system, there's also a lot of trauma which they witnessed. I did a session on climate change in the morning and older adults, and there was a comment by the audience saying when you teach something to the older adults, they're very stubborn about it. They don't want to change their ways. But what would you do if you try to involve the older adult as a part of the system, asking them like, hey, what can you do for the younger prisoners? Because they've seen what they went through in their life, what mistakes they did, how can they impart their wisdom, and that way they become productive to other prisoners. And that's one of the interventions against ageism in the community is the generational contact. The younger adults, contact with older adults can help the younger adult to learn a lot of things about maturity, wisdom, be more less impulsive, less angry. And that way you're getting the older adult be more productive and inclusive in the system, prison system too. And they're not just sitting alone, lonely. They're making their brains work. It helps with cognition. And I know it's a problem. A lot of times they don't get paroles or pardons, and a lot of them, they age at the prison. So thinking about the prison as a living environment for them, how can they be more inclusive is one way. I know the system, prison regimes and laws are not very friendly. But whatever social time they have, I think it's good for them to be involved doing things. Thank you. I appreciate it. Any other thoughts, questions, comments? I'm 81 years old, and I work part-time in a nursing home run by the Asa Community Medical So there is a large number of Korean patients, somehow they have a Korean house, they have a Korean activity therapist, but they're not lucky enough to get a Korean psychiatrist. Often it comes to me, then what do I do with 85-year-old Korean lady? So I show them a $5 bill, they say it is open, that's $5. And I show them $10 bill, that is easy. That means she can read, she can understand language, and I told them to add it sometime, they can do or can't do. Then I learn half a dozen Korean words, like chop-chop means eating, cham means sleep, that way. So I do communicate, and then I call up the family, and they are overjoyed, hardly anybody calls them from the nursing home. So it's a two-way process. It makes me feel good, and it makes the family and the patient feel good. That's mine. So you took an interest in her culture and explored that. Thank you. I work really primarily in private practice, and I found that increasingly older persons are referred, but I try to make it sort of more amenable for them in that I do mainly home visits of that population. So I go both to their individual residences, and those who are in nursing homes, then I visit the nursing homes as well, because I found that especially the ones who are still at home in their setting, because you were talking about whether it's psychotherapy and so on, I find I can do a sort of better intervention in their setting than the whole conniption of getting them to travel and get to my office, because then a family member has to bring them and the family member has to take time off from work, and it's a whole scenario. So I wasn't sure whether you do sort of home visits as well. Is that part of it? I do home visits if geriatric medicine asks me to. It reveals a lot of things when you go to their homes, especially it's sometimes interesting when you go to their homes, you see renal records, what kind of music they liked in the past, 70s classic rock or things like that. You look into the refrigerator and see what they like, a lot of ice creams too. But it reveals a lot of what they're comfortable at. Doctor's visits are anxiety-provoking for a lot of them, they take their blood pressure, they're always high, so they're at their doctor's visits. Yeah, home visits I think is something in the American medical training, I wish it was more incorporated in medical school onwards, that that is an option to treat patients, go to their home rather than have them come here. I think UK does it. Any other thoughts or questions? Hi. Thank you very much for your talk. I'm a third year psychiatry resident right now and I recently had a geriatric rotation and I had a question about, I really appreciated your talk, especially about the self-stigma, which I hadn't thought too much about before, and thinking about some patients that I've seen that maybe have been reluctant to engage in therapy or in group therapy, maybe out of concern that they might not connect with other people, or that kind of that, what you talked about with self-stigma of thinking that they're too old to participate in therapy or that, you know, any other kind of thoughts like that. So I wonder if you have any advice for kind of older patients that we might see who might be a bit reluctant because of that self-stigma. To participate in therapy? Yes, therapy or group therapy or maybe continued treatment in general. So one thing is also knowing the culture and you're coming from a lot of older men who have grown in the 70s or 80s would say, we don't talk about that stuff in a group, kind of like against the male stereotype. And for females, it's always been suppressed. So that's where you had to figure out if you're doing group therapy, what is the group's composition like? Because the group composition is very important in group therapy. Especially if you're working in the VA system, you can see geropsychology doing a lot of group therapy and it's the same age group, the same problem. They gel well with each other. So the age group composition should be very important when you're talking to group therapy that this is your, almost your same age peers. Second is also education about the patient, about why you're talking about therapy. A lot of mental illness that doesn't, that don't need medications. Maybe if you are able to talk about problems, you might, you might be able to find solutions from your peers. Or if it's individual therapy, it's a lot of older adults that don't like taking pills. They already have 20 pills in their list, why do I have to add one or two more? So that can be one way to transition, like, you're going to see me maybe every three months. Why don't you have somebody to talk to every week for the next 16 weeks? And a lot of older adults, even though I said I'm anxiety-provoking for a lot of older adults, visiting the doctor is sometimes the only way they have something to talk to. I might be the only person that they're able to talk about the problems and went out. They're not able to talk about it to their children or grandchildren or anything. I once had a patient, like last week, I had a patient to me, I like coming to your visits because you're the only person who will listen to me. And you can give that, sell that when you talk about therapy. I was there, I was trained in talking. Because a lot of older adults are not very familiar with therapy and they're thinking, like, oh, it's not going to work for me, it's not worked all these years, why is it going to work for me now? So also telling them, hey, what do you have to lose? You're not taking any medicine. This is somebody and you talk to your problem. So you probably had to educate and help them buy into it. Some people are very stubborn, that is, I'm there. Because it's also a lot of their upbringing, we don't talk about this thing, kind of thought process. I think if they have something that needs treatment, you could reframe it as a medical issue. But sometimes people also look for therapy and group therapy as sort of addressing their loneliness and having social interaction. And you can also encourage older adults to, like, go and do elder friends where they pair them up with a younger person to do activities and join their community center. And then sometimes people even use, like, meet up where they meet, like, people in their own city and town. And that's a way for them to, like, make friends and go out and do group stuff, too. One other area I found very helpful is a lot of older adults, probably it's because I come from Virginia, rural Virginia, they'll ask for Christian counseling. Do you have any counselors who have more Christian alliances? And I would, because spirituality and religion has a lot of importance, even in psychiatry or in a person's life, whatever you can get for them, go for it, even though it might be against your beliefs or something like that. Because in the end, if it's beneficial for the patient, it's not harmful, that's an option. A lot of people older adults do buy into it. And a lot of, if you look into psychologytoday.com, people are doing CBT and stuff, they will write in the site Christian counseling. Because that's how they sometimes get them into the therapy sessions. All right, one more chance, last chance. Any other thoughts, questions? Thank you very much for being part of this session. Please give our presenters one big hand. Have a great rest of the evening.

ageism

mental health

seniors

geriatric psychiatry

elder abuse

COVID-19 pandemic

healthcare access

discrimination

intergenerational contact

policy frameworks

inclusive healthcare