REVIEW ARTICLE

Geriatric mental health: The challenges for India

Pragya Lodha, Avinash De Sousa1
Research Assistant and 1Founder Trustee and Consultant Psychiatrist, Desousa Foundation, Mumbai, Maharashtra, India
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ABSTRACT

Geriatric mental health has yet to receive its due recognition in India. Geriatric mental health is plagued by many challenges
that prevent the development and progress of its services. The present article is a narrative review that looks at the various
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challenges faced by geriatric mental health in India. The article describes different specific and general unique challenges
faced by geriatric mental health and discusses in detail the nature of each challenge and what must be done to overcome it.
The challenges range from demography of Indian aging to sexual issues in the elderly, geriatric depression, dementia care,
and the aging lesbian, gay, bisexual, and transgender community. Various issues related to policy and research that challenge
geriatric mental health are also discussed. The need to incorporate geriatric mental health into primary health care along with
the need to train primary care workers and preventive work aimed at suicide prevention in the elderly is stressed. The article
addresses these challenges with the aim of positing before the clinician the various challenges faced by geriatric mental health
in India in the current era.

Key words: Caregivers, challenges, dementia, elderly care, elders, geriatric depression, geriatric mental health, geriatrics, mental
health, suicide

INTRODUCTION METHOD OF CONDUCTING THIS REVIEW

India’s demography consists of a geriatric population Articles that assessed geriatric mental health and its
which shall increase in the years ahead.[1] The scope of challenges in India were identified through searches of
geriatric mental health differs from other areas of mental the PubMed, EMBASE, and Google Scholar databases for
health as geriatric populations have unique needs, thereby articles published in English between January 1995 and
fostering many challenges.[2] These challenges are seen December 2017. The search combined the terms geriatric
at every level of care and treatment, from acceptance of mental health, challenges, geriatric mental health India,
a mental health problem to seeking help and remaining and challenges for geriatric mental health. Additional
compliant in treatment.[3] Lack of trained professionals, articles were identified by a manual search of the reference
scarce geriatric mental health infrastructure, and dearth lists of the identified articles and book chapters and
of financial resources for geriatric mental health are recent review articles obtained. Abstracts and posters
some of the challenges that our nation faces.[4] Geriatric from conferences and meetings were not included in the
mental health problems can be accurately diagnosed literature search. The authors then reviewed the identified
and effectively treated if help is sought early, but it is studies and were able to determine the general and specific
erroneously assumed that they are part of “normal aging.”[5] challenges faced by geriatric mental health in India. These
The unprecedented pace of demographic aging makes were then discussed in the current article. Both the authors
geriatric mental health a huge public health challenge have sound clinical work in the area of geriatric mental
for India.[6] The current review discusses the general and health and their personal experience has added worth to
specific challenges for geriatric mental health in India from the challenges described in the article.
a clinical perspective while proposing some solutions to
help encounter these challenges.
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For reprints contact: [email protected]
DOI:
10.4103/jgmh.jgmh_34_17 How to cite this article: Lodha P, De Sousa A. Geriatric mental health: The
challenges for India. J Geriatr Ment Health 2018;5:16-29.

Corresponding Author:
Dr. Avinash De Sousa, Carmel, 18, St. Francis Road, Off S.V. Road, Santacruz West, Mumbai ‑ 400 054, Maharashtra, India.
E‑mail: [email protected]

16 © 2018 Journal of Geriatric Mental Health | Published by Wolters Kluwer - Medknow

 Lodha and De Sousa: Challenges for geriatric mental health

GENERAL CHALLENGES FOR GERIATRIC MENTAL Challenge 3: The challenge for dementia care in India
HEALTH IN INDIA Dementia is the most common neuropsychiatric illness
besides depression as the major contributor to disability
Challenge 1: The demography of aging in India in people above 60 years of age, accounting for one‑quarter
India has a total population of 1.31 billion, the second of all disability‑adjusted life years.[24] Eight large‑scale
largest globally, and comprises 17% of the world’s total epidemiological studies have indicated that prevalence
population.[7] Currently, the growth rate of individuals aged for dementia for those aged >85 years in India ranges
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60 years and older is three times that of the population from 18% to 38% and, in those >90 years, it ranges from
as a whole.[8] Rapid advances in medicine, public health, 28% to 44%.[25] In 2010, there are 3.7 million Indians with
nutrition, and sanitation have led to large cohorts advancing dementia and the total societal costs is about 14,700 crores.
to old age.[9] A difference of percentage share in the aging While the numbers are expected to double by 2030, costs
population between rural and urban areas has resulted in would increase by three times. [26] Research indicates
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larger number of aging citizens residing in rural areas.[10] that up to 90% of the time, challenging/psychiatric
The aging population is >100 million, and projections behaviors (agitation, irritability, restlessness, sleep
predict a figure of 324 million, i.e., 20% of the total disturbance, and/or emotional distress) that occur in
population, by 2050.[11] persons with dementia may be caused by either factors
in the environment or by a caregiver approach.[27] The
In large epidemiological studies, women have shown a
management of behavioral and psychological symptoms
preponderance to mental health issues as compared to
in dementia is challenging as many of these patients show
men and this may be also due to predisposed biological
an intolerance and side effects to medication. They also
and social risk factors.[12,13] Women in old age are more
may lack the ability to describe and understand their own
prone to social insecurity, health problems, and greater
symptoms.[28] The growth in dementia patients entails
emotional/financial insecurities.[14,15] Lower levels of
the need for specialized dementia care units which are
education are shown to be associated with higher rates
conspicuous by their absence. Dementia care homes and
of dementia and consequently more among females.[16]
rehabilitation centers along with dementia day‑care centers
As mentioned above, most of the elderly live in rural
have not been developed in India, and this is the need
areas and may be poorly educated.[17] The mere increasing
that must be addressed to meet the challenge of dementia
demography of aging in India and social factors itself pose
care in India.
a challenge for geriatric mental health.
Challenge 4: Social factors that play a role in geriatric
Challenge 2: The heterogeneity of clinical
mental health problems
presentations in geriatric mental health
Multiple social, psychological, and biological factors
A key clinical issue in geriatric mental health is the
determine the level of mental health of a person at any
heterogeneity in clinical presentations that confounds
point of time.[29] Along with the typical life stressors
diagnosis and treatment of these problems. Patients
common to all people, many older adults lose their ability
usually deny the presence of mental health problems
to live independently because of limited mobility, chronic
and are reluctant to seek help.[18] In most cases, a clear
pain, frailty, or other mental or physical problems.[30] In
textbook‑like clinical picture is absent, and the skill and
addition, older people are more likely to experience some
intuition of the psychiatrist with thorough understanding
events characteristic of the phase of the life they are in
of psychosocial factors helps to determine diagnosis.[19]
such as bereavement, a drop in socioeconomic status with
Physical symptoms may be the chief complaint in many
retirement, or a disability.[31] The special social challenges
cases and the underlying psychological problems are
of the elderly population in India are as follows:
obscured under a garb of physical complaints.[20] There
1. A majority (80%) of them are in the rural areas, thus
are incomplete clinical pictures where diagnostic criteria
making service delivery a challenge[32]
are not satisfied, but the problems are severe enough
2. The government pension scheme currently reaches
to warrant treatment. This leads to issues in diagnosis,
only 2.76 million out of 28 million elderly people,
and the management is based on clinical experience
mainly urban[33]
of the psychiatrist.[21] The physical and psychological
3. Feminization of the elderly population (51% of the
symptoms in geriatric patients may change during each
elderly population are women)[34]
visit and the clinician must understand the same. Patients
4. Increase in the number of the older‑old (persons above
differ in the degree of mobility they possess as some
80 years)[35]
may be bedridden and malnourished, some may be
5. A large percentage (30%) of the elderly is below the
wheelchair bound, and others are ambulatory.[22] Varying
poverty line.[35]
degrees of medical illnesses also complicate the clinical
picture. The patient being on multiple medications and There are several social factors that subliminally or
multiple doctors treating the patient need to work in sometimes, directly, affect the mental health of the geriatric
synergy for best results.[23] Thus, clinical heterogeneity age groups as follows:
in presentation, varying symptoms, presence of medical 1. Retirement: In India, the retirement age is
illnesses, multiple medications, and being treated by approximately 56–65 years for men and women and
multiple doctors poses a clinical challenge in geriatric varies across the states. Retirement is one of the
mental health. strongest social factors that bring an overhauling

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 Lodha and De Sousa: Challenges for geriatric mental health

change in a working individual. From the next day advantage of the elderly as they enjoy special status
of retirement, the individual has no work to engage and power. However, with growing urbanization and
in (physically or mentally), his or her daily schedule is dependency on the availability of jobs, children are
lost, and the motivation to look forward to something is increasingly opting out of the extended family setup,
also gone. With retirement, also comes a sense of loss leaving behind an “empty nest” and establishing their
of authority. Dips in self‑esteem and self‑confidence own nuclear families.[47]
are also witnessed as the retired individual seems
These social problems lead patients to seek solutions not
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to have become more dependent than he or she was

before. Retirement brings in a sense of dependency only to their psychological problems, but also to these
which is not very pleasant to the senior citizen[36,37] social problems which may be beyond the realm of geriatric
2. Housing issues: The growing trend of nuclear families mental health services and thus posing a huge challenge
in India has inadvertently reduced the structure of to geriatric mental health‑care workers.
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families as support systems. Children no more wish to Challenge 5: Rehabilitation facilities for the elderly
stay with their aging parents due to the burden of care.
and interventions in old‑age homes
In another scenario when housing becomes a challenge
The changing family value system, economic compulsions
for the geriatric age group is when children decide to
of children, neglect, and abuse have caused elders to fall
move in to another space or locality. Psychosocially,
through the net of family care. Homes for the aged are
adjustment to a new place after having lived in a
ideal for elderly people who are alone and face health
locality for 60 years is a difficult adjustment to make
problems, depression, and loneliness.[48] India has four
for the elderly[11,38,39]
3. Financial issues: With retirement, financial types of resources to address geriatric mental health issues,
dependence is one of the greatest challenges that the namely state‑funded government psychiatric hospitals and
elderly face. A loss of steady source of income does nursing homes; private psychiatric hospitals and nursing
bring in a sense of helplessness and dependency. homes; nongovernmental organizations (NGOs); and, the
An National Service Scheme (NSS) survey reveals most important, informal sources – family as caregivers.[49]
that 12% of the oldest‑old, i.e., persons above the Countries like India can develop adequate training programs
age of 80 years are still involved in some economic for the family members who are the most available and largest
activity in order to meet their daily needs. Remittances chunk of caregivers in the service of the elderly. Supporting,
from children are reported as their main source of educating, and advising family caregivers is a cost‑effective
income, as reported by 49% across the cities in an strategy for developing countries as it requires only one‑tenth
NSS survey.[40] Most geriatric population finds it of the resources as invested in residential care.[50]
difficult to get insurance coverage and therefore have
to bear the cost of their health‑care expenses. Several The State and Central provide scarce facilities for day‑care
times, the elderly are denied adequate health care due centers and respite care. There is an absence of any
to shortage of funds. Thus, financial dependence has home‑based rehabilitation measures or benefits accorded
a huge influence on the quality of life for the geriatric by the State to families to address caregiver burden.
individuals.[41,42] Financial abuse is incurred by family However, various types of early intervention for health
members, friends, and caregivers of the elder person and social services are in practice today (and can be
and financial abuse within institutional settings or accommodated in our country), as follows:
by strangers may also impose a debilitating effect.[43] 1. Community‑based interventions: These are important
Domestic settings are not only a frequent setting for as early interventions as they improve the subjective
this abuse, but also their tendency to involve complex well‑being and quality of life of the elderly. These
family dynamics and deep‑seated conflicts tends to services also strive to give a greater degree of functional
make them particularly challenging[44] ability and independence. A challenge that remains is
4. Lack of transport: Many senior citizens from the to have cost‑effective programs[51]
urban and suburban areas, especially from rural areas, 2. Outpatient clinics: These clinics are important
struggle to find reliable transportation. The result is for assessment and follow‑up of mobile, geriatric
missed appointments and poor illness management, patients. There are advantages when these clinics are
even when care is readily available. Some households staffed jointly by internists and psychiatrists. In some
do not have a vehicle, or share one among multiple areas, memory clinics have been developed for the
family members. Many low‑income neighborhoods assessment of patients with early memory problems[52]
are hit particularly hard by shoddy transportation 3. Domiciliary visits: Increasingly, assessments
infrastructure and subways may not act as service areas and treatments are offered in the patient’s home;
on the fringes of a city, buses may be unreliable, and community psychiatric nurses act as a bridge between
both are vulnerable to strikes or service suspensions. primary care and specialist service. Domiciliary visits
For those who are disabled, obese, or chronically also reduce the rate of hospital admissions[53]
ill, riding the bus or the subway can be a difficult 4. Geriatric day care: Day care should provide a full range
undertaking[45,46] of diagnostic services and offer both short‑term and
5. Parents in India and Children Abroad: The extended continuing care for patients with functional or organic
family consists of at least two generations living disorders, together with support for relatives. There are
together and this arrangement has usually been to the few day‑care services by NGOs in India (i.e., HelpAge

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 Lodha and De Sousa: Challenges for geriatric mental health

India) and also state governments. Definitive criteria the elderly will have smaller networks of potential
for referral have not been essentially established. Some family caregivers.[61]
of the targeting criteria for community‑based services
These services have shown to be extremely necessary in
include dependency in two or more activities of daily
India due to varied reasons as follows:
living, no family support, dementia, many long‑term
1. Primarily, the services deem to be necessary due to
illnesses, and many hospital stays.[54]
the breakdown of the traditional familial structure,
Other forms of rehabilitation: which creates a niche in the support system for the
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1. Residential care and nursing care: Residential care elderly. With the given decrease in family sizes,
involves accommodation, ranging from independent and the patriarchal society of India, the woman
housing to sheltered housing schemes. In residential of the family, who is more often than not the
homes, the needs of the elderly can be met by care daughter‑in‑law in relation to the elderly of the
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assistants with relatively little training. Nursing care house, is forced to take up the sole responsibility of
involves trained nurses, and it is for individuals with care for the elderly.[62] Not surprisingly, but larger
more medical problems.[55] The residents in both setups households have remained associated with lower
face more cognitive impairment, depression, and caregiver strain.[63] Studies show that, even when
behavioral disturbances. They also face inadequate the responsibility of caring for the elders is taken up
quality of medical care. Training the assistants and willingly, such prolonged caregiving frequently leads
nurses can improve the functional ability of the to a negative impact on the caregivers’ emotional and
residents[56] physical health[64]
2. Hospital care: This may be either acute or a long‑term 2. Geriatric patients suffering from prolonged mental
care – depending on the purpose of admission. Inpatient disorders that severely decrease their functioning
teams should be able to provide multidisciplinary capacity, especially with disorders that are accompanied
assessment and treatment of patients with severe with psychosis, require constant observation and care.
mental health problems. There is variation in different Due to this increased responsibility, a greater caregiver
areas as to who should be a part of the multidisciplinary strain has been reported with greater patients with
setup and whether patients with functional illnesses greater psychotic symptoms[65]
need to be cared for separately or together with organic 3. Similarly, it has been reported that half of those
disorders.[57,58] However, prompt discharge should be providing care for someone with Alzheimer’s disease
the aim in acute setup because of the vulnerability develop significant psychological distress. Moreover,
of the elderly to nosocomial infections. There is still due to the lack of understanding among people of
a gap in the Indian hospitals for separate wards and behavioral and psychiatric symptoms of dementia,
care units for the geriatric population the caregivers are blamed for their behavior and are
3. Respite care: It involves care given to the elderly so often accused with providing inadequate care, adding
that caregivers can take time off to relax or take care to the jeopardy of the caregiver.[66]
of other responsibilities. Respite can vary in time from In such scenarios, community‑based services that aid the
part of a day to several weeks. It encompasses a wide caregivers in coping with the stress and help in providing
variety of services including traditional home‑based care are necessary. Unfortunately, the reliability and
care, as well as adult day care, skilled nursing, home universality of the family care system is often overestimated
health, and short‑term institutional care.[59] Research and there are minimal community‑based mental health
indicates that respite care decreases family stress services that provide aid for the elderly suffering from
and improves family functioning, life satisfaction, chronic disorders and almost none that provide support
attitudes toward family members with disabilities, to caregivers.[67] There are a few community‑based health
and the physical and emotional health of the elderly. care‑providing NGOs in India. The lack of community‑based
Respite care significantly decreases the need for costly mental health‑care services is a challenge for geriatric as
out‑of‑home placements, such as hospitalization, and mental health it hinders adequate care for the elderly
nursing home care[60] and also increases their chance of developing mental
4. Home‑based setups: Informal care often provided by disorders.[68] Thus, rehabilitation of the elderly and those
spouses, adult children, and other family members residing in old‑age homes is a challenge for geriatric mental
accounts for most of the care the elderly currently health in India.
receive in developing countries. Even today, the younger
generation in India sees it as their responsibility to Challenge 6: Lack of awareness regarding geriatric
care for their elderly and they are under social and mental health care at a primary care level
cultural pressure to do so. Care provided at home is In India, elderly people living in nursing homes and
often considered the preference of the elderly and old‑age homes are usually in a state of mediocrity until
the cost is most often borne by the family. However, it is an extremely well‑paid setting (which is afforded by
despite the increasing demand for home‑based care few). These homes do not have a psychiatrist for their
due to population aging, factors such as urbanization, residents. The primary health‑care physicians who visit are
migration, break‑up of the joint family system, change not trained to identify and treat psychiatric issues such as
in the role of women from being full‑time carers, and dementia or depression in the elderly, seen in more than
decreasing fertility rates mean that future cohorts of 40%–50% of the population.[69]

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 Lodha and De Sousa: Challenges for geriatric mental health

Primary health‑care practitioners often provide the diagnosis Challenge 8: Setting up geriatric mental health clinics
and pharmacological treatment of mental illnesses for older in India
adults. Despite an increase in subspecialty geriatric training The country has a limited number of mental health
in internal medicine, family practice, and psychiatry, professionals of around 5000 psychiatrists catering to the
instruction in the recognition and treatment of geriatric 21 million geriatric populations in need of mental health
mental illnesses remains uncommon in training.[70] Since services.[79] At present, most of the geriatric outpatient
most of the elderly reside in rural areas, it is important department services are available at tertiary care hospitals
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that geriatric mental health‑care services are a part of the in big cities. Public sector hospitals suffer from problems
primary health‑care services. Specialized training of all of inaccessibility, inequitable distribution, and lack of
primary health‑care medical officers in geriatric medicine staff, drugs, and equipment, while the private sector is
should happen. The focus of mental health care in India largely unregulated with serious complaints regarding poor
is still on tertiary care and acute management as opposed quality of care and unethical behavior.[54]
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to developing primary care or rehabilitative services.[71]

Although new initiatives such as day‑care centers, old‑age Quoting the Dementia India report, there are only
residential homes, memory clinics, helplines, counseling, 100 memory clinics in the country. This figure is appalling
and recreational facilities are being developed, most of as India has a population of over 100 million elders. There
them are urban based and concentrated mainly in the should be at least one memory clinic attached with a
southern part of India. NGOs such as HelpAge India, dementia day‑care facility in each district of the state.[26]
the Agewell Foundation, and the Dignity Foundation too Memory clinics are equipped to diagnose elders with
are actively contributing, but still efforts are far from dementia and also educate and provide families with
reaching to the masses.[72] Furthermore, factors such as a the supportive guidance required to manage those with
lack of transport facilities and dependency on somebody dementia. In the absence of memory clinics, dementia
to accompany an elderly person to the health‑care facility is diagnosed but not explained properly, resulting in
impede them from accessing the available health services. untold distress to the caregiver. In addition, the functions
Thus, peripheral health workers and community health typically performed by a memory clinic may be part of a
volunteers should also be trained to identify and refer larger special clinic that helps elders or focuses on mental
elderly patients for timely and proper treatment.[73] health and well‑being. Often, such clinics are run in
hospitals by departments such as neurology, psychiatry,
Challenge 7: Incorporating religion and spirituality and geriatrics.[80]
into geriatric mental health care In the Indian context, there is a dire need for the following:
Religion and spirituality remain important social and 1. Free or subsidized memory clinics for the
psychological factors in the lives of older adults and there underprivileged would be particularly helpful, as
is continued interest in examining the effects of religion would free or subsidized medicine
and spirituality on health status.[74] Elders with greater
2. The naming, positioning, and publicity of the
religiosity were more likely to report good health status
clinic should take into account the current pathetic
in various studies, and a positive association between
awareness around dementia in India and the stigma
organized religiosity (i.e., religious service attendance)
around a problem (the condition is often translated to
and health status has been found.[75] Religious service
local languages using stigmatizing terms)
attendance and functional status have a significant
3. People may assume that a memory clinic is only for
association, which accounts for the varied reported effects
memory problems; they may not visit it for cognitive
of religiosity on health status. In a review of religiosity and
problems if there is no predominant memory problem
subjective health in elderly community‑dwelling adults,
4. Keeping families engaged enough to come for repeated
it has been concluded that the effect of religious activity
visits is a major challenge in India. Special care needs
on perceived health disappeared when functional status
to be taken while conveying the diagnosis initially as
was controlled.[76]
many families may not come for the next visit
Many patients in geriatric mental health care may want to 5. The clinic may need to design and implement several
discuss different aspects of religion and spirituality with processes it needs. It may have to prepare or procure
the treating psychiatrist and may also want to discuss the material required for its functioning, keeping in mind
same with the psychotherapist. Questions such as death, the societal environment and the target audience
life after death, and heaven or hell along with religious 6. Modified instruments and procedures for checking
dialogs interest the elderly.[77] Psychiatrists treating the cognitive status (such as tests in local languages and
elderly need to be abreast with religion and spirituality as tests for illiterate persons)
well as religious philosophies so that they may discuss the 7. Treatment pathway, communication conventions, and
same with their patients. There is a need for psychiatrists counseling approach that take into account the need
being open to discuss the same as well as to respect the for overcoming stigma and myths and for reinforcing
religious beliefs of clients that they treat.[78] While this the diagnosis, possibly through repeated sessions
may sometimes seem challenging and outside the realm 8. Awareness material and caregiver training modules
of mental illness, it is vital to use religion and spirituality suitable for the literacy and language proficiency of
in geriatric mental health care during rapport building and the target audience. Some materials should be usable
to enhance the faith of patients in treatment. to convince friends and neighbors about the diagnosis

20 Journal of Geriatric Mental Health | Volume 5 | Issue 1 | January-June-2018

 Lodha and De Sousa: Challenges for geriatric mental health

9. More outreach efforts may be needed. As families The inadequacy of these tests can be attributed to its
may not think of coming to the clinic, you may need incapability to recognize the differing psychopathology
to actively reach out to families that may need help between younger adults and older adults that lead to a
10. Active publicity and myth‑busting in the localities mental disorder. A large autopsy study reported that older
may be needed to make people aware that the clinic adults with less severe Lewy body pathology met the
can be useful to them pathological criteria for dementia with Lewy bodies (DLB).
11. Use of the existing patient base and inpatient wards They noted a shift in the localization of Lewy bodies
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of hospitals to identify persons who may benefit from that were diffused in the neocortex of the younger adults
memory clinics. who met the criteria for DLB, to the restriction of the
Lewy bodies in the brainstem in the oldest‑old with
Challenge 9: Research in geriatric psychiatry cognitive impairment associated with DLB. None of these
Before delivering any form of relief mechanism to the oldest‑old patients with Lewy body pathology localized to
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general elderly population, it needs to be tested.[81,82] There the brainstem met the pathological criteria for Alzheimer’s
are many barriers for research to be conducted in India, dementia either. These findings indicate that dementia in
which range from monetary to ethical and permission the oldest adults is a result of a DLB phenotype, which is
delivery dilemmas. Primarily, the lack of research can be different from that in the younger adults.[89] In sum, the
attributed to the lack of funding from the government to lack of diagnosing criteria and clinical interventions adds
support ongoing research. The Government of India is to the adversity of geriatric mental health in India.
currently spending <0.1% of its gross domestic product
on geriatric health research and care.[83] With such little Challenge 11: Revision of geriatric mental health
sponsorship, there is a huge lack of national data of policies
the prevalent mental disorders, their epidemiology, and The Indian government launched the National Programme
impact across different religious, socioeconomic, regional, for the Health Care of the Elderly (NPHCE) in 2011, as
cultural, and ethnic diversity.[84] an implementation of India’s international commitments
Second, it is hard to conduct research on the elderly, to the UN Conventions on the Rights of Persons with
especially in relation to their inclusion in clinical drug trials Disabilities and the National Policy on Older Person as
with pharmaceutical interventions, due to their age‑related well as its national commitments to the Maintenance and
physiological changes. The relationship between age Welfare of Parents And Senior Citizens Act, 2007.[90,91]
and the dynamics of drugs is not well established, but The main aim of NPHCE is “to provide an easy access
it is generally believed that geriatrics are more prone to to promotional, preventive, curative and rehabilitative
adverse effects of a drug than younger participants due to services through community based primary health‑care
the prevalence of comorbidities and concomitant drugs approach.”[92] Through the programme, the government
among them.[85] aims to collaborate the health‑care services with the rural
health development‑oriented schemes and social welfare
It is believed that psychiatric disorders incapacitate the schemes to improve the quality of life of the elderly in the
ability to understand procedures of a study and give country. While this programme is criticized not only for
informed consent. It has been reported that nearly one‑third completely neglecting the role of home‑based care of the
of those with cognitive impairment were found to lack elderly within the family, which still remains to be their
decision‑making capacity.[86] While in these cases, proxy primary source of care within the nation, but also for giving
consent can be taken from one’s caregiver, it was found no specific importance to the mental health of the elderly,
that proxies often underestimated the risks associated it is considered extremely important as it recognizes
with participation in a study due to their belief that all the different, specialized needs of the geriatrics. [93]
institutionally conducted studies were safe. The inability Nevertheless, governmental support programs that address
to give informed consent breaches one of the basic ethical geriatric mental health are still almost nonexistent and
guidelines set up for all researches and thus this prevents therefore such lack of support presents itself as a challenge
researchers from taking up geriatric studies. Until Central for geriatrics in India.
Drugs Standard Control Organization (India) changes its
age limits on patient recruitment, geriatrics with mental Challenge 12: Myths related to aging in India
disorders will continue to suffer due to the shortage of There are a number of myths about aging. Of note, they are
effective relief mechanisms. Thus, the lack of research shared by practitioners, patients, and policymakers alike.
continues to be a challenge for geriatrics in India. These are as follows:[94]
1. Age is an illness
Challenge 10: Lack of Indian diagnostic tools 2. Genetics determines illness and disability
The diagnosis of mental disorders in geriatric psychiatry 3. Disability is inevitable and increasing among seniors
can be particularly difficult. This is primarily because the 4. Loss of social ties leaves the older adult alone and
preexisting diagnostic criteria are not designed specifically isolated
to assess the mental health status of older people and thus 5. Most elderly are depressed, demented, or dependent
leads to either a misdiagnosis of one’s condition or leads to 6. In a chronic illness, social factors are less important
no diagnosis at all, leaving the disorder untreated. Indian in late life
criteria keeping in mind the cultural aspects of psychiatric 7. Old age leads to physiologic and social homogeneity
diagnosis are a must.[87,88] (i.e., seniors generally have the same needs and potentials)

Journal of Geriatric Mental Health | Volume 5 | Issue 1 | January-June-2018 21

 Lodha and De Sousa: Challenges for geriatric mental health

8. Advances in biotechnology and pharmacology are depression reduces the quality of life and increases the
the most important elements in reducing late‑life risk of suicide in the elderly. According to a WHO report,
dependency patients over the age of 55 who suffer from depression
9. Projections based on the present data are sufficient for have a four times higher death rate than those without
social policy planning over the next decades depression.[102] Research indicates comparatively higher
10. Aging and mortality are synonymous prevalence of geriatric depression in India, with a median
11. The older the patient, the greater the cost. prevalence rate of 21.9%.[103] Studies have identified
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demographic factors associated with depression such as

There are a lot of myths that surround old age. Senility,
being unmarried, divorced, or widowed; residing in rural
myths, and taboo around sexual health among the elderly,
areas; illiteracy; increasing age; lower socioeconomic status;
lack of productivity, cognitive memory, changed human
and unemployment.[104] There is no single cause of geriatric
needs in the old age, and irritability are some of the myths
depression, and multiple factors at biological, social, and
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that research does not support (and rather supports the

psychological levels interact to cause depression in old
contrary).
age. Symptoms of geriatric depression affect behavioral,
The term ageism refers to a deep and profound prejudice physical, and cognitive domains of an individual, while
against the elderly.[95] In simple terms, ageism occurs when many elderly do not seek help as a stereotype myth prevails
people stereotype others based on old age. Ageism occurs that geriatric depression is normal in old age.[105]
throughout the society in varying degrees, in television,
Depression may also be the first presentation of dementia in
advertising, movies, stores, hospitals, and jobs. The four
people above the age of 60–65 years.[106] Geriatric depression
types of ageism are as follows:–[96]
can either be recurrence of a previous depressive episode
1. Personal ageism is an individual’s attitudes, ideas,
experienced earlier at younger ages or it be a first‑episode
practices, and beliefs that are biased against older
depression in late life.[107] Depression in older adults is
persons
most frequently associated with physiological changes
2. Institutional ageism involves rules, missions, and
or abnormalities of the brain, and the phenomenon
practices that discriminate against older individuals
of vascular depression has been described well in
or groups based on age
3. Intentional ageism is attitudes, rules, or practices that literature.[108] These changes may also be the result of
are implemented knowing they are biased against early changes caused by Alzheimer’s disease or vascular
older people dementia in its initial stages.[109] Antidepressant drugs are
4. Unintentional ageism is ideas, attitudes, rules, or the mainstay of treatment combined with psychological
practices carried out without the perpetrator knowing interventions. Elderly persons are more prone to side effects
these are biased against older persons. of antidepressant drugs even at lower doses. A careful
monitoring and motivation is often needed while treating
Stigma and ageism are two phenomena that greatly these patients with antidepressants.[110] Geriatric depression
affect the accurate assessment of mentally ill elderly and with its multiple facets and as a disorder thus is a challenge
ultimately, their health care. Health‑care providers, doctors, to mental health practitioners treating the elderly.
nurses, and others, including mental health‑care providers,
would benefit from awareness of stigma and ageism and Challenge 14: Medical illnesses in the elderly affected
their impact on psychiatric care for the elderly, many of by psychological problems
whom also have physical problems. Understanding these It is commonly known that geriatric patients have
influences may assist providers to make more accurate multiple illnesses, which include both noncognitive
diagnoses and a more appropriate plan of care.[97] physical (sensory, musculoskeletal) and psychiatric
illnesses. Often, some physical illnesses of the elderly
SPECIFIC CHALLENGES FOR GERIATRIC MENTAL present with psychological symptoms or vice versa.[111]
HEALTH IN INDIA The prevalence of comorbid condition of illnesses is a
powerful demonstration of the link between physical
Challenge 13: The clinical challenges posed by and mental illnesses and the interplay of multiple factors
geriatric depression between them.[112] In late life, the presence of comorbidity,
Geriatric patients comprise a particularly vulnerable group chronic conditions, and frailty requires an approach less
as they often have multiple co‑existing medical and other preoccupied with curative interventions and more focused
psychological problems with depression.[98] Depression is on rehabilitative function. This functional approach
undertreated in this group, owing to its lack of priority as requires a range of interventions that include supportive and
a public health problem in developing countries.[99] Many restorative measures along with diagnosis and treatment.
studies have looked at psychosocial factors associated The goal here is to eliminate excess (avoidable) disability,
with geriatric depression. Variables such as female sex, especially when treating dementia and depression.[38]
widowed status, nuclear families, and stressful life events
The concept of medical examination before treating
were found to be associated with geriatric depression.[100]
psychiatric illness must be addressed, and its exact
Older adults are likely to suffer from sub‑syndromal definition often is a matter of dispute. Consultants from
depression, i.e., depression that does not (always) meet the psychiatry service often question whether the patient’s
the full criteria for major depression but can lead to major symptomatology represents a psychiatric disorder or
depression if left undiagnosed or untreated.[101] Geriatric whether behavioral and cognitive changes reflect

22 Journal of Geriatric Mental Health | Volume 5 | Issue 1 | January-June-2018

 Lodha and De Sousa: Challenges for geriatric mental health

manifestations of an acute, or chronic medical condition.[113] the proportion declined from 22.7% between the ages of
Multiple medical conditions commonly encountered can 60 and 64 years to 8.2% of heavy smokers between the ages
present in an atypical fashion and mimic psychiatric of 65 and 75 years.[124] Besides substances, older adults
disorders. A missed organic cause of psychopathology can are more likely to take prescribed and over‑the‑counter
lead to significant morbidity and mortality for individuals medications than younger adults, increasing the risk for
inappropriately admitted to a psychiatric unit.[114] It is harmful drug interactions, misuse, and abuse.[125] These
important for psychiatrists to build on their medical trends were significantly observed among elderly men and
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knowledge from medical school and internship and women. Clinical research has elucidated the consequences
continue to be kept abreast of confounding symptomatology. of unrecognized substance abuse or dependence on an
Nevertheless, it is crucial for medical professionals to have aging population. Complications that occur with increasing
fundamental understanding of psychiatric conditions.[115] frequency with age, such as medical comorbidity, cognitive
A team approach works best where multiple doctors come impairment, and frailty, contribute to the potential adverse
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together to work as team. Liason between the psychiatrist interactions between substance misuse and an aging
and medical professionals is quintessential in order to brain.[126] Individuals over the age of 65 years have a
ward off the overlapping diagnostic confusions and better decreased ability to metabolize drugs or alcohol along with
geriatric care.[116] Multiple medications when used in the an increased brain sensitivity to them. Drug or alcohol
same patient increase the propensity for side effects and abuse among the elderly is particularly dangerous because
drug–drug interactions which can only be addressed by senior citizens are more susceptible to the deteriorating
a good liaison.[117] Successful management of co‑existing effects of these substances. Geriatric substance abuse may
medical and psychological problems is possible through need specialized care which may not be possible in routine
good teamwork between different medical teams and can rehabilitation centers. These patients cannot be admitted
at times be difficult to achieve. and treated with adult substance abuse patients as their
needs and causative factors differ markedly from that of
Challenge 15: Geriatric substance abuse and its adult patients with substance abuse.[127] Rehabilitation and
management management of geriatric patients with substance abuse
Substance abuse in patients aged 65 years and above is poses a challenge for geriatric mental health. The reasons
often underestimated and underdiagnosed, which can for the same are poor compliance and high relapse rates
prevent them from getting the help they need.[118] The along with poor motivation to quit substances.
Family Health Survey of India (1998–1999) reported that
Challenge 16: The management of delirium in the
regular consumption of alcohol was 18.6% prevalent in
elderly men and 3.1% prevalent in elderly women. The elderly
prevalence of alcohol consumption among the elderly Delirium is a common medical and psychiatric complication
between the ages of 60 and 64 years was found to be 25.4%, seen in geriatric patients. Most of these patients need
which declined to 10.5% in the older cohort consisting of Intensive Care Unit admissions, and the causes of elderly
the elderly above the age of 75.[119] The data are suggestive delirium vary from medical to a purely psychiatric etiology
of the fact that alcohol use may reduce with age, but it is to a combination of both medical and psychological
difficult to completely rehabilitate geriatric alcohol and factors.[128] Delirium may complicate the clinical picture
nicotine dependence. Clinically, not many elderly opt to get of dementia and make it difficult to assess clinically due
to fluctuating orientation and attention of the patient.
rid of or reduce their dependence on alcohol or nicotine.[120]
Delirium can lead to death of the patient if not detected and
Late‑onset abusers are those who start consumption of
treated early. It is paramount that there is good consultation
alcohol after the age of 65 years. It is believed to occur in
liaison framework between the medical and psychiatric
response to negative life events such as retirement and the
treating teams for optimal recovery of the patient.[129]
death of a loved one.[121] It is often observed that the senior
citizens, after their children have moved overseas or their Treatment in the right setting is prudent for recovery.
spouse has passed away, start alcohol consumption, even if Sometimes, delirium may be mistaken for excessive
they have not been an active alcohol consumer in the past. drowsiness and left untreated. Violent and aggressive
In such times, alcohol becomes an escapist from negative behavior in delirium also affects recovery and care.
life situations and stressors. These events are extremely Treatment, assessment, and clinical management of
common in old age and are further linked to psychological delirium in the elderly is yet another challenge in geriatric
and psychopathological comorbidities, particularly mood mental health. Delirium also puts an immense pressure
and anxiety disorders.[122] Some other reasons that the and challenge to the caregivers dealing with the patient
elderly take to drinking include retirement, financial on a regular basis.[130] There is a need for clinicians and
strains, relocation, troubled sleep, familial conflicts, and psychiatrists to be trained in the management of delirium
physical or mental health degradation. Conclusively, the and to recognize it early so that mortality and morbidity
data are indicative of the fact that geriatric communities are prevented.
are extremely vulnerable to substance abuse, like other
sociopsychological problems.[123]
Challenge 17: Sexual issues in the elderly
Sexuality is widely considered a taboo in India, let alone
Tobacco consumption also falls under the umbrella of sexuality in older adults. Many myths surround sexuality
substance abuse. Similar to alcohol abuse, it was found in old age, the most common being that older people
that the number of heavy smokers decreased with age, are asexual and do not practice or desire sex.[131] On the

Journal of Geriatric Mental Health | Volume 5 | Issue 1 | January-June-2018 23

 Lodha and De Sousa: Challenges for geriatric mental health

contrary, the majority of people aged 60 and older continue tended to report self‑image as a reason for decline in sexual
to engage in and, most importantly, enjoy sexual activity. It activity. The same study found that erectile dysfunction was
is also erroneously believed that older people (especially reported significantly more frequently in those men with
older women) are unattractive that older sex is disgusting, comorbid illnesses than in those without (26% vs. 9%).[141]
risky, or wrong; aging entails sexual dysfunction and sex,
Social stigma that enshrouds sex in general coupled with
as a rule, should be discouraged in old‑age homes and
ageism and the lack of time and space allocated to sexuality,
other facilities.[132] Such beliefs are internalized leading
and especially geriatric sexuality, in medical schools
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people to believe that old age and an active sex life are
and residency programs sets the scene for consistently
mutually exclusive. The media, with its huge influence on
bashful patients, unsure clinicians, and an overall neglect
popular culture, often neglects to depict older sexuality or
of geriatric sexual health. Other compounding issues
portrays it in negative light, especially in the case of older
include the many myths surrounding older sexuality, the
women, who have often been shown to exist contentedly
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discouragement of older sex by power‑wielding entities

in a chaste sexual vacuum.[133] Older men may be portrayed
such as residential homes or caregivers, stereotyped media
as sexually attractive, but usually from the perspective of
portrayals of older sex, a total absence of acknowledgment
younger and not older women. Media portrayals of older of older lesbian, gay, bisexual, transgender (LGBT) and
people also tend not to depict their normalcy, virility, and queer adults as sexual beings, and the archaic view of
intimacy, and older adults are often the subjects of humor sex solely as heterosexual intercourse or a means of
directed at physical, cognitive, and sexual impotence.[134,135] reproduction.[142,143] Essentially, geriatric sexuality in
It is hard to disentangle sexual changes of normal aging psychiatric practice remains a mostly unchartered sea and
from those related to illness and psychosocial problems. currently, those who venture out are map‑less pioneers.
Further, there is a dearth of population‑based studies Clinicians across specialties must incorporate inquiry
aimed at assessing normal older sexuality; the bulk of into geriatric sexual health as a part of the routine patient
currently available research tends to equate having sex with interview. In general, there is a dearth of research on the
heterosexual vaginal intercourse, leaving out a host of other sexual issues in the elderly and even more so in India,
orientations and activities related to sexual expression, although there has been a recent trend of research being
thus providing incomplete and misleading information.[136] boosted in this area. Sexuality is a life‑long phenomenon
Available data suggest that both older men and women and its expression is a basic human right across all ages.
consider sexuality an important part of their lives, continue Health care is currently nascent in its understanding and
to possess sexual desires, and wish to engage in intimate acceptance of geriatric sexuality and its related problems.
relationships and sexual activity (kissing, cuddling, Medical training, treatment guidelines, awareness among
foreplay, vaginal intercourse, oral sex, and masturbation) medical and mental health professionals, and geriatric care
at similar frequencies as younger adults (18–59 years old), staff’s need to be disseminated their openness in outlook
despite the presence of sexual problems. Sexual activity toward geriatric sexuality need cultivation. Physicians
may undergo adaptations or be less vigorous with age. of all specialties must routinely inquire in histories
Nevertheless, it has been shown to be as enjoyable and about the sexual concerns of older patients while being
satisfying as in younger adults.[137,138] nonjudgmental and understanding.[144,145]

Concomitant medical disorders are an extremely prevalent Challenge 18: End‑of‑life care and cancer in the
confounding factor when considering sexuality across elderly
all age groups. Lack of careful segregation of aging from There are various situations that are characteristically
morbidity is a major contributor to the widespread false encountered by the elderly. End‑of‑life issues and elderly
perception that older people are asexual. Some common with cancer are characteristic in old age. There is a lack
medical issues encountered in old age that affect sexuality of awareness of end‑of‑life care (EOLC) for people with
are hypertension and cardiovascular illnesses, diabetes, chronic, serious, progressive, or advanced life‑limiting
stroke, arthritis, depression, Parkinson’s disease, multiple illnesses, including dementia in India.[146] EOLC involves
sclerosis, dementia, visual or hearing impairment, lower good communication, clinical decision‑making, liaison
urinary tract symptoms, and incontinence. Apart from with medical teams and families, comprehensive
these, abdominal and genitourinary surgery, reconstructive assessment, and specialized interventions for physical,
surgery, or malignancies and medical devices such as psychological, spiritual, and social needs of patients and
catheters may all affect self‑image and impede sexual their caregivers.[147]
expression.[139]
Most patients with advanced, progressive, life‑limiting
Many studies quantify geriatric sexual dysfunction, illnesses in terminal stages get transferred to hospitals and
but few provide details. In women, the most common Intensive Care Units for acute, medically life‑prolonging or
perimenopausal complaints are dyspareunia and reduced supporting interventions. They later die in the hospital in
sexual desire, often associated with decreased lubrication, an environment away from their loved ones. Due to lack
prior hysterectomy, loss of a partner, depression, lack of of clear guidelines for physicians on EOLC, patients are
physical activity, smoking, or financial problems.[140] An subjected to futile treatments, often expensive, pushing the
Indian study on geriatric sexuality found that 20% of families into grave economic crises. Relatives, therefore,
women reported reduced sexual activity due to the loss are often forced to take the patients home on leave against
of a partner as opposed to 3.3% of the men. More women medical advice.[148] Misconceptions exist among health‑care

24 Journal of Geriatric Mental Health | Volume 5 | Issue 1 | January-June-2018

 Lodha and De Sousa: Challenges for geriatric mental health

providers about EOLC, with misrepresentations of EOLC to lodge a complaint and ensure that no more abuse occurs
as euthanasia, resulting in controversies. It is, therefore, while protecting the rights of the patient.
necessary to have a clear understanding of various aspects
of EOLC in India and future directions that need to be Challenge 20: Suicide in the elderly
taken. The primary caregivers, along with the treating Suicide is known to show a peak in two age groups, i.e.,
team, have to be involved in the decision‑making process the adolescent age group and the elderly. Developed
which might be complex.[149] countries also depict a peak of suicide rate in the elderly
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compared to other ages.[158] On the contrary, in India, the

Cancer is a major public health problem worldwide, peak in the rate of suicide is seen in the 15–29 years’ age
and the burden caused by cancer continues to increase. group. However, the comparatively lower rate of elderly
Depression, anxiety, fatigue, pain, and delirium are suicide in India of 7/100,000 should still be considered a
problems that can affect any cancer patient, but can significant statistic.[159] Moreover, the ratio of completed
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present unique challenges in the elderly population. In suicide to attempted suicide for elderly in India is 1:7,
addition, the elderly may be contending with cognitive which is double than that of the lower age group which is
deficits or dementia that can coexist with any of the 1:15.[160] Among the elderly, isolation and loneliness, loss
above problems. Each of these issues alone can adversely of economic independence, and reduced social activity
impact the care and outcome of these patients. More often contribute to negative thought patterns.[161]
than not, however, the elderly are challenged with not
just one but a combination of these problems. Geriatric Postmortem autopsy studies have revealed that between
psycho‑oncology is still in a nascent state and needs to 71% and 95% of the elderly who completed suicide had been
be developed in India.[150,151] diagnosed with at least one mental disorder. The presence
of serious, chronic medical illnesses is also considered
Challenge 19: Elder abuse and the role of the to be a risk factor for elderly suicide.[162] However, no
psychiatrist direct link between the status of physical health and
Older adults are also vulnerable to elder abuse – including suicidal ideation or attempt has been established yet. Many
physical, sexual, psychological, emotional, financial, researchers speculate that physical illnesses trigger certain
and material abuse; abandonment; neglect; and serious mental illnesses, particularly depression that leaves them
losses of dignity and respect. Current evidence suggests vulnerable to suicidal behavior. Researchers have found
that 1 in 10 older people experience elder abuse.[152] that one in four persons in his/her sample of terminally ill
Elder abuse can lead not only to physical injuries, but elderly patients expressed a desire of ending their lives.
also to serious, sometimes long‑lasting psychological Out of this sample, 25% of them were diagnosed with
consequences, including depression and anxiety. The depression.[163] Suicide is a neglected phenomenon in the
intersection of elder abuse and mental health is important elderly as suicidal ideation is rarely expressed by them
and complex.[153] We know from research that elder abuse and there is a dearth of suicide prevention programs for
victims have a high prevalence of depression. Depression the elderly as compared to youth and adolescents. Suicide
can easily lead to social isolation, a significant risk factor prevention in the elderly and bringing down suicide rates
for abuse. This, in turn, increases the risk of suicide in geriatric populations are a major challenge for geriatric
and the emotional devastation of abuse encompasses far mental health.
more than depression. Anxiety is common for victims Challenge 21: Meeting the needs of lesbian, gay,
due to the trauma previously experienced, continual
fear for their current and future safety, and the worry
bisexual, transgender, and queer elderly
Prior research has indicated that the LGBT populations
they feel for their abusive family members whom they
have a higher incidence of mental health distress than
often care deeply about.[154] Victims feel shame and guilt,
the general heterosexual population due to the brutal
which also contributes to social isolation. Victims may
discriminatory treatment they are subjected to. [164]
suffer from a range of physical complaints, including
The LGBT population are subjected to discrimination,
chronic pain, gastrointestinal complaints, neurological
stigmatization, and harassment that often lead to them
complaints, arthritis, and gynecological problems, such
being marginalized from many social structures including
as vaginal bleeding and pelvic pain.[155] Early death is
one’s family. Primarily, higher poverty rates among
very often the result of the slow and corrosive nature
members of the community present itself as a risk factor
of abuse. Abused elders are 300% more likely to die a
for mental health disorders. A study reported that 9.1%
premature death than their nonabused counterparts.
of elderly lesbian couples and 4.9% of elderly gay couples
Elder abuse victims who are depressed or have other
were poor, as compared to 4.6% of their heterosexual
debilitating mental health problems cannot readily protect
couple counterparts.[165]
themselves.[156] Victims of abuse often do not or cannot
adhere to medical regimens and basic health maintenance Second, the lack of social support and marginalization
because of their depression or anxiety. Some may manifest also leaves them vulnerable to psychiatric illnesses. The
multiple physical/somatic complaints without a plausible social ostracism is believed to increase psychological
diagnosis.[157] The psychiatrist treating a victim of elder distress. Further, LGBT elderly are twice as more likely
abuse has to work outside the realm of his/her psychiatric to live alone and almost four times less likely to have
work if/she needs to provide support and solace to the children than their heterosexual counterparts.[166] Thus,
victim. It is also the duty of the mental health professional the lack of informal caregiving structure not only leads to

Journal of Geriatric Mental Health | Volume 5 | Issue 1 | January-June-2018 25

 Lodha and De Sousa: Challenges for geriatric mental health

social isolation, but also increases the costs of health care 5. Grover S. Future of psychiatry in India: Geriatric psychiatry, a specialty to watch
out for. J Geriatr Ment Health 2014;1:1‑5.
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6. Bartels SJ, Dums AR, Oxman TE, Schneider LS, Areán PA, Alexopoulos GS,
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absolute terms, this is an expected increase from 900 disadvantage and reproductive health risk factors for common mental disorders
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professionals and older people themselves, and the stigma 17. Vedantam A, Subramanian V, Rao NV, John KR. Malnutrition in free‑living elderly in
surrounding mental illness makes people reluctant to seek rural South India: Prevalence and risk factors. Public Health Nutr 2010;13:1328‑32.
help. Lack of awareness, inadequate training opportunities, 18. O’Sullivan P, Chao S, Russell M, Levine S, Fabiny A. Development and
implementation of an objective structured clinical examination to provide
inequitable distribution of health resources, and virtual
formative feedback on communication and interpersonal skills in geriatric
absence of chronic care disease models are the challenges training. J Am Geriatr Soc 2008;56:1730‑5.
that confound the future of geriatric psychiatry in India. 19. Liberman RP, Hilty DM, Drake RE, Tsang HW. Requirements for multidisciplinary
Government policies providing social benefits to the teamwork in psychiatric rehabilitation. Psychiatr Serv 2001;52:1331‑42.
elderly population are in place, but coverage is inadequate. 20. Mann RS, Ford CV. A curriculum for education in geriatric psychiatry. Am J
Psychiatry 1988;145:836‑43.
For addressing geriatric mental health issues, the need
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