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Primary Care Mental
Health in Older
People
A Global Perspective
Carlos Augusto de Mendonça Lima
Gabriel Ivbijaro
Editors

123
Primary Care Mental Health
in Older People
Carlos Augusto de Mendonça Lima
Gabriel Ivbijaro
Editors

Primary Care Mental

Health in Older People
A Global Perspective
Editors
Carlos Augusto de Mendonça Lima Gabriel Ivbijaro
Unité de Psychiatrie et de Mental Health and Population Health
Psychothérapie NOVA University Lisbon
Centre Les Toises Lisbon
Lausanne Portugal
Switzerland

ISBN 978-3-030-10812-0    ISBN 978-3-030-10814-4 (eBook)

https://doi.org/10.1007/978-3-030-10814-4

© Springer Nature Switzerland AG 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
v
Foreword 1

There are three main reasons which are making me welcome this volume.
First, it is bringing together primary health-care answers to key mental health
problems which people face in older age. The problems to which the answers
have been provided have been selected because they are frequent and because
there are interventions which have been shown to be effective in reducing
their impact. The answers have been provided by an array of experts with vast
experience and deal with specific problems such as anxiety disorders and
with important background issues such as the frailty of the elderly and the
need to maintain and promote their dignity in health and disease.
A second reason for recommending the volume is that the text has not
been produced by general practitioners nor by specialists nor by practitioners
of allied professions but by all of them working together. There is no other
manual where the principle of joint work by specialists, general practitioners,
and allied professionals has been applied so rigorously in order to provide
answers to problems and advice about action based on a mix of experience
and knowledge which these three groups of people usually facing mental
health problems in old age have assembled.
A third reason for welcoming this volume stems from its timing. The vol-
ume which has been prepared by Professors Ivbijaro and Mendonça Lima
makes its appearance at the time when the United Nations have decided to
make the fight against the noncommunicable diseases one of their key politi-
cal as well as humanistic goals. Until recently, the United Nations and the
international bodies dealing with health care such as the World Health
Organization did not include mental and neurological disorders among their
priority concerns: this has happened for the first time 2 years ago when the
United Nations adopted their sustainable development goals, including
among them the promotion of mental health, and more recently in 2018 when
they specifically discussed what could be done to deal with noncommunica-
ble diseases including mental disorders. It is to be expected that the urging of
the United Nations will lead to action at country level, and when this happens,
it will be particularly important to have materials which can provide guidance
for action.

vii
viii Foreword 1

It is thus with much pleasure that I am recommending this volume to the

many who have to face mental health and other problems in the elderly and
that I am expressing my thanks to its editors who have produced a most valu-
able text based on evidence and shaped by wisdom and rich practical
experience.

Norman Sartorius
President, Association for the Improvement of Mental
Health Programmes (AMH)
Geneva, Switzerland
Foreword 2

It is timely that this valuable book is written when we are faced worldwide
with the physical and mental health problems of aging populations. While
increasing numbers of older adults are living long and robust lives, many are
facing loneliness, frailty, and multimorbidity. Primary health care is particu-
larly well-suited in countries of all types to provide a setting for the coordi-
nated health and social care required by older adults and their families.
The 1978 Declaration of Alma-Ata lays a foundation for primary health
care. However, progress over the following decades has been uneven. At least
half the world’s population lacks access to essential health services—care for
communicable and noncommunicable diseases across the life span including
mental health. Four decades later, the Declaration of Astana in October 2018
reaffirms the historic 1978 Declaration. Countries around the world have
vowed to strengthen their primary health-care systems as an essential step
toward achieving universal health coverage. Mental health has a firmer place
in this renewed commitment.
The increasing focus on global mental health is linked with this Declaration
and with two major policy initiatives related to it. One is the World Health
Organization (WHO) call for universal health coverage: to ensure that all
people have access to needed health services (including promotion, preven-
tion, treatment, rehabilitation, and palliation) of sufficient quality to be effec-
tive, without imposing financial hardship. The first initiative is the World
Health Organization (WHO) call for universal health coverage: to ensure that
all people have access to needed health services (including promotion, pre-
vention, treatment, rehabilitation, and palliation) of sufficient quality to be
effective, without imposing financial hardship. The second initiative is the
renewed focus on noncommunicable diseases (NCDs), spearheaded by the
WHO Independent High-Level Commission on NCDs and Mental Health.
Primary health care is an important setting for the realization of both these
policies—and others, notably the link to health in the UN Sustainable
Development Goals—that encourage parity of mental health within health, a
holistic approach to health care across the life span, and the engagement and
empowerment of communities in health promotion and health care. The
holistic approach to health care with a central place for mental health has
been championed for decades. The logic and urgency of this approach are
undoubted, and no more so than for older adults. Yet, large gaps remain in
primary care mental health for this population as for others. There is a need
for policy and practice guidance and demonstration of successful approaches

ix
x Foreword 2

to good primary care mental health for older adults at global and local
levels.
The editors have responded admirably to the challenge. In a comprehen-
sive volume, they have brought together authors from different disciplines
and various parts of the world in a scholarly and humane whole that offers
inspiration as well as a practical resource. True to the Declarations of Alma-­
Ata and Astana, the book is primary care- and community-focused. It covers
a number of topics relating to older people that are not commonly found in
one volume: improving health, supporting self-care, promoting equity and
universal access to care, recognizing the importance of primary care in the
treatment of mental health problems of all types, and considering the com-
plex relationship between mental and somatic health. Ensuring that each
chapter is written by a combination of primary care doctors, old-age psychia-
trists or physicians, and at least one other health professional or family carer
gives the book its unusual and special relevance for health professionals, stu-
dents, and policy-makers as well as interested lay audiences.
I am pleased to note that there are several present and past members of the
World Psychiatric Association Section of Old Age Psychiatry among the dis-
tinguished authors and editors. I congratulate the editors and contributors on
producing this book at a critical time of change in the field.

Helen Herrman
President, World Psychiatric Association
Melbourne, VIC, Australia
Foreword 3

It is with great enthusiasm that I urge you to read this incredibly important
work on mental health in the elderly written for primary care. As the global
population ages, the practitioner most likely to treat the older person is the
primary care physician. Some may lament that there are not enough mental
health specialists and particularly not enough specialist in geriatric psychia-
try. However, an equally important observation is that person-centered care
can effectively be delivered by the provider who cares for the whole person.
While there is added challenge because aging persons can have multiple med-
ical problems which need primary care attention, most primary care doctors
see large numbers of aging persons and are more experienced than is appreci-
ated. An even bigger challenge comes in the delivery of mental health care.
At any age, mental health is undertreated, even in many developed countries.
With age, the problem is magnified, often because primary care settings lack
confidence in addressing mental health in an aging and often frail population.
Serious mental health problems are not assessed because primary care set-
tings have limited resources to address newly identified problems.
Additionally, comorbidities of aging may create contraindications to some
treatments, and the absence of the specialist may leave the primary care doc-
tor without confidence. Sadly, ignoring diagnosis and treatment may also
occur because of the existing nihilism about treating elderly patients in
general.
This book offers the perfect antidote to this lack of knowledge, lack of
confidence, and the nihilism. Several of the introductory chapters provide a
framework for understanding the breadth on influences in aging health includ-
ing interaction between lifestyle and the physical, social, and economic envi-
ronment and long-standing individual characteristics. The “how to” of
interviewing for mental health and frailty are also offered. While the primary
care provider may need a wide referral network for medical specialties, it is
of note that more than seven chapters focus on non-pharmacological
approaches that provide meaningful benefit. The evidence base that social
and behavioral interventions can improve the quality of life of aging persons
is well laid out and available to the reader.
I am particularly excited about the focus on promoting dignity in serving
elders. Appreciation for the full past of the individuals as well as their present
situation can help identify the path for best care and maximize quality of life.
The book has assembled experts for the chapter on pharmacological inter-
ventions in geriatric psychiatry and also contains well-constructed chapters

xi
xii Foreword 3

on dealing with the most troublesome conditions such as agitation, demen-

tias, and suicide. Written for primary care provider, the text delivers clear
description and guidance for diagnosis and management and acknowl-
edges the need to integrate this care delivery with the family and other
systems of care.
Dr. Carlos Augusto de Mendonça Lima, who is a giant in the field of geri-
atric mental health and one of my most respected colleagues, is the editor.
After his training at the Federal University of Rio de Janeiro and his equiva-
lence in Portugal and in Switzerland, he specialized in Psychiatry in France
and received two Master’s degrees and a Doctorate preparing himself not
only for a lifetime of work in psychiatry but for a commitment to geriatric
mental health. During his time at the World Health Organization, he initiated
and then led the Collaborating Centre for Psychiatry of the Elderly. His
expertise has been recognized as he has been elected by his peers to many
leading professional organizations including the European Association of
Geriatric Psychiatry and the International Psychogeriatric Association where
I first came to know him. In this past year, he stood up to support patient and
physician rights and opportunities to continue to receive approved treatments
for dementia. His essay on the “The Old Age Psychiatry Paradox” remains on
the IPA website. In it he highlights the growing knowledge in the field of old-­
age psychiatry, the growing need to serve expanding aging population, and
the need to protect aging persons from the stigma of a secular society focused
on wealth productivity. He also laments the constant challenges by authorities
to undermine this specialty field by denying the need to support geriatric
psychiatry specialty care, training, and education of the mental health work-
force and by limiting the input of this special expertise in the development of
guidelines and care for geriatric conditions. However, not one to simply point
to such injustices, Dr. Lima has supported the generalists’ need for more
information and education to serve aging people because there are insuffi-
cient numbers of trained specialists.
Dr. Lima is joined in this effort by Dr. Gabriel Ivbijaro, MBBS, who was
trained in Nigeria and has specialties in Neurology and Psychiatry from the
United Kingdom. He is a Member of the World Organization of Family
Doctors and was President of the World Federation for Mental Health
(WFMH). He has been awarded a Member of the Most Excellent Order of the
British Empire (MBE) by Her Majesty Queen Elizabeth II. Dr. Ivbijaro is an
expert in addressing ways to reducing disparities in mental health services for
ethnic minorities, and his psychiatry expertise is further evidenced in his role
as Editor in Chief of Mental Health in Family Medicine.
Together, through this book, Drs. Lima and Ivbijaro bring their expertise
and commitment to serving the mental health needs of elderly patients
through their most likely health-care providers, primary care physicians.
Because of their leadership, they have been able to assemble international
experts to provide this work, written for a wide audience of health-care pro-
fessionals to provide understanding of the complex problems in geriatric psy-
chiatry. This advocacy in action will serve aging patients by supporting their
Foreword 3 xiii

treating physicians. I am so grateful for the role model these authors provide
and this important work. It will make contributions for many physicians and
the aging patients they serve.

 Mary Sano
 President, International Psychogeriatric Association,
 Milwaukee, WI, USA

 Professor, Department of Psychiatry,

 Icahn School of Medicine at Mount Sinai, New York, NY, USA
Foreword 4

Over the past decade, Professor Gabriel Ivbijaro, Dr. Carlos Augusto de
Mendonça Lima, and their colleagues have been leading efforts to focus
global attention on mental health concerns and to strengthen the role played
by primary care clinicians all around the world in the diagnosis and manage-
ment of mental health problems and in tackling the stigma and discrimination
that often accompany a diagnosis of mental illness.
While mental health problems can affect people of all ages, this important
new publication focuses attention on an area of clinical practice that is often
neglected and poorly managed, and sometimes even ignored: the manage-
ment of mental health problems in older people.
We are often reminded that “you can judge a society by the way it treats its
most vulnerable members.” Along with the youngest members of our com-
munities, our most senior members are often among our most vulnerable.
And those with mental health problems and disability can be especially vul-
nerable and at risk of abuse, neglect, and inadequate care.
This area of clinical practice, mental health care for older people, is at last
receiving the attention it deserves, and this book provides a timely and very
important contribution. As populations age in every country, and as multi-
morbidity increases, the number of older people with cognitive and other
mental health challenges will continue to rise, and our health-care services
need to be equipped and supported to support all our older patients.
This book is not afraid to tackle some of the most serious mental health
challenges facing older people: neurocognitive disorders, depression and sui-
cide risk, psychosis and agitation, frailty and comorbidity, bereavement and
loss, and sexuality and sexual activity.
I especially commend the human rights approach of this publication,
advocating for dignity and respect in the clinical treatment of all older people
with mental health concerns. As health professionals and carers, we should
always treat our patients with the same dignity and respect that we would
expect for our own older loved ones, and for ourselves.
I commend the editors, Professor Gabriel Ivbijaro and Dr. Carlos Augusto
de Mendonça Lima, and all the contributing authors on this new publication.
The important insights and solutions to clinical dilemmas contained in this
book will be of great interest to medical students, doctors in training, and
established medical practitioners, not only in family medicine and in psychia-
try but in all medical specialties. This book will also provide a valuable

xv
xvi Foreword 4

resource to all health-care workers involved in working in primary care and

to everyone involved in the care of older people in all settings.

 Michael Kidd
 Professor and Chair of the Department of Family
 and Community Medicine, Past President, World Organization of Family
 Doctors (WONCA) 2013–2016, The University of Toronto,
 Toronto, ON, Canada

 Director, World Health Organization Collaborating

 Centre on Family Medicine and Primary Care,
 Honorary Professor of Global Primary Care,
 Southgate Institute for Health, Society and Equity,
 Flinders University, Bedford Park SA, Australia

 Director, Beyond Blue, Hawthorn, Australia

Foreword 5

I am honored to be able to introduce this very important book. As the econo-

mies of the world develop, education and health systems improve, and people
live longer. Hence, the phenomenon of global aging represents a success
story for societies and their people. Coming with this though is a dramatic
increase in the numbers of older people who have managed to avoid or outlive
a wide range of illnesses which in the past would have cut short so many of
those lives. This raises significant health challenges for high-, middle-, and
low-income economies with an increasingly aging population and a range of
chronic illnesses and comorbidities. So for so many countries, primary care
needs to be at the forefront of health systems, and the primary care mental
health for older people remains much in need of development.
This book is written by a combination of primary care doctors, old-age
psychiatrists, physicians, and allied health professionals. It makes an essen-
tial contribution to knowledge, and the emphasis on health promotion is par-
ticularly welcomed, especially with the need to develop community resilience
and self-management strategies in older people. And so important is the
human rights approach to respecting autonomy, equity, independence, and
universal access for older people. Primary care is likely to continue to be at
the forefront of health systems because of the growing need for an emphasis
on prevention, tight financial constraints, and a lack of well-developed sec-
ondary health-care services in some countries.
I am glad to see that this book addresses the wide range of mental health
problems in older people including dementia, depression, and delirium but
also has a strong emphasis on comorbidity and polypharmacy. This means
that the book should be a reader-friendly practical resource for many clinical
services seeking to improve their primary care provision with the most impor-
tant benefit of also helping improve the care provided to older people.
I congratulate Dr. Carlos de Mendonça Lima and Professor Gabriel
Ivbijaro for putting together such a comprehensive and thoughtful book,
which, I am sure, will be of great use for many years to come.

 Martin Orrell
 Director, Institute of Mental Health, President of the
 European Association of Geriatric Psychiatry (EAGP),
 Nottingham, UK

xvii
Foreword 6

Mental health is essential for health. Mental and physical problems are inter-
woven. Mental health problems will be among the leading causes of burden
of disease in 2030 and the main causes of disability-adjusted life years.
Between 2011 and 2030, the World Economic Forum predicts that mental
illness worldwide will cost more than physical ailments such as cancer, heart
disease, or diabetes.
Older people live longer and will be the vast majority of the population in
the future. It is estimated from community epidemiological surveys that as
many as 20–30% of persons meet criteria for mental disorders, but there is a
significant gap between the prevalence of mental problems and the number of
people receiving care. Primary care helps to close this gap because the major-
ity of people report at least one primary care visit per year and maintain a
stable and enduring relationship with their primary care doctors. Therefore, it
is no surprise that most mental health treatment is provided in primary care
and most psychotropic drugs are prescribed by family physicians. In recent
years, there has been a growth in diagnosis and drug treatment, what may
represent an increased acceptance of mental illness and improved case find-
ing but may also be the result of overdiagnosis and overenthusiastic treat-
ment, and it is important to have a global perspective of mental health in
primary care.
Professor Gabriel Ivbijaro is a very respected professor at Nova University
(Lisbon) with a vast experience as Adviser of the World Health Organization,
Chair of the World Dignity Project, and Past President of the World Federation
for Mental Health. In 2012 in collaboration with an international group of
general practitioners, psychiatrists, policy-makers, mental health profession-
als, and mental health advocates, he edited an unprecedented book providing
the best available evidence for the management of patients with mental health
conditions in primary care. Following the previous successful model,
Professor Gabriel Ivbijaro and Dr. Carlos Augusto de Mendonça Lima coor-
dinated a new fantastic resource to support the delivery of holistic mental
health interventions to older adults in the primary care setting.
This book reflects their style, very didactic and complete. It addresses
functional mental health problems (such as anxiety, depression, psychotic
and personality disorders) and acquired organic mental disorders of old age
(such as dementia, cognitive impairments, and delirium) and explores the
complex relationship between mental and somatic health and health prob-
lems, including aspects of multimorbidity and polypharmacy. Editors and

xix
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