Feature

As American life expectancies continue to increase, more people are living into old age and facing fears about death and the prospect of long-term illnesses associated with aging. Alzheimer's disease and other dementias are particularly frightening because their end stages can last for years, with poor quality of life for patients and stress for family caregivers, geropsychologists note. One APA group is working to shape the growing role of psychologists in treating this group and encouraging further training and interest in geropsychology.

With 75 percent of deaths in the United States now occurring in people age 65 and older--and almost 80 percent of people 65 and older reporting having heart disease, cancer and other such chronic illnesses, according to the Robert Wood Johnson Foundation--APA's Ad Hoc Committee on End-of-Life Issues, which first met in April 2001 and will complete its final recommendations this fall, has placed a priority on establishing better mental health care for older adults. The report particularly emphasizes better care for those approaching death, says psychologist William Haley, PhD, director of the School for Aging Studies at the University of South Florida and one of the ad hoc committee members.

"Psychologists who are trained to pay attention to the special needs of older adults at the end of life will be able to make a major impact in the quality of the death experience for both patients and their families," Haley says.

Biopsychosocial trends in health care already encourage extensive treatment of chronic illnesses through work with psychologists on behavior modification and relief of related problems like anxiety and depression, Haley says, but psychological interventions should extend into end-stage treatment of fatal diseases to ease the pain of death both for the patient and the family.

As such, the report calls for an increased role for psychologists in encouraging older adults to complete advance directives regarding their wishes for end-of-life care, transitioning terminally ill patients from hospitals to hospice and palliative care to maximize their quality of life and providing psychological services to these patients and their families.

In particular, dementia, Alzheimer's and other such diseases with strong psychological aspects may make patients good candidates for hospice services, the report notes but they are particularly underserved in hospice settings. However, those conditions, which affect more than 4 million Americans and cause 7.1 percent of U.S. deaths, often fail to get the same kind of consideration for hospice treatment as other diseases like cancer and heart disease, even though they can be just as debilitating and painful at the end of life for both patients and families, says Haley.

"Part of what the committee has been most concerned about is that older adults with noncancer diagnosis get satisfactory access to hospice facilities," Haley says. "We know that hospice and palliative care programs are quite effective for Alzheimer's and dementia patients and their family caregivers, so they should have the same access that terminal cancer patients have."

Haley's research on hospice care for patients with dementia demonstrated its particular usefulness. For example, he's found that 90 percent of family and professional caregivers approve of hospice care for end-stage dementia and that it may be more cost-effective than traditional care in a hospital or nursing facility. However, dementia patients have traditionally accounted for only 1.5 percent of Medicare hospice patients, Haley adds.

Medicare, which funds most hospital care for older adults in the United States, won't pay for hospice care unless a doctor diagnoses the patient to have less than six months to live, which, even when it is the case, is difficult to discern in patients with dementia or Alzheimer's disease, Haley says.

"We know that people are living longer and that brings with it an increased frequency of dementia at the end of life," Haley says. "Dealing with the effects of dementia can be extraordinarily difficult for family caregivers, causing pain and strife as death approaches. So it's very important that insurers, especially Medicare, expand hospice access to these patients."

Current Medicare guidelines do not predict six-month survival in dementia patients beyond a chance level, but many patients and families are inappropriately denied access to care on the argument that it will go beyond six months, Haley notes.

"At a policy level, we need to find a way to pay for palliative care for dementia patients and their families during a window longer than six months," he says.