Challenges in Aging, Dementia, and Mental Health: New Knowledge and Energy to Inform Solutions

This is the authors' abstract. We don't add key points for this paper.

The millions of older Americans with mental health conditions, Alzheimer's disease, or other dementias are a looming, major public health problem. Estimates suggest that more than 5 million Americans aged 65 and older have Alzheimer's disease—a figure that is expected to triple over the next 3 decades1. Another estimated 5 million to 8 million older adults have one or more mental health or substance use conditions2. With the cohort of Americans aged 65 and older projected to nearly double from 48 million to 88 million by 20503, the numbers of individuals with these conditions will dramatically increase. Mental health plays an integral role in promoting and sustaining optimal physical health and well-being in late life. Undiagnosed and untreated mental health problems in older adults lead to poor cognitive and physical health and functional decline, as well as greater risk of emergency department visits, hospitalization, and nursing home placement2, 4. Furthermore, dementia or mental health needs substantially complicate medical diagnosis and treatment2, 5. Science has made much progress in increasing knowledge about dementia and mental health in late life, yet the field lacks a solid theoretical base, clarity about meanings of mixed findings, and solutions to the challenges of conducting clinical trials, especially for nonpharmacological interventions. What we have learned from science and implementation studies has not been translated broadly enough in practice systems to have any measurable effect on population health. Furthermore, according to the Institute of Medicine2, there are serious concerns about significant shortages, insufficient diversity, and lack of basic competence and core knowledge in the current workforce to address the complex needs of this growing population. Solutions to these three intimately interrelated challenges—in science, practice, and education and training—are urgently required to disrupt significantly the current trajectory. In response to these challenges, the National Hartford Center of Gerontological Nursing Excellence ] convened a 2-day National Institute on Aging–supported interprofessional leadership conference on aging, dementia, and mental health in July 2017 in San Francisco. The articles in this Journal of the American Geriatrics Society (JAGS) special supplement were commissioned specifically for, and first presented during, this conference. Their intent was to take stock of the field in its current state; identify needs; and reveal promising avenues for moving it forward in terms of science, practice, education and training, and policy. We also aimed to stimulate input from, and promote the ideas of, the next generation of person-oriented interprofessional researchers and scholars in the fields of aging, dementia, and mental health. Thus, we deliberately and strategically integrated the theme of mentoring into the design and programming of the overall conference and the commissioned papers and commentaries, as well as the development of this supplement. Four white papers—each accompanied by a brief commentary—and an endnote focused on salient aspects of interprofessional research, practice, education training, and policy in aging, dementia, and mental health constitute this supplement. Current early- to mid-generation scholars authored the white papers in collaboration with interprofessional junior faculty and senior scholars. We engaged junior scholars and faculty (leaders in the making) to prepare single-authored commentaries with mentorship from senior experts. Borrowing from and expanding on the model used for a previous national conference on a related topic6, one goal was to engage 3 generations of interprofessional scholars and educators with expertise in the fields of aging, dementia, and mental health to prime the pipeline of future leaders. These white papers and commentaries collectively describe a diversity of scholarship in our evolving interprofessional field, encompassing science, practice, and education and training. The first paper, by Massimo, Kales, and Kolanowski,7 summarizes the state of the science in dementia-associated apathy research. In addition, using apathy as a model for investigating behavioral and psychological symptoms in dementia (BPSD), this white paper helps establish an agenda to propel forward the science of BPSD in general and apathy in particular. Gilmore-Bykovskyi's8 accompanying commentary points to the critical need for enhanced research that uses novel trial designs, data-sharing across institutions and scholars, and concurrent improvement in understanding of the care needs of individuals with dementia and their families. The second white paper by Manning and Steffens9 describes the state of the science of the role of neural systems in late-life depression, discussing their effect on clinical presentation, treatment options, and outcomes. The authors’ recommendations for future research pathways underscore the importance of treating comorbidities in geriatric depression and improving preventive medicine practices for the subset of older adults with major depression who are most likely to experience continued cognitive decline. Wright's10 accompanying commentary builds on this work to support interprofessional team training and practice in implementing new nonpharmacological interventions for late-life depression. Authors for these two science papers independently highlighted the critical importance of a holistic approach to examining and elucidating the mechanisms underlying BPSD and depression; an appreciation of neuroscience is essential to move toward more precise diagnoses and customized interventions. In the third white paper, Callahan, Bateman, Wang, and Boustani11 provide a thought-provoking examination of why the science of new models of care in aging, dementia, and mental health diffuse inadequately into healthcare systems and communities where they might benefit older adults. The authors review a general framework for the diffusion of innovations and highlight the importance of multiple features of innovations that deter or facilitate diffusion. They describe methods designed to facilitate diffusion in the setting of complex adaptive systems, social networks, and dynamic macro environments, all currently under evaluation. Sturdevant's12 accompanying commentary applies Rogers’ Diffusion of Innovations model to the nursing home culture change movement to examine and demonstrate concerns related to its lack of widespread diffusion. The final white paper, by Farrell, Luptak, Supiano, Pacala, and DeLisser,13 reimagines the interprofessional training and education required to meet future workforce needs to care for this growing population of older adults with dementia and mental health concerns. Harris’14 accompanying commentary about curricular and health system changes to support interprofessional education, training, and practice also broadens the discussion to a global perspective, sharing successful models that may be instructive. The practice and education white papers support a more interprofessional approach to diffusion efforts and to training and mentoring the next generation to teach and practice within new models that include teams. The supplement's endnote, by Cacchione, Pike, Elinson, and Pincus,15 outlines critical policy priorities for research, reimbursement, models of care, and educating and training future scholars and clinicians. Highlighting exemplars from the Health and Aging Policy Fellows Program16, Cacchione and colleagues illustrate the essential roles we each must play to ensure that our collective work is translated into policy that will have a positive, durable effect on the care of older persons with dementia and mental health problems. We hope that this supplement will serve to help advance the science, practice, and interprofessional education and training critical to meeting the future needs of this rapidly expanding, vulnerable population. We further hope that those who provide services for older adults with dementia and mental health problems are inspired to expand their current knowledge and skills to improve care of these individuals and their families. We are grateful to the National Institute on Aging [R13AG056140 and R13AG056140-01A1 (Stephens)], the University of California, San Francisco (UCSF) Clinical and Translational Sciences Institute [KL2 TR0001870-01 (Bauer)], Claude D. Pepper Center/Tideswell at UCSF, and the National Hartford Center of Gerontological Nursing Excellence for their support in producing this special supplement to JAGS. We are also indebted to the authors who so willingly agreed to develop, present, and submit their work on an abbreviated timeline and to the editorial leadership and production staff at JAGS and Wiley and Sons who have provided helpful editorial guidance. Conflict of Interest: None. Author Contributions: Stephens, Evans, Buckwalter: concept and design of overall supplement and initial draft of editorial. Stephens, Evans, Bradway, Buckwalter: critical revision and final approval of manuscript. Sponsor's Role: The sponsors had no role in the design, conduct, writing, or decision to publish this manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.