AMA Journal of Ethics^®

Older adults face various challenges that threaten their physical and mental health. Twenty-three percent of the total global burden of disease is associated with diseases related to older adults.¹ More than 20% of adults over age 60 suffer from a mental or neurological disorder, contributing to 6.6% of all disabilities in this age group.² Chronic diseases—such as cardiovascular diseases, cancer, musculoskeletal diseases, and chronic obstructive pulmonary disease—are prominent contributors to the disease burden of older adults.¹ The burden of chronic disease can negatively affect the psychological well-being of older adults and contribute to the risk of depressed mood.³

Due to physiological changes associated with aging, older adults experience muscle and bone loss; sensory deficits related to seeing, hearing, or speaking; and cognitive deficits related to senility and dementia.⁴ These changes in older adults can result in a decline in mobility, frailty, and disability that can make them more reliant on their caregivers for their needs or require long-term care, thereby decreasing their autonomy in managing their affairs and making treatment-related decisions. A loss in autonomy can in turn impact the quality of life, well-being, and mental health of older adults.⁵ Decline in functional and cognitive abilities and poor physical and mental health are also considered strong risk factors for elder abuse, including physical injury and mental illness.⁶

Life events related to aging, including bereavement, loneliness, social isolation, and decreased finances after retirement, can add to the psychological burden of older adults. Loneliness and social isolation in particular are associated with adverse mental health outcomes, including dementia, depression, and generalized anxiety disorder.^7,8 The decline in physical and mental health of older adults can reciprocally worsen social stressors, including social isolation and increased health expenditure, leading to further stress, difficulties in accessing care, and subsequent deterioration of health.

Meeting the mental health needs of older adults poses challenges, however, given that the population of older adults is growing at a fast pace. In 2020, there were 727 million people aged 65 years or older worldwide, and this number is expected to reach over 1.5 billion in 2050.⁹ Twenty percent of the US population is expected to be 65 years or older by 2030.¹⁰ In 2012, the Institute of Medicine released a report documenting the increasing prevalence of mental health and substance use disorders in older adults and estimated that 10.1 to 14.4 million older adults will suffer from mental health and substance use disorders by 2030.¹¹ The report raised concerns about an impending crisis in the geriatric mental health workforce, with the pace of growth of the geriatric population exceeding that of trained geriatric psychiatric practitioners entering the workforce.¹¹ Psychiatric trainees entering geriatric psychiatry fellowships in the United States have also declined in the past 2 decades—from 106 geriatric psychiatric fellows in the 2002-2003 academic year to 58 in 2021-2022 academic year.^12,13 Long-standing ageism in mental health care on the part of clinicians, policy makers, and the public has created policy and financial constraints on equitable access to mental health care for older adults and made pursuing a career in geriatric mental health less lucrative.¹⁴

The current COVID-19 pandemic has taught us that older adults face significant adversity, including vulnerability to infection by the SARS-CoV-2 virus, and severe mental health symptoms, abuse, unemployment, poverty, neglect, and loneliness related to the pandemic.¹⁵ Age-related mental health inequities were exposed during the pandemic as a result of ageism, financial and digital exclusion of older adults, discrimination against racial and ethnic minorities, and social isolation measures taken to protect older adults from the virus that resulted in social exclusion and lack of access to care and resources.¹⁵

In this issue of the AMA Journal of Ethics, the contributors focus on contemporary issues related to the mental health care of older adults. The topics covered related to geriatric mental health care pertain not only to geriatric mental health care practitioners, but also to the care of older adults by health care practitioners from other clinical specialties. The contributors have provided their expert opinions on ethical issues in mental health care of older adults related to antipsychotics, culturally appropriate care in long-term care facilities, telemental health, and cognitive-friendly policies in hospitals for preventing delirium in older adults. Various ethical concerns related to mental health care of older adults are addressed in this issue, including older adults’ capacity for treatment decisions and clinicians’ need to balance respect for autonomy, justice, beneficence, and nonmaleficence while ensuring the safety of older patients and their caregivers. The contributors also address broader issues of caring for older adults in our society, including aging in health care, ageism, approval of drugs for incurable diseases, and the geriatric mental health workforce crisis. We hope that, in reading this theme issue, readers will become mindful of the various ethical concerns related to the mental health care of older adults and work with our health care systems and organizations to provide appropriate standards of care for older adults.