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We are all living longer as a result of better living conditions, reduction in infectious diseases and advances in health care. The General Register Office for Scotland predicts that the number of people living in Scotland above pensionable age will rise by 31% from 0.98 million in 2006 to 1.29 million in 2031 (1). Furthermore, the number of people aged 75 years and older is expected to rise by 81%. Such changes in our demographics create new challenges for health policy and practice.

As people live longer, we need to think of new ways to design and develop services that meet the needs of an older population. Services to address the psychological wellbeing of older people are critical, particularly as old age is often characterised by significant life events such as loss of a loved one, retirement and a gradual deterioration of physical health. Older people may also be required to become informal carers for their partners and families as there is a decline in the number of people able to provide formal care.

Mental health and welbeing in old age

Currently, over a third of older people (over the age of 65 years) experience mental health difficulties, such as depression, anxiety and dementia. As Table 1 shows, the most common mental health problem is depression, closely followed by anxiety and dementia. The rates of psychological disorders increase significantly when considering older people living in care homes.

Table 1: Percentage of people aged 65+ with different mental health problems in the community, acute hospitals and care homes

Care Homes
Depression 10-15 25 29 40
Anxiety 2-4 10-24 8 6-30
Delirium 1-2 Unknown 20 ‘Very common’
Dementia 5 Unknown 31 50-80
Schizophrenia 0.5 2-5 0.4 Unknown
Alcohol misuse 2-15 Unknown 3 Unknown
Drug misuse 11.1 Unknown Unknown Unknown

Source: 2nd report from the UK inquiry into mental health & wellbeing in later life (2007)

Older people constitute the highest population of completed suicides, with depression being the leading risk factor (2). In the UK alone, 514 older people took their own lives in 2004 (3). This is likely to be an underestimate as often it is the older person’s physical health problem that is cited on the death certificate.

Mental health difficulties not only result in personal cost in terms of a poor quality of life and premature death, there is also a significant loss to society as a whole. Older people’s contributions as grandparents, unpaid carers and volunteers total £24 billion per year, while boosting the economy a further £245 billion per year in consumer spending (4). There is also evidence that the care provided can have other beneficial effects. Care provided by the grandparents of children whose mothers are experiencing depression reduces the risk of childhood mental health problems (5). If we do not start addressing the mental health and wellbeing of older people we risk losing such contributions.

Poor mental health is not necessarily a part of growing old. Indeed, even when an older person experiences mental health difficulties, if given the appropriate psychological support they can continue to lead full and meaningful lives. However, older people’s mental health has long been a neglected area both in terms of public policy and service provision. This may be in part related to society’s beliefs about old age, which in turn have shaped service models. In 2003, a UK inquiry was launched looking into concerns about the mental health needs of older people. It attempted to address the question of how we can improve our services to better meet the needs of an ageing population.

The most recent report (6) identified five areas for action:

  • Ending discrimination;
  • Prioritising prevention;
  • Enabling older people to help themselves and each other;
  • Improving current services; and
  • Facilitating change.

Meeting mental health needs – Action in Lothian

Ending Discrimination

Current mental health policy (7), looks to address the mental health needs of all age groups and includes a commitment to increase availability of evidence-based psychological therapies for all. This age-inclusive policy is unique to the UK and may help avoid direct discrimination. So too will the requirements of the Disability Discrimination Act (1995) (8). At present, the cut-off for mainstream adult psychological services is 65 years of age. After 65 years of age individuals are under the care of older adult services. However, people below the age of 65 years of age can experience difficulties traditionally perceived as experienced by older people (such as bereavement, dementia, loss of role and physical ill health) and may benefit from the types of specialist skills associated with services for older people and vice versa.

There is also a need to address the stigma of mental illness more generally. With regards to older people, we need to consider the role of peer groups and life experiences in influencing attitudes and beliefs. For example, the current older population grew up in a culture dominated by the belief that physical health took precedence over mental health. Therefore, services need to adapt and meet the needs of specific generations. Approaches which seek to base services on need, rather than age, and which are sensitive to the differing expectations associated with differing generations can only be good for establishing sustainable services.

The risk factors associated with mental health difficulties in older people are well established. For example, research suggests that social isolation is one of the largest contributing factors towards depression. Preventative measures, based on the growing evidence base for effective interventions (9) should be developed and targeted on ‘at risk’ older people.

Supporting self-management in older people and their carers
The Scottish Executive’s, All our Futures: Planning for a Scotland with an Ageing Population (10) promotes individual responsibility for health. This should include mental health and wellbeing. Whilst the research into the efficacy of self-help for older adults is limited, there is a growing evidence base for the use of self-help for a variety of mental health difficulties in the general population.

The UK Inquiry (6) emphasises the importance of older people living within and being supported by their local community. Indeed, the majority of older people with dementia are supported in the community by informal carers, usually their spouse. However, the mental health needs of informal carers is often a neglected area. Being a carer and having a personal relationship with a person with dementia often generates significant challenges. It tends to be more demanding than providing care to an older person with a physical disability, both in terms of the physical and emotional impact (11). It is perhaps not surprising then that rates of anxiety and depression are higher than those seen in the general population (12). This is significant as mental health difficulties in caregivers not only has a negative impact on the carer, but also on the individual who is in receipt of the care. Carers may no longer be able to cope with the demands of caring and may be more likely to utilise residential care (13). Therefore, informal carers are a crucial resource and should be supported appropriately.

Improving current services
Whilst this is something of a ‘given’, the potential challenge of improving services should not be overlooked. As an example, consider the commitment made in Delivering for Mental Health (7) to train 50% of frontline NHS staff by 2010 in suicide risk assessment and prevention. One of its key areas is older people’s mental health. To implement this policy successfully, staff attitudes will need to be considered as attitudes and policies can affect help-seeking behaviour. This is particularly important when considering attitudes to suicide in older people. Research suggests that health care staff demonstrate ‘age bias’, viewing suicidal ideation in older people as a natural consequence of old age (14).

Continued workforce development will be crucial to ensure sustainable improvements in services. In particular, education and training of front-line healthcare staff will be required to ensure skills match to current and anticipated needs.

Care Homes may also be an important arena for training given the high prevalence of mental health problems within these settings. Indeed, research suggests that training staff in care homes improves detection of depression resulting in more treatment and better outcomes (15).

key points

NHS Lothian is already working to establish sustainable services through a range of initiatives. For example, the Lothian Alliance Against Depression (LAAD) is currently developing training for care home staff to recognise and respond to mental health difficulties experienced by older people. More generally, NHS Lothian is working to:

  • Address age discrimination within the NHS through education and training;
  • Reduce stigma through public education, policy and practice;
  • Involve older people in the development of services;
  • Train front-line staff in recognising and addressing mental health difficulties; and
  • Conduct more research into effective interventions for older people. However, this is not simply a task for the local NHS. Older people themselves should be involved in facilitating change by:
  • Participating in user groups that inform service development;
  • Being aware of the risks of mental health difficulties;
  • Recognising and seeking help to ameliorate the symptoms of mental health problems in family and friends; and
  • Accessing available support networks, both formal and informal.