Mental health problems in old age

THE RESEARCH 

Title: Improving Services and Support for Older People with Mental Health Problems
Authors: This is the second report from the UK Inquiry co-ordinated by Age Concern into Mental Health and Well-Being in Later Life and chaired by Dr June Crown.

OBJECTIVES 

The inquiry was launched in 2003 as a response to the concern that mental health in later life is a much neglected area. The first report of the inquiry, Promoting Mental Health and Well-Being in Later Life (June 2006), focused on older people and the ways in which mental health in older age can be sustained or improved. This second report focuses on those older people who do experience mental health problems and on the adequacy of the support and services that are available to them. It builds on a comprehensive literature review commissioned for the inquiry, supplementary work at four sites across the UK exploring the perspectives of older people and unpaid carers, evidence submitted by organisations and professionals, and a range of consultations.

FINDINGS

Discussion of mental health issues and older people often focuses on dementia. The report provides an important reminder that the range of mental health problems in older age can be diverse, ranging across depression and anxiety, delirium, schizophrenia, and alcohol and drug misuse. It details prevalence rates and maps the patterns of mental health problems in those over 65 and the extent of unmet need. For example one in four older people living in the community has symptoms of depression, often undiagnosed but severe enough to warrant attention. At least 30% of older people in acute hospitals and 40% of those in care homes meet the clinical criteria for depression. Overall, up to 60% of older people in acute hospitals experience mental health problems in some form. If tendencies continue, it is estimated that within the next 15 years, one in every 15 of the population will be an older person experiencing mental health problems.

Levels of suicide among older people are high. Women aged 75 and over have the highest suicide rates of all women in the UK, while men in the same age group have the second highest rate. Suicide attempts by older people are more likely to be successful one in four attempts lead to death compared with one in 15 attempts among the general population. The large majority of those who commit suicide have a diagnosable mental health problem, with more than half of those dying through suicide having visited their GP within the previous month. At the same time, people in the 55-74 age group have the highest rate of alcohol-related deaths in the UK.

Access to support services is limited for older people with mental health problems. For example only half of those in care homes diagnosed with depression receive any form of treatment and while a third of older people receiving home care experience depression few receive any treatment. It is estimated that only a third of older people with depression discuss it with their GP and less than half of these receive treatment. Drug therapy rather than an alternative intervention is normally prescribed. Only 6% of older people with depression receive specialist mental health care.

Older people with mental health problems who were involved in discussions on the available support and services highlighted five key areas of concern. They indicated that age barriers made some services inaccessible that indirect age discrimination is a major problem that stigma is powerful and isolating that many problems are disregarded and overlooked and that services are fragmented and distant.

ANALYSIS

Following its appraisal of the range of evidence, the Inquiry concluded that there are five main areas for action: ending discrimination, prioritising prevention, enabling older people, improving current services, and facilitating change. The report makes 35 specific recommendations.

Both direct and indirect age discrimination is experienced by older people with mental health problems, for example age barriers to accessing services or ageist attitudes towards their illness. Such discrimination is exacerbated by the stigma associated with mental health problems which combine to make older people with mental health problems invisible in policy, practice and research. The background literature review refers to “layers of invisibility” with the mental health needs of for example older people with learning disabilities or those with severe and enduring mental health problems rarely discussed.

The inquiry report outlines the evidence on the action that can be taken to prevent depression and anxiety, suicide, delirium, and alcohol and drug misuse in later life. It builds on the first inquiry report, which identified active participation, good relationships, physical health and adequate income as factors that assist in maintaining good mental health and may prevent the development of mental health problems. The risk factors for later life depression are well established: physical disability and illness and its impact on daily functioning, and social isolation and loneliness, often associated with bereavement. Preventive strategies need to reduce the risk factors where possible, reduce the impact of risk factors when they occur, and target people at times of risk.

A third focus is on enabling older people to help themselves and each other, promoting self-help and peer support. Community development approaches have a role to play in encouraging participation and in providing support for unpaid carers. Meaningful activity, support from family and friends, and access to information and to advocacy are considered to be key areas.

The need to improve current services recognises the impact for an individual of adequate and timely provision of high quality services. Older people themselves highlight the need for proactive and dependable services which can offer a range of options and can be available when they are needed. Six key areas are addressed: housing, primary care, social care, specialist mental health services, acute hospitals and care homes. The importance of good housing and the need for a range of options and the provision of housing support is often overlooked. Primary care may be the only point of contact for older people with mental health problems and is therefore core to improvements in early detection and diagnosis and to the provision of a wider range of responses. Collaboration with mental health specialists and broader community resources is required. Social care provision, in particular domiciliary care, also needs to be alert to mental health problems in older people and to respond correctly. Specialist mental health services should extend to older people the range of interventions offered to younger adults, while acute hospitals need to improve the diagnosis, treatment and management of mental health problems in older people. Finally, in care homes, where most will have mental health problems, “in-reach” services from primary care and mental health specialists matched with individual support in the care home can have beneficial outcomes.

The fifth area for action focuses on facilitating change. Three important areas are highlighted: the provision of education, training and support for the workforce increased investment, effectively targeted and the development of strong leadership. The challenges in securing an adequate workforce are not unique to this area but are particularly acute in respect of providing adequate support workers for older people with mental health problems They highlight the need to improve pay and status and to develop wider knowledge and skills. The development of benchmarking data and high level performance targets is proposed as a mechanism for accelerating change.

Alison Petch is director of Research in Practice for Adults, which promotes the use of evidence informed practice in the delivery of adult social care services

LINKS AND RESOURCES

● A literature review to inform the inquiry was commissioned from Mary Godfrey and Jean Townsend from the University of Leeds and Clare Surr, Geraldine Boyle and Dawn Brooks from the University of Bradford. Both the full report literature and policy review on prevention and services and a summary can be accessed at www.mhilli.org.

● A second report, Disregarded and Overlooked, can also viewed at www.mhilli.org. This outlines research into the needs and experiences of older people with mental health needs and their unpaid carers.

PRACTICE IMPLICATIONS

Age equality
All those involved in the planning, provision and delivery of support services for older people with mental health problems need to acknowledge the impact that age discrimination has had in this area. Whole system change is required to eliminate this discrimination and to ensure that older people with mental health problems are responded to on the basis of need not age.

Workforce development
The implications of the growing number of older people with mental health problems for the provision of an adequate workforce must be addressed. A range of strategies will be required to ensure that older people can access a variety of support options from people familiar with their needs. Home care provision should offer both emotional and practical support and support should be available for unpaid carers. Eligibility criteria should acknowledge these needs.

Education and training
The range of professionals and support workers involved with older people need to be trained to recognise and respond to signs of mental ill health in older people. This should include understanding of the risk factors associated with depression, suicide, and alcohol and drug problems, and of strategies to prevent or respond to such risks. Professionals should also be aware of the range of factors that may contribute to an individual’s mental health, including the role of housing. Procedures to ensure that care home staff are effectively identifying and supporting individuals with mental health problems should be introduced.

Community resources
The importance of social networks, of peer support and of participation in a range of activity in alleviating mental health problems in older people should be acknowledged through the development of community-based initiatives and the promotion of well-being.

Information and advocacy
Provision of information and advocacy services should both improve the understanding of older people with mental health problems of the options available to them and more generally raise the profile of often invisible groups. Positive accounts of recovery should be promoted and strategies to improve public attitudes should be developed.

User involvement
Improving support and services for older people with mental health problems should not just focus on making these neglected groups visible. Imaginative and effective strategies for involving older people with mental health problems themselves in the development of support strategies at both the individual and community level should be developed.