Mental health problems in old age – double discrimination or everybody’s business?

Dr Ian McPherson outlines some of the challenges mental health problems in old age raise for our assumptions about later life and for all services

One of the major factors that prevents mental health problems in old age being properly recognised are implicit assumptions about the quality of life we should expect as we get older. Too often it is wrongly assumed that intellectual deterioration and memory loss is a ‘natural consequence of ageing and that given their changing life circumstances it is ‘inevitable’ that older people become depressed. In addition many older people, brought up at a time when mental health problems were even more a source of stigma than they are today, are reluctant to acknowledge their distress or to seek help.

This can create the possibility of ageism being compounded with stigma and create the risk of double discrimination, with the consequence that older people frequently do not seek help when they would benefit from it and are not necessarily offered appropriate help if they do.

In the last twelve months, three major reports have been produced from Age Concern, the Alzheimer’s Society and the National Audit Office on different aspects of older people’s mental health which make challenging reading from the perspective of anyone who might develop these conditions, their carers and for society as a whole. These reports highlighted the following points:

three million older people in the UK experience symptoms of mental health problems

the annual economic burden of late onset dementia is £4.3 billion which is greater than that for stroke, cancer and heart disease combined

dementia affects 5% of those aged over 65 and 20% over 80

10-15% of all older people meet the clinical criteria for a diagnosis of depression

these numbers are set to increase by a third over the next 15 years

In response to this, the Department of Health has announced that it is to produce the first ever national dementia strategy due to be published autumn 2008 with a focus on 3 main areas:

improved awareness- focusing on developing a better understanding of dementia by public and professionals alike, ensuring that better information is provided on how to seek help and what help and treatment is available and tackling the stigma and misunderstandings that currently exist

early diagnosis and intervention- focusing on effective services for early diagnosis and intervention are available in future on a nationwide basis

improving the quality of care for dementia- focusing on improving liaison services that can enable effective management in hospital and intermediate care and building better skills and understanding of dementia in the health and social care workforce so that all those working with older people develop core skills in this area

The detail of these programmes is currently being developed in conjunction with key stakeholders, including Alzheimer’s Society, Age Concern, Help the Aged, Action on Elder Abuse and a variety of professional groups. This consultation is being supported by the Care Services Improvement Partnership (CSIP) whose specialists in older people’s mental health both nationally and in regional development centres already work closely with services and commissioners across health and local authorities as well as with the third sector to support improvement at a local level. While this focus on dementia has been widely welcomed, there remains a need to promote greater awareness of the whole range of mental health problems found in old age. Clearly this requires better developed specialist services, but it should be recognised that most people with mental health problems will be seen in primary care and other health and social care organisations.

The widespread prevalence of mental health problems in older people in generic services and the need to mainstream knowledge and skills within these is why the service development guide for integrated mental health services published in 2005 was called Everybody’s Business and a lot of CSIP’s work has focused on these areas. A good illustration of this is the Lets Respect programme designed to help nursing staff in acute hospitals become more aware of the mental health problems that many of their older patients are experiencing and of more constructive ways of responding to these in an acute hospital setting. This is now being developed for use in residential care. Similarly CSIP has worked with colleagues in the Royal College of General Practitioners, The Royal College of Nursing and Staffordshire University to produce guidance on preventing suicide in older people.

For too long the mental health needs of older adults have been marginalised in all aspects of health and social care. To overcome this legacy of ageism and stigma needs a concerted challenge to all services and to our own views about what we should expect as members of an aging society.

For more information about older peoples mental health and CSIP’s work in this area go to www.olderpeoplesmentalhealth.csip.org.uk

Dr Ian McPherson is director of the National Institute for Mental Health in England (NIMHE), part of the Care Services Improvement Partnership (CSIP) which supports policy development, policy implementation and capacity and capability development in relation to the health and social care needs of people with mental health needs, people with learning difficulties, older adults, people with physical and sensory disabilities, offenders and children and families.

Primary care

Of the 22% of people aged 65 and over who visit their GP in a two week period around 40% will have had a mental health problem but:

only a third of older people with depression discuss it with their GP and less than half of these are treated for depression;

depression is strongly associated with physical illness and disability, but in these circumstances is still responsive to treatment

Acute hospital care

A typical district general hospital with 500 beds will admit 5,000 older people each year and 3,000 will suffer a mental disorder in addition to the physical disorder for which they were admitted. On average, older people will occupy 330 of these beds at any time and 220 of these will have a mental disorder.

This means that the acute hospital will have at least four times as many older people with mental disorder on its wards as the older people’s mental health service has on theirs. Three disorders; depression, dementia and delirium, account for 80% of this mental disorder co-morbidity.

Residential care

At least 40% of older people in care homes have depression and 50-80% have dementia.

Very few care staff have training in dealing with mental health problems.