Mental health and wellbeing of older people: opportunities and challenges

By 2050, the world population over the age of 60 is expected to reach two billion.¹ A rapid growth of older people will occur in low- and middle-income countries (LMIC) with huge consequences for these vulnerable economies.² Many people live a long and happy life without any mental health problems, despite the all too prevalent impression of elderly people being sad, slow and forgetful, mental disorders are not an inevitable consequence of ageing. Nevertheless, one of the possible negative consequences of the rapid ageing of the global population is the increase in the number of people with mental disorders, which will soon overwhelm the mental health systems in all countries.²

More than 20% of people aged 55 or older may have some type of mental health problem.³ Biological changes may interfere with the brain's functioning, social changes can lead to isolation or worthlessness and somatic diseases are often important contributory factors too. Mental disorders may exacerbate the symptoms and functional disabilities associated with medical illnesses and increase the use of healthcare resources, length of hospital stay and overall cost of care.⁴

Mental health problems can have a high impact on an older person's ability to carry out basic daily living activities, reducing their independency, autonomy and quality of life. The first step to reduce these negative consequences is simply to make a diagnosis. Unfortunately, too often mental health problems are undiagnosed and untreated and many older people struggle on without proper help or any help at all.⁴

Today's older adult population is not likely to acknowledge mental illness or to access mental health services. Many stigmas exist regarding the meaning of mental illness. Many elderly people view mental illness as a sign of weakness and are unlikely to admit to experiencing problems, especially when they fear loss of independence. Too many people consider the symptoms of dementia and depression as a normal part of ageing. Many older people also lack the availability of, and access to, services.⁵

Other difficulties concern the workforce: few mental health providers have had specialised training in providing care for older adults and many come with a set of societal-transmitted biases themselves. This therapeutic pessimism of health professionals means they believe that older people cannot change and that it is too late for psychiatric care to be administered. As a result, there are few investments in the development of policies, strategies, programmes and services for older persons with mental health problems.²

It will be very difficult for all countries, no matter what their respective income levels are, to assure the development of a specific workforce to treat and care for older people with mental health disorders at the same rate that this group is growing. Other existing resources have to be used; primary care becomes mandatory.

The mental health and wellbeing of older people was chosen by the World Federation for Mental Health as the theme for the World Mental Health Day 2013. This is a very good occasion to reflect on the global situation of older people with mental disorders around the globe. This issue of Mental Health in Family Medicine is a contribution to this reflection and an affirmation that the collaboration between old age mental health professionals and primary care teams is not only possible, it is absolutely necessary.

Shulin Chen et al develop in their article how, in China, and in particular rural China, it is necessary to develop and test approaches to the care for patients with dementia. Evidence-based collaborative care models for dementia, depression and other chronic diseases that have been developed in some Western countries serve as a basis for the discussion of innovative approaches to the management of dementia in China, with particular focus on its implementation in the primary care system.

Research into mental health issues in general practice is often limited by several issues despite the importance of developing knowledge in this field. Recruitment rates of general practitioners (GPs) to carry out research vary widely. This may be related to the ability of studies to incorporate incentives for GPs and minimise barriers to participation.

Chris Fox et al make suggestions to optimise primary care for people with dementia. Authors consider key areas in primary care regarding the diagnosis of dementia. Issues surrounding assessment, policy and incentives are considered. In addition, the relevance of non-medication approaches for dementia in primary care, which aim to enhance or maintain quality of life, is deliberated. Key issues about primary care medication management are considered and relevant therapeutic strategies that improve outcomes by linking primary and secondary healthcare services with social care needs are weighed up. A key aspect of such a collaborative approach is to support informal carers in optimising medication.

Nogueira et al focus on the development of a liaison old age psychiatry (LOAP) facility. Elderly patients occupy up to 65% of acute hospital beds and a significant proportion of them present with a comorbid psychiatric condition such as depression, delirium or dementia. A LOAP service may provide psychiatric consultation in medical and surgical settings, improving at the same time the knowledge and expertise of general ward staff. A LOAP service may play an important role to effectively reduce the overutilisation and consumption of health resources through the early recognition of these conditions, effective management and prevention of adverse outcomes, and articulation with outpatient clinics, community mental health teams and day-care centres.

Syahnaz Mohd Hashim et al develop the role of primary care in the bereavement of older people. This bereavement can lead to psychological illness such as depression. While most people are able to come to terms with their grief without any intervention, some vulnerable people are not. Early recognition of elderly people with bereavement-related depressive illness is a priority. Primary care physicians need to optimise support and available resources prior to, and throughout, the bereavement period in order to reduce the caregiver's burden and suffering.

Henry Brodaty et al used a sample of GPs from the Sydney intervention and control groups from the Ageing in General Practice ‘Detection and Management of Dementia’ project, as well as GPs who had refused participation, to determine incentives and barriers to participating in research. Authors detected the contributing factors as incentives and barriers to the success of this project and they make suggestions for how to improve future recruitment of GPs.

Boadie W Dunlop et al highlight frequently over-looked aspects of the care of older patients who present with depression and anxiety in primary care. Chief among these aspects is the consideration of a thorough differential diagnosis, particularly bipolar disorder, psychotic disorders, dementia and substance abuse, each of which requires specific treatment approaches. They conclude that judicious use of benzodiazepine and appropriate referrals to psychotherapy can contribute to optimal treatment outcomes.

All these articles confirm that the shifting of focus to the ageing will have profound consequences for the workforce, healthcare systems, informal and formal caregiver capacity and society in general, and will require more and better strategies to ensure good mental health and wellbeing in the growing older population. The negative stereotypes and attitudes regarding ageing and older people must be stopped. The balance between vulnerability and resilience is central to mental health promotion and certain groups with specific burdens face a higher risk of poorer mental health. Older women often face risks that increase their vulnerability, both as sufferers of mental health problems and caregivers. Policies to support them and interventions to prevent mental health problems and isolation in older women must be strengthened.⁷

In conclusion, the promotion of healthy ageing in all its aspects is an important role for all societies. Early recognition, diagnosis and treatment of mental disorders that are common in old age are important to prevent suffering and disabilities. Care for older adults with mental illnesses requires sensitivity and observational and relational skills in order to help the older person achieve and maintain the highest possible level of functioning and wellbeing. Those who care for older people should always be protected and supported in their tasks everywhere. All these interventions can be efficiently realised in primary care.

All these actions together can certainly contribute to better mental health in old age.