Assessing the mental health needs of older people
Mental health and well-being
Good mental health and emotional well-being is as important in older age as it is at any other time of life. Many people fear growing older, and assume that old age is depressing and distressing, characterised by loss and disability, offering little to look forward to. But the reality is that older people are as capable as younger people of enjoying life, taking on challenges, coping with difficulties, engaging in satisfying activities, supporting each other with warmth and good humour, and making a real contribution to their families and communities, using their wealth of knowledge and experience.
For health and social care professionals, who often meet an older person for the first time during a crisis - when they are ill, or when other difficulties have become overwhelming - it can be hard to keep in mind the positive picture. Low expectations about life quality for older people are widespread amongst service providers, assessors and older people themselves ('What can you expect at your/my age?')
Assessors must remember that this is age discrimination, which leads to poor service responses and social exclusion for older people.
A number of reports in recent years have emphasised the need to focus on successful ageing, and living well in later life. The World Health Organisation's vision statement on Active Ageing, for example, states: 'Active ageing is the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age.' (8).
Not everyone agrees about what constitutes 'successful' ageing, however, and there are some suggestions that researchers in this area have not used criteria which older people themselves would endorse. Opportunity age (9), a strategy produced by the Department of Work and Pensions, promotes well-being and independence for older people and aims to ensure that later life is active and fulfilling. Although this is a strategy which tries to tackle age discrimination and change attitudes, there is a danger in basing the social inclusion of older people on their explicit contribution to society as paid workers or as volunteers in the community.
The Nuffield Institute for Health has produced a report, Living well in later life: from prevention to promotion (10), which argues for a switch in emphasis from avoiding higher intensity and more costly care to promoting older people's quality of life and their engagement in the community.
In 2003 the Association of Directors of Social Services and Local Government Association issued an influential discussion document, All our tomorrows: Inverting the triangle of care, arguing for major changes in tackling age discrimination and social exclusion through community strategies to promote the well-being of older people through the extension of universal services.(11)
Age Concern and the Mental Health Foundation have embarked on a broad-based three-year Inquiry into mental health and well-being in later life. The findings from the first stage, a review of literature, policy and practice, provide some evidence of 'what works' to promote mental health in older people, such as support, social contact, participation, learning new skills and sustaining a sense of purpose.
For a more detailed account, see Research Summary Chapter 2 (443kb PDF).
Important factors which contribute to good mental health in later life are:
- having a role and a purpose in life
- having good social networks
- enjoying an adequate income
- living in a supportive neighbourhood.
While most older people remain in good mental health, older people are more likely than younger people to experience events and illnesses associated with poorer mental health.
Mental health has a big impact on physical health.
There are ways to improve health and well-being in later life.
Older people's views on what is important to healthy ageing include:
- being able to adapt to continuous physical change
- engaging in relationships
- maintaining independence and taking risks
- having enough money
- fulfilling desires and personal objectives
- keeping busy by taking part in meaningful activity.
Social exclusion of older people with mental health needs is created by:
- social isolation and loneliness
- lack of civic engagement
- exclusion from basic services
- fear of crime and anti-social behaviour in neighbourhood
- age discrimination.
Many things in older age can have an adverse impact on well-being, such as poor health, declining physical and mental capabilities, financial worries, and loss of friends, family and social contacts. The aims of service provision should be to restore well-being as far as possible rather than simply meet the presenting care needs. Assessment should focus on a person's strengths as well as their difficulties. Promoting independence may not mean enabling someone to do without help, but maximising what they can do for themselves, and promoting their autonomy, self-esteem and quality of life.
If you are assessing older people, the following could help you stay positive and focus on strengths:
- Be interested in the whole person and think about what they may have been like when they were younger. Talk to them, encourage them to reminisce, so you get a sense of the person and their strengths, passions and opinions.
- Ask family members about them, to fill gaps in your knowledge and to encourage family members to remember the whole person, not only the illness.
- Think about the person's whole quality of life, not just their health and social care needs. What would give them pleasure, fulfilment, and something to look forward to? How can you help them experience such things?
- Be alert to ageism and discrimination, in yourself and your organisation. Ask yourself how services would respond if the person was a younger adult with a mental illness or a disability: would their approach be different?
Next: The main problems