Ageing and mental health

Question 1

what really constitutes old age?

Answer 1

• Old age begins at 65 (World Health Organisation, 2002).
• Some argue that chronological age is an arbitrary construct.
• Inconsistent terminology: ‘Old people’, ‘elderly’/’older people’, any more?
• Many stereotypes and prejudices associated with ‘old age’.
• Tend to think about older adulthood in negative terms
• Stereotypical attitudes and self stigmatise- fear about own ageing and mortality but it is something that affects us all
• Notion of chronological age is an arbitrary construct- it is subjective (as old as you feel)
• Inconsistent terminology- old, elderly,
  
  • Use of language is important- think carefully about how represent this stage of lifeo

Question 2

older people are a complex age group

Answer 2

• Two stereotypical images of older people (BBC News, 2013):
• The lone pensioner, huddled in a chair by the fire trying to keep warm while using as little heating as possible who doesn’t see anyone for days on end.
  
  • Epitome of loneliness and decline
• The active golf club member, allotment-keeper or busy grandparent.
  
  • Thriving socially- other extreme
• Often think about these tow as the only types of old people- actually 2 extremes that does not represent truth

Question 3

older people are a growing group

Answer 3

• In an ageing population- the population is getting older
  
  • Advances in medicine and social care
  • Leading cause of death is metabolic disease not infectious
  • Problem with living longer is the health service is not set up to cope with this e.g. not set up for dealing with frailty or the challenges of advanced old age
• Need a better infrastructure in social and health care
• More parts of the world with an ageing population- most of Europe
• Speed of population ageing is accelerating
• Key taske home message: increased accelerating of ageing and the world is not set up in the way it needs to be

Question 4

mental distress does not end with age

Answer 4

• Psychological problems presented by older people in a ‘typical’ UK health district (Department of Health, 2005).
• Important to consider wellbeing within ageing
• Mental distress does not end with age- less prevalent but is something that is uniquely challenging

Question 5

Kessler et al., 2005

Answer 5

• Lifetime prevalence of DSM-IV disorders in the National Comorbidity Survey (Kessler et al., 2005)
• Epidemiological studies assessing health problems over time over different age groups
• Lifetime prevalence of mental health disorders
• Grouped the most common mental health challenges
• Anxiety is the most prevalent group in all ages, followed by major depressive disorder then alcohol abuse
• In all cases, the elderly population is statistically significantly lower
• Compared to other ages, the prevalence of these conditions is lower
  
  • Does not mean it isn’t important to look at

Question 6

Reynolds et al., 2015

Answer 6

• Prevalence of psychiatric disorders in 4 cohorts of community-dwelling US older adults (adapted from Reynolds et al., 2015)
• Broken the 60+ group down into 3
• See that mood disorders like anxiety and depression is highest in 55-64 group
• Less variation in psychiatric prevalence as we get older- flattening effect suggests its less prevalent but also a cause

Question 7

Goldberg et al., 2012

Answer 7

• Prevalence of mental health problems among older adults admitted as an emergency to a UK general hospital (adapted from Goldberg et al., 2012)
• Broken down into symptom clusters not a diagnostic label e.g. delusions and hallucinations not schizophrenia
• For agitation or aggression, apathy, motor behaviour, delirium and dementia
  
  • Significant difference between the people with or without cognitive impairment- they are more likely to experience these symptoms
  • Cross over and interaction between different symptom. Clusters and cognitive impairment
  • Shows us cognitive impairment exacerbates pre existent mental health conditions
• Not all of these are significant differences but it is interesting to look at where there are differences
  Cognitive impairment and dementia very closely linked- biggest difference

Question 8

How should we approach old age

Answer 8

• Mental health in later life sits on the intersection of a range of interrelated concepts.
• This warrants a multidisciplinary approach to research.
  
  • Biopsychosocial approach- look at psychologically and social factors not just biological
  • By doing so we can properly comprehensively understand what is going on for this group of people
• Older adults suffer unique challenges which exacerbates these problems- take a preventative approach before people reach old age
• Person centered approach which takes into account their own lived experiences and perspectives- stereotypical approach to not include them in healthcare decisions
  
  • Need to include them in our design of services and celebrate their diversity
• Should also reflect the lives, experiences and perspectives of older people themselves.
  Gerontology- study of ageing

Question 9

why are older adults at risk of mental disorder?

Answer 9

• Local NHS data (2016/17) shows that:
• Three older adults a week were newly diagnosed with a mental disorder.
  
  • More than half were older men
  • About a third were aged over 75
  • Likely to be many more who have yet to seek help
  • Likely to be an underestimate- huge amount of people
  • Prevalence is lower but it is not 0
• Cohort effects- people that are currently ‘old’ in this country (65-75) were all born post world war 2
  
  • Their parents lived through world war 2 (think about epigenetics)
  • This will have massively shaped their resilient and personality generationally
  • Stiff upper lip- idea of getting on with it without asking for help- resignation to stress
    5 important factors that affect mental wellbeing of an old person: discrimination, social participation (in meaningful activities), relationships, poverty and physical health

Question 10

a multidimensional lifespan approach (risk of mental disorder)

Answer 10

• Older people face unique mental health challenges.
• Changes in the following ‘forces’ can influence mental health and distress: biopsychosocial approach
• Biological forces
  
  • Health problems can provide clues about underlying mental distress
  • Biological and physical states in the body can interact with mental health symptoms
  • E.g. arthritis, less likely to move, less confident to go outside, less social functioning, mental health declines
  • UTIs are the leading cause of delirium
• Psychological forces
  
  • Normative changes in psychological factors can mimic mental distress
  • Thinking about psychological changes that can influence peoples lives
  • Loneliness, motivation to seek support
• Sociocultural forces
  
  • Social norms and cultural factors influence behaviours and affect our interpretation of them
  • E.g. heritage, where we live
  • Generational differences in how much value we place on tradition e.g. going to church but cannot get there
  • Different cultures more likely to live in multigenerational households but in individualistic societies we place value on social mobility- more separated from family
  • Social support
• Life-cycle factors
  
  • Past experiences can influence behaviour
  • Transitional life events that we all go through, contextual factors in our lives that affect mental health
    Becoming a carer, having a family (being a grandparent- sense of role), traumatic life events like early childhood trauma (something may trigger it like- from being independent to dependent, trauma does not go with age), marital status transitions e.g. widowed, remarried, divorce

Question 11

Isolation, loneliness and health

Answer 11

• Increasing number of older people live alone (McCarthy & Thomas, 2004)
  
  • 11% have < monthly contact with family and friends
  • 50% report that TV is their main form of company (Griffin, 2010).
• 6 – 13% of older people report being ‘often’ or ‘always’ lonely (Campaign to End Loneliness, 2011).
  
  • Problematic as Loneliness and isolation increases risk of physical and mental health problems, including cognitive function and dementia (Hakansson et al., 2009).
    Correlation not causation but we tend to see that those who are lonely have poorer health- vicious cycle as it makes everything worse

Question 12

lifespan approach to dementia

Answer 12

• Livingston et al. (2020) in Lancet,
• Identified a range of modifiable risk factors for dementia in early life, midlife and later life.
  
  • Found that in early life education level was the biggest predictor of dementia in later life- reduction of this risk factor is eliminated
  • In midlife if we you do not have hearing loss you are 8% less likely to get dementia
  • In later life smoking is more detrimental, depression and dementia also often go hand in hand. Air pollution also associated with dementia and other outcomes
  • 40% of the variants in dementia could be modified- we can educate people, campaign to reduce smoking and alcohol: social, behavioral and environmental factors that can be mitigated
    Interesting to consider overlap between mental health and dementia risk factors.

Question 13

why does ageing make it so difficult to assess/treat mental distress

Answer 13

• Mrs Go. case study (Donnellan, 2017)
  
  • Long time married (42 years) and carer for her husband (7 years)
• Which forces are influencing Mrs Go’s behaviour?
  
  • Biological forces: has aches and pains, was not in the best physical health but it has deteriorated
  • Psychological forces: confidence had gone, lack of motivation, apathy, couldn’t open up to anyone
  • Sociocultural forces:
  • Life-cycle factors: stress of caring for her husband, bereavement for her husband
• The case of Mrs Go. raises a number of questions:
  
  • Do these forces always indicate a problem?
  • Which of the psychological ‘forces’ are symptoms and which are risk factors?
    How easy is it to assess and treat Mrs Go. for depression in the muddiness of caregiving, bereavement and physical health problems?

Question 14

what is assessment?

Answer 14

• A formal process of measuring, understanding and predicting behaviour.
  
  • Gathering medical, psychological and sociocultural information e.g. interviews, blood tests
  • Clinical interviews, observation, tests and examinations..
• How easy is it to assess and treat Mrs Go. for depression in the muddiness of caregiving, bereavement and physical health problems?
  
  • Widow with care experience
  • Recently bereaved cannot be diagnosed with major depressive disorder- a normative way to react

Question 15

does bereavement have a special status?

Answer 15

• Kendler et al. (2008)
  
  • Bereavement-related depression is similar to depression related to other stressful life events.
  • Questions the validity of the bereavement exclusion criterion à DSM-V.
• Sikorski et al. (2014)
  
  • Spousal bereavement associated with depressive symptoms but not major depressive disorder over time.
    Eliminating bereavement exclusion criterion unlikely to have effect on major depression as i. Prevalence is low, and ii. symptoms ≥ disorder.

Question 16

areas of multidimensional assessment

Answer 16

• We need age-sensitive assessment measures of mental health and distress.
  
  • A multidimensional assessment approach may be the answer.
  • The things we are going through is different to old people
• Multidimensional assessment is often done by a team of professionals. For Mrs Go.:
  
  • High blood pressure, aches and pains: e.g. medical examination
  • Crying, lack of confidence, guilt, apathy: e.g. clinical interview, questionnaire
    Caregiving, bereavement: e.g. clinical interview, self-report

Question 17

barriers to assessment and treatment- Age UK report (2016)

Answer 17

• ‘The unmet mental health needs of older people in the UK’.
• Lack of ‘joined up’ health care
  
  • 37% of Mental Health Trusts in England have no policies for providing integrated (mental and physical) care to older people.
• Fewer over 65s are being referred to IAPT services compared to the general population, despite:
  
  • Higher treatment completion and recovery among older people relative to the general population.
  • Older adults respond better to psychological therapy than working age adults (Saunders et al., 2021).

Question 18

barriers to assessment and treatment- Independent Age (2018)

Answer 18

• According to Independent Age (2018), 24% of older people felt uncomfortable with people being aware they were depressed.
• Do we stigmatise mental illness more as we age?
• Tzouvara et al. (2018)
  
  • Public and self-stigma both identified in older people living with mental illness, manifested through fear, reluctance for social interaction, shame, secrecy and withdrawal.
  • Insight into illness plays an important role in self-stigma experiences.
• Royal College of Psychiatrists (2018)
  
  • Age discrimination at societal, professional and institutional levels towards older people’s mental health needs
    Impact on mental health strategy, funding and delivery

Question 19

a multidimensional lifespan approach- Mrs Go vs Mrs C

Answer 19

• Mrs Go. and Mrs C have similar sociodemographic characteristics, and yet:
  
  • Mrs C. displays more protective traits and gives/receives social support despite health problems.
  • This is the case throughout care- and bereavement periods.
    Unlikely to receive a diagnosis of depression.

Question 20

what would a good older peoples mental health service look like?

Answer 20

• What would a good older people’s mental health service look like?
• Co-production in planning of local services
• Psychoeducation and information
• Specialist, age-appropriate services
• Integration with social care
  Seamless care across services

Question 21

Introducing NHS TTad

Answer 21

• NHS TTad (formerly known as IAPT) is the psychological therapy service offered in the NHS
  
  • These services are recommended in national guidelines as a first line treatment for common mental health problem
  • Stepped-care model. Step 2 (low intensity treatments), Step 3 (high intensity treatments)
  • Provide evidence-based treatments (e.g. cognitive behavioural therapy, interpersonal therapy) in one-to-one or group settings
    >1 million people access NHS TTad each year. People can self-refer or by referred from community services, primary care, secondary care

Question 22

access to psychological therapies for people with dementia

Answer 22

• Access to psychological therapies is poor for older people in general (Burns et al 2015), and these issues are compounded in people with dementia.
  
  • 60% of people affected by dementia need emotional support, but of those signposted to mental health services, 57% report a wait time of >12 months to access support (Alzheimer’s Society 2022).
    Primary care staff may perceive psychological therapies to be less appropriate in patients with cognitive impairment, and may withhold referrals (Collins et al., 2018; Baker et al. 2021).

Question 23

inequalities in access to psychological therapy services in NHS for people with dementia (El Baou., in prep)

Answer 23

• Aim: To test inequalities in access to NHS TTad in people living with dementia compared to people without dementia.
  
  • Data Source: Secondary data used from electronic healthcare records. Data used from >5 million people referred to NHS TTad services since 2012, linked to hospital and mental healthcare records.
  • Dementia diagnosis: We identified people with a diagnosis of dementia in medical records who had been referred to NHS TTad.
  • Statistical analyses: (1) Logistic regression was used to test whether having a dementia diagnosis was associated with lower likelihood of being seen for an assessment, or subsequently entering therapy. The dementia sample was matched to the non-dementia sample on key characteristics (e.g., age, gender etc). (2) Multinomial logistic regressions were run to test whether having a dementia diagnosis was associated with reasons for discharge.
  • Of those referred, 27.4% of people with dementia and 41.0% of people without dementia received therapy.
  • After propensity score matching, people living with dementia were:
    
    • Less likely to be assessed [AdjOR=0.55 (0.51; 0.60) p<.0001].
    • Once assessed, they were less likely to receive therapy [AdjOR=0.69 (0.63; 0.76), p<.0001].
      People living with dementia were up to 2 to 5 times more likely to be discharged because the service is not suitable or to be referred on to further services.

Question 24

barriers and facilitators to access

Answer 24

• Aim: to understand the potential facilitators and barriers to accessing and engaging with CBT for people living with dementia or MCI as perceived by clinicians working in primary care psychological therapies services.
  
  • Participants: 14 qualified psychological therapists working in NHS TTad.
  • Methods: One-to-one semi structured interviews were conducted. Participants were asked to provide demographics, details on their current role and previous clinical experience. Then they were asked about their experience of working with older adults and people living with dementia or MCI, the positives and challenges of this work, how dementia or MCI affected their work, their confidence in working with this client group, and their awareness of the evidence base.
    Analyses: Thematic analysis.

Question 25

are psychological therapies effective for people living with dementia? Bell et al., 2022

Answer 25

- Aim: To test effectiveness of psychological therapies offered routinely in NHS TTad in people with dementia, and compare outcomes to people without dementia. - Data Source: Secondary data used from electronic healthcare records. Data used from >5 million people referred to NHS TTad services since 2012, linked to hospital and mental healthcare records. - Dementia diagnosis: We identified people with a diagnosis of dementia in medical records who had received therapy in NHS TTad. Statistical analyses: (1) Paired t-tests were used to investigate pre-post differences in depression and anxiety scores for the dementia group. (2) Logistic regressions were used to test whether dementia diagnosis was associated with likelihood of improving mental health symptoms over the course of therapy. Analyses were run using a comparison group without dementia matched on key characteristics (e.g., age, gender etc).