IMPROVING MENTAL IMPROVING MENTAL HEALTH & WELL BEING IN HEALTH & WELL BEING IN LATER LIFE: EVERYBODY’S LATER LIFE: EVERYBODY’S BUSINESS BUSINESS (INCLUDING (INCLUDING YOURS!)YOURS!)

OCT 31OCT 31STST 2008 2008Alisoun Milne, Senior Lecturer in Alisoun Milne, Senior Lecturer in Social Gerontology, University of Social Gerontology, University of KentKent

a.j.milne@kent.ac.uka.j.milne@kent.ac.uk

MENTAL HEALTH IN LATER LIFE: WHY EXPLORE IT?

Old age is not a stage of life associated with ‘inevitable decline’ of health

Chronic ill health affects only a minority of older people; much can be done to ameliorate both risks & symptoms

But… defining & conceptualising ‘mental health’ in later life is not straightforward

Its links to the broader constructs of ‘well being’ and ‘quality of life’ are little explored

By illuminating these we may extend understanding of mental health in later life & expose opportunities for promotion

MENTAL HEALTH IN LATER LIFE: IS IT IMPORTANT?

Good mental health is as important in later life as at any other stage of life

Everyone has mental health needs whether or not they have a diagnosis of mental illness

Our mental health has a powerful influence on how we feel & act

… In fact it is central to overall health and well being & has a profound impact on quality of life

Mental health is routinely identified by older people themselves as pivotal to ‘ageing well’ (Bowling, 2005)

MENTAL HEALTH IN LATER LIFE: WHAT IS IT?

Research consistently identifies that: Having a role; good social relationships with family,

friends & neighbours; an adequate income, being physically fit & living in a supportive neighbourhood, are promoting of mental health

Deteriorating health, loss of independence, loneliness, fear of death, living in poor housing & neighbourhood and decreased income are undermining of mental health

The negative impact of losses & physical illness are key risk factors (Godfrey and Denby, 2004)

How well an older person adjusts to late life challenges is a key factor in determining ongoing mental health (Victor, 2005)

MENTAL HEALTH IN LATER LIFE: HOW CAN IT BE DEFINED?

WHO (2003) defines mental health as: ‘a state of well being whereby individuals recognise their abilities, are able to cope with the normal stresses of daily life and make a contribution to their families and communities’

Older people consider mental health to be characterised by: a sense of well being, the ability to make and sustain relationships, and the ability to meet the challenges and circumstances which later life brings

The Mental Health Foundation views good mental health as the ability to: develop emotionally, creatively, intellectually and spiritually; initiate, develop and sustain mutually satisfying personal relationships; face problems, resolve them and learn from them; are confident and assertive; are aware of others and empathise with them; use and enjoy solitude; play and have fun; laugh, both at themselves and at the world (2006)

MENTAL HEALTH & QUALITY OF LIFE Considerable synergy exists between those

issues that contribute to good mental health and those that promote ‘quality of life’

QoL is a concept encompassing emotional, social, psychological, and health related, domains - broadly it encapsulates ‘how good’ a person’s life is overall

Recent work identifies the following dimensions as the ‘building blocks’ of QoL: ‘having an optimistic outlook & psychological well being, having good health & functioning; having good social relationships, preventing loneliness; maintaining social roles; living in a neighbourhood with good community facilities & that feels safe; having an adequate income; and maintaining a sense of independence & control over one’s life’ (Bowling, 2005)

MENTAL HEALTH & QoL (2) QoL is a dynamic & multi-level construct reflecting

macro - societal, meso - community, and micro - family & individual, influences

It is also a collection of objective and subjective dimensions which interact together (Lawton, 1991)

Of particular note is the concept of ‘psychological capital or well being’ which subsumes the dimensions of ‘mental health’, ‘life satisfaction’, and ‘self efficacy’

‘Self efficacy’ is a particularly important factor in the promotion of mental health: contributes to enhancing ability to adapt to change & challenge (Godfrey & Denby, 2004)

Dovetails with emerging evidence about ‘resilience’ across the life course: underpins ‘disability paradox’

MENTAL HEALTH & SUCCESSFUL AGEING

‘Successful ageing’ is a concept closely aligned to that of quality of life (Livingstone et al, 2008)

Literature tends to define successful ageing as the ‘avoidance of physical or cognitive impairment’, neglecting the possibility of positive adaptation

Tends to prioritise physical health domains over those related to ‘resilience’, self efficacy or mental health

Whatever the distinctions between QoL & successful ageing concepts are often conflated by older people

In a recent study older people identified ‘successful ageing’ as incorporating: being able to adapt to continuous physical change; engaging in relationships; maintaining independence; having enough money to participate; fulfilling desires and personal objectives; & taking part in meaningful activity (Reed et al, 2003)

MENTAL HEALTH, QUALITY OF LIFE & SUCCESSFUL AGEING There is considerable common ground between the

conceptual & theoretical constructs of mental health, quality of life & successful ageing

Whilst ‘mental health’ may be viewed as a narrower construct than its ‘parent’ frameworks, it is an much a product of quality of life as it is a component

Whatever the differences, there is broad agreement that mental health is: an equally important part of QoL as physical health, & is intrinsically bound up with a range of dimensions that both directly and indirectly impact upon it

The next step is to extend understanding about the determinants of mental health, a key stage on the path to improving it (Age Concern, 2007)

DETERMINANTS OF MENTAL HEALTH - RISKS & PROTECTIVE FACTORS

In order to explore the determinants of mental ill health in later life it is useful to draw upon a framework that conceptualises risks to mental health as being located in three broad spheres: Background factors; Stressors; & Protective/Vulnerability factors

Framework illuminates the links between macro level societal factors, meso level community issues & micro level family or individual resources

Also accommodates the life course perspective Further, building up a coherent understanding of

risks & protective factors will help inform the development of strategies to prevent mental ill health & promote mental health

BACKGROUND RISK FACTORS, STRESSORS & PROTECTIVE/ VULNERABILITY FACTORS

Background Risk Factors: Age, gender & ethnicity Socio-economic situation

Stressors: Previous experience of mental ill health Experience of loss, such as ill health or disability Specific life events e.g. bereavement Key points of transition in the ageing process such

as retirement Protective/Vulnerability Factors:

Personal/psychological Social relationships & social support Environmental factors

BACKGROUND RISK FACTORS: SOCIO-ECONOMIC SITUATION

Living in poverty provokes stress & loss of control over life; it is a specific risk factor for loneliness, depression & exclusion (Victor, 2009)

Being poor reduces an older person’s capacity to make choices, & participate & undermines independence

Two million older people live in poverty in the UK: older women, carers & ethnic minority elders are at particular risk

Conversely, having access to a reasonable income has a positive impact on mental health & well being

Provides the means to take advantage of opportunities to feel safe & supported ,& facilitates social inclusion

Older people with money also tend to live in nicer neighbourhoods & are less exposed to crime and environmental decay

Money can also cushion the effect of loss, EG: the negative impact of a disability may be mediated by access to private treatment or alternative therapy

BACKGROUND RISK FACTORS, STRESSORS & PROTECTIVE/ VULNERABILITY FACTORS

Background Risk Factors: Age, gender & ethnicity Socio-economic situation

Stressors: Previous experience of mental ill health Experience of loss, such as ill health or disability Specific life events e.g. bereavement Key points of transition in the ageing process such

as retirement Protective/Vulnerability Factors:

Personal/psychological Social relationships & social support Environmental factors

STRESSORS: LOSS – ILL HEALTH & DISABILITY

Losses accumulate in later life, especially very old age 26% of people aged 50 to 64 in Britain report a long term illness

or disability; this is the case for 74% of people aged 85+; key causes are musculoskeletal illness & cardiovascular disease

Physical ill health & disability are the most consistent risk factors relating to depression among older people

Rates of depression are approx double compared with healthy counterparts; estimated that 70% of new cases of depression in older people are related to poor physical health

Highlights the fact that it is not age per se which creates vulnerability but the impact of disability &/or chronic illness which are simply more common amongst older people

Further, that it is specifically their role in increasing immobility, reducing opportunities to go out & undermining independence that create mental health problems

Higher levels of education appear to be ‘protective’ (Victor, 2005)

BACKGROUND RISK FACTORS, STRESSORS & PROTECTIVE/ VULNERABILITY FACTORS

Background Risk Factors: Age, gender & ethnicity Socio-economic situation

Stressors: Previous experience of mental ill health Experience of loss, such as ill health or disability Specific life events e.g. bereavement Key points of transition in the ageing process such

as retirement Protective/Vulnerability Factors:

Personal/psychological Social relationships & social support Environmental factors

PROTECTIVE/VULNERABILITY FACTORS: SOCIAL RELATIONSHIPS & SOCIAL SUPPORT There is considerable evidence to suggest that engagement in

family, social & community life promotes mental health Involvement in meaningful activities & having relationships with

other people, meets a range of social & emotional needs: for intimacy, companionship & enjoyment (Godfrey & Denby, 2004)

Higher levels of social support are known to act as a buffer against depression

Where age related losses, such as those related to a disability, impact on social engagement & social relationships, mental health may be threatened.

Having a role in the local neighbourhood, volunteering, or taking a class are all identified as protective of mental well being

Community facilities, civic and social opportunities & accessible leisure & educational resources all protect against isolation & exclusion & enhance opportunities for participation

PROMOTING MENTAL HEALTH IN LATER LIFE - SECURING WELL BEING

The framework: makes visible the dimensions of later life that contribute to mental well being & provides a lens through which to identify & explore them

It also acknowledges the role of the life course & the interlocking & overlapping nature of many of the issues

… And foregrounds the fact that the determinants of mental health are located at a number of different ‘levels’ within the individual & their family; the community; & wider society

These can helpfully be conceptualised as concentric circles extending from the individual outwards

It axiomatic that interventions to promote mental health need to be directed at each ‘level’

MENTAL HEALTH PROMOTION: CIRCLES OF INFLUENCE

hhhhhhhhhhhIndividual & Family

Community & Neighbourhood

Society/National

PROMOTING MENTAL HEALTH IN LATER LIFE – ADDRESSING THREATS TO QUALITY OF LIFE

Domain Elements of Quality of Life

Risk Factors Interventions Individual & family Physical health

Personal/social Relationships

Social Activities

Loss of health

Loss of function/restrictedness

Loss of role/ connectedness/belonging

Community facilities/resources

Outreach activities

Befriending initiatives (for housebound elders)

Community Participation & engagement

Quality of physical environment

High levels of crime/fear of crime

Lack of engagement

Poor physical/social environment

Inadequate services

Enhancing social & physical capital (neighbourhood improvement schemes)

Improved public transport, social & preventive services

Visible police activity/crime prevention schemes

National/Societal Material resources for a comfortable old age

Inclusion

Poverty

Marginalisation/exclusion

Policy commitment to an ‘adequate’ state pension

Enhance access to benefits/advice

Social exclusion initiatives

SOCIO-CULTURAL MODEL: MENTAL HEALTH & SUCCESSFUL AGEING

Socioeconomic situation

• Material circumstances

• Social & physical environment

Dynamic of gains and losses

Meaning of the experience

• Cultural and normative expectations

• Constraints and opportunities

Personal resources

• Individual

• Social network: family & friends

• Community

Stimulates adaptivebehaviour

(selection compensation optimisation)

Successful ageing

SOCIO-CULTURAL MODEL OF SUCCESSFUL AGEING

SCIE E-LEARNING OBJECTS ‘Introduction to mental health of older people’

See Model link = http://www.scie.org.uk/publications/elearning/mentalhealth/index.asp

A NOTE ON DEMENTIA ….. The framework has considerably more

explanatory power in relationship to functional mental ill health than for organic disorders

BUT … dementia, especially vascular dementia, does have some roots in disadvantage: poverty, diet, level of education

Even with Alzheimer’s disease there is recent evidence that environmental factors do play a role: smoking, & high blood pressure & high cholesterol levels in mid life increase the risk (Alzheimer's Society, 2007)

Also vascular disease predisposes people to AD as well as to vascular dementia

Although more work is needed, suffice to say that dementia does not entirely overwrite life course & socio-cultural influences

CONCLUSION Mental health is both a part of, and intrinsically

bound up with, overall well being; identified by older people as a pivotal dimension of quality of life

Mental health outcomes are a product both of life course issues & current access to resources

Threats to mental health exist in a number of domains; as do protective factors - role of mental health promotion is to bolster protection & address risks

Effective promotion of older people’s mental health requires action across a range of different areas at a number of levels

Poor mental health is not inevitable in old age; much can be done to reduce the incidence & impact of mental ill health & promote mental health

REFERENCES Age Concern (2007) Improving services and support for older people with mental

health problems, London, Age Concern Age Concern & Mental Health Foundation (2006) Promoting Mental Health & Well

Being in Later Life, London, Age Concern Alzheimer’s Society (2007) Dementia UK, Alzheimer’s Society, London Bowling, A (2005) Ageing Well: Quality of Life in Old Age, Open University Press,

Berkshire Godfrey, M & Denby, T (2004) Depression and Older People, Policy Press, Bristol Livingstone, G., et al, (2008) Successful ageing in adversity - the LASER

longitudinal study, Journal of Neurology, Neurosurgery & Psychiatry, 79: 641-645 Milne, A (2009) Mental Health & Well Being, in T. Williamson (Ed) Older People’s

Mental Health Reader. Mental Health Foundation & Pavilion Publishing, Brighton Milne, A and Williams, J (2000) Meeting the Mental Health Needs of Older Women:

Taking Social Inequality into Account, Ageing and Society, Vol. 20, No. 6 pp 699-723

Office for National Statistics (2004) Focus on Older People, ONS: London Social Care Institute for Excellence e-learning ‘An introduction to mental health of

older people’ - http://www.scie.org.uk/publications/elearning/mentalhealth/index.asp

Victor, C (2005) The Social Context of Ageing, A Textbook of Gerontology, Routledge, Abingdon

Victor, C., et al (2009) The Social World of Older People: Understanding Loneliness and Social Isolation in Later Life, McGraw Hill