Meeting the Mental Health Needs of Seniors

by Simone Powell

According the World Health Organization, five of the 10 leading causes of disability are related to mental disorders. It is expected that in less than 20 years, depression will be the second leading cause of disability in the world. In Canada (1998), mental disorders were the third highest source of direct health care costs, at $4.4 billion. Furthermore, it is estimated that one in every six Canadians will have a mental health problem at some point in their lives.

Seniors More at Risk?

While most mental conditions are no more prevalent in older adults than in other age groups, certain disorders, such as dementia and delirium, are more common among seniors. The most common is by far dementia, which affects approximately 8%, or 250,000 current adults aged 65 and over, and 34.5 % of those 85 and over. With the aging of the population, the number of Canadians with dementia could rise to 592,000 by 2021 and to 750,000 by 2031.

Unlike dementia, which can be considered a disorder associated with later life, depression is not more prevalent in seniors than in other age groups. In fact, it tends to be less. Major depression, the most common mood disorder among all Canadians, affects approximately 2 to 4% of seniors living in the community compared to 8% for the general population.

However, when seniors experiencing milder depression symptoms are counted, the rate is significantly higher – somewhere between 10 and 15%. Unfortunately, for various reasons including ageism and lack of appropriate training, depression often goes unrecognized and therefore untreated in older adults, particularly the very old. The consequences of this are serious and can include declines in physical health, excessive use of health care services, increased length of stay during hospitalization, poor compliance with treatment and increased risk of death. Furthermore, depressed older adults are three to four times more likely to have alcohol-related problems than are older people who are not depressed.

Of particular concern is the high rate of suicide among men aged 80 and over, which is one of the highest of all age groups. A recent Quebec study indicated that older adults who commit suicide tend to have a psychiatric problem, including minor depression, and many actually have had contact with a primary care physician in the months prior to their suicide.

In addition, many of those who committed suicide had expressed the idea of death or showed indirect suicidal behaviours. Given their findings, the authors of the study concluded that there is an important role for primary care physicians as well as family and friends in the detection of mental health problems and that these people all need to be included in any strategy created to prevent suicide among the seniors.

Coping with the Challenges of Later Life

Coping with change is certainly not unique to later life – it is something we all face throughout life, usually successfully. While aging does not necessarily lead to mental health problems, it is fair to say that there are some changes or transitions that are common in later life which can affect mental health and emotional well-being. For example:

Certainly, individuals cope differently with such later life transitions, and some seniors will have a more difficult time than others. Key factors influencing how well older adults may cope include personality; socioeconomic factors such as income, housing and supportive relationships; cognitive functioning; physical health; and access to services such as home care and transportation. Gender also plays a role: women tend to live longer and outlive their spouses, which means they are more likely to live alone and are possibly more at risk for loneliness and isolation. In addition, women’s longer life span means that more women than men will eventually develop chronic health problems that can limit their social interaction. Men, on the other hand, can have more difficulty coping with the loss of a spouse as a lifetime of being cared for makes them less prepared than women for this loss. They are also less likely to turn to others in times of grief to help them through emotionally difficult times. As already mentioned, men over the age of 80 have among the highest rates of suicide. They also have significantly higher rates of alcohol abuse than older women.

How Can We Best Help Seniors Cope with the Challenges of Age?

Health Canada’s Population Health Fund (PHF), under the “later life” component, financed four projects seeking to answer this question. The B.C. Psychogeriatric Association’s “Psychosocial Approaches to the Mental Health Challenges of Later Life” project hopes to raise awareness about the importance and effectiveness of certain psychosocial or nonmedical approaches in preventing and alleviating mental health problems in later life, in particular, those that occur as a result of life transitions. To this end, the Association has been interviewing seniors to find out how they cope with critical transitions and what elements of programs and services they believe are most helpful to them. Community-based service providers have also been interviewed in order to identify successful psychosocial approaches and models for promoting seniors’ mental health and preventing/addressing mental health problems. The findings will contribute to the development of a variety of community resources (available by March 2004), including critical transition pamphlets and a psychosocial resource manual, as well as a mental health impact model to help assess the effect of policies and programs on seniors’ mental health. In addition, the project has helped form an interdisciplinary national network of individuals who are interested in psychosocial approaches to seniors mental health – the Seniors Psychosocial Interest Group.

Seniors Well Aware Program has also been working to build community capacity and identify best practices to help seniors, specifically those who are at risk for developing, or who have already developed, a problem with alcohol use. Their PHF project, “Seeking Solutions: Canadian Community Action for Seniors and Alcohol Use”, completed at the end of August 2003, has involved seniors’ groups, addiction services and health and community agencies across Canada to raise knowledge levels, improve skills bases, foster positive attitudes and enhance resource and networking capacities of people who are in contact with seniors so that they have a better understanding of alcohol related matters affecting seniors. One of the concrete results of this project is a series of “Best Practices and Successful Strategies” worksheets which provide practical ideas for reaching and helping seniors with alcohol use challenges. The project has also involved the ongoing sharing of information through focus groups, “joint action meetings” and email-Internet discussions through the Older People and Alcohol List Serve (OPAAL).

Different Settings, Different Needs

Many seniors live independently, coping well with changes in life. According to results from the Canadian Community Health Survey, 66% of people aged 65 and over rated their mental health as very good or excellent whereas only 6.5% rated it fair or poor. What often keeps them well is the support they receive from both formal and informal caregivers. This applies whether seniors live on their own, with their families or friends, or within long-term care facilities.

In recognition of the important role that home care can and does play in meeting the mental health needs of seniors in the community, the PHF funded Canadian Mental Health Association (CMHA) project examined this role and tried to determine ways of implementing a holistic model of care incorporating both medical and psychosocial supports of care. The CMHA found that home care continues to be well-positioned to contribute to seniors’ mental health, however, to fulfill this role requires a number of policy changes in order to improve access to and the provision of home care services. For example, policies are required which would support home care organizations in their role of helping seniors and caregivers navigate the health and social service system. In addition, CMHA also identified key practice skills for home care staff which are required to support seniors mental health. These skills are related to communication, advocacy and the involvement of seniors in decision making.

The CMHA completed this project in 2002 and its findings and recommendations have been published in the form of two guides, Supporting Seniors' Mental Health through Home Care: A Policy Guide and Supporting Seniors' Mental Health: A Guide for Home Care Staff.

Adopting a broad approach to meet the mental health needs of seniors is no less important for people living in long-term care facilities. In fact, the mental health needs of this population group are significant. Studies suggest that between 15 and 25% of nursing home residents have symptoms of major depression and another 25% have depression symptoms of a lesser severity. In Canada, the population of long-term care residents has grown from 203,000 in 1986 to 240,000 in 1996, and it is expected to triple over the next 25-30 years.

Together, these facts suggest that we are heading toward a potential crisis in mental health care for seniors living in long-term care institutions, which is why the Canadian Coalition for Seniors’ Mental Health, with support from Health Canada’s PHF, has undertaken an initiative to address the current gaps in mental health services for seniors in long-term care settings. The problem, according to the Coalition, is that we are not prepared to meet this demand given that already, “the need for an appropriate range of mental health services for seniors in long-term care settings substantially outweighs the system’s current capacity to provide these much-needed services”. Currently, only a limited amount of formal mental health services are provided to residents and line staff receive very little training with respect to mental health.

The Coalition considers that action is needed in several key areas to meet the needs of seniors living in long-term care:

As a first step, the Coalition has been creating awareness about the need for improved mental health services within long-term care settings, enhanced training for front line workers and improved support for caregivers. By March 2004, it will have completed two inventories of educational resources, one for front line workers and one for caregivers.

The Goal: Mental Health for All in Later Life

While disorders such as dementia and depression can and do occur in later life, the vast majority of seniors can look forward to mental health – which is a positive state of emotional well-being. When we seek to address the mental health needs of seniors, we therefore need to be concerned not only with the identification and treatment of problems but also with the promotion and maintenance of good mental and emotional well-being for all seniors living in both community and long-term care settings. This means recognizing the particular needs of the senior population, adopting a holistic approach that takes into consideration the broad range of factors that contribute to mental health, and incorporating both medical and nonmedical approaches to supporting the needs of seniors.

Project Contact Information:

Psychosocial Approaches to the Mental Health Challenges of Later Life. Contact: P. MacCourt at pmaccourt@shaw.ca or visit the project Web site at www.seniorsmentalhealth.ca.

Seeking Solutions: Canadian Community Action for Seniors and Alcohol Use. Contact: C. Spensor at cspenser@shaw.ca or visit the project Web site at www.agingincanada.ca.

Canadian Coalition for Seniors Mental Health. Contact: S. Haber at s.haber@sympatico.ca or visit the project Web site at www.ccsmh.ca.

Supporting Seniors’ Mental Health Through Home Care. Contact the Canadian Mental Health Association by phone at (416) 484-7750 or by email at national@cmha.ca or visit their Web site at www.cmha.ca.