improving mental health & well being in later life: everybody’s business (including yours!) oct 31...

IMPROVING MENTAL HEALTH & WELL BEING IN LATER LIFE: EVERYBODYS BUSINESS (INCLUDING YOURS!) OCT 31 ST 2008 Alisoun Milne, Senior Lecturer in Social Gerontology, University of Kent [email protected]

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 persons 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 ones 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)

M ENTAL HEALTH, Q UALITY OF LIFE & S UCCESSFUL 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

B ACKGROUND RISK FACTORS : S OCIO - 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 persons 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

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)

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

M ENTAL H EALTH PROMOTION : CIRCLES OF INFLUENCE hhhhhh hhhhh Individual & Family Community & Neighbourhood Society/National

P ROMOTING MENTAL HEALTH IN L ATER LIFE A DDRESSING THREATS TO Q UALITY OF LIFE Domain Elements of Quality of Life Risk FactorsInterventions 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) CommunityParticipation & 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/SocietalMaterial 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

S OCIO - CULTURAL M ODEL : M ENTAL H EALTH & S UCCESSFUL A GEING 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 adaptive behaviour (selection compensation optimisation) Successful ageing

S OCIO - 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 http://www.scie.org.uk/publications/elearning/mentalhealth /index.asp

A NOTE ON D EMENTIA .. 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 Alzheimers 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

C ONCLUSION 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 peoples 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 Alzheimers Society (2007) Dementia UK, Alzheimers 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 Peoples 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.asphttp://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

improving mental health & well being in later life: everybody’s business (including yours!) oct 31...

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