Transcript Slide 1

IMPROVING MENTAL
HEALTH & WELL BEING IN
LATER LIFE:
EVERYBODY’S BUSINESS
(INCLUDING YOURS!)
OCT 31ST 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’
MENTAL HEALTH IN LATER
LIFE: WHAT IS IT?
 Research
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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?
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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’
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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
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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
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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
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(Godfrey & Denby, 2004)
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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
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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)
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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
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BACKGROUND RISK FACTORS,
STRESSORS & PROTECTIVE/
VULNERABILITY FACTORS
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Background Risk Factors:
Age, gender & ethnicity
 Socio-economic situation
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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
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Protective/Vulnerability Factors:
Personal/psychological
 Social relationships & social support
 Environmental factors
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BACKGROUND RISK FACTORS: SOCIOECONOMIC SITUATION
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Living in poverty provokes stress & loss of control over life; it is a
specific risk factor for loneliness, depression & exclusion (Victor,
2009)
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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
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Background Risk Factors:
Age, gender & ethnicity
 Socio-economic situation
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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
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Protective/Vulnerability Factors:
Personal/psychological
 Social relationships & social support
 Environmental factors
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STRESSORS: LOSS – ILL HEALTH &
DISABILITY
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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
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Background Risk Factors:
Age, gender & ethnicity
 Socio-economic situation
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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
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Protective/Vulnerability Factors:
Personal/psychological
 Social relationships & social support
 Environmental factors
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PROTECTIVE/VULNERABILITY FACTORS:
SOCIAL RELATIONSHIPS & SOCIAL SUPPORT
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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’
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MENTAL HEALTH PROMOTION:
CIRCLES OF INFLUENCE
Society/National
Community &
Neighbourhood
hhhhhh
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Individual
& Family
– ADDRESSING THREATS TO QUALITY OF
LIFE
Domain
Elements of
Risk Factors
Quality of Life
Interventions
Individual & family
Physical health
Loss of health
Personal/social
Relationships
Loss of
function/restrictedness
Community
facilities/resources
Social Activities
Loss of role/
connectedness/belonging
Lack of engagement
Community
Participation &
engagement
Quality of physical
environment
National/Societal
Poor physical/social
environment
Inadequate services
Outreach activities
Befriending initiatives
(for housebound elders)
Enhancing social &
physical capital
(neighbourhood
improvement schemes)
High levels of crime/fear
of crime
Improved public
transport, social &
preventive services
Material resources for a
comfortable old age
Visible police
activity/crime prevention
schemes
Policy commitment to an
‘adequate’ state pension
Inclusion
Poverty
Marginalisation/exclusion
Enhance access to
benefits/advice
Social exclusion initiatives
SOCIO-CULTURAL MODEL: MENTAL HEALTH & SUCCESSFUL
AGEING
Dynamic of gains
and losses
Socioeconomic situation
• Material
circumstances
• Social & physical
environment
Personal resources
Meaning of the experience
• Cultural and normative
expectations
• Constraints and
opportunities
Stimulates adaptive
behaviour
(selection compensation
optimisation)
Successful ageing
• Individual
• Social network: family &
friends
• Community
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, &
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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
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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
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REFERENCES
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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