Primary Care Mental Health in Older People: A Global Perspective

This book is a practical resource that will support the delivery of holistic mental health interventions in the primary and community care setting for older people. Primary care delivery is discussed in relation to both functional mental health problems, such as anxiety, depression, and psychotic and personality disorders, and acquired organic mental disorders of old age, such as dementia, cognitive impairments, and delirium. Careful consideration is paid to the complex relationship between mental and somatic health problems, as well as the impacts of multimorbidity and polypharmacy. Further topics include, for example, epidemiology, wider determinants of health, different care models, history taking, neurocognitive and capacity assessment, and pharmacological, psychological, and physical interventions.

The wider goals of the book are to support the development of community resilience and self-care in older people; to promote universal access and equity for older people in order to enable them to achieve or recover the highest attainable standard of health, regardless of age, gender, or social position; and to promote pathways to care for older people with mental health problems respecting their autonomy, independence, human rights, and the importance of the life-course approach. This book will be an invaluable resource for all professionals who work with older adults with mental health problems and those training in these fields including physicians, psychiatrists, family doctors, geriatricians, general practitioners, nurses, psychologists, neurologists, occupational therapists, social workers, support workers and community health and social care workers.

• Language: English
• Publisher: Springer
• Release date: Aug 7, 2019
• ISBN: 9783030108144

Book preview

Part IIntroduction to Primary Care Mental Health in Older Adults

© Springer Nature Switzerland AG 2019

Carlos Augusto de Mendonça Lima and Gabriel Ivbijaro (eds.)Primary Care Mental Health in Older Peoplehttps://doi.org/10.1007/978-3-030-10814-4_1

1. Aims and Concept of Primary Care Mental Health in Older Adults: A Global Perspective

Gabriel Ivbijaro¹, ²   and Carlos Augusto de Mendonça Lima³

(1)

NOVA University, Lisbon, Portugal

(2)

Waltham Forest Community and Family Health Services, London, UK

(3)

Unity of Old Age Psychiatry, Centre Les Toises, Lausanne, Switzerland

Gabriel Ivbijaro

Primary care mental health in older adults: a global perspective is a resource to support improved care for a growing population of older adults with mental health difficulties that recognises innovative solutions to support the dignity of older adults whilst embracing new technology.

As we celebrate the 40th anniversary of the Alma-Ata Declaration, we need to recognise that not everyone has fully benefitted from the opportunities provided by the move to primary care [1] especially many older adults with mental health difficulties.

We can do better, and the world can do better, but, for this to happen, primary care needs to be more receptive to the special needs of older adults with mental health difficulties and better skilled to address these common problems.

In 1978, the world had a total of 4,287,000,000 habitants; 248,998,000 of them were over 65 years of age representing 5.81% of the total population. Forty years later, the world has a total population of 7,530,000,000 habitants; 654,568,000 of them are over 65 years of age representing 8.70% of the total population. Older adults are now the group with the greatest growth rate [2].

In the context of the rapid growth in numbers of the older adult population, the mental health of older adults has become a huge challenge for all concerned, especially with the high prevalence of mental health issues in this group.

The ageing world population needs to be central in all policies and programmes in order to enable health systems to be more equitable, inclusive and fair. Services need to be designed to respond to the mental health needs of older adults; educational programmes need to be offered for professionals to improve their specific skills to treat and care for this important group.

Carers of older adults with mental health difficulties are an important resource and need to be supported to prevent their own burn out. The population needs to be educated about the ageing process and encouraged to be advocates for older adults with mental health difficulties to combat misconceptions, prejudices, stigma and discrimination [3], and we have provided some resources that can be used to inspect places where older adults with mental health difficulties can be cared for.

Keeping up with technological advances and innovations is very important in delivering quality care to older adults with mental health difficulties to support their continuing independence and dignity, and we have provided some examples of this.

Integrated and collaborative care between primary care, specialists, social services, the voluntary and charitable sector, patients, carers, families and government bodies should always be considered and embraced when developing care packages for older adults with mental health difficulties [4–7].

The WPA-Lancet Psychiatry Commission on the Future of Psychiatry [8] has identified several priority areas for mental health over the next decade including health-care system reform embracing stepped care, increased use of multidisciplinary teamwork, more of a public health approach and the integration of mental and physical health care. The collaboration between primary care teams and other sectors of the health-care system, as well as improving knowledge and skills, will help to improve the mental health care of older adults.

1.1 Structure

The book is structured to enable individuals to understand the complex network of factors that contribute to the mental health of older adults, and each chapter opens with key messages.

Parts I and II provide an introduction to the foundations of integrated systems to promote good mental health in older adults, including the wide determinants of health, the general concept of frailty and the importance of sometimes complex multimorbidity in this particular population.

Part III describes the tools for assessment, including neurocognitive assessment.

Part IV describes therapeutic strategies including the importance of promoting mental and physical health and strategies to advocate for better support for those in need.

Parts V and VI describes common mental health problems in older adults and how to manage them using a multidisciplinary approach.

Part VII is focused on psychosocial and neurocognitive rehabilitation.

Part VIII presents a range of case examples from professionals working with older adults with mental health difficulties.

References

1.

World Health Organization. Primary health care: report of the International Conference on Primary Care, Alma-Ata, USSR, 6–12 Sept 1978. Geneva: WHO; 1978.

2.

The World Bank. https://​data.​worldbank.​org/​indicator/​SP.​POP.​65UP.​TO.​ZS. Accessed 16 Sept 2018.

3.

Graham N, Lindsay J, Katona C, et al. Reducing stigma and discrimination against older people with mental disorders: a technical consensus statement. Int J Geriatr Psychiatry. 2003;18:670–8.Crossref

4.

WHO, WONCA. Integrating mental health into primary care: a global perspective. Geneva: WHO/WONCA; 2008.

5.

WHO, WPA. Psychiatry of the elderly: a consensus statement. Geneva: WHO; 1996. WHO/MNH/MND/96.7.

6.

WHO, WPA. Organization of care in psychiatry of the elderly. Geneva: WHO; 1997. WHO/MSA/MNH/MND/97.3.

7.

WHO. The world health report 2008: primary care—now more than ever. Geneva: WHO; 2008.

8.

Bhugra D, Tasman A, Pathare S, et al. The WPA-lancet psychiatry commission on the future of psychiatry. Lancet Psychiatry. 4:775–818. https://​doi.​org/​10.​1016/​S2215-0366(17)30333-4.Crossref

© Springer Nature Switzerland AG 2019

Carlos Augusto de Mendonça Lima and Gabriel Ivbijaro (eds.)Primary Care Mental Health in Older Peoplehttps://doi.org/10.1007/978-3-030-10814-4_2

2. Epidemiology and the Scale of the Problem

Yaccub Enum¹  , Wolfgang Spiegel², Karen Bernard¹, Monica Hill¹ and Taofik Olajobi³

(1)

Public Health Department, London Borough of Waltham Forest, London, UK

(2)

Centre for Public Health, Medical University of Vienna, Vienna, Austria

(3)

College of Nursing, Midwifery and Healthcare, University of West London, London, UK

Yaccub Enum

Abstract

Population ageing is taking place in nearly all parts of the world. Ageing results from decreasing mortality and declining fertility. Older adults are increasingly playing important roles in society through volunteer work, caring for their families and paid workforce. However, not all older adults enjoy good health. The burden of non-communicable diseases is increasing, and this has now become a major public health issue. Many older adults are living with ill health including poor mental health. Factors that influence older adults’ mental and emotional wellbeing include individual characteristics or attributes, socioeconomic circumstances and the broader environment in which they live. With the increasing population of older adults, it is vital that services plan adequately to provide healthcare and wellbeing care to meet the growing demand. This is especially relevant to primary healthcare providers where older adults often seek help in the first instance. Loneliness and social exclusion are important risk factors for poor mental health among older adults. Efforts to improve mental wellbeing of older adults should include tackling loneliness. Collaborative care, bringing together health and social services, is a good way of managing mental health problems in older adults.

Keywords

AgeingPrevalenceIsolationLonelinessDementia

Key Points

Population ageing is taking place in nearly all the countries of the world. The largest increase will occur in Asia, followed by Africa and Latin America, respectively.

Mental health and emotional wellbeing are equally important in older age as at any other stage of life.

Factors that influence older adult’s mental and emotional wellbeing include individual characteristics or attributes, socioeconomic circumstances and the broader environment in which they live.

Mental health problems in older adults globally are underestimated and generally under-detected by healthcare professionals.

Primary care has a very important role to play in detecting mental health problems in older adults.

Collaborative care is a useful model for providing holistic care for older adults.

2.1 Introduction

There is no agreed definition of ‘older adults’ or ‘old people’, and there are wide variations in what people consider to be old. For the purpose of this paper, we will use the United Nations agreed cut-off numerical criterion of 60+ years to refer to the older population [1].

Population ageing is taking place in nearly all the countries of the world. Ageing results from decreasing mortality and, most importantly, declining fertility. This process leads to a relative reduction in the proportion of children and to an increase in the share of people in the main working ages and of older persons in the population [2].

2.2 Demography of Older Adults

In 2015, there were 901 million people aged 60 or over, comprising 12% of the global population. The population aged 60 or above is growing at a rate of 3.26% per year. The number of older persons in the world is projected to be 1.4 billion by 2030, 2.1 billion by 2050 and 3.2 billion in 2100. Sixty-six per cent of the increase between 2015 and 2050 will occur in Asia, 13% in Africa and 11% in Latin America and the Caribbean. In Europe, 24% of the population is already aged 60 years or over and that proportion is projected to rise to 34% in 2050 [2].

Older persons are projected to exceed the number of children for the first time in 2047. About two thirds of the world’s older persons live in developing countries. Because the older population in less developed regions is growing faster than in the more developed regions, the projections show that older persons will be increasingly concentrated in the less developed regions of the world. By 2050, nearly eight in ten of the world’s older population will live in the less developed regions [2].

For most nations, regardless of their geographic location or developmental stage, the older population is itself ageing. The population aged 80 and over is growing faster than any younger segment of the older population. At the global level, the average annual growth rate of persons aged 80 years or over (3.8%) is currently twice as high as the growth rate of the population over 60 years of age (1.9%) [3]. Globally, the number of persons aged 80 or over is projected to increase from 125 million in 2015 to 434 million in 2050 and 944 million in 2100. In 2015, 28% of all persons aged 80 and over lived in Europe, but that share is expected to decline to 16% by 2050 and 9% by 2100 as the populations of other major areas continue to increase in size and to grow older themselves [2].

The older population is mostly female. Because women tend to live longer than men, older women outnumber older men almost everywhere. In 2013, globally, there were 85 men per 100 women in the age group 60 years or over and 61 men per 100 women in the age group 80 years or over. The male to female sex ratios are expected to increase moderately during the next several decades, reflecting a slightly faster projected decline in old-age mortality among males than among females [4].

2.3 Social and Political Participation

Older adults are increasingly playing a critical role in society through volunteer work, caring for their families, paid workforce and transferring experience, skills and knowledge. However, not all older adults enjoy good health. The burden of non-communicable diseases is increasing, and this has now become a major public health issue. Many older adults are living with ill health including poor mental health. Mental and emotional well-being is equally important in older age as at any other stage of life. Approximately 15% of adults aged 60 and over suffer from a mental disorder [5].

2.4 Risk Factors for Poor Mental Health in Older Adults

Factors that influence older adult’s mental and emotional wellbeing include individual characteristics or attributes (age, sex, genes), socioeconomic circumstances in which older persons find themselves and the broader environment in which they live. It can be a single aspect or a combination of factors [6].

Older adults are more likely to experience events such as bereavement, a drop in socioeconomic status with retirement or a disability that may trigger distorted emotional responses. All of these factors can result in isolation, loss of independence, loneliness and psychological distress which can impact on mental wellbeing. The neurobiological changes associated with getting older (alterations in memory function that are associated with normative ageing), prescribed medication for other conditions and genetic susceptibility (which increases with age) all impact on mental wellbeing [6].

2.4.1 Co-morbidity of Mental and Physical Health Problems in Older Adults

Many people with long-term physical health conditions also have mental health problems. Getting old is a risk for long-term conditions like cardiovascular disease. Cardiovascular disease management has great benefits for older adults’ health. Similarly as older adults lose their ability to live independently because of limited mobility, chronic pain or frailty, they are at an increased risk for poor mental wellbeing. Mental health has an impact on physical health and vice versa. For example, older adults with physical health conditions such as heart disease have higher rates of depression than those who are medically well. Conversely, untreated depression in an older adult with heart disease can negatively affect the outcome of the physical illness [7, 8].

2.4.2 Alcohol Abuse

Alcohol abuse is a problem that affects people of all ages, but it is more likely to go unrecognized among older adults [9]. Some reasons for alcohol abuse in older age include loneliness, bereavement and other losses, physical ill health, disability and pain, loss of independence, boredom and depression. Retirement may also provide more opportunities for drinking too much as there is no pressure to go to work each day. According to the Royal College of Psychiatrists, a third of older adults with alcohol problems (mainly women) develop them for the first time in later life [10].

2.4.3 Medication

Prescribed medications can cause symptoms associated with mental illness in older adults. Many older adults take some kind of medication, and some take several at the same time. There are risks associated with taking multiple medications (both prescribed and over-the-counter medications) due to drug interaction. This can cause problems such as confusion.

2.4.4 Abuse

Older adults are vulnerable to elder abuse—including physical, sexual, psychological, emotional, financial and material abuse, abandonment, neglect and serious losses of dignity and respect. Elder abuse can lead not only to physical injuries but also to serious, sometimes long-lasting, psychological consequences, including depression and anxiety.

2.4.5 Retirement

Retirement from work or career that has been a major part of one’s life can affect:

The social aspect of life through loss of work friendships/relationships

Sense of self-worth and self-esteem if one felt valued at work

Financial security

2.5 Mental Health Problems in Old Age: Epidemiology

Older adults aged 60 and over constitute a substantial proportion of vulnerable group of people with an elevated risk of developing mental health problems [11, 12]. They are more likely to have high levels of functional dependency and psychosocial needs which have implications for their health and the delivery of care. According to the World Health Organization (WHO), 6.6% of cases of disability (disability-adjusted life years—DALYs) occurring among older adults aged over 60 is attributable to neurological and mental health problems which account for 17.4% of years lived with disability (YLDs) [13].

It is estimated that about 20% of people at old age have mental health conditions that are not considered as part of normal ageing [14]. An earlier report suggests that the number of older adults with major mental health disorders will increase substantially by 2030 [15]. However, it is argued that the true prevalence of mental health problems globally are underestimated and generally under-detected by healthcare professionals [16, 17].

2.5.1 Common Mental Disorders

Common mental disorders (CMD) among the general population include anxiety-related disorders, panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD) and depression [18].

The most common mental disorders reported among older adults are anxiety-related disorders, including phobias and obsessive-compulsive disorder; severe cognitive impairment, including Alzheimer’s disease; and dementia, depression and substance use disorders [19–21].

It is estimated that 3.8% of the older population have anxiety related disorders, about 1% are affected with alcohol and drug dependence disorders and in addition about 25% of deaths relating to self-harm and suicides occurred among elderly people aged 60 or above [13]. A meta-analysis of the prevalence of mental disorders in older adults in Western countries shows that the most prevalent mental disorder is dimensional depression (19.5%) followed by lifetime major depression (16.5%). Lifetime alcohol use disorders are estimated to be 11.7%, while drug use disorders, bipolar disorder and current agoraphobia have the lowest prevalence rates [11].

Findings from the Global Burden of Disease Study 2010 indicate that depressive disorders had the highest proportion of total burden among older adults across all regions and accounted for most DALYs (40.5%) caused by mental and substance use disorders. This is followed by anxiety disorders, drug use and alcohol use disorders [22].

2.5.2 Severe Mental Illness (SMI)

Severe Mental Illness is defined according to diagnostic criteria of the International Classification of Mental and Behavioural Disorders, which include major depression, bipolar disorders, schizophrenia, paranoid and other psychotic disorders [23].

A report on the prevalence of serious mental illness among US adults estimated a prevalence of 3.1% for older adults aged 50 years and above [24]. A meta-analysis estimated the prevalence of current bipolar disorder among older adults in 15 different Western countries (Europe and North America) to be 0.5% and 1.1% for lifetime bipolar disorder [11]. Another study estimated the lifetime prevalence of major depression for older adults aged 75 years and older as ranging between 3.7% and 28.0% [20].

2.5.3 Dementia

The prevalence of dementia rapidly increases from about 2% to 3% among those aged 70–75 years to 20% to 25% among those aged 85 years or more [25]. Several studies show the overall prevalence of dementia varies widely among countries, being influenced by cultural and socioeconomic factors [26]. Dementia rates are growing at alarming proportion in all regions of the world and are related to population ageing [27]. The prevalence of dementia is rising with increasing longevity, and this presents a great economic burden [28].

There were an estimated 35.6 million people living with dementia worldwide in 2010, with 58% of them in middle- or low-income countries. The number of people living with dementia is expected to almost double every 20 years, to 65.7 million in 2030 and 115.4 million in 2050. The proportion living in middle- or low-income countries is also projected to increase to 63% in 2030 and 71% in 2050 [29].

However, it has been argued that there is a general trend for overdiagnosis of mild cognitive impairment since the ageing of the population by some is seen as a commercial opportunity [30]. Le Couteur and colleagues point out that the belief that there is value in screening for pre-dementia or mild cognitive impairment is creeping into clinical practice, with the resulting overdiagnosis having potential adverse consequences for individual patients, resource allocation and research [30].

The prevalence of dementia in people aged 75 and over in the poorest regions of Latin America was estimated to be higher than in other regions of the world. This may be due to a combination of low to average educational attainment and high vascular risk profile among Latin American elderly population [25].

A systematic review and meta-analysis of the literature on the global prevalence of dementia in people aged 60 and over found that the age-standardized prevalence in most world regions varied between 5% and 7%. The exceptions were in Latin America, with a higher prevalence of 8.5% and a lower prevalence of 2–4% in some sub-Saharan African regions [29].

A meta-analysis of dementia prevalence surveys in the Chinese population found that the prevalence of Alzheimer’s disease in the population aged 60 years or older was 1.9% and for vascular dementia was 0.9% [31].

In Europe the number of people with dementia is expected to increase by 90% between 2013 and 2050, from 11 million to 21 million [32].

Current estimates suggest that about 4.2 million adults in the USA have dementia and that the economic cost of their care is about $200 billion per year [33]. This report also estimates that the worldwide prevalence is expected triple to 135.5 million by 2050.

2.6 Suicide in Older Adults

The three most frequent life problems associated with suicide are physical illness, interpersonal problems and bereavement [34]. Long-term conditions and bereavement are common among older adults, and these conditions increase the risk of depression. Social isolation, which is a risk factor for depression, is common among older adults, especially in Europe and the USA. People who are depressed are at a greater risk of suicide and untreated depression can increase the risk of suicide. Even though suicide rates vary by age group in different regions, suicide rates globally are highest in people aged 70 years and over [35]. The primary care setting is an important venue for late life suicide prevention. Primary care providers should be well prepared to diagnose and treat depression in their older patients.

2.7 Conclusion

Population ageing presents challenges for healthcare and social care systems worldwide. However, many older adults are living well. The variability in the prevalence rates reported may be attributed to the use of different diagnostic criteria, geographical and cultural differences in the included studies. Given the demographic transformation taking place in older adults, it is vital that services plan adequately to provide healthcare and wellbeing care to meet the growing demand. This is especially relevant to primary healthcare providers where older adults often seek help in the first instance. Loneliness and social exclusion are important risk factors for poor mental health among older adults. Efforts to improve mental wellbeing of older adults should include tackling loneliness. Collaborative care, bringing together health and social services, is a good way of managing mental health problems in older adults.

References

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World Health Organization. Definition of an older or elderly person: Proposed Working Definition of an Older Person in Africa for the MDS Project. http://​www.​who.​int/​healthinfo/​survey/​ageingdefnolder/​en/​. Accessed 15 Dec 2015.

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United Nations. World population ageing 2013. http://​www.​un.​org/​en/​development/​desa/​population/​publications/​pdf/​ageing/​WorldPopulationA​geing2013.​pdf. Accessed 15 Dec 2015.

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United Nations. World population ageing 1950–2015: Demographic profile of the older population. http://​www.​un.​org/​esa/​population/​publications/​worldageing19502​050/​pdf/​90chapteriv.​pdf. Accessed 15 Dec 2015.

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World Health Organisation. United Nations Department of Economic and Social Affairs ǀ Population Division. World population aging. http://​www.​un.​org/​en/​development/​desa/​population/​publications/​pdf/​ageing/​WorldPopulationA​geing2013.​pdf. Accessed 29 Feb 2016.

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World Health Organisation. Mental health and older adults, Fact sheet N°381, 2015. http://​www.​who.​int/​mediacentre/​factsheets/​fs381/​en/​. Accessed 17 Dec 2015.

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World Health Organisation. Risks to mental health: an overview of vulnerabilities and risk factors. http://​www.​who.​int/​mental_​health/​mhgap/​risks_​to_​mental_​health_​EN_​27_​08_​12.​pdf. Accessed 1 Feb 2016.

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Egede LE, Ellis C. Diabetes and depression: global perspectives. Diabetes Res Clin Pract. 2010;87(3):302–12.Crossref

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Moussavi S, et al. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet. 2007;370(9590):851–8.Crossref

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Centre for Substance Abuse Treatment. Substance abuse among older adults. Treatment Improvement Protocol (TIP) Series 26. http://​www.​ncbi.​nlm.​nih.​gov/​books/​NBK64422/​. Accessed 15 Dec 2015.

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Royal College of Psychiatrists. Alcohol and older people. http://​www.​rcpsych.​ac.​uk/​healthadvice/​problemsdisorder​s/​alcoholandolderp​eople.​aspx. Accessed 29 Feb 2016.

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Volkert J, Schulza H, Härtera M, et al. The prevalence of mental disorders in older people in Western countries—a meta-analysis. Ageing Res Rev. 2013;12:339–53.Crossref

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Challis D, Tucker S, Wilberforce M, et al. National trends and local delivery in old age mental health services: towards an evidence base. A mixed-methodology study of the balance of care approach, community mental health teams and specialist mental health outreach to care homes. Program Grants Appl Res. 2014;2(4):1–479.Crossref

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WHO. Mental health and older adults. 2015. http://​www.​who.​int/​mediacentre/​factsheets/​fs381/​en/​. Accessed 4 Jan 2016.

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Bartels SJ. Caring for the Whole Person: integrated health care for older adults with severe mental illness and medical comorbidity. J Am Geriatr Soc. 2004;52:S249–57.Crossref

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Kessler RC, Aguilar-Gaxiola S, Alonso J, Chatterji S, Lee S, Ormel J, Üstün TB, Wang PS. The global burden of mental disorders: an update from the WHO World Mental Health (WMH) Surveys. Epidemiol Psichiatr Soc. 2009;18(1):23–33.Crossref

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Baxter AJ, Patton G, Scott KM, Degenhardt L, Whiteford HA. Global epidemiology of mental disorders: what are we missing? PLoS One. 2013;8(6):e65514. https://​doi.​org/​10.​1371/​journal.​pone.​0065514.CrossrefPubMedPubMedCentral

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Goldberg SE, Whittamore KH, Harwood RH, et al. The prevalence of mental health problems among older adults admitted as an emergency to a general hospital. Age Ageing. 2012;41:80–6. https://​doi.​org/​10.​1093/​ageing/​afr106.CrossrefPubMed

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Luppa M, Sikorski C, Luck T, et al. Age- and gender-specific prevalence of depression in latest-life—systematic review and meta-analysis. J Affect Disord. 2012;136:212–21.Crossref

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Ferri PC, Prince M, Brayne C, et al. Global prevalence of dementia: a Delphi consensus study. Lancet. 2005;366(9503):2112–7.Crossref

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Rizzi L, Rosset I, Roriz-Cruz M. Global epidemiology of dementia: Alzheimer’s and vascular type. BioMed Res Int. 2014. http://​www.​hindawi.​com/​journals/​bmri/​2014/​908915/​. Accessed 5 Jan 2016.

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Kalaria RN, Maestre GE, Arizaga R, et al. Alzheimer’s disease and vascular dementia in developing countries: prevalence, management and risk factors. Lancet Neurol. 2008;7(9):812–26.Crossref

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George-Carey R. An estimate of the prevalence of dementia in Africa: a systematic analysis. J Glob Health. 2012;2(2):020401.Crossref

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Le Couteur DG, Doust J, Creasey H, Brayne C. Political drive to screen for pre-dementia: not evidence based and ignores the harms of diagnosis. BMJ. 2013;347:f5125.Crossref

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Zhang Y, Xu Y, Nie H, et al. Prevalence of dementia and major dementia subtypes in the Chinese populations: a meta-analysis of dementia prevalence surveys, 1980–2010. J Clin Neurosci. 2012;19(10):1333–7.Crossref

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© Springer Nature Switzerland AG 2019

Carlos Augusto de Mendonça Lima and Gabriel Ivbijaro (eds.)Primary Care Mental Health in Older Peoplehttps://doi.org/10.1007/978-3-030-10814-4_3

3. Wider Determinants of Health

Sabine Bährer-Kohler¹, ²   and Brendan McLoughlin³

(1)

International University of Catalonia (UIC), Barcelona, Spain

(2)

Dr. Bährer-Kohler & Partners, Basel, Switzerland

(3)

Clinical Senior Cognitive Behavioural Therapist, Efficacy, London, UK

Sabine Bährer-Kohler

Email: [e-mail]

Email: [e-mail]

Abstract

Wider determinants of health are most complex, and there exists a complex interaction between lifestyle and the physical, social, and economic environment and individual characteristics. Wider determinants of health play an important role in the mental health of older adults. During primary care assessment of patients’ mental wellbeing, it is important to consider the broader influences on the individual, such as physical health, family/friends and social networks, finances/debts, alcohol and drug use, life events, etc. These wider determinants should be taken into consideration when giving health promotion information. As the wider determinants are often outside the scope of primary care, GPs and others should work with other professionals such as social workers in order to ensure holistic assessment of the older adult’s needs and appropriate care planning. Professionals should be mindful of cultural influences, diversities, and differences, maintaining the individual’s dignity during the process.

Keywords

Social determinantsLife courseSocial networksSocial supportSocial participationDiagnostic aspectsAssessment toolsPrimary care assessmentHealth promotionComprehensive primary health care

Key Points

The mental health of older adults is influenced by wider determinants and their life course.

By considering the wider determinants of health and the concepts of flourishing and languishing involved parties can understand better the impact on health of the interaction between the person and their environment.

Primary care assessment needs to be holistic and gather information from validated questionnaires and interviews with the person and those close to them.

Evaluations can be necessary to understand the needs and unmet needs of older adults in primary care settings within their individual situations.

Evaluations and performance assessments in primary care settings should be explained within national and additional social contexts.

Heath promotion and intervention needs to be provided by health professionals, local communities, friends, family, and other social networks.

Health promotion consists of modifying specific components of individuals, groups, and populations, with the inclusion of intrapersonal, interpersonal, institutional, environmental, and societal aspects.

Primary and community health-care teams should have knowledge of the wider determinants of mental health and interventions to promote mental health.

The role that clients/patients and networks could play in the improvement of health care and primary health care and for an everyday reality in all countries needs to be highlighted.

3.1 Wider Determinants of Health: An Introduction

The UN projected that the proportion of persons aged 60 (+) is expected to double between 2007 and 2050, and their actual number will more than triple, reaching around two billion by 2050 [1]. Developing countries worldwide will see the largest increase in absolute numbers of older persons. Dementia/Alzheimer’s disease is strongly associated with increasing age [2, 3].

Wider determinants of health are most complex [4], and there exists a complex interaction between lifestyle and the physical, social, and economic environment and individual characteristics. One of the first works in the field was the Whitehall study published during the 1970s, one of the more current publications is the WHO publication—Social Determinants of health—the solid facts (2003) [5]. The Dahlgren and Whitehead model (1991) [6] as a conceptual background guide underlines the broad and complex content of social determinants. For example, socioeconomic aspects and access to social and health services, health partnerships [7], social involvement, and empowerment are important areas for older adults, besides the improvement and stability of resources [8] of the individual in his individual context. Attention to social determinants during the course of life with the inclusion of individual’s autonomy, independence, and human rights in order to minimize, e.g. risk factors, chronic diseases, and/or multimorbidity [9] and deficiencies of older adults is urgently required.

It is as well very well documented that, e.g. to be part of ethnic minorities [10], living conditions, social participation [11], physical activities, and lifestyle factors are relevant social determinants of health and death amongst older adults [12].

The intersectorial and transsectorial perspective of social determinants with the greatest impact on health-related quality of life (HRQL) must have a high priority in the health sector with sustainable political implementations and with a special focus on management, exploration with diagnostic criteria, and evaluation especially in the primary care settings.

3.2 Nature of the Problem Using a Life Course Approach

The World Health Organization defines mental health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community [13].

When applying this definition to an older person, there may be differences. As someone ages, their potential may change—perhaps through the onset of physical illnesses such as chronic obstructive pulmonary disease can significantly limit activity. Older adults are less likely to work formally, so their fruitfulness may be different to that of someone engaged in traditional employment. They remain in a position to contribute to their communities, for example, through volunteering, and cope with the stresses of normal life. Although the potential of an older person may be different from that of a younger one, they can nonetheless realize it [14].

A further perspective on the definition of health is suggested by Keyes [15]. He has challenged the continuum model of mental health and mental illness, with each being the polar opposite of the other. He proposed that there are two different continua, one measuring the extent of illness and the other with the poles of languishing and flourishing.

The concepts of languishing and flourishing are distinguished by variation in the domains of social acceptance, personal growth, social actualization, purpose in life, social contribution, environmental mastery, social coherence, autonomy (exhibits self-direction and resists unsavoury social pressures), positive (warm and satisfying) relations with others, and social integration.

Using this model, the health continuum (languishing-flourishing) may help to prevent or precipitate a negative movement along the illness continuum. Thus, flourishing may contribute to personal resilience and protect someone developing a mental illness, despite factors which might be associated with onset. Similarly, languishing may make it harder for someone to be able to defend against challenges, leading to illness [15].

Whitehead and Dahlgren’s [16] model considers a range of factors which can influence our health known as the Wider Determinants of Health [16].

The WHO Commission on Social Determinants of Health [17] reported on socioeconomic and policy influences on health and its wider determinants.

These models for determinants of health will be used to inform the content of this chapter, which will take a life course approach and consider the mediating influence of Keyes work on flourishing and languishing.

Factors which are associated with mental health and wellbeing in later life include [14]:

Discrimination

Participation in meaningful activity

Relationships

Physical activity

Poverty

There have been challenges to the applicability of such findings to rural as opposed to urban populations (such as the application of the interaction between health and wealth in rural older women in Canada [18]), but other studies of older rural adults would support them (a relationship existing between health and wealth in rural populations in Vietnam and Brazil [19, 20]).

When older adults themselves were asked what was important in maintaining their wellbeing in Scotland in the UK, they cited [21]:

Family and friends

Attitudes (their own and that of society)

Keeping active

Maintaining capability and independence

Negotiating transitions

There are clear overlaps between these, with the most notable difference being that older adults identified transitions as a factor, whereas the previous report included poverty (not having enough income to provide for a decent standard of living and opportunities to participate in society).

Other factors have been identified in different countries and cultures. For example, in Brazil, better self-assessed health was associated with being a widow with independent income [20].

If these are accepted as the prevalent factors once in old age, how can the life course influence them? Within a life course approach, the stages of life which can influence health include:

Perinatal

Childhood and young adulthood

Adulthood

Old age

Through these stages, a person will be exposed to influences on their health as a result of their own actions and, as noted above, within the context of wider society and culture, systems, economics, and politics. Some of the influences are discussed below.

Perinatal

The unborn child can potentially experience undernourishment as a result of a poor and stressed mother. Maternal depression can have a significant impact on a child, affecting weight and bonding and increasing the risk of future depression [22]. Social isolation and self-rated maternal health are often connected with economic deprivation. Social isolation in a mother can pass this disadvantage onto the child [23]. Poor water quality and sanitation [24] and health systems [4] can contribute further risks.

Childhood and Young Adulthood

Where children grow up in abusive families, with neglect and violence, they are at increased risk of later health and social problems. This is more likely to occur in lower socioeconomic groups [25]. For those in these lower groups, the impact of poverty and associated issues, e.g. poor access to education, poor nutrition, and infections, contributes to further risks for health [26]. Children who experience social isolation are more likely to have lower educational levels and lower socioeconomic status and are more likely to be obese, smoke, and have psychological problems in the future [27]. Young people are at risk of being bullied for being different in any way, including race, sexuality, and weight. Bullying has adverse social, physiological, and psychological consequences [28]. Adolescence can be a time of increased risk of substance misuse and smoking, which can then continue into adulthood and old age. Levels of physical activity and diet can similarly have significant impacts at this and later stages [29]. Failure to progress in society in developed countries through education and employment deprives young people of the chance to develop social and life skills which contribute to their integration into society and increases the risk of future poor health [30].

Adulthood

Unemployment and poor-quality employment are significant risk factors for health problems, a consequence of low income and poverty. These affect diet, living conditions, and the mental health of parents. Unemployment reduces opportunities for social contact through colleagues, etc. and through reduced income and embarrassment about their position. Being out of work makes it harder to find work too, making unemployment a particularly pernicious factor affecting social inclusion and health [31]. It is perhaps unsurprising then that depression and anxiety disorders are two to three times more common in the unemployed [32]. Having experienced depression once, 50% of people will experience it again [33].

Older Age

All of the preceding life stages can have an impact on older age, e.g. socioeconomic and educational status [16]. Significantly, by older age, many people have developed long-term physical health conditions, a predictor of mental illness. There is an increasing risk of isolation and perceived loss of status. Transitions were identified by the sample of older adults as a factor effecting their health and wellbeing. Retirement can be a significant transition when contact with friends and colleagues can reduce, together with the sense of participation, capability and independence. Bereavement and the loss of loved ones are inevitable features of older life and can contribute to reduced social contact. These can be compounded by stigma and discrimination—commonly experienced in older age in some communities [17]. Other determinants will influence mental health such as the environment and perceptions of safety [34].

Following on from Keyes’ use of the term autonomy [15], increased isolation and reduced participation can contribute to less autonomous behaviour as an older adult may be more dependent on others and less self-directing. This possibly reduced autonomy and dependence on friends, family, and carers and can have implications for their human rights [35] (such as their right to freedom of movement, equality, and access to public services) as they make an older adult vulnerable to a range of abuses (see below).

3.3 Management of the Problem (Topic) Using a Stepped Care Framework to Include

3.3.1 Aspects of Diagnostic Criteria Including Assessment Tools

Evaluations are necessary, for example, to understand the needs and unmet needs of older adults in primary care settings within their individual situations [36], including the possibilities of withdrawal, resignation, and low expectations, not merely to collect information and data. Many older adults and carers do not appear to seek help for their needs for a range of very complex reasons.

It is important to use diagnostic criteria by assessment tools which have a broad spectrum, which include social determinants, which feature liability, comprehensibility, and which are scientifically based and established, means with the possibility of e.g. reliability and validity, self-rated or rated aspects. The strength of social networks has been documented to be one of the biggest determinants in the context.

Around the world, researchers, primary care occupational groups, and others may be able to find assessment tools [37] (APA and others). It is important for a senseful, meaningful, and sustainable manageability in every planned context to find evaluation tools, which are useful, tailored, and aligned to the desired exploration. Primary care workers and others in the health field should be trained to work with scales but also in examining situations for health promotion in a broader, holistic context without any scales. Awareness, effective communication styles, and empathy are substantial content modules.

In the following an extract of possible tools with diagnostic criteria and survey aspects in the broad context of social determinants will be presented, exactly to the following determinants: social networks, social participation, social support, quality of life, agitation, griefs, stress factors, life change events, and social capital.

3.3.2 Specific Issue for Primary Care Assessment

In order for people to get help, they must first come forward for it and be able to access it. Older adults have the same stigmatizing attitudes towards mental illness as the rest of society and can in fact be more stigmatizing. More age appropriate and culturally appropriate services can help with this. The inclusion of a range of stakeholders will contribute to the services and support which will help them to engage [61–63].

Assessment of mental health in older adults by the primary care team needs to be holistic and take into account each person’s own life course or story and experiences. This can help to identify and understand the range of influences on that person’s health and wellbeing.

In conducting the assessment, the practitioner needs to consider [64]:

Physical health: Long-term physical health conditions, functional (including visual) limitations, changes in body mass index

Mental health: Depression and anxiety, cognitive impairment, self-efficacy

Social health: Frequency and nature of social contact, relationships

Lifestyle: Levels of physical activity, alcohol use, smoking

These different aspects of someone’s health and wellbeing might frequently interact. A long-term physical condition, for example, might reduce functioning, increase social isolation, and reduce self-efficacy and be associated with the development of depression and/or anxiety. These in turn can inhibit management of the long-term condition, and a vicious circle can develop. The interaction between these issues will be idiosyncratic, hence the need for a holistic, personalized assessment.

Health professionals may not be trained or have the time to enable consideration of these broad perspectives. The use of validated scales (see above) may be helpful, but they do require time and training. This can sometimes be mitigated by the person completing questionnaires prior to their consultation with the health professional. Primary care assessment may be most effective if it brings together information from a range of sources [65]. As noted above, the person themselves, any relatives, friends, or carers will be able to supply relevant information for the range of determinants which have been identified above.

They would also need to approach such assessment from perspectives which they are not familiar with. In this case, the views of the older person and any relatives or carers may be more significant than observed symptoms or even rating scales. Such interaction needs time with the conversation steered by knowledge of those factors identified as risk factors for poorer wellbeing and functioning.

What is often required is time and the ability to listen judiciously, being aware of issues and facts to focus on and explore, rather than seeking symptoms which might lead to a diagnosis. This may be carried out effectively by health workers with appropriate basic training and pre-existing social skills, i.e. an understanding of signs and symptoms of disorders and an attitude of understanding of the person, and their world [66]. They could be drawn from local communities and so have a knowledge and understanding of local factors which might contribute to mental health or illness too. This workforce would then consult with other health professionals, pooling the knowledge and information obtained from their respective assessments which can then lead to a more holistic and personalized plan of care, including physical, mental, and social health interventions, and lifestyle advice.

At the population level, where public health bodies are seeking to reduce the incidence or impact of particular conditions, they can undertake screening for such conditions. Given the prevalence of mental health conditions in older adults, and stigmatizing attitudes to mental health and to older adults (from themselves and others), it is good practice to routinely screen for common mental illnesses at each consultation with an older adult. This can be done using the PHQ 4, a validated measure designed as a screening tool for primary care, which asks four questions to predict severity of anxiety or depression [67]. If a system of health checks for older adults is in place, this can be added to them, but this instrument is brief enough to enable routine use in everyday consultations too. Screening in this context is likely to be beneficial as it would identify issues earlier when there are potential interventions which could improve the current situation and possibly prevent deterioration or development of further problems over time [68].

When assessing older adults, practitioners need to be sensitive to the risk of elder abuse. This has been defined as a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person [69]. Such abuse can take the form of:

Physical

Emotional

Financial

Sexual

Neglect

The WHO recognizes this as a significant issue affecting the rights as well as the health and welfare of older adults [70]. This problem can be hard to identify—people (including the abused) will frequently hide such issues through shame and stigma. Where identified in more developed countries, there are often specific services which address such issues. In less developed countries, where such services do not exist, it may be harder to deal with.

3.3.3 Health Promotion

According to the WHO definition, health promotion is the process of enabling people to increase control over and to improve their health [71]. The background concepts of health promotion, self-care, and community participation emerged during the 1970s, related to policies promoting, e.g. social justice and social equity. The Ottawa Charter, a very important milestone in health promotion practice worldwide, defines five key strategies for health promotion actions: building a public health policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services.

Health promotion in general consists of modifying specific components of individuals, groups, and populations, with the inclusion of intrapersonal, interpersonal, institutional, environmental, and societal aspects. Before considering the implementation of any public health promotion programme, several points such as appropriateness, feasibility, cost-effectiveness, and potential need to be carefully considered [72].

There is documented evidence that intrapersonal factors including beliefs, attitudes, knowledge, skills, self-concepts, motivation, self-control, emotional regulation, coping variables, and resources can have a strong impact [73]. A better socioeconomic position and good housing quality are further important gradients [74, 75]. For older adults, for example, results demonstrated that adults with higher-quality social relationships might be motivated to be engaged in health-promoting behaviours such as leisure activities and, in turn, reap more health benefits [76].

Whenever public health education intervention attempts to modify erroneous values and opinions regarding health promotion, sufficient consultation and conversation time, reminders, and follow-up visits are applied in every case at the intrapersonal level [73].

It has to be faced that primary care professionals are pointing at barriers in the context of primary prevention and health promotion in clinical practice, such as heavy workloads, a lack of skills, competences and knowledge, problems related to the professional-patient relationship, and lack of confidence in the effectiveness of these interventions [77–79]. One reason of the lack of confidence can be the missing knowledge that different segments of the population respond differently to identical public health intervention [80]. Indispensable necessary for health promotion are multidisciplinary knowledge, skill-related competence, and competence with respect to attitudes and personal social characteristics [81].

One aspect of finding solutions to improve the effectiveness of interventions can be to investigate the possibility of using technological innovations. This can be useful in improving patient self-care and care, perhaps using SMS messaging (with reminders) to improve outpatient attendance, or eHealth to improve the clinical management of identified risk factors through provision of tailored feedback, tailored educational materials, and referral to online self-management/empowerment programs [82].

3.4 Self-Care and Interventions

As has been noted above, assessment requires consideration of the older person’s life story and their perspective on their lives and health. Many of the influences which have been discussed might be best addressed by the individual with the provision of any support if needed. By old age, some of the damage to health can have already happened. The emphasis needs to be then on what might be done to either mitigate the effects of earlier behaviour and life experience or prevent further problems from developing.

Such interventions might include an increase in physical activity and exercise, stopping smoking, and reducing alcohol intake. If someone is currently engaging in unhealthy behaviour, it can be very hard for them to change those patterns—which may well have become ingrained over many years. Whilst self-care will be central to any improvement in mental health and wellbeing, older adults’ capacity to undertake it will vary depending on their physical and mental health and circumstances.

In helping someone to undertake such a behaviour change programme, it is important to work across a range of domains and with a range of supporting organizations [83]. It requires an understanding of the person, their context and circumstances, what barriers to change they may encounter, and how to overcome them. Whilst professional input can contribute to this, professionals are unlikely to be able to provide sufficient time and be available at the right time that someone needs that support. Family members and friends ought to be considered as part of the care and support network for an older person. There is increasing interest in the role and benefits of peer support for people with mental health conditions [84] and some evidence that older adults can help their peers to improve their mental health conditions [85]. Supporting a peer is also good for the supporter, giving them many of the benefits of employment such as a sense of contributing and purpose [84].

Taking a lead from Keyes [15], older adults can be encouraged to focus on, for example, their social contribution, sense of purpose, positive relationships, and social integration. Support from a peer or other sources may be needed to achieve these or other aspects of flourishing such as environmental mastery and autonomy.

3.4.1 Biopsychosocial Interventions

The important role for self-care with aid and support from friends, family and carers, and health-care teams makes a significant contribution.

In the context of the holistic assessment previously discussed, a number of issues may have been identified which are amendable to intervention. Medical treatments for pain experienced as a result of a long-term condition, for example. This may be restricting someone’s activity and having an impact on their social contact. Effective treatment through analgesia might enable someone to go out more, take more physical exercise, and lead them to feel more independent and capable and results in their being more active participants in their communities, reducing social isolation [86].

Similarly, depression, anxiety, and sleep problems can be treated using psychotropic medication. Medication prescribed for mental illness in adults however needs to be used with greater caution in older adults, due to the potential for side effects to be more significant [87]. Tolerance of these drugs is affected by changes in absorption, distribution, metabolism, and excretion of substances which occur with age. Hypotension, for example, is a common side effect of psychotropic medication. This increases the risk of falls. Further caution is advised over polypharmacy and interactions between drugs, especially with older adults being more likely to be taking medication for their physical heath [86]. There is concern over the use of neuroleptic drugs in those with cognitive impairments and challenging behaviour, and high use of psychotropic medication is reported in those in hospital and care homes [88].

This risk of drug interactions adds further emphasis to the need for health-care teams to be communicating effectively.

Where available, the option of taking therapies can reduce the requirement for drug treatments. Psychological therapies such as cognitive behavioural therapy and counselling are effective for older adults and lack any physical side effects. In the major national rollout of psychological therapy services in England [89], recovery rates were generally higher amongst older adults (58% for over 65 years, 45.2% for 36–64-year-olds, and 42.4% for 18–35-year-olds) [90].

Many of the wider determinants of mental health identified above are not amenable to specific health interventions, though those interventions may be useful. Also, thinking back to the Keyes’ model [15] interventions might best be tailored to promoting contributions, relationships, and integration. Those beyond the health-care team must therefore contribute to improvement in health. A key function for the health team might be to have knowledge of the wider determinants of health and sources of help to address them. Problems with accommodation, for example, can have a significant impact on health [18] but would be addressed best by a specialist advocate rather than a health professional. Similarly, social isolation may be reduced more by the interventions of a small local charity. The heath-care team therefore would need to signpost people to a range of organizations as indicated by the holistic and person-centred assessment.

The role of primary care might therefore be more about intervening where there are clear treatable health conditions which are having an effect on, for example, social isolation or physical activity and helping people to understand where help with other issues can be found, signposting them to it, and encouraging people to take greater control over influences where they can. By providing greater understanding and support for increased control, they can empower older adults [91].

3.4.2 Evaluation of Interventions

Evaluation, as defined in The American Heritage Dictionary, is action to ascertain or fix the value or worth of something [92]. As documented, e.g. in patients’ experience survey measures, access, interpersonal and intrapersonal communication, coordination, and health promotion in general are important items in the overall context of evaluation in primary health care [93].

Although the lines between intervention research and programme evaluation are not always clearly defined, both are necessary and requested in the context of social determinants [94]. It is generally accepted that better evidence about interventions and brief interventions [95] around the social determinants of health in action are essential [96].

To evaluate social determinants in the broad field of primary care, it is important how primary care is defined, how task shifting is regulated, how interprofessional teams are composed, and how more consistent primary care data to build workforce strategies can be assembled [97].

Social determinants are always embedded in and related to social systems. Any evaluation of interventions including social determinants should reflect and integrate these dependencies and should highlight that the social systems, which make up societies, are not static objects [98].

In general, evaluations and measurements of performance increasingly play an important role in health-care reforms. Stakeholders need quantitative and qualitative information to form and guide their opinions and political will, engagements, decisions, and recommendations in steering health systems in a variety of settings [99]. This requires analysing and evaluating the responsiveness of all participants during interventions as well as the conditions that can impact on behaviour and wellbeing, such as person’s internal locus of control [100]. Finally, finding aspects of an answer how care and cure in primary care settings within social determinants can be managed effectively and sustainably.

Further, evaluations and performance assessments in primary care settings should be explained within national and additional social contexts, for example, across countries at similar levels of income and educational attainment.

A final major requirement of evaluations and performance assessments is to start from a proper framework and conditions from which measures