Ageing and mental health – a forgotten matter

Brussels,september 2014

Ageing and mental health – a forgotten matter

Background

Most of European countries are currently facing a major demographic challenge: we are living in ageing societies with low birth rates and increasing longevity. The implications are yet to be calculated – but governments and policy-makers already agree that we will soon have to make important changes in how we deal with the growing number of elderly people who ask for adequate support and demand full participation in our societies. According to Eurostat, in 2000, 15% of the European population was 65 years old or older, and nearly 7% of it was 75 years or older – and, by 2030, these figures will increase to 24% and 12%, respectively. This means that within 15 years 1 out of 4 people in the EU will be 65 or older, and 1 out of 8 will be over 75! Mental health organisations warn: the effect of this tendency on health care will be amplified by a disproportionate increase in dementia, depression, anxiety, schizophrenia, and delirium in our societies.

Prevalence of mental health problems

Numbers may give rough proportions of the problem arising with ageing populations, but specific trends give further weight to the problem: several mental health issues are more prevalent within these population groups, such as anxiety, suicide, (psychotropic) drug and alcohol use, dementia and depression. Furthermore, a worryingly high number of 10-15 % of persons over 65 years are affected by depression – and this is just an estimation by experts who warn us that the real number might be much higher. Evidence shows that depression in older adults is a risk factor for functional disability and may also predict premature mortality.¹ Besides, co-morbid depression in older people also increases the frequency and cost of professional help, and the risk of premature placement into nursing homes.²

It is a well-known fact that older age often brings along symptoms of dementia as well. According to recent studies, the percentage of people getting Alzheimer’s Syndrome, the most common form of dementia, rises from 2% at the age of 65 to 22% at the age of 85.³ These numbers are expected to increase both in Western Europe, where they are likely to double, and in Eastern Europe, where 

research suggest they might increase threefold in the coming decade – all due to the longer life expectancy in our societies.

Burden or asset

Apart from mental health problems, there are also other risks that affect the lives of our elderly. For example, there are regular reports by NGOs and human rights organisations on serious abuses against elderly people either in their own homes or in residential institutions i.e. in live-in care homes.⁴ Although these cases occasionally raise public interest with regards to the quality of services old people receive but things are usually left unchanged mostly due to the fact that public opinion sees social services as burdens and not as tools to support or to empower old people.

Yet, decision-makers not always follow this opinion and they see the older age groups more and more as potential resources. Governments across Europe are planning to increase the contributions of older people to society, therefore the neglect of older people’s mental health and wellbeing represents a waste of human potential that cannot be afforded.⁵

Support services

Of course, it is important to ensure that these plans are supported by adequate social measures: appropriate pension schemes, community support services and health insurance plans all belong to the toolkit to ensure that older people live a full life in dignity. However, such measures not always reflect on real needs which has grave impacts on the rest of societies.

First of all, the need for support mechanisms is increasing. The future anticipated growth in the very old age group (75+), who are expected to have fewer children to look after them, will increase the need not only for professional care but also community-based services, adapted housing and transport facilities.⁶ It is estimated that only half of older adults with mental health problems receive treatment from any health care provider, and only a fraction of those receive support from specific mental health services. This is a serious problem and we need to see that better allocation of funds is needed to ensure that those services get resources that are the most effective and give the best quality of support at the same time.

Looking at the history of the field helps us understand the direction of changes and may also lend weight to policy-planning. Historically, funding for adult mental health services was targeted mostly toward intensive and costly institutional care. However, in the last two decades in many European countries the focus has shifted and the service priorities have changed in favour of community-based services.⁷ This shift towards community-based alternatives is also seen in the field of childcare and services for people with disabilities and people with mental health problems and we can conclude that a wide range of scientific evidences and users’ accounts validate the trend.⁸ Furthermore, the focus on community care has now been also enhanced by the ratification of an international treaty, the United Nations Convention on the Rights of Persons with Disabilities (CRPD) by the European Union and most of its Member States. The Convention is a legally binding document that makes it mandatory to its state parties to comply with it – which includes a focus on accessible community services that people receive with informed consent.

Not only the CRPD but everyday accounts of older people also emphasize the need for accessible support: people demand affordable and accessible transportation services, too. “They may live in rural areas without adequate mental health services, or they live near services but far from family members. They may not be able to come to a doctor’s office simply as a result of their physical frailty”⁹ – states one report.

Effectiveness and quality

Effectiveness of community services for older people is crucial: studies suggest that community ‘old-age mental health teams’ are more effective than usual forms of institutional care in the management of depression, dementia and other mental disorders in older people. These specialized teams can also be responsible for prevention, crisis intervention, treatment and aftercare as well as for consultation for staff in institutions for foster homes for the elderly.¹⁰ Mainstream health services such as general practitioners and clinics must also improve: a significant number of especially older adults with depression are underdiagnosed and undertreated by their primary care physicians (and other services).

However, innovative methods of support may make it easier to deliver the help to those in need: Information and Communication Technologies – ICT solutions (such as E-health) may have an increased use in the future. Additional monitoring options such as tele-health and tele-care and ‘smart house’ technologies are introduced¹¹, often with the help of EU-funds. Finally, according to reports of service providers, even when community-based services have the capacity to respond to the mental health concerns of older people, they are challenged by the lack of adequate reimbursement and by the lack of staff, and lack of adequate geronto-psychiatric training. The latter is a continuous problem across Europe.

Recommendations

To the Member States

1. We recommend that EU Member States support early and effective diagnosis schemes when relevant, treatment, support and prevention, with adequate funding at all levels.

1. We recommend the increasing use of individual therapy for the bereaved and interventions using for example cognitive behaviour techniques and psychotherapy as these are potentially cost-effective and show decreases in depressive symptoms.

1. We recommend that EU Member states put a focus on ensuring that national and local prevention strategies and initiatives identify older people as a priority group. They should amend presently running prevention strategies and they should develop new programmes that include the elderly.

1. We recommend that Member States offer mental health education and outreach in locations frequented by older adults and their families, including rural areas.

1. We recommend that Member States work on the training of practitioners in mental health services to recognise and respond to older people’s mental health needs.

1. We recommend that Member States ensure that mental health issues of elderly people are better known and also how to prevent those. Fortified awareness-raising activities (also at local level) are necessary and should be supported financially.

To the European Union

1. The EU Commission and European Parliament must recognize depression as a major public health issue and key risk factor for the EU populations health and wellbeing
2. Good practices in older people’s mental health services must be shared widely and more use of community development initiatives should be promoted in order to enable older people to help themselves and each other.
3. The EU should promote the development of community-based initiatives to reduce isolation and enhance social support for older people who have, or who are at risk of developing mental health problems. Would mental health problems develop, all available specific therapeutic and rehabilitative interventions should be offered to the persons.
4. In line with the European Commission Staff Working Document “Investing in Health” (2013) of the Social Investment Package, the European Commission must invest into actions that aim “to contribute to the practical understanding of patient empowerment and support

exchanges of experience in this field by launching a mapping of current policies and evidence”¹². Present and future actions must always include and consult organisations of

1. Susanne Rolfner Suvanto (2012): Elderly care and psychiatry.
2. Jané-Llopis, E., and Gabilondo, A. (Eds). (2008). Mental Health in Older People. Consensus paper. Luxembourg: European Communities.
3. Duthey, B. (2013) : Background paper 6.11. – Alzheimer Disease and other dementias, WHO. http://www.who.int/medicines/areas/priority_medicines/BP6_11Alzheimer.pdf
4. Cooper, C. et al. (2007) : The prevalence of elder abuse and neglect: a systematic review. Age and Ageing, 37
6. (2) 151-160.
7. Age Concern England (2007). Improving services and support for older people with mental health problems. London.
8. Jané-Llopis et al. (2008)
9. Department of Health and Human Services, Ageing (2001). Older Adults and Mental Health: issues and opportunities. http://www.globalaging.org/health/us/mental.pdf
10. European Expert Group on the Transition from Institutional to Community-based Care (2013) : Common European Guidelines on the Transition from Institutional to Community Based Care http://deinstitutionalisationguide.eu/
11. Department of Health and Human Services, Ageing (2001).
12. Draper B, Low L (2004) What is the effectiveness of old-age mental health services? Copenhagen, World Health Organisation Regional Office for Europe: http://www.euro.who.int/__data/assets/pdf_file/0008/74690/E83685.pdf
13. Age Concern England (2007)
14. The European Commission has already made one very positive step in opening a call for grants titled ‘Promoting mental wellbeing in the ageing population PHC-22-2015’ http://ec.europa.eu/research/participants/portal/desktop/en/opportunities/h2020/topics/2281-phc-22-2015.html