While mental illness is not a typical attribute of ageing, mental health is important to consider as we age. Daniella Kanareck and Karen Lazarus identify the common mental illness in late life, the barriers to treatment and the essentials for optimal mental health as we age.

Emotional wellbeing and good mental health are important throughout the lifecycle. Mental health is not a discrete aspect of a person’s life. It is influenced by and influences other aspects of life: family, relationships, work, housing, education, finances, creativity, hope, and the physical and social environment in which each of us lives. (The Roadmap for National Mental Health Reform 2012–2022).

A mental illness significantly affects how a person feels, thinks, behaves and interacts with other people. It is diagnosed according to standardised criteria. Mental illness in the older community can present as mental illness that has emerged in youth or adulthood and has been chronic or recurrent over many years; or as a late onset mental illness, with the first occurrence after the age of 65.

Triggers that might exacerbate vulnerability to mental illness for older people include: retirement; financial stress; loss and grief; isolation and loneliness; alcohol and substance misuse; functional decline; cognitive decline; elder abuse or neglect; medications / polypharmacy; physical ill health; falls risks; chronic pain; entering residential care; and carer stress.

Common mental illnesses in the older population

Anxiety Disorders: Anxiety might be triggered by realistic concerns associated with a medical, functional or social comorbidity. An anxiety disorder is more severe, more enduring and interferes with the person’s day-to-day functioning. Anxiety can be difficult to differentiate from depression, or may co-occur with depression.

Depressive Disorders: An older person with depression may express a loss of interest in life or report physical symptoms and complaints about their memory so that family and carers may attribute their problem to dementia, age or physical illness. Contrary to a stereotype of ageing, depression is not the norm for older people living in the community. Depression affects less than a fifth of people aged over 65 in the general community, but the incidence of depression increases for those with conditions such as Parkinson’s disease, stroke, dementia or chronic pain and those living in Residential Aged Care. For people who develop depression in later life, it is important to consider whether a medical illness is the cause, as depression can be the first symptom of an undiagnosed medical condition. When depression does occur in older people, it is more likely to be associated with chemical changes in the brain.

Psychotic Disorders: Psychosis is a distorted view of reality effecting how a person thinks (delusions), perceives (hallucinations) and behaves. Medical illness, poor eyesight/hearing and significant distress are risk factors for late onset psychosis. Higher occurrence of psychosis is noted with cognitive impairment and dementia.

Dementia and other cognitive disorders: Dementia is a degenerative disorder that can affect memory, language, general intellectual function and personality. These impairments result in difficulties performing daily functional tasks and routines. Dementia of the Alzheimer’s type and vascular dementia have the highest rate of occurrence. Cognitive impairment often coexists with other mental health disorders.

Epidemiological studies from around the world demonstrate that about 12.7-16% of older adults living independently in the community report symptoms of sufficient severity to meet criteria for a psychiatric disorder (Psychiatric Disorders in Ageing, Wijeratne et al, 2012). Outcomes of psychiatric and psychosocial interventions are comparable for older people to those of younger people; yet older Australians receive fewer specialist psychiatric consultations than any other population group (SESLHD Aged Care Services Plan 2015-2018).

Barriers that contribute to underutilisation of mental health services include:

• Ageist stereotypes can mask symptoms of mental illness. Too often we hear older people referred to as irreversibly frail and feeble, lacking resilience and unable to recover from emotional distress or mental illness. These are incorrect perceptions that can result in older people with mental illness not being identified, diagnosed and treated in a timely manner.

Case example: Mrs Barlin, an 88 year-old was seen in the Emergency Department due to extreme weight loss. Her daughter, Penny reported that Mrs Barlin, “like all elderly people would sit in her chair all day, looking sad”. What Penny failed to understand is that her mother was experiencing a depressive episode. Mrs Barlin responded well to medication and psychological support and within three months, she resumed her former routines.                      *Case example is anonymised

• The stigma of mental illness can result in older people being marginalised and/or victimised, resulting in poor screening and management of risks and symptoms.

Case example: The neighbours of Mr Soto, a 78 year old man, called out the police as he had repeatedly and aggressively accused them of conspiring against him. They described him as an odd, intrusive old man who should “be put in an old person’s home” in order that he no longer be a nuisance. On clinical assessment, it became evident that Mr Soto was suffering from a psychosis. He was experiencing delusions about his neighbours wanting to harm him. He was admitted to hospital where he was successfully treated for late onset schizophrenia. On discharge he was able to continue living independently in his community with no further concerns raised by his neighbours.                 *Case example is anonymised

• Mental illness is often viewed as a taboo by older people, which can result in shame, negative self-beliefs and can exacerbate feelings of helplessness and hopelessness.
• Older people are less likely to voice psychological or psychiatric symptoms (often these are expressed in terms of physical ailments) and they are less likely to engage with mental health services.
• Older people are at greater risk of being socially isolated due to physical, social and environmental impediments. Loneliness has a significant impact on mood and mental health.
• Cognitive decline in older people at times masks mental illness; conversely mental illness might mask an underlying cognitive impairment.
• There is interplay between physical illness and mental health. Older people might experience and express their psychological symptoms as physical symptoms, such as fatigue and pain. Ill health might also herald a mental health disorder such as anxiety and depression. Symptoms can also complicate diagnosis; such as loss of appetite could be a medical condition or a depressive illness.
• Older people with a mental illness are too often, by default, referred to aged care services that tend to focus on physical health needs as opposed to mental health needs. As aged services tend to focus on compensating for functional decline, services often are skewed toward dependency rather than recovery.
• Older people often experience a range of complex comorbid health needs that involve multiple services; their care is compromised when services occur in silos such as primary health, aged care, social and mental health services.
• Current mental health policy and research tends to be focused on the youth sector, which in turn directs service funding to younger cohorts.

It is fundamental that as a society there is greater awareness of identifying symptoms and risks of mental illness in the older population, and there is provision of appropriate clinical pathways based on the individuals’ needs. It is imperative that mental health services are well placed to meet the needs of an expanding ageing community.

The World Health Organisation’s report on ageing and health in 2015 states that rather than steering older people towards predetermined social purposes; public-health policy would be better aimed at empowering older people to achieve things previous generations could never imagine.

Essentials for promoting emotional wellbeing and optimal mental health of older people

• Foster age-friendly communities that provide opportunities for and encourage engagement in regular exercise, healthy diet, social engagement and mental stimulation.
• Involvement of a GP is vital in care planning to ensure regular medical and medication reviews. People with a chronic mental illness have a higher prevalence of early death due to compromised self-care, poor diet and not accessing appropriate medical care for treatable illness such as cardiac problems and diabetes.
• Campaigns and programs that actively encourage positive ageing.
• Public education to demystify and provide a better understanding of signs and symptoms of mental illness in the older community; and to ensure a greater awareness of beneficial treatment options for older people experiencing mental illness.
• To endorse the voice of older people who have a lived experience of mental illness and who can promote the principals of recovery. It is imperative that older people with a lived experience of mental illness should lead their care planning. Likewise it is a fundamental necessity to have the input of older people in planning and implementation of mental health services.

• There are excellent mental health programs within the aged care sector. However, mental health interventions should be delivered by specialists; experts in mental health service practice and delivery. Older people should be afforded intervention that facilitates recovery goals consistent with current trends in general mental health services. Failure to do so is an inequity.
• It is essential to move towards cross sector collaboration to address older people’s mental health needs so that they receive a continuum of person centred-care. Older people experiencing a mental illness require a flexible continuum of care to meet their individual needs.
• Community mental health services that are accessible to older people.

• Mental health clinicians working with older people need to have a holistic understanding of ageing and a positive approach to recovery.
• Anyone working with older people should receive training that includes strategies to foster good mental health outcomes, such as:
  • Engagement, flexible and person-centred care.
  • How to identify signs and symptoms of poor mental health.
  • How to respond to risks.
  • A knowledge of appropriate services and treatment pathways .
• Education for families and carers about mental illness in late life should include support and strategies to manage carer stress.
• Accessible mental health services for people from culturally and linguistically diverse backgrounds should be provided. By 2026 one in every four people aged over 80 in Australia, will be from culturally and linguistically diverse backgrounds (AIHW 2001).

In order to foster optimal mental health in the expanding older population, our society needs to reflect an affirmative value on ageing. Communities should promote and provide opportunities for positive ageing and deliver timely and accessible recovery orientated mental health services, working in collaboration with other health and social services.

Daniella Kanareck and Karen Lazarus are Social Workers in the Aged Care Psychiatry Service (ACPS) at the Prince of Wales Hospital, Randwick. ACPS provides specialised assessment, treatment and management of older people with a mental illness. ACPS has a 6-bed inpatient unit and provides outpatient services to people living independently in the community or in Residential Aged Care Facilities. Contact No. 9382 3753.

ACPS does not provide an acute intake service. In case of an emergency contact the person’s GP, visit the Emergency Department, call an ambulance or call the NSW Mental Health Access Line on 1800 011 511.