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Improving mental health services for older people

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The UK Inquiry into Mental Health and Well-Being in Later Life published its second and final report this month (UK…


VOL: 103, ISSUE: 34, PAGE NO: 21

Nerys Hairon

The UK Inquiry into Mental Health and Well-Being in Later Life published its second and final report this month (UK Inquiry, 2007a). It published its first report last year (UK Inquiry, 2006).



According to the inquiry, supported by Age Concern, over 3.5 million older people experience mental health problems (UK Inquiry, 2007b). It warns that ‘an inadequate government response’ means these people do not receive satisfactory support, and makes 35 recommendations to improve mental health services for older people.



The report outlines a vision for a society ‘where the needs of older people with mental health problems and the needs of their carers are understood, taken seriously, given their fair share of attention and resources, and met in a way that enables them to lead meaningful and productive lives’.





The inquiry predicts that the number of older people with mental health problems is set to increase by a third over the next 15 years. A wide range of mental health problems can be experienced in later life, including depression, anxiety, delirium, dementia, schizophrenia, and alcohol and drug misuse. Key findings suggest that community nurses can play a major role in detection and prevention.



The report states that a quarter of people aged 65 and over living in the community have symptoms of depression that are sufficiently severe to warrant intervention, while only a third of older people with depression ever discuss the problem with their GP. Only half of these are diagnosed with depression and treated, primarily with antidepressants.



Fewer than half of older people with dementia ever receive a diagnosis. The report adds that a third of people who provide unpaid care for an older person with dementia have depression.



The inquiry found that delirium/acute confusion affects up to 50% of older people who have surgery. In addition, the report findings highlight that people aged 55-74 have the highest rates of alcohol-related deaths in the UK, and that rates of both prescription and illicit drug misuse in later life are under-estimated.





The inquiry has identified five main areas for action: ending discrimination; prioritising prevention; enabling older people to help themselves and each other; improving current services; and facilitating change.



- Ending discrimination: discrimination includes direct age discrimination, ageist attitudes and stigma. Key actions outlined include removing age barriers to services, tackling stigma associated with mental health problems and paying more attention to ‘invisible’ groups such as older people with alcohol and drug misuse problems.



- Prioritising prevention: social isolation is a common risk factor for a range of problems. This indicates that nurses have a key role in health promotion among older people. The report recommends challenging the ‘widespread defeatism’ that leads to the assumption that mental health problems are an inevitable part of growing older. Reducing isolation, improving social support, and focusing on preventing depression and delirium are outlined as key actions.



- Enabling older people: only a small percentage of older people with mental health problems receive help through formal services, so support for self-help and peer support is necessary. Key actions focus on community development initiatives, promoting peer support and support for unpaid carers of older people.



- Improving current services: many older people turn to primary care services for help. The report emphasises that providers play a crucial role in the initial identification of mental health problems and the coordination of care. It adds that acute hospitals and care homes are also important settings. A key action recommended involves developing models of collaborative working with mental health specialists.



- Facilitating change: the report recommends that a key aspect in this area is improved education and training, and the provision of support for those who work with older people.





The report’s 35 recommendations are directed at a range of bodies including government, health and social care commissioners, health and housing departments, and voluntary organisations. Some of the recommendations are targeted specifically at the NHS and care homes (see Box, below). It is clear nurses have a key role in improving services.



The first report made 15 recommendations (UK Inquiry, 2006). For example, it said practice nurses and care home staff may be able to contribute to the establishment of healthy ageing programmes. There was also a call for community-based projects for older people and a targeted approach to encouraging this group to take advantage of opportunities for social interaction and physical activity.



Some recommendations focused on retirement, suggesting that nurses have a role to play in asking retired patients about their mental well-being when they present with other conditions.



The second report urges health and social care commissioners to ensure staff work with mental health specialists to recognise and respond to known risk factors for depression, anxiety, suicide, delirium and alcohol and drug problems in older people (UK Inquiry, 2007a). It calls for standards that require services to provide regular surveillance to address physical health problems. This could be implemented by nurses doing health checks in over-75s.



Flexible home care that offers emotional as well as practical support to older people with mental health problems and their carers should be provided at an early stage. Commissioners should also promote advocacy, self-help and peer-support groups for older people with mental health problems and their carers.





The National Service Framework for Older People comprises eight standards to improve services for older people (Department of Health, 2001). Standard 1 involves tackling age discrimination but the inquiry found that since 2001 ‘explicit age discrimination had not declined in mental health’ (UK Inquiry, 2007b). Standard 7 of the NSF concerns mental health. The DH (2007) says progress in this is patchy.



NICE has also been asked by the DH to develop guidance on public health interventions to promote mental health in older people (NICE, 2007). The guidance, which is expected to be issued in April 2008, will cover interventions and activities that promote mental well-being in older people.





The report argues that the facts about mental health problems in later life should ‘generate a sense of urgency and of anger about the lack of attention paid to them’, but there is ‘still a resounding silence’. It concludes: ‘There is no time to waste. As our population ages, we must ensure that the numbers of older people who suffer mental health problems are minimised.’





The NHS should:



- Support initiatives to reduce social isolation for older people who have, or are at risk of developing, mental health problems



- Ensure that initiatives to maximise choice and control are developed for and offered to older people with mental health problems and their carers l Involve both of these groups in the planning, delivery and monitoring of services



Acute trusts should:



- Train staff to recognise and respond to the mental health needs of older people and encourage staff to reflect on and improve the quality of care they deliver



- Establish systems to address older people’s mental health needs in hospital, from admission to discharge



Care homes should:



- Establish procedures to ensure that staff have the skills and resources to recognise, monitor and respond to depression in older residents.

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