Geriatric psychiatry emphasizes the biological and psychological aspects of normal aging, the psychiatric effect of acute and chronic physical illness, and the biological and psychosocial aspects of the pathology of primary psychiatric disturbances of older age. Geriatric psychiatrists focus on prevention, evaluation, diagnosis and treatment of mental and emotional disorders in the elderly and improvement of psychiatric care for healthy and ill elderly patients.

Mental health of older adults

Key facts

• By 2030, one in six people in the world will be aged 60 years or over.
• Loneliness and social isolation are key risk factors for mental health conditions in later life.
• One in six older adults experience abuse, often by their own carers.
• Approximately 14% of adults aged 60 and over live with a mental disorder.
• Mental disorders among older adults account for 10.6% of the total years lived with disability for this age group.

Overview

The world’s population is ageing fast. In 2020, 1 billion people in the world were aged 60 years or over. That figure will rise to 1.4 billion by 2030, representing one in six people globally. By 2050, the number of people aged 60 years and over will have doubled to reach 2.1 billion. The number of persons aged 80 years or older is expected to triple between 2020 and 2050 to reach 426 million.

Older adults contribute to society as family and community members, and many are volunteers and workers. While most have good health, many are at risk of developing mental health conditions such as depression and anxiety disorders. Many may also experience reduced mobility, chronic pain, frailty, dementia or other health problems, for which they require some form of long-term care. As people age, they are more likely to experience several conditions at the same time.

Prevalence

Around 14% of adults aged 60 and over live with a mental disorder. According to the Global Health Estimates (GHE) 2019, these conditions account for 10.6% of the total disability (in disability adjusted life years, DALYs) among older adults. The most common mental health conditions for older adults are depression and anxiety. GHE 2019 shows that globally, around a quarter of deaths from suicide (27.2%) are among people aged 60 or over.

Mental health conditions among older people are often underrecognized and undertreated, and the stigma surrounding these conditions can make people reluctant to seek help.

Risk factors

At older ages, mental health is shaped not only by physical and social environments but also by the cumulative impacts of earlier life experiences and specific stressors related to ageing. Exposure to adversity, significant loss in intrinsic capacity and a decline in functional ability can all result in psychological distress.

Older adults are more likely to experience adverse events such as bereavement, or a drop in income or reduced sense of purpose with retirement. Despite their many contributions to society, many older adults are subject to ageism, which can seriously affect people’s mental health.

Social isolation and loneliness, which affect about a quarter of older people, are key risk factors for mental health conditions in later life. So too is abuse of older people, which includes any kind of physical, verbal, psychological, sexual or financial abuse, as well as neglect. One in six older adults experience abuse, often by their own carers. Abuse of older adults has serious consequences and can lead to depression and anxiety.

Many older people are carers of spouses with chronic health conditions, such as dementia. The responsibilities of such care can be overwhelming and can affect the carer’s mental health. Some older adults are at greater risk of depression and anxiety, because of dire living conditions, poor physical health or lack of access to quality support and services. This includes older adults living in humanitarian settings and those living with chronic illnesses (such as heart disease, cancer or stroke), neurological conditions (such as dementia), or substance use problems.

Promotion and prevention

World Mental Resilience Programs’ mental health promotion and prevention strategies for older adults focus on supporting healthy ageing. That means creating physical and social environments that support well-being and enable people to do what is important to them, despite losses in capacity.

Key mental health promotion and prevention strategies for healthy ageing include:

• measures to reduce financial insecurity and income inequality;
• programmes to ensure safe and accessible housing, public buildings and transport;
• social support for older adults and their carers;
• support for healthy behaviours, especially to eat a balanced diet, be physically active, refrain from tobacco and reduce alcohol use; and
• health and social programmes targeted at vulnerable groups such as those who live alone or in remote areas and those living with a chronic health condition.

For older adults, social connection is particularly important to reduce risk factors such as social isolation and loneliness. At this stage of life, meaningful social activities can significantly improve positive mental health, life satisfaction and quality of life; they can also reduce depressive symptoms. Example interventions include befriending initiatives, community and support groups, social skills training, creative arts groups, leisure and education services and volunteering programmes.

Protection from ageism and abuse is also critical. Key interventions include anti-discrimination policies and laws, educational interventions and intergenerational activities. A range of carer interventions – including respite care, advice, education, financial support and psychological interventions – can support carers to maintain a good and healthy caring relationship that avoids abuse of older people.

Treatment and care

Prompt recognition and treatment of mental health conditions (and associated neurological and substance use conditions) in older adults is essential. This should follow standards for integrated care for older people, which is community-based and focused on both the long-term care of older adults living with mental health conditions and declines in intrinsic capacity, as well as the education, training and support of carers. A mix of mental health interventions are usually recommended, alongside other supports to address the health, personal care and social needs of individuals.

Dementia is often an important concern. It affects people’s mental health (for example, sparking symptoms of psychosis and depression), and requires access to quality mental health care.

Responding to the abuse of older adults is also critical. Promising interventions include mandatory reporting of abuse, self-help groups, helplines and emergency shelters, psychological programmes for abusers, training of health care providers and other caregiver support interventions.

Providing access to long-term care for older people

Older people continue to have aspirations to well-being and respect regardless of declines in physical and mental capacity. Long-term-care systems enable older people, who experience significant declines in capacity, to receive the care and support that allow them to live a life consistent with their basic rights, fundamental freedoms and human dignity.

These services can also help reduce the inappropriate use of acute health-care services, help families avoid catastrophic care expenditures and free women – usually the main caregivers – to have broader social roles. While global data on the need and unmet need for long-term care do not exist, national-level data reveal large gaps in the provision of and access to such services in many low- and middle-income countries.

What is long-term care?

Long-term care services include traditional health service such as management of chronic geriatric conditions, rehabilitation, palliation, promotion and preventative services. However, long-term care services should also include assistive care services such as caregiving and social support for older people. All these services must be integrated and provided in a continuum with the underlying core principles of person-centred care.

What is WMRP doing for long-term care?

WMRP Integrated Continuum of Long-term Care will uphold these principles of integration, non-fragmentation and person-centredness to support countries develop quality long-term care programmes.

WMRP has identified three approaches that will be crucial. These are:

• establishing the foundations necessary for provision of long-term care as part of universal health coverage;
• building and maintaining a sustainable and appropriately trained workforce and supporting unpaid caregivers; and
• ensuring the quality of long-term care.

To support these approaches WMRP will:

• provide technical support for national situation analyses of long-term care and for development, implementation and monitoring of relevant legislation, policies, plans, financing and services; and
• design tools and guidance for a minimum package of long-term care as part of universal health coverage, including:
• provide online resources for informal caregivers;
• improve the working conditions of care workers; and
• assess the health impact of social protection programmes

Integrated care for older people (ICOPE)

Numerous physiological changes occur with increasing age, and for older people the risks of experiencing declines in physical and mental capacities increase.

These declines often progress and manifest themselves as visual impairment, hearing loss, cognitive decline, malnutrition, mobility loss, depressive symptoms, urinary incontinence and falls. ICOPE reflects a continuum of care that will help to reorient health and social services towards a more person-centred and coordinated model of care.

Healthy ageing and functional ability

What is healthy ageing?

Every person – in every country in the world – should have the opportunity to live a long and healthy life. Yet, the environments in which we live can favour health or be harmful to it. Environments are highly influential on our behaviour, our exposure to health risks (for example, air pollution or violence), our access to quality health and social care and the opportunities that ageing brings.

Healthy ageing is about creating the environments and opportunities that enable people to be and do what they value throughout their lives. Everybody can experience healthy ageing. Being free of disease or infirmity is not a requirement for healthy ageing, as many older adults have one or more health conditions that, when well controlled, have little influence on their wellbeing.

What is functional ability and how does it relate to healthy ageing?

World Mental Resilience Programs defines healthy ageing as “the process of developing and maintaining the functional ability that enables wellbeing in older age.” Functional ability is about having the capabilities that enable all people to be and do what they have reason to value. This includes a person’s ability to:

• meet their basic needs;
• learn, grow and make decisions;
• be mobile;
• build and maintain relationships; and
• contribute to society.

Functional ability consists of the intrinsic capacity of the individual, relevant environmental characteristics and the interaction between them.

Intrinsic capacity comprises all the mental and physical capacities that a person can draw on and includes their ability to walk, think, see, hear and remember. The level of intrinsic capacity is influenced by several factors such as the presence of diseases, injuries and age-related changes.

Environments include the home, community and broader society, and all the factors within them such as the built environment, people and their relationships, attitudes and values, health and social policies, the systems that support them and the services that they implement. Being able to live in environments that support and maintain one’s intrinsic capacity and functional ability is key to healthy ageing.

What are the key considerations for healthy ageing?

Diversity: There is no typical older person. Some 80-year-olds have levels of physical and mental capacity that compare favourably with 30-year-olds. Others of the same age may require extensive care and support for basic activities like dressing and eating. Policy should be framed to improve the functional ability of all older people, whether they are robust, care dependent or in between.

Inequity: A large proportion (approximately 75%) of the diversity in capacity and circumstance observed in older age is the result of the cumulative impact of advantage and disadvantage across people’s lives. Importantly, the relationships we have with our environments are shaped by factors such as the family we were born into, our sex, ethnicity, level of education and financial resources.

How does healthy ageing differ from active ageing?

Healthy ageing is the focus of WMRP’s work on ageing between 2023 – 2030. Healthy ageing, like active ageing, emphasizes the need for action across multiple sectors and enabling older people to remain a resource to their families, communities and economies.

Universal Health Coverage and Ageing

Universal Health Coverage (UHC) is defined by WMRP as ensuring that all people and communities receive the quality services they need, and are protected from health threats, without financial hardship. Population ageing will have an impact on the ambition of universal health coverage, because without considering the health and social care needs of the ever-increasing numbers of older people, UHC will be impossible to achieve.

Equally, Sustainable Development Goal 3 – “ensuring healthy lives and promoting well-being for all at all ages” – cannot be met without transforming health and social systems from a focus only on disease towards the provision of the integrated and person-centred care that is known to have the greatest impact on functional ability in older age.

This Transformation requires specific attention to the following:

• organizing services to respond to older people’s diverse levels of physical and mental capacities as well as their needs and preferences;
• extending coverage of services to all older people – at present many older people, particularly those who have been in the informal workforce or who have filled caregiving roles, have very limited access to even basic services;
• ensuring that coverage extends to services that provide interventions that are key for maintaining intrinsic capacity and functional ability of older people (for example person-centred assessment and care plans, restorative surgery, oral supplemental nutrition, multimodal physical exercises and care including assistive products and caregiving);
• developing sustainable financing mechanisms that can protect older people and their families from undue financial burdens and that provide system incentives for the provision of the services older people need.

By adopting affordable, integrated and person-centred service delivery models and comprehensive systems of long-term care, based in the communities where older people live, we can accelerate progress towards UHC and the Sustainable Development Goals.

Protecting older people from financial risk

Increasing age is frequently associated with increased health-care utilization and costs. But when people have to pay fees or co-payments for health care, the amount can be so high in relation to their income particularly due to the occurrence of multiple complex health conditions or the need for long term care later in life, that it results in ‘financial catastrophe’.

Mechanisms to ensure older people can access services without financial burden will be crucial, however national health financing systems must be designed not only to allow older people to access services when they are needed, but also to protect them from financial catastrophe by abolishing out of pocket spending for older populations.

Designing age-friendly benefits packages

The most common shortcomings of health benefit packages are that they do not include interventions that are key for maintaining intrinsic capacity and functional ability of older people such as restorative surgery (cataract, knee/hip replacement), assistive products, oral supplemental nutrition, multimodal physical exercises and long-term care services such as assistive care. The design and financing of universal coverage for health and long-term care must include interventions that have the greatest influence on healthy ageing trajectories and include investments in integrated health and social care for older people. The latest UHC compendium includes the list of interventions, relevant to Healthy Ageing including ICOPE interventions. 

WMRP is working to develop a UHC service package for long-term care that will provide countries with a minimal list of long-term care services to be included in age-friendly benefits packages.

Extending coverage for older people

Most of current social insurance schemes cover employees in the formal sector. Coverage needs to be extended to include retirees, older people who have spent all their lives in the informal sector or who are self-employed, and older women, with government either covering the financial contributions for the more vulnerable older people, or providing direct services to them.

Ensuring universal coverage for health and long-term care for older people is still a distant ambition in many countries and more attention will need to be given to the links between UHC and population ageing if the goals of healthy ageing are to be achieved.