From: Best practice guidelines for mental health promotion programs: Older adults 55+ (© 2010, 2011 CAMH)
From a population health perspective, the health status of individuals, subgroups within the population and the population as a whole is the result of complex interplay among various factors. These factors include individual characteristics, the physical environment, and social and economic factors (i.e., the determinants of health). In Seniors Mental Health Policy Lens, MacCourt (2004*) draws from the theoretical literature to examine the influence on older adults’ mental health of these population health determinants and the changes that occur as part of the natural aging process, such as retirement, changes in income, physical changes and changes in social support networks. While these changes are common among older adults, individuals may vary widely in their responses to the changes. The material that follows draws liberally on McCourt’s work.
Some older people may welcome retirement as an opportunity to engage in activities that had been set aside while working and/or raising a family. For others, retirement may signal a significant reduction in income, a narrowing of their social network and support system, a negative change in self-image and identity, and the recognition of their mortality.
The retirement process may involve passing through a series of phases, the precise nature of which is influenced by a person’s reasons for retirement and the age of retirement. Older people who have inadequate income, are in poor health, or need to adjust to attendant stresses such as the death of a partner have the most difficulty adjusting to retirement. Retirement also impacts a person’s partner and may require both people to adjust to changing roles and expectations (e.g., while a partner remains in the workforce, a retiree may experience increased loneliness).
Changes in income
Older people generally have lower incomes than their younger counterparts, with women who are unattached (e.g., as a consequence of divorce or bereavement) being particularly vulnerable to poverty. However, improvements in women’s educational and employment opportunities may result in improved financial circumstances for older women in the future.
Physical changes and increased vulnerability to chronic health conditions are often seen as the hallmark of aging, and can significantly impact older people’s psychological and social well-being. Health problems may limit older people’s mobility, thereby narrowing their social contact and potentially precipitating mental health problems. In addition, MacCourt refers to studies showing the significance to health of other factors, including an older person’s perception of his or her own health status. In these studies, more health problems were associated with lower education, lower income, less health knowledge and poorer health practices, as well as lower perceived health status and lower self-efficacy. By contrast, older people who felt they were healthy and self-sufficient had fewer health problems, greater knowledge of health issues, and better health practices.
Changes in social support networks
The presence of a social support network is associated with better health. Changes in support networks pose challenges and may affect older people in a myriad of ways, including increasing a person’s risk for developing mental health problems. Three key circumstances in which older people may find their social support networks transformed are caregiving, spousal bereavement and social isolation.
- Caregiving: At some point in their senior years, many older adults may become caregivers to others (e.g., an older person, such as a parent or partner, who may be experiencing cognitive impairment or physical frailty). This is not in itself a risk factor for mental health problems, but depression has been shown to be common in caregivers of people with a psychiatric disorder and most common for women providing care to someone with dementia. Witnessing the physical, psychological and social decline of a person with dementia can have a significant impact on a caregiver, particularly if the caregiver receives little support from others. Spousal caregivers are at particular risk for experiencing loneliness and decreased social support. As compared to those who have good social support, caregivers who feel burdened and lonely are more likely to also experience depression.
- Spousal bereavement: Studies indicate that grieving the death of a partner is frequently a cause of medical and psychiatric problems for both older men and older women. In one study, changes in older women’s mental and physical health, morale and social functioning were examined over an eight-year period. As compared to women who had never married or were still married, the women who were widowed during the course of the study showed declines in mental health that exceeded the age-related declines in mental (and physical) health experienced by the study’s subjects as a whole.
- Social isolation: Widowed women are especially at risk for social isolation, since the proportion of older women who are widowed and living alone has risen over the past century. While the trend is attributed to no single factor, it has been suggested it may be affected by age and the degree to which her family (“kin”) is available.
Loneliness is defined as “an unwelcome feeling of loss of companionship, or feeling that one is alone and not liking it” (Forbes, 1996, cited in MacCourt, 2004*). As this definition makes clear, the experience of loneliness is subjective: circumstances that cause loneliness for one person may be experienced as welcome solitude by another. Nonetheless, loneliness in later life affects about 10 per cent of older adults, and is closely related to depression and an ensuing risk of suicide.
Loneliness increases gradually with age, is more common in women and is highly correlated with physical health, although causality is not clear. Other risk factors include low economic status and a lack of security and social networks.
The absence of supportive friendships appears to be a major determining factor for loneliness. Further, widowed men and women report higher levels of loneliness and depression than their married counterparts. However, in older adults who are married vs. those who are single, and among those who have children vs. those who are childless, perceptions of well-being are reported as similar.
Reducing loneliness may be addressed by improving older people’s functional status and socialization, although it is thought that research into coping strategies used by older people who do not experience loneliness may offer further insight into other solutions.
It is widely believed that depression is common in older adults, but in fact prevalence rates vary widely. Mild depression and situational depression (i.e., depression in response to physical or social losses) are more frequent than major depression. Depression is more frequent in older women and people over 85.
Depression in older adults may manifest differently than in younger people, requiring different approaches to identification and treatment. For example, signs and symptoms are often physical rather than emotional, and may include changes in sleep patterns, decline in appetite, weight loss, constipation and minor aches and pains.
Depression in older adults is associated with increased morbidity and mortality, and so is important to notice and address. This requires care, because symptoms of depression in older people may overlap with the symptoms of other conditions or may be seen as a normal part of aging, resulting in the depression’s being overlooked.
Risk of suicide
Older adults over 65 have a higher rate of suicide than other groups, with men at higher risk than women. Other risk factors include depression, anxiety, physical illness, history of stroke, and being widowed and living alone. Uncertainty and fear about the ability to influence one’s own dying and a “weariness of life” may also be risk factors.
While older people are less likely than younger people to indicate suicidal intentions, 50 per cent of suicide attempts by people over 65 are successful (compared to 13 per cent of attempts by people under 50 years).
Sexual orientation and gender identity1
Sexual orientation and gender identity are central aspects of who a person is throughout his or her life, including in old age. When people feel they must keep this aspect of their identity hidden, it prevents them from living and expressing themselves fully. This can have a negative effect on their mental health.
People who are lesbian, gay, bisexual, transsexual, transgender, two-spirit, intersex or queer (LGBTTTIQ) face discrimination from people they know, from strangers and from health care and social service providers. While rates of substance use and mental health problems are high in this community, many people do not access care because of fear of discrimination and stigma. LGBTTTIQ people may have developed alternative family structures of support, which may not be recognized or welcomed by mainstream services. Many of the present generation of older people who are LGBTTTIQ may have hidden lives or go “back into the closet” to avoid facing the discrimination of service providers.
1. This section is adapted from: CAMH Healthy Aging Project. (2008). Improving Our Response to Older Adults with Substance Use, Mental Health and Gambling Problems: A Guide for Supervisors, Managers, and Clinical Staff. Toronto: Centre for Addiction and Mental Health.
In Best practice guidelines for mental health promotion programs: Older Adults 55+