The State of Mental Health and Aging in America

The State of Mental Health and Aging in America

By

Dr. David J. Koehn

Taken from a series of articles on the internet here is a treatise on aging and MH.  Some key facts are: Globally, the population is aging rapidly.

• Between 2015 and 2050, the proportion of the world’s population over 60 years will nearly double, from 12% to 22%.
• Mental health and well-being are as important in older age as at any other time of life.
• Mental and neurological disorders among older adults account for 6.6% of the total disability (DALYs) for this age group.
• Approximately 15% of adults aged 60 and over suffer from a mental disorder.

Older adults, those aged 60 or above, make important contributions to society as family members, volunteers, and active participants in the workforce. While most have good mental health, many older adults are at risk of developing mental disorders, neurological disorders, or substance use problems as well as other health conditions such as diabetes, hearing loss, and osteoarthritis. Furthermore, as people age, they are more likely to experience several conditions at the same time.

Why is Mental Health a Public Health Issue?

The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. Because mental health is essential to overall health and well-being, it must be recognized and treated in all Americans, including older adults, with the same urgency as physical health. For this reason, mental health is becoming an increasingly important part of the public health mission. The mental health of older Americans has been identified as a priority by the Healthy People objectives, the White House Conference on Aging, and the Surgeon General’s report on mental health. The goals and traditions of public health and health promotion can be applied just as useful in the field of mental health as they have been in the prevention of both infectious and chronic diseases. Public health agencies can incorporate mental health promotion into chronic disease prevention efforts, conduct surveillance and research to improve the mental health evidence base, and collaborate with partners to develop comprehensive mental health plans and enhance coordination of care. The challenges for public health are to identify risk factors, increase awareness about mental disorders and the effectiveness of treatment, remove the stigma associated with mental disorders and receiving treatment for them, eliminate health disparities, and improve access to mental health services, particularly among populations that are disproportionately affected.

Mental Health Problems in Older Adults

It is estimated that 20% of people age 55 years or older experience some type of mental health concern. The most common conditions include anxiety, severe cognitive impairment, and mood disorders (such as depression or bipolar disorder. Mental health issues are often implicated as a factor in cases of suicide. Older men have the highest suicide rate of any age group. Men aged 85 years or older have a suicide rate of 45.23 per 100,000, compared to an overall rate of 11.01 per 100,000 for all ages.

Dementia as a Mental Health Issue

Dementia is a syndrome, usually of a chronic or progressive nature, in which there is deterioration in memory, thinking, behavior, and the ability to perform everyday activities. It mainly affects older people, although it is not a normal part of aging.

It is estimated that 50 million people worldwide are living with dementia with nearly 60% living in low- and middle-income countries. The total number of people with dementia is projected to increase to 82 million in 2030 and 152 million in 2050.

There are significant social and economic issues in terms of the direct costs of medical, social, and informal care associated with dementia. Moreover, physical, emotional, and economic pressures can cause great stress to families and careers. Support is needed from the health, social, financial, and legal systems for both people with dementia and their careers.

There is no medication currently available to cure dementia but much can be done to support and improve the lives of people with dementia and their caregivers and families, such as:

• early diagnosis, to promote early and optimal management;
• optimizing physical and mental health, functional ability, and well-being;
• identifying and treating accompanying physical illness;
• detecting and managing challenging behavior; and
• providing information and long-term support to careers.

Risk factors for mental health problems among older adults

There may be multiple risk factors for mental health problems at any point in life. Older people may experience life stressors common to all people, but also stressors that are more common in later life, like a significant ongoing loss in capacities and a decline in functional ability. For example, older adults may experience reduced mobility, chronic pain, frailty, or other health problems, for which they require some form of long-term care. In addition, older people are more likely to experience events such as bereavement, or a drop in socioeconomic status with retirement. All of these stressors can result in isolation, loneliness, or psychological distress in older people, for which they may require long-term care.

Mental health has an impact on physical health and vice versa. For example, older adults with physical health conditions such as heart disease have higher rates of depression than those who are healthy. Additionally, untreated depression in an older person with heart disease can negatively affect its outcome.

Older adults are also vulnerable to elder abuse - including physical, verbal, psychological, financial, and sexual abuse; abandonment; neglect; and serious losses of dignity and respect. Current evidence suggests that 1 in 6 older people experience elder abuse. Elder abuse can lead not only to physical injuries but also to serious, sometimes long-lasting psychological consequences, including depression and anxiety.

The Significance of Depression

Depression, a type of mood disorder, is the most prevalent mental health problem among older adults. It is associated with distress and suffering. It also can lead to impairments in physical, mental, and social functioning. The presence of depressive disorders often adversely affects the course and complicates the treatment of other chronic diseases. Older adults with depression visit the doctor and emergency room more often, use more medication, incur higher outpatient charges, and stay longer in the hospital. Although the rate of older adults with depressive symptoms tends to increase with age, depression is not a normal part of growing older. Rather, in 80% of cases, it is a treatable condition. Unfortunately, depressive disorders are a widely under-recognized condition and often are untreated or undertreated among older adults.

The Behavioral Risk Factor Surveillance System and Indicators

A core public health function related to mental health is the collection of surveillance data that can be used for priority setting and as the foundation for developing public health programs. Through CDC’s Behavioral Risk Factor Surveillance System (BRFSS), states this system is the focal point in collecting data on the mental health of older adults. The BRFSS questionnaire consists of three parts: 1) core questions asked to all 50 states, the District of Columbia, and three territories, 2) supplemental modules which are a series of questions on specific topics (e.g. mental health, adult asthma history, intimate partner violence), and 3) state-added questions that are selected by individual states. There are BRFSS core questions related to mental health that collect information on the prevalence of social and emotional support, life satisfaction, and the number of mentally unhealthy days. An Anxiety and Depression module was developed for the BRFSS to collect additional information on mental health conditions. Most states and three territories used this module to determine the prevalence of current depression, lifetime diagnosis of depression, and lifetime diagnosis of anxiety. Based on this data collection, six key indicator findings are noted below which relate to the mental health of the U.S. population age 50 years or older, with a focus on age, racial/ethnic differences, and sex.

Social and Emotional Support Indicator - Social support serves major support functions, including emotional support (e.g., sharing problems or venting emotions), informational support (e.g., advice and guidance), and instrumental support (e.g., providing rides or assisting with housekeeping).

• Adequate social and emotional support is associated with reduced risk of mental illness, physical illness, and mortality (9). • The majority (nearly 90%) of adults age 50 or older indicated that they are receiving adequate amounts of support.

• Adults aged 65 or older were more likely than adults age 50–64 to report that they “rarely” or “never” received the social and emotional support they needed (12.2% compared to 8.1%, respectively).

 • Approximately one-fifth of Hispanic and other, non-Hispanic adults age 65 years or older reported that they were not receiving the support they need, compared to about one-tenth of older white adults. • Among adults age 50 or older, men were more likely than women to report they “rarely” or “never” received the support they needed (11.39% compared to 8.49%).

Life Satisfaction Indicator - Life satisfaction is the self-evaluation of one’s life as a whole, and is influenced by socioeconomic, health, and environmental factors.

• Life dissatisfaction is associated with obesity and risky health behaviors such as smoking, physical inactivity, and heavy drinking.

• Nearly 95% of adults age 50 or older reported being “satisfied” or “very satisfied” with their lives, with approximately 5% indicating that they were “dissatisfied” or “very dissatisfied” with their lives.

• Adults aged 50–64 were more likely than adults aged 65 or older to report that they were “dissatisfied” or “very dissatisfied” with their lives (5.8% compared to 3.5%, respectively).

• Other, non-Hispanic adults aged 50–64 were the group most likely to report that they were “dissatisfied” or “very dissatisfied” with their lives (9.7% compared to 7.0% of Hispanics, 7.2% of black, non-Hispanic adults, and 5.25% of white, non-Hispanic adults in the same age group).

• Men and women age 50 or older reported similar rates of life satisfaction (4.7% to 5.0%, respectively).

Frequent Mental Distress Indicator- Frequent mental distress (FMD) may interfere with major life activities, such as eating well, maintaining a household, working, or sustaining personal relationships.

 • FMD can also affect physical health. Older adults with FMD were more likely to engage in behaviors that can contribute to poor health, such as smoking, not getting recommended amounts of exercise, or eating a diet with few fruits and vegetables.

• The overwhelming majority of older adults did not experience FMD, in 2006, the prevalence of FMD was only 9.2% among U.S. adults age 50 or older and 6.5% among those age 65 or older.

• Hispanics had a higher prevalence of FMD (13.2%) compared to white, non-Hispanics (8.3%) or black, non-Hispanics (11.1%).

• Women aged 50-64 and 65 or older reported more FMD than men in the same age groups (13.2% and 7.7% compared to 9.1% and 5.0%, respectively).

Current Depression Indicator - Depression is more than just a passing mood. Rather, it is a condition in which one may experience persistent sadness, withdrawal from previously enjoyed activities, difficulty sleeping, physical discomforts, and feeling “slowed down”

 • Risk factors for late-onset depression included widowhood, physical illness, low educational attainment (less than high school), impaired functional status, and heavy alcohol consumption.

• Depression is one of the most successfully treated illnesses. There are highly effective treatments for depression in late life, and most depressed older adults can improve dramatically from treatment.

• Contrary to popular belief, most adults age 50 or older were not currently depressed only 7.7% in this age group reported current depression, and 15.7% reported a lifetime diagnosis of depression.

Lifetime Diagnosis of Depression Indicator - In 2006, adults aged 50–64 reported more current depression and lifetime diagnosis of depression than adults age 65 or older (9.4% compared with 5.0% for current depressive symptoms and 19.3% compared with 10.5% for a lifetime diagnosis of depression, respectively).

• Hispanic adults age 50 or older reported more current depression than white, non-Hispanic, black, non-Hispanic adults, or other, non-Hispanic adults (11.4% compared to 6.8%, 9.0%, and 11%, respectively).

• Women age 50 or older reported more current and lifetime diagnoses of depression than men (8.9% compared to 6.2% for current depressive symptoms; 19.1% compared to 11.7% for lifetime diagnosis).

Lifetime Diagnosis of Anxiety Disorder Indicator - Anxiety, like depression, is among the most prevalent mental health problems among older adults. The two conditions often go hand in hand, with almost half of older adults who are diagnosed with major depression also meeting the criteria for anxiety.

• Late-life anxiety is not well understood but is believed to be as common in older adults as in younger age groups (although how and when it appears is distinctly different in older adults). Anxiety in this age group may be underestimated because older adults are less likely to report psychiatric symptoms and more likely to emphasize physical complaints.

• More than 90% of adults age 50 or older did not report a lifetime diagnosis of anxiety.

• Adults aged 50–64 reported a lifetime diagnosis of an existing anxiety disorder more than adults aged 65 or older (12.7% compared to 7.6%).

• Hispanic adults age 50 or older were slightly more likely to report a lifetime diagnosis of an anxiety disorder compared to white, non-Hispanic, black, non-Hispanic, or other, non-Hispanic adults (14.5% compared to 12.6%, 11%, and 14.2%, respectively).

• Women aged 50–64 years report a lifetime diagnosis of an anxiety disorder more often than men in this age group (16.1% compared to 9.2%, respectively.)

Technical Information

For the past three decades, CDC’s Behavioral Risk Factor Surveillance System (BRFSS) has helped states survey U.S. adults regarding a wide range of health issues and behaviors that affect their health. The crucial information gathered through this state-based telephone surveillance system is used by national, state, and local public health agencies to identify populations that might be most at risk and to monitor the need for and the effectiveness of various public health interventions.

A subset of BRFSS survey questions assesses how many people are experiencing mental health issues, including frequent mental distress, current depression, lifetime diagnoses of both depression or an anxiety disorder, as well as the availability of social and emotional support, which may reduce the risk of emotional distress. BRFSS’s Anxiety and Depression Module used the PHQ-8, a well-validated, brief, self-reported measure for detecting current depression.

The PHQ-8 asked 8 questions about depressive symptoms. This questionnaire is based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) diagnosis of depressive disorders (14). The PHQ-8 is effective for detecting current depression in various races/ethnicities as well as in older adults. For the BRFSS, PHQ-8 questions were modified to be comparable to other BRFSS questions by assessing the number of days in the past 2 weeks the respondent experienced a particular depressive symptom (12, 17). Each question asked about the number of days the symptom occurred in the past two weeks and a score was assigned based on the number of days (0 to 1 days=0 points, 2 to 6 days=1 point, 7 to 11 days= 3 points, and 12 to 14 days=4 points). The scores for each item were summed to produce a total score between 0 and 24 points. A respondent with a total score of ≥10 was defined as having current depression.

While the BRFSS is a useful tool for assessing the mental health of the older adult population, it has some limitations: It excludes people who do not have telephones or are in institutions, such as nursing homes; it may under-represent people who are severely impaired because of the functional capabilities required to participate in the survey; and responses to BRFSS are self-reported and therefore have not been confirmed by a healthcare provider. Despite these limitations, the BRFSS is a uniquely powerful tool to provide the prevalence of mental health issues among older community-dwelling U.S. adults, due to its large sample size and proven reliability and validity. The BRFSS is administered and supported by the Division of Adult and Community Health, the National Center for Chronic Disease Prevention and Health Promotion, and the CDC. For more information, please visit http://www.cdc.gov/brfss.

Next Steps

Older adults are experiencing life satisfaction, social and emotional support, and good mental health which are essential to healthy aging. For those who do need assistance, programs, and services should be accessible and tailored to meet the unique needs of older adults. Public health professionals, while relatively newcomers to the field, have an essential role to fulfill in assuring that the mental health status of the older adult population is monitored through surveillance systems such as the BRFSS. This information then can be used to support evidence-based programs and interventions.

Treatment and care strategies to address the mental health needs of older people

It is important to prepare health providers and societies to meet the specific needs of older populations, including:

• training for health professionals in providing care for older people;
• preventing and managing age-associated chronic diseases including mental, neurological, and substance use disorders;
• designing sustainable policies on long-term and palliative care; and
• developing age-friendly services and settings.

Health promotion

The mental health of older adults can be improved by promoting Active and Healthy Ageing. Mental health-specific health promotion for older adults involves creating living conditions and environments that support well-being and allow people to lead healthy lives. Promoting mental health depends largely on strategies to ensure that older people have the necessary resources to meet their needs, such as:

• providing security and freedom;
• adequate housing through a supportive housing policy;
• social support for older people and their caregivers;
• health and social programs targeted at vulnerable groups such as those who live alone and in rural populations or who suffer from a chronic or relapsing mental or physical illness;
• programs to prevent and deal with elder abuse; and
• community development programs.

In summary, prompt recognition and treatment of mental, neurological, and substance use disorders in older adults are essential. Both psychosocial interventions and medicines are recommended.