Dr Alan Maryon-Davis highlights the key recommendations for primary care and commissioners from NICE Guideline 32 on independence and mental wellbeing in older people
Read this article to learn more about:
- how to identify older people who are most at risk of having poor mental wellbeing
- the importance of encouraging, advising, and supporting older people in becoming engaged with their communities.
According to the latest figures, older people in England are living longer than ever.1 The population of the UK as a whole has aged markedly in recent decades. Over the past 40 years, the proportion of people aged 65 years and over has increased by nearly one half and now makes up around 18% of the total population, while the proportion of those aged 75-plus has nearly doubled to 8%.2
Apart from dementia (the topic of NICE Clinical Guideline 42)3 the main mental wellbeing issues for older people are worry and low spirits, which may manifest as anxiety state and depression. A 2013 survey of wellbeing in the UK found that the proportion of older people with anxiety or depression declined in late middle age, but rose again in their 70s and 80s, reaching about 20%.4
According to the Royal College of Psychiatrists, depression can affect 1 in 5 older people in the general community and 2 in 5 living in care homes.5 These problems, in turn, may lead to a disinclination to engage in social activities and a tendency to become isolated and lonely.6 -8 They may also lead to excessive smoking or drinking, with obvious further consequences. A recent meta-analysis of 70 studies found that social isolation, loneliness, and living alone increased the risk of premature death by about 30%.9 A major UK-wide review in 2006 found five key determinants of mental health and wellbeing in later life (see Figure 1, below):10,11
- participation in meaningful activities
- physical health
Low levels of social engagement are a recognised marker for subsequent ill-health.12
The challenge for primary care staff and others who come into contact with older people is to help them build resilience to these potential threats to their mental health, wellbeing, and independence.
Impacts on primary care
Every GP knows that patients with mental health problems make up a large part of their workload, and that many of those presenting with physical symptoms have a large element of psychological overlay. Mental ill-health and physical ill-health often go together, each compounding the other, especially in older people.13 Furthermore, a lack of independence adds significantly to demand for NHS and social care resources, including primary care. If matters reach crisis level, hospitalisation may be required, adding hugely to costs. Clearly, interventions or support that can help to prevent or delay the slide into mental ill-health and the need for healthcare or social care are to be welcomed.
Why guidance is needed
Evidence suggests that there is a widespread lack of awareness of the risks facing this often silent and invisible group of older people, and that much can be done to help them. This can be through helping individuals to build self-confidence, a feeling of self-worth, and a sense of wellbeing by motivating them to participate in social activities and become more involved in their communities. Further evidence suggests that this may help to prevent or postpone a decline into mental and physical ill-health and loss of independence.6
NICE Guideline 32 and primary care
NICE Guideline 32 (NG32) on Older people: independence and mental wellbeing (see Boxes 1 and 2, below) was published in December 2015.14 The recommendations are aimed at all those with a responsibility for, or whose work brings them into contact with, older people; for example, those who work in the NHS (notably general practice, pharmacists, podiatrists, optometrists, community and domiciliary services) and at voluntary organisations. It is also aimed at older people themselves and their families and carers, and a range of local authority services, from social care to housing, and from community safety to leisure.
With regard to primary care, this guideline is not directly concerned with the prevention or clinical management of any particular condition or disability. It is also not concerned with occupational therapy or physical activity, or with assessment for social care or welfare benefits. These topics are dealt with by related NICE guidelines.
Key recommendations for primary care
The recommendations most relevant to primary care cover the following interventions:14
- raising awareness among frontline staff about the risk many older people face of sliding into poor mental wellbeing and loss of independence
- identifying those people most at risk of decline
- encouraging, advising, signposting, and supporting these patients (and their families and carers) in becoming more involved in meaningful activities and engaging with their communities.
A big part of the problem is that many front-line workers, including primary care staff, do not fully appreciate how negative the impact of poor mental wellbeing and lack of independence can be on their older patients' health and quality of life; how much it can 'shrink' an older person's existence and lead to a downward spiral of loneliness, despair, and self-neglect. This applies particularly to staff who do not do home visits or who rarely have time to delve into the detail of their patients' day-to-day lives.
Raising awareness of this issue, not only in staff but also to some extent in the local community, is a crucial role for primary care teams and should be a key element of staff induction and ongoing training.14
One of the biggest challenges is raising people's awareness of mental health problems and loss of independence among older people, and more particularly how it can be prevented or at least postponed. Many people—healthcare and social care staff, voluntary workers, carers, and patients themselves—see these things as inevitable and 'just part of growing old', and think that there is not much anyone can do about it. They are unaware that there are many ways to promote and protect mental wellbeing and to maintain independence in the later years of life.
Identifying those most at risk
Practice staff are in an excellent position to help identify people most at risk of a decline in their independence and mental wellbeing; for example, older people whose partner has died in the past 2 years.14 Box 3 (see below) lists the life events or circumstances most likely to increase this risk.
Box 3: Circumstances that increase the risk of a decline in mental wellbeing in older people14
Older people are more at risk of a decline in their independence and mental wellbeing if they:
- have lost their partner in the past 2 years
- are carers
- live alone and have little opportunity to socialise
- have recently separated or divorced
- have recently retired (particularly if involuntary)
- were unemployed in later life
- have a low income
- have recently experienced or developed a health problem (whether or not it led to admission to hospital)
- have had to give up driving
- have an age-related disability
- are aged 80 or older.
Adapted from NICE. Older people: independence and mental wellbeing. NICE Guideline 32. NICE, 2015.
Reproduced with permission
There are many opportunities in primary care for picking up on these issues and steering the conversation to consider mental wellbeing and independence. It is about knowing one's patients and understanding their circumstances. The NHS Health Check interview might provide an opportunity to identify issues in some patients. Close linkage with voluntary organisations in touch with older people might also bring at-risk patients to light.
Some local authorities have a designated local coordinator (sometimes called a village or town agent or community navigator) who knows the local population well and who can work with general practices, council services, and voluntary organisations to identify older people at higher risk.14
General practitioners and practice staff can do much to encourage, advise, and support older people in becoming engaged in creative, educational, physical, or community activities, and to signpost them towards local opportunities, networks, and services. This means motivating them to get out and get involved, and giving them advice and information to help them to take that first step. The particular role of primary care staff is to help tailor activities to the individual’s needs, circumstances, and clinical condition.14
Group activities that involve engaging with other people in some collective endeavour, using a range of attributes and skills, and different levels of ability or fitness, are most likely to be beneficial in terms of improved mental wellbeing and quality of life.14 The sorts of activities for which there is strongest evidence include singing in a choir (such as a professionally led community choir), arts and crafts (and other creative activities), walking programmes and other group physical activities (see also NICE Public Health guideline PH16, Mental wellbeing in over 65s: occupational therapy and physical activity interventions),15 and intergenerational activities involving, for example, older people helping with reading in schools or young people providing older people with support to use new technologies.
One-to-one approaches include programmes to help people develop and maintain friendships; for example, peer volunteer home visiting programmes, programmes to learn about how to make and sustain friendships, or befriending programmes such as those based in places of worship.16
Training and ongoing technical support that encourages older people to use information and communication technologies such as mobile phones, internet-enabled TVs, and computers is an important way of helping them stay connected and engaged.16
Particular emphasis should be placed on the value and benefits of older people volunteering. There is evidence that volunteering provides the opportunity to socialise, have an enjoyable experience, and help others to benefit from their experience, knowledge and skills, thereby increasing the older person's feeling of self-worth and sense of purpose. Unlocking older people's potential could benefit families, communities, and civil society. As an example, 65% of volunteers in the UK are aged 50 or older and 25% of carers are 60 or older.1,16
Posters and leaflets in the waiting area of health centres can be used to publicise local activities. So too can the practice website or newsletter. Many health centres run activities for older people on their own premises.
Information on local opportunities to get involved in these things is provided through many different channels, e.g. local newspapers or radio; libraries; council 'one-stop shops' and information points; Citizens Advice Bureaux; community hubs such as village halls or places of worship; and other community networks. Much useful information is provided online, either through local websites such as the local authority or local adult learning centre, or national organisations such as Age UK, Independent Age, or the Mental Health Foundation.
Support for older carers
There are estimated to be 1.3 million people aged over 65 in the UK with caring responsibilities, and 670,000 carers of people with dementia, the vast majority of whom are over 60. Research undertaken by Carers Trust found that 4 in 10 older carers stated their mental wellbeing had deteriorated in the previous year; 69% said that caring had a negative impact on their mental health, and many carers felt that there was a lack of choice for the future for both them and the person they care for.17
Carers Trust runs a large network of carers' centres across the nation and offers a wide range of services, including: carer break prescriptions; counselling courses; holistic therapies; mindfulness; caring skills workshops; social activities, and various carer support worker interventions.
Implications for commissioners in England
In moving towards more integrated healthcare and social care services, local commissioners including local authorities and clinical commissioning groups (CCGs) should look for ways to work together to prevent mental ill-health and dependency in their older populations and postpone the need for more resource-intensive or crisis-focused services and interventions.
The Care Act 2014 places a duty on local authorities to promote wellbeing and independence by providing, or arranging for, services to prevent, delay, or reduce care needs.18
These drivers should inform the Joint Strategic Needs Assessment undertaken by the Director of Public Health and Director of Adult Social Services, which in turn informs the local Health & Wellbeing Strategy and local commissioning plans.
Commissioners of primary care services should take account of the recommendations in NICE NG32 in seeking to achieve these goals.
- Loneliness, lack of self-confidence or self-belief, feeling excluded or discriminated against, and low mood are common in older people
- These feelings often lead to a downward spiral of worsening mental wellbeing, increasing risk of anxiety or depression, with a loss of independence and an impact on healthcare and social care services
- Primary care staff can help raise awareness of this issue among those whose work brings them into contact with older people
- General practitioners, practice teams, pharmacists, optometrists, and podiatrists can help to:
- identify older people who are at higher risk of decline in mental wellbeing
- encourage them to participate in leisure, educational, and social activities
- signpost older people to appropriate local facilities and opportunities
- support them in staying engaged and involved, including help with mobility issues and linking to social and community services.
GP commissioning messages
written by Dr David Jenner, GP, Cullompton, Devon
- GPs and their teams are well placed to identify mental health problems in older people and can help address these through personal health plans as required by the dementia domain in the QOF and the unplanned admission DES
- Health commissioners in CCGs should work with local departments of public health to recognise the health needs of the communities they serve through JSNAs and include an assessment of older people's health
- Health and wellbeing boards should then respond to the JSNA and identify the interventions to address those health needs and include the needs of older people in the annual health and wellbeing plan
- Each area can then craft interventions to help support older people through various agencies (e.g sheltered housing, community care workers, and older people's health checks)
- Public health budgets are facing real-time cutbacks so commissioners would be wise to look to charities and the voluntary sector to help intervene to support older people at risk of mental illness (e.g through lunch clubs and befriending services).
QOF=quality and outcomes framework; DES=directed enhanced service; JSNA=joint strategic needs assessment
- Public Health England. Recent trends in life expectancy at older ages: update to 2014. London: PHE, 2016.
- Office for National Statistics. Population Estimates for UK, England and Wales, Scotland and Northern Ireland, Mid-2014—ONS, 2015. Available at: www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/annualmidyearpopulationestimates/2015-06-25 (accessed 8 March 2016).
- NICE. Dementia: supporting people with dementia and their carers in health and social care. Clinical Guideline 42. NICE, 2006. Available at: www.nice.org.uk/guidance/cg42
- Beaumont J, Loft H. Measuring national well-being: health, 2013. London: Office for National Statistics, 2013. Available at: www.ons.gov.uk/ons/dcp171766_310300.pdf
- Royal College of Psychiatrists. Depression in older adults. RCP, 2014. Available at: www.rcpsych.ac.uk/healthadvice/problemsdisorders/depressioninolderadults.aspx (accessed 8 March 2016).
- Windle K, Francis J, Coomber C. Research briefing 39: preventing loneliness and social isolation: interventions and outcomes. London: SCIE, 2011. Available at: www.scie.org.uk/publications/briefings/files/briefing39.pdf
- Beaumont J. Measuring national well-being: older people and loneliness 2013. London: Office for National Statistics, 2013. Available at: www.ons.gov.uk/ons/dcp171766_304939.pdf
- O'Connor S. Over 1 million older people in the UK feel lonely. Age UK, 2014. Available at: www.ageuk.org.uk/latest-news/archive/1-million-older-people-feel-lonely/ (accessed 10 March 2016).
- Holt-Lunstad J, Smith T, Baker M et al. Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci 2015; 10 (2): 227–237.
- Lee M. Promoting mental health and well-being in later life: a first report from the UK inquiry into mental health and well-being in later life. London: Age Concern and the Mental Health Foundation, 2006. Available at: www.apho.org.uk/resource/item.aspx?RID=70413 (accessed 8 March 2016).
- Mental Health Foundation. Fundamental facts about mental health 2015. Available at: www.mentalhealth.org.uk/sites/default/files/fundamental-facts-15.pdf
- Bennett K. Low level social engagement as a precursor of mortality among people in later life. Age and Ageing 2002; 31: 165–168.
- Naylor C, Parsonage M, McDaid D et al. Long term conditions and mental health—the cost of co-morbidities. London: The King's Fund and Centre for Mental Health. 2012. Available at: www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/long-term-conditions-mental-health-cost-comorbidities-naylor-feb12.pdf
- NICE. Older people: independence and mental wellbeing. NICE Guideline 32. NICE, 2015. Available at: www.nice.org.uk/guidance/ng32
- NICE. Mental wellbeing in over 65s: occupational therapy and physical activity interventions. Publication Health Guideline 16. NICE, 2008. Available at: www.nice.org.uk/guidance/ph16
- NICE. Evidence review 1: what are the most effective ways to improve or protect the mental wellbeing and/or independence of older people? Submitted to NICE Guideline 32. Available at: www.nice.org.uk/guidance/NG32/documents/older-people-independence-and-mental-wellbeing-evidence-review-12
- Hannan R. Interventions to support older carers Carers Trust. NICE, 2015. Available at: www.nice.org.uk/guidance/ng32/evidence/expert-paper-2-interventions-to-support-older-carers--ruth-hannan-2242569854
- Care Act 2014. Available at: www.legislation.gov.uk/ukpga/2014/23/contents/enacted (accessed 8 March 2016) G