Mental Health Services For Older Adults Research Articles

Scanning the horizon: How might the psychological needs of the older adult population change in the recovery stage of the Covid-19 pandemic? Part two: Covid-19 and PTSD

This document was developed by clinical psychologists working in community older adult mental health services during Covid-19. Born out of discussions about what the profession should expect during the recovery phase, the present authors decided to write a document to inform and guide those working in psychological services on identifying and working with changes in the population’s mental health needs. This document focuses on the likely role of clinical psychology and is structured in two parts. The second part addresses the potential for patients to experience post-traumatic stress disorder (PTSD) and how we can assess and treat PTSD in these populations.

Scanning the horizon: How might the psychological needs of the older adult population change in the recovery stage of the Covid-19 pandemic? Part one: Covid-19 and complicated grief

This document was developed by clinical psychologists working in community older adult mental health services during Covid-19. Born out of discussions about what the profession should expect during the recovery phase, the present authors decided to write a document to inform and guide those working in psychological services on identifying and working with changes in the population’s mental health needs. This document focuses on the likely role of clinical psychology and is structured in two parts. The first part highlights the possibility of an increase in the prevalence of complicated grief before outlining how to work psychologically with it.

The experiences and perspectives of older adult mental health professional staff teams when supporting people with young-onset dementia.

Background. The diagnosis of young-onset dementia presents significant challenges both for the person and their families, which often differ from the challenges faced with late-onset dementia. Evidence of the experience of service users and carers tends to reveal a negative appraisal of the care received, citing longer diagnosis times, poor clinician knowledge and lack of age-appropriate care. However, evidence looking into staff experiences of supporting someone with young-onset dementia is relatively scarce. The aim of this study was to explore the experiences and reflections of health and social care staff who support people with young-onset dementia within older adult mental health services, and whether their knowledge of the systems they work in could reveal the existence of barriers or facilitators to young-onset dementia care. Methods. Health and social care professionals working with people and carers with young-onset dementia across England were remotely interviewed between September and December 2021. Data were analysed using inductive thematic analysis. Findings. Sixteen staff members were interviewed. Three themes were constructed with six sub-themes. The first theme related to the perception of greater complexity around young-onset dementia support. The second theme describes staff fears around their ability to effectively support people with young-onset dementia, including the perception that young-onset dementia requires specialist input. The final theme describes systemic and structural inefficiencies which provide additional challenges for staff. Conclusions. Providing effective support for people with young-onset dementia and their families requires adjustments both within the clinician role and mental health services. Staff considered young-onset dementia support to be a specialist intervention and felt the services they work for are suited to generic mental health and dementia provision. Findings are discussed with recommendations relating to developing a standardised model of dementia care for young-onset dementia which recognises and responds to the unique experiences of young-onset dementia.

Evaluating the effectiveness of trauma-informed care training delivered to staff in community Older Adult Mental Health Services

Purpose By older adulthood, the majority of individuals will have experienced at least one traumatic event. Trauma-informed care (TIC) is proposed to improve effectivity of health-care provision and to reduce likelihood of services causing retraumatisation. This study aims to assess the effectiveness of staff training in TIC in older adult services. Design/methodology/approach TIC training was delivered across eight Older Adult Community Mental Health Teams in the same UK organisation. Questionnaires were administered before and after training: a psychometrically robust measure, the Attitudes Related to Trauma-Informed Care, was used to assess TIC-related attitudes, and a service-developed scale was used to measure changes in TIC competence. Data was analysed using linear mixed effects modelling (LMM). Qualitative data regarding the impact of training was gathered one month after training through a free-text questionnaire. Findings There were 45 participants, all of whom were white British. LMM on pre- and post-data revealed that staff training significantly increased competencies across all measured TIC domains. Overall, staff attitudes were also significantly more trauma-informed after training. Qualitatively, staff identified time as the only additional resource required to deliver the skills and knowledge gained from training. Practical implications Training was found to be effective in increasing TIC-related skills and attitudes. Organisations aiming to become trauma-informed should consider staff training as one aspect of a wider development plan. Originality/value To the best of the authors’ knowledge, this paper is the first to examine TIC training for staff working in Older Adults Mental Health Services. Recommendations for services aiming to develop a trauma-informed culture have been provided.

The relationship between older adults’ perceptions of ageing and depression: a systematic review

Purpose Perceptions of ageing towards the self and towards others can positively and negatively impact an older adult’s mental wellbeing. This paper aims to consolidate literature examining the relationship between perceptions of ageing and depression in older adults to inform both practice and policy for older adult mental health services. Design/methodology/approach Quantitative research articles examining perceptions of ageing and depression in older adults were identified through searches on three electronical databases, alongside forward and backwards citation searches. A total of 14 articles involving 31,211 participants were identified. Findings Greater negative attitudes towards ageing were associated with higher levels of depressive symptoms and greater positive attitudes towards ageing were associated with lower levels of depressive symptoms or higher levels of happiness. However, the causal direction of this relationship could not be determined. Studies demonstrated that perceptions of ageing also act as a moderator in the relationship between depression and health status, hopelessness and personality traits. Future research should attempt to examine the relationship between perceptions of ageing and depression in older adults to attempt to identify the causal direction of this relationship. Originality/value This is the only systematic review the authors are aware of consolidating literature which explores the relationship between older adults’ perceptions of ageing and depression. It is hoped that these findings will be able to inform both policy and practice to improve older adults’ care and support for depression.

Severity and symptoms of depression in older adults presenting to mental health services during COVID‐19 lockdown – an experience from south London region

AbstractBackgroundSocial restrictive measures during COVID‐19 pandemic has influenced people’s mental health conditions across different countries. Global studies indicated an increased prevalence of anxiety disorder and depression with varied impacts among different age groups. Most studies in the elderly have been done via surveys or internet medias missing out on people with no access to digital technology tools. We aimed to investigate the prevalence of depression among elderly people aged 65 years and above who attended mental health service for older adults (MHOA).MethodsRetrospective data was collected from the South London and Maudsley NHS Foundation Trust (SLaM) Biomedical Research Centre (BRC) Case Register for MHOA. Using this large mental health care database in South London, United Kingdom, we identified referrals to MHOA during the first UK lockdown (March ‐ July 2020) and compared those to a corresponding pre‐COVID period (February ‐ July 2019). Logistic regression analysis adjusted for age, gender, ethnicity, diagnosis and living conditions were done to examine association between COVID‐19 lockdown and severity and symptoms of depression.Results536 patients were referred and seen within the MHOA during the first UK COVID‐19 lockdown period compared to 1,455 patients during the pre‐COVID‐19 corresponding period. We found presence of COVID‐19 lockdown had no effect on overall severity of depression but significantly associated with depressive symptoms such as anhedonia (1.64, 95% CI 1.14‐2.37, p = 0.008), lack of energy (1.65. 95% CI 1.65 (1.25‐2.16), p<0.001), tearfulness (1.43, CI% 1.15‐1.78, p = 0.001), agitation (1.32, CI% 1.07‐1.63, p = 0.009), disturbed sleep (1.37, CI% 1.11‐1.70, p = 0.003) and guilt feelings (1.45, CI% 1.04‐2.03, p = 0.030)ConclusionsThere was an increased prevalence of certain depressive symptoms among older adults within MHOA during first COVID‐19 lockdown which implies impact of isolation and possibly physical ill‐health on mental well‐being. This needs to be explored further for potential prevention and managements.

Loneliness in older adult mental health services during the COVID-19 pandemic and before: Associations with disability, functioning and pharmacotherapy.

ObjectivesLoneliness is associated with psychiatric morbidity. Restrictions placed on the population during the first COVID‐19 lockdown may have disproportionately affected older adults, possibly through increasing loneliness. We sought to investigate this by examining loneliness in referrals to mental health of older adults (MHOA) services during the first UK COVID‐19 lockdown.MethodsReferrals to MHOA services from a large South London catchment area were identified for the 16‐week period of the UK lockdown starting in March 2020 and for the corresponding period in 2019. A natural language processing algorithm identified loneliness in the patients' records. We applied logistic regression models adjusted for age, gender, ethnicity and diagnosis, to examine associations of loneliness in the study population.Results1991 referrals were identified, 56.9% of whom were female, with a mean age of 77.9 years. Only 26.9% occurred during the 2020 lockdown, but with a higher prevalence of loneliness (22.0 vs. 17.7%, p = 0.028). In the whole sample, loneliness was associated with non‐accidental self‐injury (Odds ratio [OR]: 1.65), depressed mood (OR: 1.73), psychotic symptoms (OR: 1.65), relationship problems (OR: 1.49), problems with daytime activities (OR: 1.36), and antidepressant use (OR: 2.11). During lockdown, loneliness was associated with non‐accidental self‐injury (OR: 2.52), problem drinking or drug‐taking (OR 2.33), and antidepressant use (OR 2.10).ConclusionsLoneliness is associated with more severe symptoms of affective illness, worse functional problems and increased use of antidepressant medication in older adults. During lockdown, loneliness in referrals to MHOA services increased and was associated with increased risk‐taking behaviour. Loneliness is a potential modifiable risk factor for mental illness, and efforts to minimise it in older adults should be prioritised as we emerge from the pandemic.

Assessing DNA rates for new referrals in older adults

AimsTo assess DNA rates for initial assessment medical appointments offered for new referrals within an Older Adults CMHT.To establish any correlation between waiting time and DNA rates.To establish if the initial appointments offered were in keeping with the National guidelines (18 weeks) and our local Trust policy (1-4 weeks).BackgroundIn the Uk 15% of adults 60 and above suffer from a mental disorder. Despite the increasing mental health burden, analysis indicate that a quarter of mental health trust received less investment from 2017 to 2018. Financial pressures have also increased appointment waiting time. The NHS has stated that by 2023 there will be a 4-week waiting time for older adult mental health services. Current national guidelines state that initial referrals should be seen within 18 weeks.MethodThis is a retrospective audit looking at all first time referrals to an Older Adult CMHT in East Birmingham. 110 patients were included in this audit. Factors recorded included age, gender, reason for referral, waiting time for appointment, and whether this complies with guidelines.Electronic patients' notes (RIO) were used for data collection.ResultOut of 110 new referrals 11 were not offered any appointments. Out of the remaining 99, 13 cancelled and 8 did not attend.In total, 78 attended the initial appointment offered, out of which 77 were seen within 18 weeks as per national guidelines. 43 patients were seen within the 4-week period (trust policy). 1 patient was offered an appointment at 19 weeks and 3 days from the referral date. The patients who did not attend their appointments were followed up except for one, to find out the reasons of the DNA. This included 2 (physically unwell), 1 (unaware of appointment), 1 (refused), 1 (forgot), 1 (couldn't get to clinic), 1 (asthma attack). Another appointment was offered to those who could attend.ConclusionThere was no significant correlation between a longer waiting time and an increased DNA rate for first appointments. Even though the time for an initial appointment was within the NHS guidelines, only 56% of the appointments met our Trust's policy of a 4 week wait.When discussing the results with the relevant team it was clear that a number of factors affected the waiting time including: number of available clinicians and a large catchment area.

Expanding arts therapies provision: a pilot project in Older Adult Mental Health Services, Aneurin Bevan University Health Board

ObjectivesThe aim of the report is to summarise the progress made during a six-month pilot project expanding arts therapies provision from an inpatient service to community services, in a National Health Service health board's Older Adult Mental Health Services, in response to the need for direct therapy with older adults who have severe cognitive impairment and communication difficulties arising from dementia and/or complex mental health difficulties. Study designThis is a case report on a pilot project. MethodsThe level of need for the service was explored, and indicators of effectiveness were gathered using evaluation forms—observer feedback forms and ARM-5 (Agnew Relationship Measure - 5) - to indicate the therapeutic alliance, team review and feedback from colleagues. ResultsTo gather indications about the level of need, we recorded the following: number of referrals (n = 125) and waiting list numbers at the end of the project (n = 34). ConclusionsThis pilot project indicates that there is need for psychological interventions in older adult community mental health services that arts therapies provision can help address. The number of referrals is one indicator of the level of need, and positive feedback from clients, families and colleagues, is an indicator that the team delivered effectively. The areas of client need addressed in sessions as documented in observer feedback forms indicate that for these clients, arts therapies was a valuable resource in addressing challenges arising from mental health difficulties and/or dementia.

New horizons in supporting older people's health and wellbeing: is social prescribing a way forward?

Older people's health and care needs are changing. Increasing numbers live with the combined effects of age-related chronic illness or disability, social isolation and/or poor mental health. Social prescribing has potential to benefit older people by helping those with social, emotional or practical needs to access relevant services and resources within the local community. However, researchers have highlighted limitations with the existing evidence-base, while clinicians express concerns about the quality of onward referral services, liability and upfront investment required. The current article provides a critical review of evidence on social prescribing, drawing on the RE-AIM Framework (Glasgow et al., 1999) to identify questions that will need to be addressed in order to inform both the design and delivery of services and the evolving research agenda around social prescribing. We emphasise the need for researchers and planners to work together to develop a more robust evidence-base, advancing understanding of the impacts of social prescribing (on individuals, services and communities), factors associated with variation in outcomes and strategies needed to implement effective and sustainable programmes. We also call on policymakers to recognise the need for investment in allied initiatives to address barriers to engagement in social prescribing programmes, provide targeted support for carers and improve access to older adult mental health services. We conclude that social prescribing has potential to support older people's health and wellbeing, but this potential will only be realised through strategic alignment of research, local level implementation and national policy and investment.

Clinical supervision in older adult mental health services

Purpose The purpose of this paper is to explore how supervision is applied in the context of National Health Service services for older adults, with particular regard to the profession of clinical psychology and psychotherapy. Design/methodology/approach The clinical supervision theories that are considered in this exploration are the Seven-Eyed Model (Hawkins and Shohet, 2012) and the Cyclical Model (Page and Wosket, 2015). The discussion also integrates an overview of psychological dynamics as presented by the existing literature with the author’s reflections on the influence of ageing stereotypes in the therapeutic work with older adults. Findings The theoretical models of clinical supervision considered can offer a robust framework and pathway for supervisory work in psychology and psychotherapy for older people. However, this alone seems insufficient and needs to be combined with the supervisor’s knowledge on psychology of ageing as well as their own self-reflection on internalised ageing stereotypes. Practical implications The paper suggests a need for health care professionals, providing clinical supervision on older adult therapeutic work, to be familiar with the aspects analysed. Originality/value Clinical supervision handbooks overlook aspects related to age as an issue of difference. This paper adds value to the clinical work with older people through a novel attempt to link implications of ageing stereotypes with the therapeutic and supervisory practice.

Improving Care Provision to Older Adults with Dual Diagnosis: Recommendations from a Mixed-Methods Study

Older adults with dual diagnosis remain an under-diagnosed population in mental health services, with complex needs and high rates of medical comorbidity. Dual diagnosis is a significant challenge to contemporary mental health services, with recognition of the increased rate of relapse and costs of care of poorly managed dual diagnosis identified through comprehensive research. Unfortunately, the research attention paid to those with dual diagnosis in younger age groups has not been replicated in the older adult cohort, with few studies specifically exploring the treatment needs of these individuals. Of the studies that do exist, many identify poor screening and assessment, clinician frustration and a lack of cohesive treatment for co-occurring alcohol and other drug use disorders for older adults. We draw from a mixed methods exploratory study conducted in an inner Melbourne community older adult mental health service providing care to consumers with dual diagnosis to formulate recommendations to improve the care provision to this cohort. We discuss changes to the way older adult mental health services operate that are essential to improve the care and response to consumers presenting with dual diagnosis. Ultimately, we aim to discuss how older adult mental health services can improve to provide timely, responsive care to those with dual diagnosis.

Stepped-care treatment of anxiety and depression in older adults: A narrative review.

Stepped care models are a possible solution to address service gaps in the provision of psychological therapies for anxiety and/or depression. The benefits may be particularly relevant for people in rural and remote areas and other under-serviced and/or hard to reach populations, such as older adults. Narrative literature review. Narrative literature review of the PubMed, Medline, and Psycinfo databases for studies reporting on the results of stepped care psychological interventions for older adults with anxiety and/or depressive symptoms. Seventy-seven papers were identified for evaluation of which nine papers met the study criteria (reporting on four individual trials). We identified four controlled studies. Three of the four studies found stepped care intervention to be associated with significantly better clinical outcomes and cost-effectiveness compared to treatment as usual. Studies primarily targeted subthreshold symptoms, mostly in primary care. Various interventions and stepping models were used. Stepped care has been associated with improved clinical outcomes and costs in older adults, particularly in primary care. There have been no rigorous studies of stepped delivery of psychological interventions to older depressed and anxious adults in alternative settings such as in specialist older adult mental health services or in private clinics. Although the evidence-base for stepped care interventions is growing, it is not clear what evidence-based treatment model should be adopted and in what services it could apply. More research is needed. However, the evidence to date is promising and suggests that stepped care approaches are feasible in older adults, and are likely to increase access to high quality interventions for older adults living in rural communities.

Safe prescribing in cognitively vulnerable patients: the use of the anticholinergic effect on cognition (AEC) tool in older adult mental health services.

Aims and methodMedication with anticholinergic action is associated with potentially serious adverse effects in older people. We present an evaluation of a novel anticholinergic burden scale introduced into routine practice in older adult services in the South London and Maudsley (SLaM) NHS Foundation Trust. Our aim was to assess whether this tool improved the accurate identification of anticholinergic medication and guided safer prescribing in cognitively vulnerable older people. RESULTS: The introduction of the anticholinergic effect on cognition (AEC) tool into clinical practice led to an increase in the identification and reporting to general practitioners of anticholinergic medication from 11 to 85% of cases (P = 0.0015).Clinical implicationsApplication of the AEC tool led to improved detection of anticholinergic medication and advice to primary care on when a medication review is necessary. This is an important step towards improving the safety of prescribing in this patient group.Declaration of interestSLaM NHS Foundation Trust owns both the app and IP for Medichec.

AGING AND MENTAL HEALTH: THE U.S. PERSPECTIVE

AbstractBy 2040 21% of those living in the U.S. will be 65 years of age and older. U.S. citizens come from different cultures and bring with them varying views of aging. However, the U.S. has long been a country with a primary focus on youth. Even though the U.S. population is rapidly becoming older, ageism persists. It is estimated that 20% of the older population experience mental health problems, including dementias, depression, anxiety and substance misuse. However, ageism and mental health stigma create barriers to adequate attention being focused on later-life mental health issues. National health insurance programs reimburse for mental health services for older adults, and recent federal policies have increased insurance compensation for metal health disorders. However, application of the federal policies vary by state, and service gaps still exit. Cultural and political factors impacting older adult mental health services will be considered.

Prevalence of co-occurring alcohol and other drug use in an Australian older adult mental health service.

Co-occurring mental illness and substance use disorder, known as dual diagnosis, is a significant challenge to mental health services. Few older adult specific alcohol and other drug treatment services exist, meaning older adult mental health services may become the default treatment option for many. Evidence suggests that dual diagnosis leads to substandard treatment outcomes, including higher rates of psychiatric relapse, higher costs of care and poorer treatment engagement. This paper explores the prevalence of co-occurring alcohol and other drug (AOD) use in an older adult community mental health service in inner Melbourne, Australia. This aim was accomplished by using a retrospective file audit of clinical intake assessments (n = 593) performed on consumers presenting to the service over a two-year period, June 2012-2014. Of consumers presenting to the service, 15.5% (n = 92) were assessed by clinicians as having co-occurring AOD use. Depression predominated in the dual diagnosis group as the primary mental health disorder. Dual diagnosis consumers in this sample were statistically more likely to be male and younger than their non-dual diagnosis counterparts. A limitation of this audit was the lack of implementation of screening tools, leaving assessment to clinical judgement or the interest of the clinician. This may also explain the discrepancy between the results of this study and previous work. Although appearing to be a relatively small percentage of assessments, the results accounted for 92 individuals with complex mental health, AOD and medical issues. Poor screening procedures in a population that is traditionally difficult to assess need to be rectified to meet the future challenges inherent in the ageing baby boomer generation, changing drug use trends and extended lifespans through harm reduction initiatives and medical advancements.

Stepping up: Implementing psychological therapies and interventions in adult and older-adult mental health services

Widening access while ensuring quality is a particular challenge – especially at a time of austerity. This is just one of many areas in which the NES Psychological Interventions Team has a key role.

Maturing out, natural recovery, and dual diagnosis: What are the implications for older adult mental health services?

In 1962, Charles Winick proposed that addiction was a self-limiting process, whereby individuals stopped using substances once the stresses of life transitions ceased. The notion of maturing out, as labelled by Winick, often forms the basis of the natural recovery movement in alcohol and other drug (AOD) research, aiding the notion that older individuals either cease their substance use or fall victim to the higher mortality rates prevalent in substance-using populations. As more consumers present to adult mental health treatment settings with co-occurring substance use disorders, the idea that individuals will simply cease using AOD is outdated. Given the future challenges of an ageing population, it is prudent to explore those who fail to mature out of substance use, as well as challenge the notion that older adult mental health services rarely encounter substance-using individuals. The present study explores Winick's research in the context of an ageing population and older adult mental health services. It also ponders the proposition put forth in subsequent research that older individuals with lifelong substance use switch to substances that are easier to obtain and better tolerated by their ageing bodies.

Recognising falls risk in older adult mental health patients and acknowledging the difference from the general older adult population

Older adults admitted to inpatient mental health units present with complex mental health care needs which are often compounded by the challenges of living with physical co-morbidities. They are a mobile population and a high risk group for falling during hospitalisation. To address quality and safety concerns around the increased risk for falls, a qualitative research study was completed to obtain an improved understanding of the factors that increase the risk of falling in this patient cohort. Focus groups were conducted with mental health professionals working across older adult mental health services in metropolitan Western Australia. Data were analysed using content analysis and three themes emerged that were significant concepts relevant to falls risk in this patient group. These themes were (1) limitations of using generic falls risk assessment and management tools, (2) assessment of falls risk not currently captured on standardised tools, and (3) population specific causes of falls. The findings demonstrate that older adult mental health patients are a highly mobile group that experience frequent changes in cognition, behaviour and mental state. The mix of patients with organic or functional psychiatric disorders within the same environment also presents complex and unique care challenges and multi-disciplinary collaboration is central to reduce the risk of falls. As this group of patients are also frequently admitted to both general inpatient and aged care settings, the findings are relevant to the assessment and management of falls risk across all health care settings.

Preventing falls in In-Patient Older Adult Mental Health Services: Different Causative Factors in Mental and Neurocognitive Disorders

Aims: To compare falls sustained in two groups of patients (one with mental disorders and the other neurocognitive disorders), in two acute inpatient older adult mental health services in Western Australia (WA). Background: Falls are the most common adverse event experienced during inpatient care. Older people with mental disorders and neurocognitive disorders constitute a high-risk group for accidental falls in hospitals. Methods: Data relating to 207 fall events from 2010-2011 reported in medical records and incident reports were collected. Individuals who sustained a fall were grouped as having a mental disorder (n=73) or neurocognitive disorder (n=134) according to their primary ICD10 diagnosis. Results: Significant differences in the factors that contributed to the fall between the two groups were highlighted. Falls sustained by those with a neurocognitive disorder were due to confusion and disorientation, and psychotropic medication effects. Their falls were more likely to be unwitnessed and injuries were generally less severe. Falls sustained by older adults with mental disorders were attributed to symptoms of their illness or medication side effects and tended to result in more severe injuries requiring medical treatment or further investigation. Conclusions: Older adults with neurocognitive disorders and behavioural and psychological symptoms associated to dementia have different falls risk factors related to their specific illness and cognitive functioning. There is a need for health professionals to receive training to assess, manage and provide appropriate interventions to reduce the specific falls risks in patients with both mental disorders and neurocognitive disorders.