Mental Health Promotion and Risk Reduction Strategies for Mental Disorders in Older Persons: Why Should Governments and Policymakers Care?

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WE HAVE NOT COME VERY FAR

Health and mental health are fundamental human rights that are indispensable to the exercise of other human rights. Every individual is entitled to the enjoyment of the highest attainable standard of health conducive to living a life in dignity [1, 2]. “There is no health without mental health”, according to the World Health Organization (WHO) [3]. Sadly, but not surprisingly, mental disorders remain one of the top ten leading healthcare-related burdens worldwide [4]. Despite mental health systems having functioned in crisis mode for decades, no net reduction in the associated burden has been seen in the past 30 years [4, 5]. Mental illnesses account for at least 18% of the global disease burden, with a projected annual global cost of US$6 trillion by the year 2030 [6]. It is therefore critical that governments and policymakers focus on the scarce resources and time available to create a paradigm shift that emphasizes upstream interventions that have the potential to improve mental health systems and the population’s health. The foundation of this transformation must converge on innovative, evidence-based strategies for prevention of mental health conditions, the promotion of mental health maintenance, the reduction of the impact of psychosocial disability, as well as effective and timely treatment programs for persons who live with mental health conditions [4]. The fundamental human right to mental health has been flagrantly violated for decades with dire consequences to global society, health, and the economy — this must be urgently rectified.

THE CLOCK IS TICKING

Today, there are 703 million people aged 65 or older, a number that is projected to reach 1.5 billion by 2050 [7]. Of these, approximately 20% will have mental health conditions such as dementia, depression, anxiety, and suffer other issues such as substance abuse, often complicated by physical and psychosocial comorbidities culminating in disability [8]. These ominous trends have been accelerated by the COVID-19 pandemic with widespread increases in mental health challenges.

Easily accessible, dependable, and reliable community, hospital-based, and residential mental health care is urgently needed for older persons. Timely access to care, in close proximity to the older person’s family, by a team of collaborative healthcare provider services, who have received special education and training in the care of older persons with mental health conditions, is critical. All care and treatment planning must balance the degree of risk posed to self and others by the older person’s mental health condition with their personal need for dignity, desire for autonomy and independence [9].

The promotion of the mental and psychosocial wellbeing of the older population is in alignment with the WHO’s vision of the Decade of Healthy Ageing (2021–2030) and Sustainable Development Goals (SDGs) [10]. Governments and policymakers must mainstream older persons’ mental health and support for their dignity and human rights [1]. This paradigm shift will require health care providers to work collaboratively as team players with members of other societal sectors such as education, labor, justice, transport, environment, housing, welfare, academia, civil society, and the private sector to pave the way improving the lives of older people, their families, and the communities in which they live.

A PERFECT STORM

Ageism is a massive, but nevertheless conquerable barrier that governments and policymakers must also deal with in order to successfully transform mental health care systems. Ageism is highly prevalent, extremely toxic to the health and dignity of older persons, and very costly to society [11, 12]. A shocking one out of every two people in the world are ageist [13]. Ageism has a colossal, albeit stealthy impact on older people’s as well as global health and the economy [14]. Ageism is associated with poor health outcomes in 95.5% of studies with a strong association between mental health conditions and ageism, particularly depression, as reported by a comprehensive global review of the health consequences of ageism, a meta-analysis with over 7 million participants [15]. Ageism’s staggering annual health care cost in the United States alone is $63 billion; thankfully, health benefits and cost reduction are predicted if ageism’s toxic effects are negated by interventions targeting societal, legislative, and policy changes [16]. The WHO’s Global Report on Ageism outlines three evidence-based strategies for combating ageism — education, intergenerational contact, and changes to policy and laws, which must be adopted by all governments and policymakers. Complex intersections of ageism include mentalism, ableism, sexism, and racism, and other biases, culminating in poor quality of life and premature death [13, 17].

MONUMENTAL GAPS

Monumental gaps in our society permit deeply rooted ageism to stealthily disregard the human rights of older persons, especially those living with mental health conditions. These include inequity in accessing physical, mental, social, and end of life care, work and justice, transportation, safe and inclusive living options, lifelong learning, protection against elder abuse, financial insecurity, abetting the digital divide and climate change and exclusion from lifesaving and life-enhancing research and the collection of meaningful data. These critical elements are relied upon by governments, institutions, corporations, and others to create the current unfair and unjust ageist policies and laws. Exclusion, inequity, debarring, and blatant abuse of fundamental human rights have seriously eroded older persons’ dignity, autonomy, and independence.

IMPACT OF COVID-19

The recent tragedy of the COVID-19 pandemic, superimposed upon decades of deep-rooted ageism, has resulted in a dual pandemic creating a deplorable situation for older people. It has posed a major ethical, moral, and legal challenge to civil society, governments and policymakers, compelling them to examine ways in which they might enhance and protect the basic human rights of older people [18–22]. Abundant cases of older people have been witnessed who were previously functioning well but have struggled to survive and succumbed as a result of the dual pandemic and the ravages of human rights violations. Dreadful and pervasive cases of social isolation, loneliness, insurmountable fear, paralyzing anxiety, and depression have been commonly accompanied by suicidal ideation, suicidal behavior, or requests for medically assisted suicide. This has been frequently compounded by malnutrition, dehydration, deconditioning, and frailty due to sedentariness, resulting in a precipitous decline in the physical and mental health of countless older people, not to mention devastation experienced by their family members and loved ones [11]. Social isolation and physical distancing measures during the COVID-19 pandemic have seriously damaged the cognitive and mental health of people with neurocognitive disorders across the world. Out of 15 studies describing the effects of COVID-19 isolation measures on the health of 6442 patients living with dementia, 60% reported changes in cognition, 93% reported worsening or new onset of behavioral and psychological symptoms, and 46% reporting functional decline in daily activities. Urgent guidance is needed that balances infection control measures with necessary mental health care during pandemic times for this population [23].

Rates of elder abuse have increased during the COVID-19 pandemic [24]. Elder abuse can lead to serious physical injuries and long-term psychological consequences. Approximately one in six people aged 60 years and older have experienced some form of abuse in community settings, with much higher rates in institutions, e.g., long-term care settings, where two in three staff report committing abuse in the past year.

Social isolation, namely the number of relationships and frequency of contact a person has with others, is a risk factor for loneliness, that is, a subjective perception of a lack of meaningful relationships [25, 26]. Social isolation affects 24% of older people living in the community and is considered a major public health priority. It is considered to be as toxic to health as smoking fifteen cigarettes per day, and is causally linked to multiple cardiovascular diseases, anxiety, and depression. Loneliness, which has been reported by 43% of community-dwelling older people, can also lead to depression, alcoholism, and suicidal thoughts, and is known to accelerate cognitive decline, especially during the dual pandemic [27, 28]. In 2017, Medicare reported an additional $6.7 billion in costs that could be attributed to social isolation, which was reported by 14% of older adults in the US [29]. Reported rates of loneliness are at least double among long-term care residents than those of older community-dwelling adults [25].

PAUSE AND REFLECT

By 2050, one in six people in the world will be over the age of 65 [30]. While this demographic shift poses significant challenges to the healthcare, workplace, technology, housing, and other sectors, especially in the post-pandemic world, there are also many opportunities to harness the social and economic power of a multigenerational society. We must seek the key opportunities that accompany this demographic shift to realize the vision outlined in the UN Decade of Healthy Ageing and the SDGs [7]. We must pause and reflect: What are most innovative ways in which we can encourage healthy aging around the world? What are the areas of cooperation in which governments, the private sector, and multilateral organizations can collaborate to support this population? In what creative ways can we enhance the quality of life, and mental and physical health to benefit this growing segment of our population [3]?

THE WAY FORWARD

In the current WHO framework, universal, selective, and indicated preventive measures are all included within primary prevention. Primary preventive interventions in mental health are those targeting risk factors and promoting mental health in individuals without a clinically diagnosable mental disorder. Such interventions may be “universal”, targeting the mental health of the general public regardless of individual risk, and can be applied without professional advice or assistance. In contrast, “selective” interventions target a particular subpopulation known to be at increased risk of mental illness, whilst “indicated” interventions target individuals at high risk of mental illness who are showing sub-threshold clinical manifestations [31, 32]. The promotion of mental health and prevention of mental illness in older persons requires an “all hands on deck” approach. Leveraging the combined resources and capacity of health professionals, local volunteers, the private sector, and many others in a given community setting represents a successful and efficient use of human health resources. Using technological devices, especially during the COVID-19 pandemic, could promote positive mental health during a time when older persons are at the greatest health risk. Providing support to older persons willing to navigate technology can enable them to stay connected to their community, serving as a protective factor against adverse health outcomes [33]. Digital interventions are particularly suited to mitigating psychosocial consequences at the population level. In times of physical distancing, quarantine, and restrictions on social contact, decision makers should develop digital strategies for continued mental health care and invest time and efforts into the development and implementation of mental health promotion and mental illness prevention programs [34].

THE IMPERATIVE

Governments and policymakers can and must implement evidence-based, cost-effective public mental health interventions to promote mental wellbeing and resilience, and to reduce the risk of the development of mental disorders amongst older persons. Currently, preventative interventions in this space are virtually absent, where very few individuals with mental illnesses can gain access to adequate treatment when needed. To this end, an excellent and comprehensive Mental Health Policy review by Campion et al. was recently published, outlining the specific actions needed for preventative mental health, with positive health, social, and economic outcomes predicted if implemented appropriately [6]. While Campion’s review focuses on strategies focused on the general population, we must remember that people are, on average, living longer, and a more specific focus on realizing better mental illness prevention and promotion of mental health strategies is needed to address the needs of older people [35, 36]. Governments and policymakers must build the capacity for preventative mental health services, utilizing health promotion to encourage successful aging [37].

Although most older persons wish to age at home, as their conditions deteriorate this is not always feasible or desirable for all. Having a mental health condition, such as dementia, is a risk for placement in a residential setting, where the physical, social, organizational, cultural, and the care components impact each resident’s daily life and manifestation of neuropsychiatric symptoms and have become particularly prominent during the recent pandemic. Traditional large-scale buildings where residents are segregated and confined within the residence, separated from the community at large and often from other residents with poor outcomes and ineffective in supporting everyday functioning, and may even be harmful. Inactivity, high levels of agitation, depression, and other neuropsychiatric symptoms, use of physical restraint, high levels of psychotropic drugs, loneliness, and stigmatization. There is an urgent need for the development and design of inclusive care environments in which older persons with mental health conditions and psychosocial disabilities can be supported to enjoy their human rights [38].

Older people with dementia, those with serious mental illness, and those with intellectual disability are vulnerable to “bad deaths” due to violations of these rights. An integrated care model that encompasses physical and mental health, palliative care, and social and spiritual support must be on offer, while recognizing that good dying is needs-based and self-determined, i.e., based on what the person needs and wants at the end of life [39].

Governments must be encouraged and supported to adopt policies integrating the promotion of mental health and prevention of mental illness into public health and, indeed, general social policy [40]. The stigma of ageism stealthily harms global health, the economy, violates human rights, creates inequity and injustice, results in a loss of dignity, causes intergenerational conflict, and creates a barrier to policies that promote healthy ageing. Ageism intersects with ableism, mentalism, sexism, and racism, causing poor quality of life and premature death, compounding disadvantages over the course of individuals’ lives [11]. Stigma results in a lack of attention from governmental policymakers and the public, which then results in a lack of resources and morale, decaying institutions, lack of leadership, inadequate information systems, and inadequate legislation [40]. The WHO global report on ageism [13] recommends three evidence-based interventions to combat ageism which must be adopted by all governments and policymakers: 1) education, both formal and informal, at various levels during each individual’s formative years (primary school to university, formal and informal) to help provide more accurate information and refute stereotypical examples to enhance empathy, dispel misconceptions, and reduce age-based prejudice; 2) intergenerational contact interventions, known to reduce ageism, intergroup prejudice, and stereotypes by nurturing communication between people of different generations; and 3) policies and laws to reduce ageism by strengthening policies and legislation to address age discrimination, inequality, and human rights laws. Older people, especially those with mental health conditions, have largely been ignored in human rights frameworks. This requires governments to adopt modifications of the existing instruments — which currently permit age discrimination — and new instruments at the local, national and international level. There is an urgent need for all governments to support and ratify a UN convention on the rights of older persons [41]. This could guide governments on ways to protect each older person’s rights. It could form a basis for policy, programming, public awareness, and education.

LEAVE NO ONE BEHIND

As the world grapples with surviving the COVID-19 pandemic, the emerging mental health crisis is plaguing the world. At the heart of this decades-long mental health crisis are major gaps in legislation, policies, and practices driven by stigma that predominantly target older people. The central transformative promise of the UN’s 2030 Agenda to “Leave No One Behind” remains a very elusive goal [42]. Evidence-based interventions designed to prevent or reduce the risk of common mental health conditions and psychosocial disability are already available and should be scaled up [43, 44]. Governments have a major role to play in joining the campaign to end ageism and the human rights violations of older persons.

A UN convention provides the legally binding protection of older persons’ rights under international law, which views them as rights holders. It acts as an anti-discriminatory tool to challenge negative stereotypes and enforces the view of older people as individuals with knowledge, power, wisdom, and experience. A UN convention could guide the Government on ways to protect each older person’s rights. This could form a basis for policy, programming, public awareness, and education. Government has a role to play in joining the campaign to end ageism and the human rights violations of older persons, including those with mental health conditions and psychosocial disability.

Currently, strong biases are entrenched in people’s hearts and minds as institutional ageism. They are in the form of policies and laws that currently dominate the outlook of, and opinions available to individuals and, indeed, society at large. These biases strongly influence how older people, especially those with mental health conditions, are perceived and treated. “All hands on deck” will be needed to succeed at combatting ageism and mentalism, to help every human being to think, feel, and behave more positively towards older persons. This is in alignment with the UN’s Decade of Healthy Ageing (2021–2030), calling for a global collaboration of Sustainable Development Goals that brings together governments, civil society, international agencies, professionals, academia, the media, and the private sector to improve the lives of older people, their families, and the communities in which they live.

Funding: The article was written without external funding.

Conflict of interests: The author declares no conflict of interest.

About the authors

Kiran Rabheru

Author for correspondence.
Email: kiranrabheru@hotmail.com
ORCID iD: 0000-0003-0467-3715

MD, CCFP, FRCP, DABPN, Geriatric Psychiatrist, Professor of Psychiatry, Department of Psychiatry, Chair, Steering Group, Chair of the Board

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