Older adults' mental health before and during the COVID-19 pandemic: Evidence paper

Older adults’ mental health services

This section focuses on findings related to the access and delivery of older adults’ mental health services.Evidence is first presented about how the access and delivery of older adults’ mental health services compares with other age groups’ services. Research findings are discussed relating to how the access to and delivery of these services were impacted by the COVID-19 pandemic. Last, research is outlined that has compared older adults with different characteristics (e.g., older men compared with older women) in terms of the access and delivery of mental health services.

Compared with other age groups

Accessing mental health services

This review was unable to identify research that directly compared older adults to other age groups in terms of their access to mental health services. Feedback following consultations with third-sector organisations^[105] gave insights into issues that are more likely to affect older adults..

Age-related self-stigma (i.e., when someone holds negative and unfair beliefs about themselves) was particularly emphasised as making it less likely that older adults will access mental health services. For example, seeking help for mental health might affect older adults’ self-esteem, as they might view it as embarrassing or self-indulgent, or as affecting how others view them (e.g., as having lost status or the ability to make decisions for themselves). Relatedly, it was suggested that older adults may feel too proud or stoic to seek help, find it difficult to be open about their mental health, want to avoid being a burden, or believe that other people require the services more.

Knowledge about mental health and support was also indicated in the consultations to affect older adults’ accessing of mental health services. Specifically, compared with younger adults, older adults were suggested to be less aware of signs of mental health issues, modern therapies or treatments for these issues, or how to access mental health support. In research concerning local authorities’ COVID-19 helplines^[106], findings suggested that callers to these helplines were often older, and seemed distressed, anxious and isolated. This finding could therefore suggest that older adults do not have sufficient knowledge about mental health and associated services and, as a result, they reach out to less appropriate services.

Transition to and delivery of older adult mental health services

Evidence concerning the transition to and delivery of older adult mental health services highlighted three key issues. First, the transition from adult to older adult statutory mental health services varies greatly between local authorities, and is indicated to be problematic. Second, there is a lower availability and quality of older adult services compared with adults services. Third, older adults with mental health issues are suggested to be detrimentally impacted when admitted to wards that also see older adults with dementia, compared with wards that only see patients with mental health issues. A key piece of evidence relating to both of these issues is a report from the Mental Welfare Commission for Scotland^[107], which presents findings based on visits to 23 National Health Service wards for older adults with ‘functional mental illness’ (which excludes dementia).

Regarding the transition from adult to older adult mental health services, the variability of the transition was captured in the Mental Welfare Commission for Scotland’s consultations with psychiatrists. Specifically, a third of the psychiatrists reported that a discussion with the patient about the transition occurs at 65, while a minority reported an automatic transfer at 65 (7%) or the patient remaining in general adult services (6%). Other processes for transitions were also outlined, including different cut-offs (e.g., 70) or being dependent on the patient developing further mental or physical health problems. The majority of psychiatrists consulted (24 out of 44) indicated that the patient was involved in the transition decision, and the commission’s report indicated that there was ‘a sense’ that automatic transfers should not occur due to age limits being arbitrary (i.e., not reflecting retirement age). As a result of the transition between adult and older adult mental health services, patients moving between the services were indicated to commonly experience a disruption in their mental health support.

Regarding the availability and quality of older adult mental health support, the psychiatrists consulted for the Mental Welfare Commission for Scotland’s report suggested that, there was a smaller range of social work services, as well as a lack of Crisis Assessment and Support Teams for those in crisis, longer waiting times for multidisciplinary team services, and fewer specialist services (e.g., eating disorders). Staff lacking experience of working with older adults was also highlighted in the Mental Welfare Commission for Scotland’s report, such as nursing staff turnover being seen to result in less experience working with older adults. Research conducted for the Age in Mind project^[108] also found that older adults using mental health services reported experiencing discrimination from health and social care staff, such as overhearing abusive comments, not being believed or listened to, and being made to feel worthless. The Health and Social Care Alliance Scotland consultation with older adults, and those who support and work with them, found that older adults reported that their services were less aspirational^[109]. This was also supported with our consultation with Support in Mind Scotland, who expressed a cultural perception that deteriorating mental health is ‘part and parcel’ of older adulthood.

Concerning dementia and mental health issues, the Mental Welfare Commission for Scotland found that the majority of wards for older people with ‘functional mental illness’ (19 out of 23) reported being mixed wards – i.e., including older adults with dementia and mental health issues – or being mental health wards that regularly admitted dementia patients (e.g., due to bed shortages). Mixing older adults with dementia and/or mental health issues was viewed by staff contributing to the report as negatively affecting older adults with mental health issues. In roundtable discussions conducted as part of the ‘Falling Off a Cliff at 65’^[110] project, participants suggested that dementia takes attention away from mental health issues in older age. Furthermore, in focus groups detailed in the Fragile Foundations report^[111], care staff mentioned that if an older adult is diagnosed with dementia, any mental health issues they might experience are often neglected or attributed to their dementia.

Before and during the COVID-19 pandemic

Specific aspects of the pandemic likely affected older adults accessing services (e.g., fear of catching COVID-19, concern about putting pressure on the National Health Service, increase in remote or digital appointments)^[112].

Public Health Scotland data concerning psychological therapies indicates that the number of adults being referred to and starting therapy and the percentage of older adult referrals seen within 18 weeks all decreased following the start of the pandemic^[113]:

• Regarding referrals of older adults to psychological therapies:
• Regarding the number of older adults starting psychological therapies:
• From these two periods in 2020, the number of older adult referrals for these services increased to 4,855 in April to June 2021.
  • The number of older adult referrals to psychological therapies decreased from 4,083 during January to March 2020 (mainly before pandemic related restrictions) to 2,599 during April to June 2020 (mainly coinciding with the first lockdown).
• Regarding the proportion of older adults seen within 18 weeks of a referral to psychological therapies:
• Concerning numbers of mental health inpatients, there were fewer older adults patients in the 2020/2021 financial year (3,010 in psychiatric specialities, and 8,020 in any specialities), compared with before the pandemic in 2019/2020 (3,250 in psychiatric specialities, and 8,840 in any specialities)^[115].

With regards to dementia, in a roundtable conducted as part of the ‘Falling Off a Cliff at 65’^[116] project, the mixing of older adults with mental health conditions and dementia was suggested to have increased since the previously discussed Mental Welfare Commission for Scotland’s report^[117], which was published shortly before the pandemic. As these mixed wards tend to be viewed as detrimental to older adults with mental health conditions, the increased mixing might have made this situation worse. However, further evidence is needed to confirm the extent to which such wards have become more mixed.

In addition to health services, other services providing mental health support to older adults were likely impacted by the pandemic. Through consultations with older adults and people who work with them, the Health and Social Care Alliance^[118] reported that other agencies and services were more difficult to access during the pandemic, such as social work, housing associations, and community groups (e.g., churches). As a result, some older adults in these consultations indicated that they felt as if they had been left to cope on their own during the pandemic.

Demographic differences

Older adults are not a homogenous group and different characteristics might influence some older adults’ interactions with mental health services.

Experience of mental health services before turning 65

Through our stakeholder consultations as part of the mental health EHRF^[119], older adults who had had experience of accessing mental health support and services before turning 65 were viewed to be at an advantage (e.g., better knowledge about services). As a result, concerns were expressed in these consultations that older adults accessing mental health services for the first time are likely at a disadvantage.

However, in the ‘Falling Off a Cliff at 65’ roundtables^[120], older adults were said to potentially experience a loss of access to or continuity of mental health services when they turned 65 (e.g., community psychiatric nurse support, psychiatrists). As a result, older adults who have been engaged in mental health services in earlier adulthood might experience a reduction or loss in support networks that they have developed over time when they turn 65.

Relatedly, participants in the Age in Mind research project’s focus groups^[121], highlighted that some financial benefits (e.g., Disability Living Allowance) were only available to those who developed a mental health issue before 65. As such, older adults who develop a mental health issue after 65 might experience financial issues as a result, which might have an impact on their mental wellbeing (as indicated in the SHeS 2016-2019 analyses).

Older men and women

Public Health Scotland’s mental health inpatient activity data^[122] provides information separately for older men and women. The data indicates that a higher number of older women were inpatients and discharged in the 2019/2020 financial year. The same pattern was observed in the 2020/2021 financial year with regard to inpatients and discharges from any specialities, although more older men were inpatients and discharged from psychiatric specialities. Despite these differences being observed, it is difficult to draw strong conclusions based on these data, as the figures include inpatients with dementia and the increasingly higher proportion of older women within the older adult population as age increases could explain the differences.

Concern was expressed in our stakeholder consultations that older women’s mental health was not viewed as a sufficiently serious issue, and that even healthcare professionals minimised older women’s experience of mental health issues^[123]. This was specifically mentioned in relation to the greater consideration given to stressors that affect younger women, such as pregnancy and maternity. The Scottish Women’s Convention also spoke with older women as part of a consultation on older women’s mental health in 2021, where several participants stated that they felt insufficiently supported, and that there is an expectation in society that older women should be able to deal with their own mental health issues. However, a service provider participating in the consultation reported having unused capacity to support older women, but had experienced issues in identifying older women who would benefit from the service.

LGBTI+ People

Through our stakeholder consultations^[124], older LGBTI adults were suggested to be concerned about experiencing a lack of understanding from services (including care homes), as well as experiencing discrimination or feeling ‘invisible’, and receiving poorer treatment. This is evidenced as an existing issue in research pre-pandemic. Older LGBTI adults were also suggested to conceal their true identity when engaging with services to avoid stigma and discrimination, as well as due to concerns about the services’ confidentiality (e.g., informing the individual’s family or friends).

Ethnic and religious background

Older adults from Black, Asian and Minority Ethnic (BAME) groups^[125] appear to be overrepresented in mental health services. In the ‘Racial Inequality and Mental Health in Scotland’ report^[126], the Mental Welfare Commission for Scotland present National Health Service data showed that 7% of admissions and detentions to older adult beds were people from BAME groups, compared with 1% of older adults in Scotland being from BAME groups.

In several stakeholder consultations^[127], the lack of information, advice and support provided in languages other than English was raised as an obstacle for some older adults accessing mental health services. These services were also suggested to be insufficiently sensitive to minority ethnic and religious needs of older adults, instead taking a ‘one size fits all’ approach^[128].

Physical health conditions and sensory impairments

Mental health support is suggested to be negatively impacted if older adults also have other health conditions. As outlined earlier in this section, dementia is suggested to have a large influence on older adults’ mental health services. For example, the Fragile Foundations report^[129] indicated that an older adults’ mental health issues might be neglected if they are diagnosed with dementia. This appeared to extend to any physical issues experienced by older adults, as participants in the Health and Social Care Alliance’s consultations^[130] suggested that general practitioners typically focus on older adults’ physical health issues to the detriment of their mental health needs.

Changes to services during the pandemic were also seen to pose specific challenges for older adults with hearing loss. Through a survey conducted during the pandemic of older adults with varying degrees of hearing loss^[131], participants expressed experiencing stress due to the lack of transparent masks available for healthcare staff, as well as highlighting that remote communication was not always suitable due to hearing loss.

Isolation

For older adults who were geographically isolated, or who were digitally excluded, access to mental health services was highlighted to be problematic. In Support in Mind Scotland’s ‘Well Connected Communities’ report^[132], older adults living in rural communities stated that there were transport barriers to accessing in-person mental health support, particularly in the most rural areas, and in the evenings and at the weekends. Through consultations with older adults^[133], older adults were suggested to be more likely to be digitally excluded, and, therefore, excluded from digital forms of mental health support and services, which became the main form of delivery during the pandemic. It should be noted that being geographically isolated and digitally excluded are not mutually exclusive, as older adults living in remote areas might not have access to reliable internet^[134].

Receiving care

For older adults living in care homes or receiving care at home, accessing mental health support or services was considered challenging. The Fragile Foundations report^[135] in particular highlighted this issue through focus groups with care staff working across the independent social care sector. The care staff stated that there was often a neglect of older adults’ mental health in their care plans, and further emphasised that dementia can distract from the mental health needs of older adults receiving care. Supporting the mental health needs of older adults receiving care at home was viewed as particularly problematic, as care staff’s contact with the individual was extremely limited. However, limited time to support older adults was also cited for care home staff, as there were typically competing demands that the staff had to deal with.