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

Conclusions and next steps

Conclusions

This evidence review sought to answer the following 3 research questions:

1. How does older adults’ mental health and the access and delivery of older adults’ mental health services compare with other age groups?

2. How has the COVID-19 pandemic affected older adults’ mental health and the access to and delivery of older adults’ mental health services?

3. How do individual characteristics (e.g., ethnicity) affect older adults’ mental health, and the access to and delivery of older adults’ mental health services?

The key conclusions to be drawn from the review are:

While older adults (65+) appear to report better mental health outcomes than younger adults, this might alternatively reflect that they are less likely to report poor mental health. The grouping of all older adults into one age range (e.g., 65+) might also conceal differences across the life course, with tentative evidence suggesting that those in later older adulthood (e.g., 75+) might report poorer mental health outcomes than those in earlier older adulthood (e.g., 65-69).

The COVID-19 pandemic appeared to have a detrimental effect on older adults’ mental health, particularly loneliness.

Older adults with a physical health condition (compared with those without), and who live alone (compared to living with other) indicated poorer mental health for some specific outcomes, (e.g., mental wellbeing, loneliness). Differences based on older adults’ demographics could not be assessed for several characteristics (e.g., ethnic and religious background) as large gaps in evidence were identified.

Several challenges for older adults’ mental health services were identified, including: the varied approach to older adults transitioning from adult to older adult services; low availability and quality of services; and dementia being seen to lead to a neglect of older adults’ mental health.

In terms of psychological therapy referrals, waiting lists and new patients, older adults’ mental health services show signs of recovering following a decrease in these rates during the COVID-19 pandemic.

Large evidence gaps were also identified in relation to demographic differences in older adults’ mental health services.

Limitations of evidence

Lack of evidence

The largest limitation of the findings from this review concerns the lack of evidence to meet some of its aims. The scarcity of evidence concerning older adults’ mental health was also emphasised by stakeholders and other researchers^[136]. A lack of evidence concerning demographic differences meant that strong conclusions could not be drawn, particularly on the basis of LGBTI+ identities, ethnic and religious backgrounds, caring responsibilities and finances and deprivation. Regarding older adults’ mental health services, there was little evidence concerning non-statutory services, with most available evidence regarding statutory services, such as National Health Service wards. There was also a general lack of evidence from during the pandemic, which could be a result of practical issues (e.g., restrictions on in person meetings), and the time taken from collecting evidence to publishing a report.

Inconsistency in methods used to generate evidence

The evidence presented in this review does not allow strong conclusions to be drawn, as there is inconsistency in how the evidence included in the review was generated. For example, the evidence varied in terms of: the mental health outcomes that were focused on (e.g., loneliness, anxiety, mental wellbeing); how a mental health outcome was assessed (e.g., a scale or one question); how older adults were defined (e.g., 55+, 70+); and the groups older adults were compared with (e.g., 18-29 year-olds, 30-59 year-olds). The different points at which data on mental health was collected during the pandemic is also important to consider, as evidence collected two months’ apart might not be comparable due to different restrictions being in place.

Small and unrepresentative samples

Several studies had small or unrepresentative samples. Such samples make it difficult to conclude how meaningful a difference is, or whether the findings can be applied to others not represented in the sample. The SHeS 2016-2019 analyses was conducted to address these issues, as the SHeS 2016-2019 data allowed more robust conclusions to be drawn due to the larger and more representative samples involved. The representativeness of samples during the pandemic should be considered in particular, as many studies had to be conducted online due to restrictions. As older adults might be less likely to be able to get online^[137], those participating in the studies might not be representative of the wider older adult population.

Reliance on self-reported data

When assessing mental health, there is a large reliance on self-reported data (e.g., survey questions). As a result, it is not possible to conclude whether differences between two groups (e.g., younger and older adults) reflect different experiences of mental health, or different willingness in reporting mental health issues. As older adults tend to have more stigmatising views of mental health^[138], they could be expected to underreport their experiences of poor mental health, resulting in the false impression that they experience better outcomes than younger age groups. As such, the findings from self-reported data should be considered with caution.

Lessons learned and next steps

Avoid viewing older adults as a homogenous group

Findings from this review indicated differences (e.g., in mental wellbeing) between older adults of different ages (e.g., 65-69 and 75+). However, older adults were commonly grouped into one broad category (e.g., 65+), which prevents an understanding of how mental health experiences and needs from services change over the course of older adulthood. Relatedly, where evidence was identified, findings indicated differences between older adults who differed in terms of other characteristics (e.g., older men/women, living alone/with others).

Distinguish between dementia and mental health

A clear distinction should be made between dementia and mental health, particularly in older adulthood. Evidence indicated that an older adult’s mental health issues might be neglected if they are diagnosed with dementia. Relatedly, mixed wards (i.e., patients with dementia, mental health issues or both) were viewed as detrimental for older adults with mental health issues. Without making a clear distinction between these, a clearer understanding of each is impeded.

Age-related stigma

Findings from this review indicate that age-related stigma affects older adults in various ways, such as affecting how they are treated in services (e.g., mental health issues to be expected in older adulthood), as well as affecting how they engage with services (e.g., not accessing services due to not wanting to be a burden).

Evidence needs

There is an overall need for more and better evidence concerning older adults’ mental health and mental health services. Specific evidence needs include:

• Greater consistency in the assessment of mental health outcomes (e.g., mental wellbeing, anxiety). For example, if mental wellbeing is consistently assessed with WEMWBS, comparisons across studies are more robust.
• Clearer reporting of older adult samples in terms of age (e.g., narrower older adult age ranges, average age and range in older adult sample) and demographic characteristics (e.g., proportion of men/women, from different ethnic backgrounds).
• More quantitative and qualitative data. Where appropriate, more data from large and representative samples are needed to enable robust analyses and comparisons to be conducted. However, qualitative evidence is also needed to capture the experiences of older adults – and the various people involved in their care – in more detail. Such qualitative data can also mitigate practical issues with quantitative data collection (e.g., insufficient numbers of older adults with specific characteristics being recruited).
• More service data. While more service data are needed in general, data concerning non-statutory services are also particularly needed, as most evidence identified in this review concerned statutory services. Additionally, the ‘Falling Off a Cliff at 65’^[139] project emphasised the need for data concerning the patient journey, such as how many times they are admitted, what issues they had, what treatment they received.
• Clearly distinguishing older adults with dementia and/or mental health issues.

How to access background or source data

The data collected for this social research publication:

may be made available on request, subject to consideration of legal and ethical factors. Please contact social_research@gov.scot for further information.