Mental Health Virtual Issue Editorial
Mental health and well-being in older people
This paper is the second in a series of special virtual issues of the Australasian Journal on Ageing (AJA) to be released on the Internet. This editorial provides a commentary on a collection of papers published in the AJA from 2005 to 2014 on the theme of mental health. Mental health is the 2015 Hot Topic of the Australian Association of Gerontology, a partner organisation of AJA.
The World Health Organisation defines mental health as ‘… a state of wellbeing in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’ . As the key concept in this definition is well-being, this commentary focuses on papers related to these positive aspects of mental health (well-being and quality of life (QOL)) and papers related to factors that prevent well-being in older people (depression, anxiety, loneliness and elder abuse). Over the past 10 years, there have only been a handful of articles on each of these topics. The main focus has been on QOL (seven papers) and well-being (six papers). There were four papers on depression, four on elder abuse, three on loneliness and only two on anxiety. The lack of focus on anxiety is surprising, given this condition is at least as prevalent as depression among older people .
Papers related to dementia were excluded unless it was a secondary focus. As there were approximately twice as many papers on dementia compared to the selected topics combined, we chose to highlight mental health issues that affect older people but receive less attention. Articles on other major mental health issues such as schizophrenia or bipolar disorders were sought; however, none were published within the time frame.
The published well-being literature over the last 10 years has focused on factors that maintain and improve psychological well-being. The importance of social connectedness and the promotion of social activities and networks by service providers to improve client well-being were evident.
In a brief report, Learmonth and colleagues  interviewed 10 frail older women to explore how experiences of community benefit emotional well-being. Both having support and supporting others within the community enhanced a sense of belonging. As the overarching theme appeared to be social interaction, the authors suggested that service providers increase community-based activities and opportunities for social interaction.
As part of a longitudinal cohort study that began in 1978, Wilhelm et al.  explored the ways in which baby boomers maintained well-being and life satisfaction at the 30-year follow-up in 2008. Satisfied older people attributed their well-being to social connectedness, and knowing what they need to maintain well-being, such as exercise, participation in hobbies and planning for retirement. Planning for retirement was explored by Quine and colleagues  through surveys and focus groups with older people pre- and post-retirement. Those who had been made redundant were more likely to rate themselves as having worse health, lower levels of physical activity and lower levels of social activity than those who had time to plan and more choice in the decision.
Hays  conducted in-depth interviews and focus groups with 54 community-dwelling older adults to explore the ways in which music can maintain emotional well-being. Listening to and/or playing music contributed to positive ageing, positive self-esteem and prevented feelings of isolation and loneliness. Davidson and colleagues  also investigated this relationship in older adults participating in an eight-week singing program. In semi-structured interviews, participants indicated they enjoyed the increased social contact and a sense of belonging and community.
Quality of life
In response to the difficulty in defining QOL, Hambleton and colleagues  reviewed the QOL literature related to older people from 1990 to 2006. The various conceptualisations of QOL measurement were categorised into four subfields – health-related measures, broad measures, disease-specific measures and domain-specific measures. They noted that the subjective views of older people were rarely explored.
QOL measurement detailed in the AJA over the past 10 years has predominately been health related. In a longitudinal study by Byles and colleagues  between 1996 and 2002, health-related QOL was investigated in older women from urban, rural and remote environments. Health-related QOL scores as measured by the SF-36 declined over time, with steeper drops evident as participants moved into their late seventies. Foottit and Anderson  found strong correlations between perception of wellness and QOL related to general health, mental health and vitality in a sample of 328 community-dwelling older adults. In another survey, Wilkinson and colleagues  found QOL in older people living in low level care in New Zealand was related to feeling positive about entry into residential care, being more physically able, not being depressed and having more family and emotional support. While not using a specific QOL measure, Russell and colleagues  explored caregivers' views about QOL in their relatives with end-stage dementia and found physical health, the physical and social environment and being treated with respect and dignity to be general indicators of QOL.
Over the past decade, five papers in the AJA have focused on depression. Three investigated the role of health professionals and aged care workers in identifying depression in different populations of older people. One evaluated the reliability of a shortened version of the Geriatric Depression Scale .
In 2006, Lewin et al.  conducted a prospective study to examine prevalence, risk factors and service use over 12 months for depression in older adults receiving home care. Participants were either newly referred for Home and Community Care services or undergoing routine reassessment. While the prevalence rate was higher than previously reported (62%), the authors posited several explanations that require further investigation. However, the outcomes highlighted the critical role that home care agencies can play in detecting depression in home care populations.
Snowdon and colleagues  found that awareness of depression among staff in residential care increased through the routine use of the Cornell scale for depression in dementia (CSDD). However, very few management strategies were implemented or monitored as a result. A need for staff education and policy implementation was identified to ensure the CSDD is used to its full potential. Rees and colleagues  also highlighted this need after surveying eye health professionals and rehabilitation workers about their knowledge of depression and their confidence in working with patients with depression. Symptoms of depression were often missed or not distinguished from symptoms of other health conditions, and staff appeared to lack confidence in discussing depression with patients and their families.
Anxiety has similar prevalence rates to those seen in depression; however, noticeably fewer studies have focused on anxiety, with no research published between 2005 and 2012. Matheson and colleagues  examined the psychometric properties of the Geriatric Anxiety Inventory (GAI) in Parkinson's disease (PD). The GAI performed well in psychometric evaluation against the Speilberger State Trait Anxiety Inventory and the Diagnostic and Statistical Manual Edition IV diagnoses of anxiety disorders. The GAI proved more appropriate for PD patients than the other anxiety scales as it does not include questions on somatic symptoms, which are present in both PD and anxiety states, and could create confusion in making an accurate diagnosis.
As a result of the lack of investigation into the impact of anxiety on QOL, Sarma and Byrne  investigated this relationship in 40 older people with mental health disorders. Anxiety, as measured through the GAI, correlated with decreasing QOL in the psychological, social and emotion domains of the World Health Organization Quality of Life Scale. Depression correlated only with the environmental domain, suggesting that anxiety may have a greater impact in QOL than depression. Given the small sample size however, further investigation would be required.
In the past 10 years, three papers in AJA have focused on loneliness among older people. Two were cross-sectional surveys that sought to determine the prevalence of loneliness and associated factors among community-dwelling older people. The third evaluated the use of fact sheets containing self-help information to alleviate loneliness in a retirement village community .
A sample of 353 older people living in Perth, Western Australia, were stratified and surveyed. Loneliness was measured via a direct question about how often the respondent felt lonely, the UCLA Loneliness Scale and the De Jong Gierveld Loneliness Scale. Steed and colleagues  found that 7% of the sample experienced severe loneliness and 31.5% felt lonely sometimes. Living alone and poorer self-rated health were associated with greater loneliness, and social networks were important in alleviating loneliness.
In a more recent study, La Grow and colleagues  investigated the relationship between loneliness and health in a sample of 332 older New Zealanders. Overall, 52% of the sample was found to be either moderately or severely lonely on the De Jong Gierveld scale, and both those who were either severely or moderately lonely and had lower physical and mental health scores, according to the SF-36, than those who were not lonely.
Of the four papers published in the AJA on elder abuse in the past 10 years, two examined perceptions of elder abuse among various groups, one was a prevalence study, and the fourth was a qualitative study exploring the experiences of 16 community-based health and welfare practitioners working with older adults who have experienced abuse .
Boldy and colleagues  conducted a survey of over 1000 health and government organisations, and 129 general practitioners to ascertain the extent of and risk factors associated with elder abuse in Western Australia. An overall prevalence rate of actual or suspected cases of 0.58% was observed over a six-month period. Although consistent with other studies using a survey approach, it was thought to be much lower than the actual prevalence rate, due to stigma and shame associated with elder abuse and limitations of the survey method. Most cases involved more than one type of abuse, with financial and psychological abuse most common. Risk factors included the older person having decision-making disability, being dependent on the abuser and being unable to voice their needs. The study recommended education for both professionals and the general public, and further investment in interventions such as respite care, counselling and advocacy.
Two different elder abuse scenario questionnaires were used in the studies by Helmes and Cuevas  and Dow and colleagues . Both found significant differences between groups in their perceptions of what constituted abuse and/or its severity. Helmes and Cuevas, using a questionnaire with 10 different abuse scenarios, found that general medical practitioners (GPs, n = 48) viewed all types of abuse scenarios as less severe than older adults. The authors thought this might be explained by caution on behalf of the GP to label a situation as abusive before further information was sought. Older adults (n = 40) perceived sexual abuse and neglect as more severe than physical, psychological or financial abuse, which was interesting given the latter two are the most common forms of abuse experienced by older adults.
Dow and colleagues , using the Caregiver Scenario Questionnaire, found that health students (n = 127) were more likely to rate forms of restraint as abusive than practising health professionals (n = 120). Like Boldy and colleagues , they found there was a clear need for further education about elder abuse as less than half the health professionals included in the study, all of whom were working with older adults, had received any education on elder abuse.
Much of the literature on the above topics – depression, anxiety, QOL, well-being, loneliness and elder abuse – focuses on understanding the issues relating to mental health, whether by determining prevalence, understanding risk factors or the role of health professionals in detecting mental health problems. There is less focus on evaluating interventions that alleviate mental health problems or improve well-being or QOL. Interestingly, it is in the well-being literature that the few interventions are to be found. Clearly, social connection is important for older people's well-being, and there is also promise for improved well-being through music interventions.
There is little published research on anxiety, which clearly needs more of a focus, and there was also a notable gap in literature relating to the mental health of family carers. Given this group has the poorest mental well-being of any group in the community , this is a surprising omission.
Mental health is a very broad topic, and many more papers would have been included if we had included dementia, delirium and papers that incorporated a mental health outcome but focused on another topic, such as medication prescription. However, as this commentary shows, mental health has been a topic of interest for AJA throughout the past 10 years, particularly the more positive aspects, such as QOL and well-being.