This is a third in a series of responses by CMHA Ontario to the discussion document, “Every Door is the Right Door: Toward a 10-Year Mental Health and Addictions Strategy.” This report provides feedback on the strategy from the perspective of meeting the needs of seniors. (August, 2009)
CMHA Ontario’s main report includes our overview response to “Every Door’ and addresses in detail the specific strategic directions and priorities discussed in the discussion document. We have also collaborated with the Wellesley Institute in another report, “Focus on Equity”, to offer advice on how to integrate equity into all aspects of the strategy.
Mental illnesses and addictions affect Ontarians at all ages and stages of life, but some problems develop with age and are unique to seniors. As Ontario’s population continues to age, mental health services and supports for seniorswill increase in demand. In Ontario, there are now approximately 1.5 million seniors, representing 40 percent of Canada’s seniors. That number is expected to double by 2028.
As the population ages, the necessity to address diversity in older adults will become an additional challenge. While all seniors are at-risk of mental health problems due to losses that can accompany aging (loss of family, certain physical capacity, paid work, identity or status, etc.), immigrant seniors, particularly women, are specifically at risk for mental health problems since they are among Canada’s most isolated groups.
Seniors are an at-risk population for mental illness and addictions
The Minister’s Advisory Group should be commended for recognizing the impacts of mental illness and dementia on seniors. The challenge is to ensure that the specific and complex circumstances and needs of older adults – and those who work and care for them, are recognized and addressed.
In addressing the mental health needs of older adults, it is essential to recognize that there are two distinct groups: those growing older who already have a mental illness; and those with age-onset mental illness, most commonly, depression and anxiety disorders related to multiple losses, co-morbidity with chronic disease and medication interactions.
‘Every Door’ makes reference to teenage suicide, but the significant incidence of suicide among older adults is not mentioned. Older persons with depression experience a suicide rate which is five times higher than that of any otherage groups. In Canada, men over the age of 85 have the highest rate of completed suicides.
Older people who are depressed are three to four times more likely to have alcohol related problems than are older people who are not depressed. Between 15 and 30% of people with major late-life depression also have alcohol problems.
Use of medications, both prescribed and over the counter, is higher among older adults and some of the most widely-prescribed medications for seniors are known to be addictive and can cause side-effects.
The integration of mental health, problematic substance use and problem gambling services into a single strategy can serve the older adult population well, if the strategy includes a focus on responding to concurrent and co-occurring conditions in seniors.
Distinguish mental Illness in older adults from dementia
“Every Door” notes that some problems develop with age and are unique to seniors, and that for seniors, the “stigma associated with loss of mental functioning often prevents them from accessing services, leaving them in unnecessary and dangerous isolation.” This leaves the impression that older adults’ mental illness is usually related to cognitive diminishment. The strategy needs to clearly distinguish between dementia and mental illness among older adults. Dementia is primarily a disease of the very old, generally those 80 years and older, as compared to depression and other conditions affecting aging adults.
There are unique opportunities to anticipate issues that may lead to age-onset depression and anxiety disorders; and to intervene early so as to mitigate the consequences of mental illness in older adults.
There is also an important role for peer-based programs among older adults themselves, and for those in the caregiver roles, including adult children, family members and personal support workers.
Transforming the system
Many adult community mental health services do not serve those over 65 years, and there are few age specific older adult community mental health support services outside of the formal psycho-geriatric, acute and long-term care systems. These services are mainly focused on people with dementia . What is lacking are services to support older adults in the community dealing with age-onset depression and anxiety disorders.
Many long-term care facilities are not properly resourced to house seniors with mental illness, despite the fact that supportive housing options are not available as an alternative.
Although there is a desire for implementing best practices, there has been a relative lack of attention in Ontario focused on best practices for seniors (outside of long-term care facilities). Other jurisdictions, such as British Columbia’s Best Practice in Seniors’ Mental Health Program and Policy Design Project, the national Victorian Order of Nurses’ Reach Up, Reach Out Best Practices in Mental Health Promotion for Culturally Diverse Seniors project and the Canadian Collaborative Mental Health Initiative have begun to address this need. Ontario should build on this work and develop our own best practices for addressing mental illnesses and addictions in seniors.
Strengthening the workforce
The shortages of qualified personnel to work with older adults dealing with mental illness is a critical need. Those who work directly with older adults, notably personal support workers, often have little formal education and little training in best practices to meet the needs of older adults with mental illness.
Moreso, community mental health service providers require special training on aging and providing specialized services to older adults.
Address stigma and discrimination
Reducing stigma and discrimination are extremely important when discussing older adults’ mental health. “Every Door” focuses primarily on the needs of children, youth and adults. However in many instances, the specific needs of older adults are not alluded to. The stigma of ageism must be addressed.
While workplace stigma and discrimination are of concern, older adults with mental illness experience significant discrimination in housing. This issue is essential to address.
Build community resilience
Social support is an issue for all older adults, especially those dealing with mental illnesses. Studies have found rates of loneliness in older populations ranging from 20% – 60%. Older adults need opportunities for affordable recreation and other activities that support social inclusion to build social networks and provide social support.