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At the request of the Department of Health (DH), the National Institute for Health and Clinical Excellence (NICE) recently produced public health guidance aimed at primary care and residential care on interventions that promote the mental wellbeing of older people.

The guidance focuses on the role of occupational therapy and physical activity interventions in the promotion of mental wellbeing for older people. It has been developed to complement and support, but not replace, pre-existing NICE guidance such as that on supporting people with dementia and their carers in health and social care; managing depression in primary and secondary care and assessing and preventing falls in older people. Most encouragingly it is anticipated that this is the first of a range of NICE public health guidance on the health and wellbeing of older people.

‘Mental wellbeing’ can be a nebulous concept but the definition used in the guidance sensibly follows that developed by NHS Health Scotland as part of their national programme of work on mental health improvement. It includes such concepts as life satisfaction, optimism, self-esteem, mastery and feeling in control, having a purpose in life, and a sense of belonging and support (NHS Health Scotland, 2006).

Public health need and practice
The guidance puts the public health issue into context. It notes there are 9.7 million people aged 65 and older in the UK and that by 2020 one in five UK citizens will fall into this age group. It lists (well known) problems faced by older people during the transition into later life, whilst acknowledging that many older people lead “happy, well-balanced and independent lives”. These should not come as any surprise to anyone living or working with older people and include physical health, financial security, societal attitudes, geographical location, access to support and services and responsibility for the care of others (Age Concern England and Mental Health Foundation, 2004).

Longer lives, unhappier people
Despite better health and wealth over the last 50 years, the report suggests (possibly a paradoxical effect of actually living longer?) that many older people are becoming increasingly dissatisfied, lonelier and more depressed, many living with low levels of life satisfaction and wellbeing (Allen, 2008). A further 40 per cent of older people attending GP surgeries, and 60 per cent of those living in residential institutions are reported to have ‘poor mental health’ (UK Inquiry into Mental Health and Well-being in Later Life, 2006), but a decline in mental wellbeing should not be viewed as a natural and inevitable part of the ageing process.

The UK Inquiry into Mental Health and Well-being in Later Life found five key factors affecting mental health and wellbeing of older people: discrimination (for example, by age or culture), participation in meaningful activity, relationships, physical health (including physical capability to undertake everyday tasks) and poverty.

Discrimination
Discrimination is still experienced by older people despite all the initiatives in place to eradicate it. Direct and indirect age discrimination is evident through reductions in service and investment for older people’s mental health (Mental Health and Older People Forum, 2008). In particular, the Faculty of Old Age Psychiatry (2007) has voiced major concerns about the “piecemeal destruction of specialist services that is unfairly penalising vulnerable patients and their families” and that the DH “appears prepared to watch the ad hoc destruction of specialist mental health services in the NHS to meet financial pressures”.

The report observes commissioning, service provision and regulatory processes still do not consistently reflect established national policy. This reflects the perennial problem of transposing ‘political’ rhetoric into reality, the gulf between which can appear massive if viewed upwards from the clinical ‘shop floor’.

Isolation
The report notes that isolation is a particular risk factor for older people from minority ethnic groups, those in rural areas and for people older than 75 who may be widowed or live alone (Office of the Deputy Prime Minister, 2006). Needless to say social activities, social networks, keeping busy and ‘getting out and about’, good physical health and family contact are among the factors most frequently mentioned by older people as important to their mental wellbeing (Audit Commission, 2004). Providing these groups with appropriate opportunities to engage socially is therefore vital, and the DH note that health and social care services have an important role in promoting and maintaining physical activity, health and independence (DH 2005a, DH 2005b).

Physical exercise
The report notes that regular exercise has beneficial effects on general health, mobility and independence, but is also associated with a reduced risk of depression and related benefits for mental wellbeing, such as reduced anxiety and enhanced mood and self-esteem (DH, 2005c). Physical health and mental health, in turn, also have an impact on older people’s economic circumstances and on their ability to participate in society (Marmot et al., 2003).

Recent guidance for residential care homes reports that the provision of meaningful daily activities can restore and improve the health and mental wellbeing of residents (College of Occupational Therapists and National Association for Providers of Activities for Older People, 2007). Implicit in this is the essence of self determination (about personal routines and activities) and a level of independence despite being in residential care, an essence which if addressed will certainly improve health and wellbeing. For those still living at home, the guidance notes that in England in 2008 reforms to home care will give older people greater independence and the right to choose their own home-helps and personal carers through means-tested personal budgets (DH, 2007).

Local and national initiatives
The guidance suggests there is already a framework of local and national initiatives (emphasising the need for local authorities, health and social care services to prioritise improvement in older people’s services) in place from which initiatives may be developed for older people’s wellbeing, and that central to the success of these initiatives is the involvement of older people in service planning, particularly those groups whose health and wellbeing may be compromised by advanced age or disability (DH, 2006).

Since 2000, empowered by the Local Government Act (2000), local authorities have had discretionary power to promote social, economic and environmental wellbeing, and a duty to engage the local community in community planning. Better Government for Older People is a UK-wide partnership in which older people are key partners. It aims to ensure older people are engaged at all levels of decision making, and in shaping the development of strategies and services for an ageing population.

Another ongoing initiative led by the Department of Health is the Partnerships for Older People Projects (POPP – started in 2005 with a budget of £60m for councils to develop innovative ways to help older people avoid emergency hospital visits and to live independently longer). It aims to shift resources and culture towards earlier and better targeted interventions for older people within community settings. Early findings from POPP pilot sites have demonstrated improved access for excluded groups and greater involvement of older people within steering groups, commissioning, recruitment, provision and evaluation.

Recommendations
The recommendations provide guidance on occupational health and physical activity interventions aimed at promoting the mental wellbeing of older people.

Recommendation 1 – Occupational therapy interventions
Focused on the needs of older people and their carers, this is directed at occupational therapists or other professionals trained to apply the principles and methods of occupational therapy in community and residential settings. The recommended actions are:

• Offer regular group and/or individual sessions to encourage older people to practice and carry out daily activities aimed at maintaining or improving health and well-being. These sessions should:
  - Involve older people as experts and partners
  - Pay attention to communication, physical access, length of session and informality to encourage the exchange of ideas and foster peer support.
  - Take place in a setting and style which best meets the needs of the older person or group.
  - Provide practical solutions to problem areas.
• Increase older people’s awareness of where to get reliable information and advice on meeting healthcare needs, nutrition, personal care, staying active, accessing services and benefits, home and community safety and using local transport schemes. This could be by providing information directly, inviting local advisers to give talks, arranging trips and social activities.
• Invite regular feedback and use it to gauge motivation and refine the content of the sessions.

Recommendation 2 – Physical activity
Again, directed at physiotherapists, registered exercise professionals and fitness instructors and other staff with the qualifications, skills and experience to deliver exercise programmes appropriate for older people, the recommended actions are:

• To offer tailored exercise and physical activity programmes in the community focussing on:
  o Mixed exercise programmes of moderate intensity e.g. dancing, walking, swimming
  o Strength and resistance exercises, especially for the frail elderly person
  o Toning and stretching exercise.
• Ensure that exercise programmes reflect the preferences of the older person.
• Encourage attendance at least once or twice a week by explaining the benefits of regular physical activity.
• Give advice on how older people and their carers can exercise safely for 30 minutes a day (broken down into 10 minute bursts) on 5 days a week or more.
• Invite regular feedback and use it to gauge motivation and refine the content of the sessions.

Recommendation 3 – Walking schemes
This recommendation is directed at GPs, community nurses, public health and health promotion specialists, “Walking the way to health initiative” walk leaders, local authorities and a range of leisure, voluntary sector and community development groups as well as older people themselves. The recommended actions are:

• Offer a range of walking schemes of low /moderate intensity with a choice of local routes suitable for different abilities.
• Promote regular participation as a way to improve mental wellbeing, provide health advice and information on the benefits of walking.
• Encourage and support full participation according to individual needs and preferences.
• Ensure the walking schemes:
  o Are organised and led by workers trained in first aid and in creating suitable walking routes
  o Incorporate a group meeting at the outset to introduce participants
  o Offer opportunities for local walks at least three times a week (timing and location agreed by the participants)
  o Last about 1 hour and include 30-40 minutes of walking plus stretching, warm up and cool down exercises (depending on individuals’ mobility and capacity)
  o Invite regular feedback to gauge motivation and refine the content of the session

Recommendation 4 – Training
This focuses on the training needs of health and social care professionals, domiciliary care staff, residential care home managers and staff and support workers including those in the voluntary sector.

It is directed at those professional bodies and other organisations and individuals responsible for developing training programmes and setting competencies in statutory, voluntary and private sectors, and states that they should:

• Involve occupational therapists in the development of locally relevant training schemes including:
  o Knowledge and application of principles and methods of occupational therapy, health and wellbeing promotion
  o Effective communication skills, including group facilitation and person centred approaches
  o How to use feedback to evaluate and redesign services as necessary.
• Ensure practitioners have the skills to:
  o Communicate effectively with older people, encouraging an exchange of ideas and fostering peer support
  o Encourage older people to carry out daily routines and activities to maintain and improve health and wellbeing
  o Support and develop older people’s ability to carry out daily routines and promote independence
  o Collect and use regular feedback from participants.

Martin Curtice
Consultant in old age psychiatry, Birmingham
Shan Williams
Consultant in old age psychiatry, Bristol

BGS Newsletter, Dec 2008
Issue 19 ISSN 1748-6343 19