Happily, a number of efforts are now underway to prepare communities and the aging services system for the elder boom. Sadly, mental health doesn’t figure into most of them in any significant way despite the simple and obvious fact that you cannot age well without your mental health.
The new initiatives go by such names as “livable communities,” “age-friendly cities,” or just “modernization.” The beauty of them all is that they are not built on the ageist myth that most older adults are poor, decrepit, and disabled. Instead, they assume, what is true, that most older adults are relatively healthy (give or take a few chronic conditions), able, even skilled, experienced, energetic, and interested in getting the most out of life. So, livable communities, age-friendly cities, and other modernization initiatives focus on social and recreational opportunities, creative activities, and opportunities to be productive through paid or volunteer work. They also focus on such mundane, but very important matters as transportation, access to shopping, and affordable housing. With regard to health, they stress access to health care for all and various services and supports for those older adults who need help in order to continue to live where they want—in the community.
But mental health is barely an afterthought. Yes, there are passing references to mental health in some of these initiatives—usually to depression and Alzheimer’s Disease—but the references are almost always brief and superficial.
For example, AARP’s Livable Communities: An Evaluation Guide, an admirable document in most ways, says only that affordable mental health services should be available for people with “chronic depression” who cannot get adequate help from clergy or “friendly community members” and that, for people with Alzheimer’s Disease, home health and day care programs are useful and that freestanding nursing homes may be necessary for those who cannot afford continuing care communities.
Obviously, this is not all that needs to be included in a livable community or an age-friendly city to respond to the mental health needs of older adults. What else should be available?
Information and referral about geriatric mental health as well as long-term care services is a very important resource for individuals and families who are often at a total loss when it comes to mental health problems. This should include telephonic crisis intervention, particularly suicide prevention, since older adults are more likely to take their own lives than any other population.
Mental health education in community settings is also very important so that older adults and their families can learn what mental illness is, that it can be successfully treated, and where to turn for help.
Mental health maintenance and promotion activities, such as the kinds of recreational, social, and vocational activities included in most modernization initiatives, are important to help older adults maintain or recover their mental health. There are also new products available, some of which may be effective, to improve or at least maintain cognitive functioning as one ages.
Mental health services integrated into primary health care practices are essential to help the majority of older adults who go to their family doctors first for help. Although some providers are quite skilled, mental and substance use disorders usually go undetected and untreated or are treated inappropriately in primary care practices. Screening for mental and substance use disorders and having mental health professionals on-site who follow up with patients being treated for mental illness both contribute to positive outcomes.
Mental health services integrated with home health care, including screening, referral, and in-home intervention can result in improved care and reduction of placements in nursing homes.
Adequate mental health services in assisted living facilities and in nursing homes result in improved quality of life for individuals and for others living in the same facility. Some of these facilities provide good care, but there is a widespread consensus that mental health needs are usually not addressed well.
Housing alternatives to nursing homes especially for people with co-occurring serious physical and mental health problems are needed and could reduce the number of unnecessary placements in nursing homes and provide continuity of caring relationships, especially for those who are currently served in mental health facilities.
Support for family caregivers, who provide 80% of the care for people with disabilities and who are at high risk for depression, anxiety, and physical illness reduces mental and physical illnesses and delays nursing home placements by up to 18 months. Family support is needed for working age adults caring for aging parents, older adults caring for grown up mentally disabled relatives, and grandparents raising grandchildren.
Accessible and affordable mental health treatment services, particularly services in people’s homes and in community settings to which they go for other purposes such as houses of worship and senior centers, could result in older adults and their families getting needed treatment they are likely not to get currently.
Mental health services should be integrated into aging services programs such as adult protective services, senior housing, naturally occurring retirement communities (NORCs), social adult day care, and senior centers. These settings offer opportunities for screening, referral, on-site treatment, and even on-site integrated physical and mental health services.
Culturally, as well as clinically competent mental health services, including services in the client’s primary language, are critical to be able to adequately serve people from minority cultures, whose numbers are growing rapidly.
Older adults can be good service providers for other older adults who have mental health or substance use problems. Communities should be making efforts to engage older adults in help-providing roles. This includes retired professionals and paraprofessionals and retired people who need to learn new skills and have special roles in order to be helpful to their peers.
It is unfortunate that mental health services and supports of the kind noted above are not included in efforts to develop communities that are conducive to living well in old age. Including them, we believe, vastly increases the likelihood that older adults of the next generation will age well. Hopefully, the structural blinders, stigma, and ageism that now result in the neglect of mental health will fall away soon, before it’s too late to meet the mental health challenges of the elder boom.
Michael B. Friedman is the Director of the Center for Policy, Advocacy, and Education of The Mental Health Association of New York City. He is also Chair of the Geriatric Mental Health Alliance of New York. Kimberly A. Williams (formerly Steinhagen) is the Director of Advocacy for the Center and Director of the Geriatric Mental Health Alliance. The opinions in this article are their own and do not necessarily represent the opinions of The Mental Health Association. They can be reached at center@mhaofnyc.org.
