Socio-economic disadvantage and poverty

Chapter 5 is the first of three chapters exploring the impact of age related risks affecting particular sub populations of older people. Socioeconomic disadvantage in later life tends to reflect a lifecourse status. It amplifies what is already present. In 2016/17 one million older people were living in poverty; an additional 1.2 million were living just above the poverty line. These numbers are rising. Those aged 85 years or over, frail older people, older women and single older people are particularly at risk. Poor older people are also more likely to live in poor housing and be exposed to fuel poverty. Being poor - and its concomitants - compromises mental health in a number of profound ways. It undermines an older person’s capacity to make choices, retain independence, save for a crisis, maintain social contacts and be digitally included. It is linked with worry, loss of control over life and shame. Poor older people are at heightened risk of isolation and loneliness, stress, anxiety and depression. The UK has a weak policy record, compared with other developed countries, of sustainably and coherently addressing poverty in later life. One of the cornerstones of doing so is a continued commitment to the basic state pension as a fundamental building block of a secure old age. Addressing poor housing is also pivotal.

Introduction

Despite much emphasis on mental illness in later life, limited work has focused on mental health. This book aims to address this deficit by exploring, and explaining, mental health outcomes in later life through the lens of critical social gerontology and via the conduit of life course analysis. It adopts an approach underpinned by a commitment to understanding, and making visible, the role of lifecourse, and age related inequalities in creating or amplifying risks to mental health, as well as exploring those issues that afford protection. It aims to offer a critical review of existing discourse and disrupt the ‘taken for granted’ paradigm, including in the dementia arena. This approach not only recognises that mental health in later life is a complex multi-dimensional issue that cuts across time, cohort, social categories and individual experiences but that it is affected by a wide range of lifecourse and age related issues. It also encourages the development of understanding that adopts a wide lens of analysis and of policy and service related responses that reduce risks to mental health during the lifecourse and in later life itself. Further, it engages with the potential to learn from older people’s perspectives and lives.

Conceptualising dementia

The way dementia is conceptualised influences the wellbeing and treatment of people living with the condition. The traditional neuro-degenerative model has increasingly been challenged. Significant contributions include the 1970’s concepts of malignant social psychologv and personhood, the 1990’s drive to engage with the social model of disability, and the recent development of the social citizenship approach. Not only has this new paradigm widened the conceptual lens through which dementia is viewed but it has incorporated issues, beyond the biomedical, that extend our understanding of dementia as a situated condition and lived experience. It is situated in relationships, a lifecourse and a socio-political context and is shaped by inequalities and limited engagement with rights and social justice. Dementia is a multi-dimensional phenomenon and requires a response that addresses its clinical, psychological, social and political dimensions. The new paradigm helps re-focus policy, care and research on the person rather than the condition; relocates the ‘problem’ from the individual to societal structures, attitudes, policy and services; demands new forms of critical practice; and engages with the perspectives of people living with dementia. Whilst there are dementia specific policies in the UK they have limited legal traction and are not integrated with other relevant policies.

The fourth age, frailty and transitions

One of the implications of an ageing population is the growing number of people aged 85 years and over. This cohort is increasingly described as belonging to the fourth age: a life stage that ‘demarcates experiences that occur at the intersection of advanced age and impairment’. The fourth age intersects with frailty: a biomedical status characterised by multiple impairment, decline and dependency.26 per cent of those aged 85 years and over are considered to be frail. The losses and challenges that accompany the fourth age, including becoming frail, can be conceptualised as transitions. Physical, psychological and experiential transitions tend to multiply in the fourth age and to co-occur. The fourth age, frailty and transitions intersect in a complex and mutually reinforcing way posing a profound challenge to mental health and psychological wellbeing. Autonomy, agency, dignity, independence, identity, choice and control are all threatened. Older people’s accounts draw attention to a need to accommodate both change and continuity and to preserving selfhood. A discourse dominated by a focus on ill health and frailty tends to obscure the influence of the lifecourse, including inequalities, on health outcomes. A policy and practice focus on ‘managing frailty’ is a key example.

Conclusion

In the conclusion, ways forward, located in five cross cutting domains, are proposed. Firstly, if many of the factors that place an older person at risk of impaired mental health are lifecourse and age-related inequalities it is axiomatic that policy should address these. Secondly, as the link between inequalities and health is accepted in the public health field, adopting a public mental health approach may hold considerable potential. There is also scope to refocus policy, services and practice in the dementia arena, including public and policy acknowledgment that some dementia risks are located in the lifecourse. Thirdly, when services are offered within the context of an older person’s lifecourse and life narrative it is possible to adopt a truly person-centred approach that upholds dignity and promotes quality of life. Refocusing research lenses is a fourth issue. This includes developing a concept of ‘late lifeadversity’, engaging to a greater degree with older people’s perspectives and effectively capturing links between lifecourse factors and mental health outcomes. Fifthly, there is a need to make visible the neo-liberal values that underpin policy. Mental health in later life is a political issue as well as a research, policy, service and health related concern.

The impact of age-related risks and inequalities on mental health in later life

In broad terms there are two sets of age-related risks to mental health. The first set are those arising directly from experiences and losses common to later life, including physical ill health and/or disability, being a carer, retirement, and bereavement. These are associated with impaired psychological wellbeing and heightened risk of depression, particularly amongst older people with few economic or social resources. The second set of risks arise from ageism and age discrimination, and their intersection with other types of discrimination such as sexism for older women. Direct and indirect discrimination is widespread; it is located in all areas of society including health and social care services. It is profoundly damaging to older peoples’ psychological wellbeing and is associated with fear, helplessness, low self-esteem, anxiety and depression. It is also linked to exclusion, marginalisation and abuse. In recent years there have been efforts to ensure that older people are overtly included in policies intended to improve the population’s physical and mental health; this includes access to treatments e.g. for depression. There has also been a focus on addressing age discrimination in specific arenas e.g. in employment and mental health services. These initiatives have had mixed success.

Demography, topography and mental health problems in later life

Chapter 1 offers an overview of the UK’s socio-demographic and policy context. The UK has an ageing population that is increasingly diverse and heterogenous. Whilst for many older people health outcomes have vastly improved since the introduction of the welfare state, prevalence of ill health does increase with advancing age. The number of older people living with dementia is 850,000, a figure expected to rise to over 2 million by 2051. Disability, pain, chronic physical illness and dementia are risk factors for both depression and suicide. It is estimated that 30 per cent of older people have ‘depressive symptoms’ and that 1 in 8 of all suicides relate to older people. 4 per cent of older people suffer from ‘anxiety disorder’. Although not mental health problems as such, a growth of the number of older people experiencing isolation and loneliness, problem alcohol issues and social exclusion are contributors. In terms of policy, all four UK nations, have specific policies relating to dementia, on the one hand, and policies relating to preventing and treating functional mental health problems on the other. The former tends to be older age focused whilst the latter extends across the whole adult lifespan.

Abuse, mistreatment and neglect

Between 2% and 10% of all older people are estimated to be victims of abuse. Isolation, frailty, dementia and dependency are all risk factors. Abuse and mistreatment occur in all contexts - family members are often implicated in domestic settings and paid workers in care settings. Whatever its aetiology abuse, in all its guises, has profoundly negative mental health consequences, including depression, anxiety, learned helplessness and post-traumatic stress disorder. These are pronounced in situations where exposure to abuse has been long term. At present all ‘types’ of abuse - domestic abuse, sexual violence, institutional abuse, abuse by a relative -are managed under the institutional umbrella of ‘safeguarding’. This model not only uncouples abuse from its (often) lifecourse roots but tends to foreground age as its defining dimension. Most policy related literature does not refer to frailty, socioeconomic disadvantage, gender, or issues of power. As power lies at the very heart of abuse of older people in all contexts this is a profound oversight. Policy and practice responses struggle to accommodate the complex causes of abuse, structural issues, or the perspective of the older person. They also fail to engage with a discourse of rights and social justice.

The life course, inequalities and mental health in later life

Chapter 3 explores the contribution of the lifecourse approach and social gerontology to understanding mental health outcomes in later life. It also explores the role played by health and social inequalities. By bringing these perspectives together the Chapter makes visible the ways in which lifecourse inequality and adversity e.g. childhood abuse, create and/or amplify risks to mental health in later life. It also exposes the embedded and structural nature of causative mechanisms. Health inequalities have profound implications for mental health. People from disadvantaged socioeconomic backgrounds suffer disproportionately from common mental disorders, such as depression, across the whole lifecourse. They are also exposed to higher levels of chronic psychosocial stress which, independently and additively, undermines mental wellbeing. These effects are cumulative over the longer term and in more unequal societies; also by exposure to discrimination and oppression. These arguments challenge the dominance of the ‘inevitable decline’ model of ageing exposing a more nuanced complex set of intersecting risks to mental health that are structurally located and socially produced. The role of policy in addressing health inequalities and their social determinants was a key dimension of mental health policy until 2011; since then it has become increasingly uncoupled from the policy agenda.

Promotion and prevention

Mental health in later life is promoted and protected by a range of factors. Protective personal attributes include positive self-esteem, self-efficacy, resilience and mastery. The positive psychological benefits of taking part in exercise is well established, especially in a group. There is a vast literature on the mental health benefits of social relationships, social networks and social participation. It is the quality rather than the quantity of relationships that is protective; having a confidante is especially important. Membership of an accepting faith community, having a meaningful occupation and a reasonable income are also protective. For people living with dementia important factors are social and family relationships; effective communication; and involvement in decisions. How older people protect their mental health is underexplored. Most older people regard prevention and promotion as conjoined; the two fields intersect. Risks and protective factors can be conceptualised as located in the individual, community and national/societal domains. In order for policy to engage meaningfully with preventing mental ill health in later life, it needs to address risks in all three domains and tackle the social determinants of health inequalities. Many risks to mental health in later life are a product of, and are embedded in, the lifecourse.