There is an assumption that mental health problems are a ‘normal’ aspect of ageing but most older people do not develop mental health problems and they can be helped if they do.
While a significant number of people do develop dementia or depression in old age, they are not an inevitable part of getting older. Factors that contribute to increased risk of mental health problems in older adults can include:
- Disability or mobility problems.
- Major physical or chronic illness.
- Excessive alcohol use.
- Significant events, such as recent hospital admission or bereavement.
- Decline in social activity, loneliness and social isolation.
- Financial difficulties and fuel poverty.
- Less support available due to smaller family size and living alone.
Below we highlight two of the most common mental health problems in older people – depression and dementia. More detail on all-age mental health can be found in the Mental Health and Wellbeing chapter.
It is predicted that 3,591 Bexley residents aged 65+ suffer from depression (8.7% of the older population) and 1,136 are predicted to have severe depression (2.7%). As the population ages within Bexley, the number of people affected by depression is expected to increase.
Figure 63: People aged 65+ predicted to have depression/severe depression in Bexley, projected to 2035
Source: POPPI, Crown Copyright 2016
This, however, may be a significant underestimation. Nationally, it is estimated that depression may affect as many as 1 in 5 older people living in the community and 2 in 5 living in care homes. Age UK estimate that, nationally, about 3.5% of older people live in care homes. Based on an estimated 41,000 older people living in Bexley in 2018, this could equate to as many as 7,900 older people in the community and 570 older people in care homes with depression.
Depression is three times more common in people with end-stage renal failure, chronic obstructive pulmonary disease and cardiovascular disease than in people who are in good physical health and it is more than seven times more common in those with two or more chronic physical conditions.
 Royal College of General Practitioners, Mental Health Toolkit, Fact Sheet on ‘Management of depression in older people: why this is important in primary care’, originally published Feb 2011. Review date: June 2017
 Better Mental Health For All – A public health approach to mental health improvement, Faculty of Public Health and Mental Health Foundation, 2016
 This is based on an estimated 1,435 older people living in care homes (3.5% of the older population in 2018) with up to 40% of them estimated to suffer with depression. This leaves an estimated 39,565 of Bexley’s older population living in the community of which up to 20% are estimated to suffer from depression.
The latest predictions show that there are estimated to be 3,041 people aged 65+ living with dementia in Bexley; this is expected to rise to 4,659 in the next 20 years, representing about 8% of the estimated older population by 2035. In addition, more than 50% of older people predicted to have dementia will be aged 85 and over by 2030.
Figure 64: Predicted number of Bexley residents aged 65+ living with dementia by age group, 2017 – 2035
Source: POPPI, Crown Copyright 2016
In 2016/17, there were 1,941 people on GP practice registers with a diagnosis of dementia in Bexley. This represents 0.81% of the total practice population of 238,439 in that year.
It is estimated that around 70% of people with dementia in Bexley have been diagnosed and recorded on GP dementia registers. Bexley’s dementia detection rate is 14th lowest in London. This highlights the importance of raising public awareness of the condition, as well as ensuring earlier identification and diagnosis of people with dementia. More detail on local risk factors, prevalence, and impact on local services can be found in the JSNA Dementia chapter.
What are we doing about it?
GP Practices in Bexley: Local GPs give treatment and care for both physical and mental health and also explore other options, which may include referral to mental health services provided in the Bexley area or self-referral for support and advice to organisations in the voluntary sector, including our social prescribing service called ‘Community Connect’.
Mind in Bexley: Mind in Bexley aims to make a positive difference to the mental health of people in Bexley, working in partnership to provide a range of services to help people tackle the challenges they face. This includes providing:
- The IAPT (Increasing Access to Psychological Therapies) service, commissioned by NHS Bexley CCG, for people experiencing mild to moderate depression and anxiety.
- A Recovery College, which is accessed via referral from either a Bexley GP, health practitioner or social worker, and provides a range of courses and workshops to empower people with mental health problems to become experts in their own recovery.
- Emotional support, peer support activities and information and advice to relatives and friends caring for someone aged 18+ experiencing mental ill health and/or drug and alcohol problems in Bexley.
Oxleas NHS Foundation Trust: Oxleas provides mental health and learning disability services to people living in Bexley. These services are provided in a variety of settings. This includes a dementia intensive care unit at Queen Mary’s Hospital in Sidcup, which cares for adults and older adults with complex needs and behaviour related to their dementia. Longer term support and care is provided within the community mental health recovery service. Oxleas also provide a service to adults over 65, including people with dementia, helping people to achieve their personal goals and continue to live as independently as possible.
South London and Maudsley NHS Trust: SLaM provides specialist services to people living in Bexley, including support around substance misuse and neuropsychiatry and memory services.
Bexley Ageing Well Strategy: The strategy sets out how the Council is working with partners to develop an effective suite of prevention programmes that support people to live and age well. The strategy brings together practical examples of existing initiatives and projects being delivered in the Borough to promote personal and community resilience, and self-care. This includes information about current support services available in the community for people with dementia and their carers:
- Supporting dementia carers to be more active through free swimming memberships and reduced price admission on other leisure centre activities.
- Supporting older people and those with dementia through physical activity.
- Library groups and reminiscence sessions.
- Crossroads Care South East London – Memory Lane Café
- Alzheimer’s Society Bexley – Dementia Support Workers and Advisers, Dementia Café, Singing for the Brain group, and other Carer, Peer and Activity Support Groups.
The strategy also sets out future priorities for action (see Section 16 – Community Voice for more information).
Oomph! Sessions – Oomph! sessions provide regular exercise classes for older people and those with dementia. They are adapted for people with various levels of fitness and ability to enable them to do the same class. Oomph! sessions in Bexley are delivered at leisure centres after referral from the Alzheimer’s Society or the Bexley Memory Centre. Oomph! Sessions are delivered all over the country in care homes, supported living and community-based settings. Oomph! Programmes provide accredited on-site training, equipment and resource packs, on-site and telephone support and peer networking opportunities.
 NHS England, The Improving Access to Psychological Therapies Manual, June 2018
 NHS England and NHS Improvement, A Practice Primer on Mental Health in Older People, Sept 2017
9.4 What works and best practice?
NICE Quality Standard on mental wellbeing and independence for older people: This quality standard covers interventions to maintain and improve the mental wellbeing and independence of people aged 65 or older, and how to identify those at risk of a decline. Where people are at risk of decline, the NICE quality standards suggest that tailored, community based physical activity programmes and activities that promote social participation should be offered to reduce the risk of decline in individuals’ mental health and wellbeing.
Increasing Access to Psychological Therapies: University of East Anglia provide IAPT Older People’s training resources. This includes a compendium about how to make IAPT more accessible to older people and Clinician’s guides to Cognitive Behaviourial Therapy with older people. The older people’s IAPT positive practice guide provides best practice guidance to therapists and top tips on commissioning IAPT services for older people. Age UK also promote talking therapies with key information and video clips available on their website. NHS England have published an IAPT manual to improve the delivery of, and access to, evidence-based psychological therapies within the NHS. This describes the IAPT model in detail and how to deliver it with a focus on the importance of providing NICE-recommended care.
A Practice Primer on Mental Health in Older People: NHS England and NHS Improvement have published ‘A Practice Primer on Mental Health in Older People’ for GPs and health professionals in primary care, which highlights symptoms often attributed to ‘old age’ but where a mental health diagnosis and follow-up is more appropriate. The publication is supported by the Royal College of GPs, the Royal College of Psychiatrists, the British Geriatrics Society and Age UK.
Living Well with Dementia and the Dementia Challenge: Nationally and locally, there is increasing focus on dementia as an issue, in terms of prevention, diagnosis and treatment, quality of care and support, and social attitudes towards people with dementia. This includes a range of initiatives and programmes that seek to spread best practice and improve the care and support available for people with dementia and their carers from diagnosis through to end of life care. In 2016, the government published a refreshed nursing strategy, setting out how nurses can provide high quality compassionate care and support for people with dementia so they can live well with dementia within all care settings. The government has also published a guide to the support people should get from local services in England. As well as action at an individual level, there are examples of larger scale interventions, such as the development of Dementia Action Alliances, networks of trained Dementia Friends and the development of dementia-friendly towns, buildings and communities.
Alzheimer’s Society – A dementia-friendly London by 2022: The Alzheimer’s Society held its first annual Dementia Friendly London Summit at the Greater London Authority on 21 May 2018. Alzheimer’s Society is working with the GLA, London Health Board and other partners to achieve a dementia-friendly capital city by 2022.
 NHS England, Resources on Dementia: https://www.england.nhs.uk/mental-health/dementia/
 Department of Health and Social Care, After a diagnosis of dementia: what to expect from health and care services, May 2018
 LGA Resources for creating dementia-friendly communities: https://www.local.gov.uk/creating-dementia-friendly-communities-resources
 Alzheimer’s Society, How to become a recognised dementia-friendly community
Figure 65: Progress in achieving a dementia-friendly London, May 2018
Source: Alzheimer’s Society and Greater London Authority / London ADASS, May 2018
What are the gaps?
Increasing Access to Psychological Therapies: Psychological therapies are as effective for older people as for those of working age. However, despite IAPT services being open to all adults, older people are underrepresented amongst those accessing services. Analysis of national data shows:
- The proportion of older people (65+) referred to IAPT services is lower than the proportion in the general population.
- Once referred, a greater proportion of older adults complete treatment than their working age counterparts.
- Older people achieve good outcomes from IAPT treatment.
In 2016/17, data for Bexley shows that over 65 year olds accounted for about 5% of IAPT referrals and the proportion of over 65’s completing their first treatment, who then went on to finish their full course of treatment was 59%. This was higher than the proportion of younger adults (45%) who went on to complete their full course of treatment.
Table 18: IAPT Referrals by age group in Bexley, 2016/17
Source: NHS Digital, Feb 2018
NHS England has highlighted a number of barriers that may deter older people from accessing IAPT services. These include perceptions held by some older people that psychological therapies are not relevant or helpful in addressing their problems or practical barriers to access (e.g., in terms of mobility and sensory problems). It’s also possible that IAPT services have not been sufficiently promoted among older people.
Dementia Challenge 2018-2021: In 2018, there is evidence of an upward trend in the number of complex individuals with dementia, both in the community and in care homes. A range of services and sources of support are available to people with dementia and their carers in Bexley but there is a need to improve co-ordination between services and integrate care pathways to provide a more proactive and personalised approach that meet the needs of people with dementia and their carers. Key priorities have been identified around helping people to achieve independence and live well with dementia, better coordination of care and support, and preventing admissions to hospital and care homes. A variety of work streams are underway to increase public awareness of dementia, enable earlier diagnosis and utilise the voluntary sector. A new Dementia Strategy and Action Plan is being developed for the Borough to ensure we continue to focus on the right areas in the future and deliver the ‘step-change’ required.
- Review the range and breadth of mental health and wellbeing support available to ensure these remain appropriate to tackle instances of depression, the effects of loneliness and low level anxiety. Ensure mental health pathways are clear to all partners, so that residents experience the impact of integrated working.
- Work with providers to improve and promote access to psychological therapies for older people.
- Develop and implement a new Dementia Strategy and Action Plan to ensure we continue to focus on the right areas and deliver the ‘step-change’ required to meet the growing challenge of dementia.
- Further explore the steps required to become a dementia-friendly community and engage with a wide range of partners and communities to work towards achieving this ambition. One of the first steps is to form a Local Dementia Action Alliance (as recommended in the Dementia chapter).