Barriers and facilitators

Barriers and facilitators

Mental ill-health is a key unmet need amongst older adults (Abdi et al., 2019): older people are more likely to experience mental health conditions but less likely to get timely access to care than younger adults (Davidson, 2021; Stickland & Gentry, 2016). An estimated 85% of older people with depression did not receive any treatment from the NHS in 2015 (Burns, 2015); and one national survey found that only 1 in 8 older adults believed ‘older people are given the support they need to manage their mental health’ (Independent Age, 2020).

Barriers to accessing mental healthcare 

National evidence suggests that some groups of older adults, such as people aged 80+ and older people from Black, Asian and minority ethnic backgrounds, are more likely to face barriers to accessing mental health services. Older adults with complex emotional needs associated with the diagnosis of a ‘personality disorder’ (Penders et al., 2020) and autistic older adults may also find it harder to access mental health support (Tse et al., 2022).

The Royal College of Psychiatrists suggests that ageism underlies many of the barriers to accessing mental healthcare faced by older people. This occurs through the direct impacts of ageism on older people, the neglect of older adults’ mental health in policy and service provision, and the attitudes of healthcare professionals (The Royal College of Psychiatrists, 2018). Ageism can be (Centre for Ageing Better, 2023a):

  • Institutional: embedded into law, policies and practices of institutions (e.g. the planning of health services)
  • Interpersonal: in the interactions between individuals
  • Self-directed: when someone modifies their behaviour and thinking after internalising ageism

Research literature identified the following barriers to accessing care in addition to general barriers to accessing mental health support. These barriers can occur at a structural, healthcare system and individual level. (add link to Ch2)

Structural

  • Historic underfunding of older people’s mental health services, compared to that of younger adults (The Royal College of Psychiatrists, 2018).
  • Practical barriers to accessing services, such as lack of transport or lack of accessible services for people with reduced mobility.
  • Digital exclusion: many support services and information are online, but 1 in 4 older people do not have internet access at home (Ofcom, 2022).

Healthcare

  • Limited time in consultations, which leads to physical health being prioritised (R. Frost et al., 2019).
  • Healthcare professionals’ perceptions of older people’s mental health, including that older people view depression as a normal part of ageing and that psychological therapies would be ineffective for older people (R. Frost et al., 2019).
  • Perceived lack of services for older people, including community-based services to address the cause of mental health issues (R. Frost et al., 2019).

Individual

  • People may find it difficult to recognise symptoms of mental health conditions (Lynch, 2019).
  • People may be unaware of what support is available (Lynch, 2019).
  • People may perceive that support will not be effective because of their age (Lynch, 2019).
  • ‘Normalisation’ of poor mental health as a result of physical health problems (Centre for Mental Health & Age UK, 2024).
  • Internalised stigma: a 2020 survey of older adults in the UK found that 35% felt uncomfortable or unsure about discussing their mood/mental health with others, often because they felt this was a private issue, they didn’t want to worry anyone and they felt that there was nothing anyone could do about it (Independent Age, 2020).

What do local people say?

Feedback collated by the Service User Network (SUN) shows that older adults in Cambridgeshire and Peterborough feel that mental health services can be disjointed and focuses mainly on dementia, and there is not enough focus on other conditions such as depression, anxiety, and personality disorders (Sidney, 2023a). The SUN Network also raises multiple reasons why older people in Cambridgeshire and Peterborough may feel there is no point in accessing mental health services (Sidney, 2023b), including:

  • The point they are at in their life (feeling that ‘you can’t teach an old dog new tricks’).
  • They have been repeatedly let down by mental health services.
  • They feel that the GP will just prescribe them with medication.
  • They do not believe they would benefit from talking therapies or do not want to share their personal challenges with someone else. People also report that short courses of therapy are not enough.
  • They do not want to be a burden.
  • They do not know where to access support.
  • Waitlists, or the perception that there will be a long waiting list.
  • Fear around dementia and receiving a dementia diagnosis.

Other barriers older people report facing include:

  • Practical barriers: transport is a huge issue, and some older people face digital exclusion.
  • Some services have not been reinstated since the start of the COVID-19 pandemic.
  • Mental health services do not always adapt to suit older people, which means that they have to adapt to be able to use services.
  • Some older feel ‘left behind’ and that they are no longer an important part of society.
  • Some older people do not feel listened to or believed.

Local professionals raise that services should consider how past experiences of older adults (such as in terms of the ‘post-war generation’ or knowledge of historic psychiatric hospitals) can impact people’s perception of mental illness and mental health services. There is limited local research exploring if all older adults experience the same barriers to accessing mental health support.

Reasonable adjustments 

A high proportion of older adults live with sensory impairments (such as hearing loss), disabilities and physical health conditions. This includes some people who have multiple conditions, such mild cognitive impairment and frailty. As a result, many people require reasonable adjustments to be able to access healthcare, such as having a longer time to understand information in appointments or wheelchair accessible clinics (NHS England, 2023b).

Organisations providing public services have a legal duty under the Equality Act 2010 to ensure that disabled people have equal access to their services as people who don’t have a disability. Services must proactively plan what adjustments may be needed, rather than wait to be told (Mind, 2023a).

How many older people are assessed for sensory impairments?

A 2022 audit of the Cambridge Memory and Assessment Clinic looked at 30 patients diagnosed with dementia, to investigate whether they were assessed for sensory impairment. This audit found that only 13% were assessed for visual impairments, and 16% had a hearing assessment; and recommended that there should be greater awareness of sensory impairments among clinicians.

Additional resources

References

Full list of references is included at the end of this chapter.

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