L22 Psychological Medicine Mid-life and later adulthood (Changed 25_3)

Overview

The lecture sets out why mental health care for older adults matters and how it should be framed. It opens with the demography of population ageing (longer life expectancy, falling birth rates, a rising old age dependency ratio) and the “ageing tsunami” of disability, multimorbidity and mental health burden that follows. It then challenges the idea that older adults are a burden, examining ageism, stigma and the social determinants of mental health in later life, with social isolation and loneliness as a major mortality and morbidity risk. The second half is the positive counterweight: the four positive determinants (wisdom, resilience, meaning in life, community engagement), and the framework of positive psychiatry and successful ageing, from the MacArthur model to a broader modern definition. The core source is Reynolds, Jeste, Sachdev and Blazer (2022), “Mental health care for older adults: recent advances and new directions in clinical practice and research”, World Psychiatry 21:336-363, whose key words map the lecture’s territory: positive psychiatry of aging, cognitive aging, neurocognitive disorders, major depression, schizophrenia, substance use disorders, comorbidities, collaborative care, measurement-based care, caregivers.

Demography of ageing

Key drivers:

• A global trend of longer life expectancy combined with lower birth rates.
• An increasing old age dependency ratio, defined as the number of persons aged 65 or over per 100 persons in the working age group. China is given as an example.

Numbers of people aged 65 or over, 2019 to 2050 (UN World Population Prospects 2019), in millions, with percentage change:

Region	2019	2050	Change
World	702.9	1548.9	120%
Sub-Saharan Africa	31.9	101.4	218%
Northern Africa and Western Asia	29.4	95.8	226%
Central and Southern Asia	119.0	328.1	176%
Eastern and South-Eastern Asia	260.6	572.5	120%
Latin America and the Caribbean	56.4	144.6	156%
Australia and New Zealand	4.8	8.8	84%
Oceania excluding Australia and New Zealand	0.5	1.5	190%
Europe and Northern America	200.4	296.2	48%

Numbers of people aged 80 or over, same source, in millions:

Region	2019	2050	Change
World	143.1	426.4	197.9%
Sub-Saharan Africa	3.7	12.4	238.1%
Northern Africa and Western Asia	5.2	20.3	291.0%
Central and Southern Asia	18.5	62.6	239.0%
Eastern and South-Eastern Asia	48.6	177.0	264.1%
Latin America and the Caribbean	12.0	41.4	245.2%
Australia and New Zealand	1.2	3.3	168.4%
Oceania excluding Australia and New Zealand	0.1	0.2	269.1%
Europe and Northern America	53.9	109.1	102.6%

Points to take from the tables:

• The 80+ group grows faster than the 65+ group worldwide (about 198% versus 120%), so the older population is not just larger but older within itself.
• Australia and New Zealand, highlighted on the slide, has the smallest proportional growth in the 65+ group (84%), because it is already an aged population; the regions with the largest percentage growth (Northern Africa and Western Asia, Sub-Saharan Africa) start from a young base.

Share of total population aged 65 or over, 1990-2050 (UN figure, estimates to about 2020 and projections thereafter): every region’s share rises. Europe and Northern America is highest throughout, from roughly 12-13% in 1990 to about 25% by 2050. Australia and New Zealand is next, about 11% rising to about 22%. Eastern and South-Eastern Asia rises most steeply, from about 5-6% to about 22%, converging with Australia and New Zealand. The world line rises from about 6% to about 15%; Latin America and the Caribbean reaches about 17%; Sub-Saharan Africa remains lowest and nearly flat, under 5% throughout. Values read off the graph are approximate.

The “ageing tsunami”

The consequences of this demographic shift, as the lecture frames them:

• Increasing disability.
• Increasing burden of mental health disorders in older adults.
• Multimorbidity: care of older adults is complex and labour intensive, and often involves both physical and mental health conditions.

Ageism, stigma and social determinants

The lecture explicitly names the “common misconception that older adults are a burden to society” as a misconception, and presents ableism, ageism and mentalism as an interlinked triad of discriminations.

The slide presents ABLEISM, AGEISM and MENTALISM as three vertices of a triangle with no explanatory text; the intended relationship between the three terms is not stated on the slide.

Social determinants of mental health in older adults

Negative determinants fall into three groups:

1. Those affecting overall health: nutrition, education, employment, living environment.
2. Those unique to mental health: stigma, mental health care disparity, flawed criminal justice systems, homelessness.
3. Ageing-related social determinants: ageism, workforce shortage, social isolation and loneliness.

Positive determinants (the four developed later in the lecture): wisdom, resilience, meaning in life, community engagement.

Ageism and stigma

Described as “an insidious scourge on society”, and one of the four action areas of the Decade of Healthy Ageing (2021-2030) declared by the UN and WHO.

• Ageism is defined by stereotypes, prejudice and discrimination toward people based on their age.
• It operates at institutional, interpersonal and, with or without these, self-directed levels.
• It causes inequality and has detrimental effects on the individual, the community and society.
• Negative stereotypes are propagated by the general public and by the media.
• These are internalised by older adults and then enacted, creating a vicious circle that results in poorer mental health outcomes.
• Stigma against mental illness is even greater in later life. Example: in the US there are more people with severe mental disorders (excluding dementia) and substance use disorders ageing in prisons and jails than in hospitals.

Social isolation and loneliness

Headline claim: more Americans die from loneliness and social isolation related conditions than from stroke or lung cancer.

From the US Surgeon General’s 2023 advisory “Our Epidemic of Loneliness and Isolation”:

• Lacking social connection is as dangerous as smoking up to 15 cigarettes a day. In the mortality comparison (odds, lnOR; Holt-Lunstad, Robles and Sbarra 2017), the ranking from largest to smallest effect is: lacking social connection (largest, about 0.65) > smoking up to 15 cigarettes daily (about 0.5) > drinking 6 alcoholic drinks daily (about 0.3) > physical inactivity (about 0.2) > obesity (about 0.17) > air pollution (smallest, about 0.05). The comparison groups are high versus low social integration, not smoking versus smoking under 15 cigarettes daily, abstinence versus more than 6 drinks daily, activity versus inactivity, low versus high BMI, and low versus high air pollution. Bar magnitudes are read off the axis and are approximate; the slide itself notes the graph is a visual approximation.
• A synthesis across 16 independent longitudinal studies found poor social relationships (social isolation, poor social support, loneliness) associated with a 29% increase in risk of heart disease and a 32% increase in risk of stroke.
• Chronic loneliness and social isolation can increase the risk of developing dementia by approximately 50% in older adults.

Social isolation is arguably the strongest and most reliable predictor of suicidal ideation, attempts and lethal suicidal behaviour, across samples varying in age, nationality and clinical severity (2010, "The Interpersonal Theory of Suicide").

Wisdom

Definition: a personality trait composed of prosocial attitudes and behaviours (empathy and compassion), self-reflection, emotional regulation, acceptance of uncertainty and diversity of perspectives, social decision making, and possibly spirituality.

Key points:

• Associated with better overall physical and mental health outcomes, including better overall physical and mental health, happiness, and lower levels of depression and loneliness.
• Associated with life satisfaction, subjective well-being and greater resilience.
• Neurobiology: investigations implicate the prefrontal cortex, the insula and the limbic striatum (particularly the amygdala) in the various components of wisdom.
• There is a strong inverse relationship between loneliness and wisdom, especially the compassion component.
• Evidence suggests potential for both individual and societal level interventions to enhance compassion and other components of wisdom in older adults, reducing loneliness and improving well-being.

The illustrative example given is intergenerational contact, “The Benefits of Mixing Aged Care with Child Care”.

Resilience

Definition: a trait or outcome describing recovery or bounce back from adverse situations, or a process of adapting well in the face of adversity, trauma, threats or other sources of major stress.

Key points:

• Sex and widowhood: men experience greater feelings of loneliness and have increased difficulty adjusting to widowhood compared with women. The exception is veterans: male veterans exposed to death while serving in the military show greater resilience and less loneliness than civilian widowers.
• Resilience is associated with better health and functioning and greater longevity in all age groups, but especially in very old adults.
• Framing point on COVID-19: it is a mistake to think of older adults as simply victims during the pandemic; they are more resilient than assumed. [the slide does not identify who “Carolyn”, the quoted speaker, is]

Measuring it: the Grit Scale

A 10-item self-report questionnaire (Angela Duckworth, Grit: The Power of Passion and Perseverance), each item rated across five columns from “Not at all like me” to “Very much like me”.

Reverse scored items (5 4 3 2 1):

1. New ideas and projects sometimes distract me from previous ones.
2. I often set a goal but later choose to pursue a different one.
3. I have a difficulty maintaining my focus on projects that take more than a few months to complete.
4. My interests change from year to year.
5. I have been obsessed with a certain idea or project for a short time but later lost interest.

Forward scored items (1 2 3 4 5):

1. Setbacks don’t discourage me. I don’t give up easily.
2. I am a hard worker.
3. I finish whatever I begin.
4. I am diligent. I never give up.
5. I have overcome setbacks to conquer an important challenge.

The pattern to notice: items describing distractibility and shifting interests are reverse scored, items describing perseverance and consistency are forward scored, so a high total reflects sustained effort and consistency of interest.

Meaning in life

Definition: meaning or purpose in life is the value and importance attributed to one’s own life and activities, and the core significance of one’s personal existence.

Key points:

• Multiple studies show a strong link between purpose in life and better physical, psychological and overall health outcomes, including social engagement in older adult populations.
• Meaning in life is a protective factor against suicide.
• Life review therapy is an individual or group storytelling intervention focused on integrating life stories across different phases of life. An RCT found it significantly improved quality of life in older participants and had a moderate effect on depressive symptoms in older adults.

Across the lifespan (Aftab et al., J Clin Psychiatry 2019, 1042 community-dwelling adults, Meaning in Life Questionnaire): the Presence of meaning subscale stays relatively flat and high with age, while the Search for meaning subscale declines with age. Trends are read from fit lines on a dense scatter plot; exact values are not legible on the slide.

Community engagement

Two structures are given:

WHO Global Network for Age-friendly Cities and Communities: a global network with member countries and individual member cities marked on a world map, including Canada, the United States, Cuba, Colombia, Bolivia, Argentina, Iceland, Finland, the Russian Federation, Belgium, Andorra, Israel, the United Arab Emirates, Sri Lanka, China, Japan, Australia and New Zealand.

Compassionate Communities and Cities: four quadrants around a central hub of “connectedness and shared humanity”.

Quadrant	Components
Compassionate individuals	Mindful awareness and integration; attunement to self and others; kindness and courage; knowledge and skills; wisdom and action
Compassionate relationships	Between family members; patient and caregiver; team members; organisations; systems
Compassionate communities	Solidarity; social attitudes; shared values; sense of belonging; interoceptivity
Compassionate organisations	Policy and structure; leadership and governance; guidance and accountability; economic sustainability

Positive psychiatry and successful ageing

Positive psychiatry is the science and practice of psychiatry that seeks to understand and promote well-being through assessment and interventions involving positive psychosocial factors, in people with or without mental or physical illnesses. Its critical construct for older adults is successful ageing.

The MacArthur model

The MacArthur model of successful ageing, described by John Rowe and Robert Kahn (1987; also 1997, 1998) through the MacArthur Research Network on Successful Ageing, transformed the study of ageing from a discipline focused on disease and decline to one emphasising health and growth. Its central claim is that the lifestyle choices you make now, more than heredity, determine health and vitality.

Three core components of successful ageing:

1. Absence of chronic disease and disability.
2. Engagement with life.
3. Cognitive and physical function.

Contributing domains and their factors:

• Socio-demographics: household income; occupation level; attained education; health insurance.
• Nutrition and lifestyle: not smoking; adherence to a healthy diet; low BMI; high physical activity; quality sleep.
• Psychological factors and self-perceived physical health: optimism; plans for the future; feeling needed; self-rated health; absence of pain.

[the slide labels four contributing domains but only three are legible/listed]

Broader definition of successful ageing

a) Subjective well-being with a low level of perceived stress, perceived stress being the extent to which an individual perceives that current demands or challenges exceed their ability to cope with them.
b) Flourishing, involving eudemonic well-being, including meaning in life and close social relationships.
c) Post-traumatic growth.
d) Sustained remission or recovery in people with severe mental disorders, typically including absence or marked reduction of symptoms along with functional independence.

Ageing is characterised by notable heterogeneity, so the proposed model would not be applicable to all older adults.

Self-test

1. Define the old age dependency ratio.
2. State the two global demographic trends driving population ageing.
3. Compare the projected growth of the 65+ and 80+ populations worldwide between 2019 and 2050, and explain what the difference implies for health services.
4. Explain why Australia and New Zealand shows the smallest percentage increase in its 65+ population (84%) while Northern Africa and Western Asia shows one of the largest (226%).
5. List the three consequences of population ageing grouped under the “ageing tsunami”.
6. Define ageism, naming its three constituent elements.
7. Describe the three levels at which ageism operates and the vicious circle by which it worsens mental health outcomes.
8. Name the initiative for which combatting ageism is one of four action areas, and give its years.
9. List the three groups of negative social determinants of mental health in older adults, with examples of each.
10. Name the four positive social determinants of mental health in older adults.
11. Give the evidence that stigma against mental illness is greater in later life.
12. Rank lacking social connection, smoking up to 15 cigarettes daily, obesity and air pollution by their mortality effect size.
13. State the increases in risk of heart disease, stroke and dementia associated with poor social relationships or chronic loneliness.
14. Explain why social isolation is significant in suicide risk assessment in older adults.
15. Define wisdom and list its components.
16. Name the brain regions implicated in the components of wisdom.
17. Explain the relationship between wisdom and loneliness, and why this makes wisdom a target for intervention.
18. Define resilience.
19. Distinguish the experience of widowhood in men, women and male veterans, and state what this suggests about resilience.
20. Describe the Grit Scale, including how forward and reverse scored items differ in what they describe.
21. Define meaning or purpose in life.
22. Describe life review therapy and the outcomes an RCT found for it.
23. Distinguish the lifespan trajectories of the Presence and Search subscales of the Meaning in Life Questionnaire.
24. List the four quadrants of the Compassionate Communities and Cities model and the construct at its centre.
25. Define positive psychiatry.
26. List the three core components of successful ageing in the MacArthur model.
27. List the contributing domains of the MacArthur model with two factors from each.
28. Explain what the MacArthur model changed about the study of ageing, and its central claim about heredity.
29. List the four elements of the broader definition of successful ageing.
30. Define perceived stress as used in the broader definition of successful ageing.
31. Explain why the successful ageing model cannot be applied to all older adults.
32. An 82 year old man is referred after his wife’s death six months ago. He lives alone, has stopped attending his bowls club, and describes feeling that his life no longer matters. Using the lecture’s framework, identify the risk factors present and the positive determinants that could be targeted.
33. A health board proposes cutting funding for an intergenerational programme placing a childcare centre inside an aged care facility, arguing it has no clinical benefit. Using the lecture content, construct an argument against the cut.
34. Integrative: explain how ageism, social isolation and successful ageing connect, tracing the pathway from societal attitude to individual health outcome.

Answers

Reveal answers

1. The number of persons aged 65 or over per 100 persons in the working age group.
2. Longer life expectancy globally and lower birth rates.
3. The 65+ population roughly doubles, from 702.9 million to 1548.9 million (120% increase); the 80+ population grows faster, from 143.1 million to 426.4 million (197.9% increase). The older population is not only larger but older within itself, so services face more of the frailest, most multimorbid group.
4. Australia and New Zealand is already an aged population, so growth is proportionally smaller from a large base; Northern Africa and Western Asia starts from a young population and a small base, so the same absolute change is a much larger percentage.
5. Increasing disability; increasing burden of mental health disorders in older adults; multimorbidity, making care of older adults complex, labour intensive and often involving both physical and mental health conditions.
6. Ageism is defined by stereotypes, prejudice and discrimination toward people based on their age.
7. Institutional, interpersonal and self-directed. Negative stereotypes are propagated by the general public and the media, internalised by older adults, then enacted by them, creating a vicious circle that results in poorer mental health outcomes; ageism also causes inequality with detrimental effects on the individual, community and society.
8. It is one of four action areas of the Decade of Healthy Ageing (2021-2030), declared by the UN and WHO.
9. (i) Determinants affecting overall health: nutrition, education, employment, living environment. (ii) Determinants unique to mental health: stigma, mental health care disparity, flawed criminal justice systems, homelessness. (iii) Ageing-related determinants: ageism, workforce shortage, social isolation and loneliness.
10. Wisdom, resilience, meaning in life, community engagement.
11. In the US there are more people with severe mental disorders (excluding dementia) and substance use disorders ageing in prisons and jails than in hospitals.
12. Lacking social connection (largest, about 0.65 lnOR) > smoking up to 15 cigarettes daily (about 0.5) > obesity (about 0.17) > air pollution (smallest, about 0.05). Values are approximate.
13. Poor social relationships: 29% increase in risk of heart disease and 32% increase in risk of stroke (synthesis of 16 longitudinal studies). Chronic loneliness and social isolation: approximately 50% increase in risk of developing dementia in older adults.
14. Social isolation is arguably the strongest and most reliable predictor of suicidal ideation, attempts and lethal suicidal behaviour across samples varying in age, nationality and clinical severity, so it must be actively elicited rather than assumed benign.
15. A personality trait composed of prosocial attitudes and behaviours (empathy and compassion), self-reflection, emotional regulation, acceptance of uncertainty and diversity of perspectives, social decision making, and possibly spirituality.
16. The prefrontal cortex, the insula, and the limbic striatum, particularly the amygdala.
17. There is a strong inverse relationship between loneliness and wisdom, especially the compassion component. Because compassion and other components of wisdom can be enhanced by individual and societal level interventions, targeting them offers a route to reducing loneliness and improving well-being in older adults.
18. A trait or outcome describing recovery or bounce back from adverse situations, or a process of adapting well in the face of adversity, trauma, threats or other major stress.
19. Men experience greater loneliness and more difficulty adjusting to widowhood than women. The exception is male veterans exposed to death while serving, who show greater resilience and less loneliness than civilian widowers, suggesting prior exposure to adversity can build resilience to later loss.
20. A 10-item self-report questionnaire (Duckworth) rated across five columns from “Not at all like me” to “Very much like me”. Reverse scored items describe distractibility and shifting interests (new projects distracting from old, changing goals, difficulty maintaining focus beyond a few months, interests changing yearly, losing interest after brief obsession). Forward scored items describe perseverance and consistency (setbacks not discouraging, being a hard worker, finishing what is begun, diligence, overcoming setbacks to conquer a challenge). A high total therefore reflects sustained effort and consistency of interest.
21. The value and importance attributed to one’s own life and activities, and the core significance of one’s personal existence.
22. An individual or group storytelling intervention focused on integrating life stories across different phases of life. An RCT found it significantly improved quality of life in older participants and had a moderate effect on depressive symptoms.
23. Presence of meaning stays relatively flat and high across the lifespan; Search for meaning declines with age.
24. Compassionate individuals, compassionate relationships, compassionate communities, compassionate organisations, arranged around a central hub of connectedness and shared humanity.
25. The science and practice of psychiatry that seeks to understand and promote well-being through assessment and interventions involving positive psychosocial factors, in people with or without mental or physical illnesses.
26. Absence of chronic disease and disability; engagement with life; cognitive and physical function.
27. Socio-demographics (household income, occupation level, attained education, health insurance); nutrition and lifestyle (not smoking, healthy diet, low BMI, high physical activity, quality sleep); psychological factors and self-perceived physical health (optimism, plans for the future, feeling needed, self-rated health, absence of pain).
28. It transformed the study of ageing from a discipline focused on disease and decline into one emphasising health and growth, claiming that the lifestyle choices you make now, more than heredity, determine health and vitality.
29. Subjective well-being with low perceived stress; flourishing (eudemonic well-being, including meaning in life and close social relationships); post-traumatic growth; sustained remission or recovery in people with severe mental disorders, typically absence or marked reduction of symptoms plus functional independence.
30. The extent to which an individual perceives that current demands or challenges exceed their ability to cope with them.
31. Because ageing is characterised by notable heterogeneity, so the proposed model would not be applicable to all older adults.
32. Risk factors: widowhood in a man (greater loneliness and more difficulty adjusting than in women), social isolation following withdrawal from the bowls club (a predictor of suicidal ideation and behaviour, and a risk factor for heart disease, stroke and dementia), and loss of meaning in life (whose presence is protective against suicide). Targets: meaning in life, for example life review therapy, which improved quality of life and had a moderate effect on depressive symptoms in an RCT; community engagement, restoring social connection through age-friendly or compassionate community structures; and interventions enhancing compassion and other components of wisdom, given the inverse relationship between wisdom and loneliness.
33. Social connection is not a soft outcome: lacking it carries a larger mortality effect than smoking up to 15 cigarettes a day, and poor social relationships raise heart disease risk by 29% and stroke risk by 32%, while chronic loneliness and isolation raise dementia risk by about 50%. Intergenerational contact of exactly this kind is the lecture’s illustration of enhancing compassion and wisdom, which is inversely related to loneliness. Cutting it also enacts ageism, treating older adults as a burden rather than a resource, which itself worsens mental health outcomes.
34. Society and the media propagate negative age stereotypes (ageism at institutional and interpersonal levels). Older adults internalise and enact these, which is self-directed ageism, and this vicious circle produces poorer mental health outcomes and inequality. One consequence is withdrawal and social isolation, itself an ageing-related social determinant, which raises risk of heart disease, stroke, dementia and suicidal behaviour. Successful ageing is the counter-model: by promoting the positive determinants (wisdom, resilience, meaning in life, community engagement) and the MacArthur components of engagement with life, function and absence of disease, positive psychiatry interrupts the pathway at the point where societal attitude becomes individual outcome.