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NICE Underpinning Review
The overarching question addressed in this review is: What are the most effective ways to improve or protect the mental wellbeing and/or independence of older people?
86 papers were included in this review covering a number of different types of activity, and 20 evidence statements related to 6 identified themes have been drafted. 9 papers from the UK covering 7 studies, as well as 2 from the Republic of Ireland have been included in this analysis, but most of the interventions and activities discussed are feasible to implement in a UK context. These interventions come from many different countries around the world, but are dominated by US set studies.
There is less focus in the review specifically on interventions to maintain independence, perhaps because many interventions in this area are targeted at individuals who are already at risk of a loss of independence because of poor physical and mental health.
The review indicates that there is promising evidence, albeit often from weak study designs, that various forms of social resources are beneficial for mental well-being in older people. These include improving access to social contacts and networks and participation in social activities and general community life. This is not surprising as later life covers an extended period of the life course and is likely to include changes in health, social engagement and networks with family and friends. For example, older people are more vulnerable to decreasing social networks as they are at greater risk of losing their partner and friends, which at the same time makes them more dependent on other social resources within the society. Further, being socially integrated in society in terms of participation and frequent social contacts and activities has been previously proven to be beneficial for mental health and wellbeing among older people e.g. (Forsman et al. 2012).
One evidence statement focuses on a number of different intergenerational activities that in particular bring older people and school aged children together. These have been seen as one way of reducing isolation, while at the same time they can also help to challenge negative attitudes towards older people and ageing in society.
Given the focus of the review on actions largely outside of the health and social care sector, one area of some focus is on a range of interventions related to arts and creative activities and their impact on mental wellbeing. Studies looking at the impact of continued participation in education beyond retirement age (third age learning) have been identified.
There is also a cluster of studies focused around the use of new technologies to aid in communication between older people and their social networks.
The review found little specifically on tackling ageism and effective ways of identifying at risk groups, nor information on effective ways of commissioning services. It is also clear from the evidence statements and the detailed tables in the appendix that a great number of different outcome measures are used to look at mental wellbeing and independence, making it impossible to produce any meaningful type of meta- analysis. It is also notable that almost no study makes use of the Quality Adjusted Life Year (QALY) as an additional outcome measure alongside independence and mental wellbeing, although some 53 studies do report outcomes using the SF-36 or SF-12 instruments, from which it is possible to derive Quality of Life Scores.
The review findings suggest that there is a broad range of interventions and activities that can be used to promote and protects the mental wellbeing and independence of older people. These findings are in line with previous reviews on aspects of this literature (Windle, Francis 133 and Coomber 2011, Collins 2014, Dickens et al. 2011, Choi, Kong and Jung 2012, Park et al. 2014, Hagan et al. 2014), albeit with some differences in inclusion criteria given the focus here on older people who do not currently have substantive health and social care needs and largely on actions and activities which are not delivered by health and social care professionals.
Based on the reviewed evidence, it can be concluded that many aspects of the complex concept of mental wellbeing are strongly correlated with social resources (e.g. social contacts, social participation, social cohesion, sense of belonging) among older adults. These findings are also supported by previous reviews (Cattan et al. 2005, Masi et al. 2011, Collins 2014). These social aspects - that have been shown to be associated with positive mental health and mental wellbeing in a growing body of research - are often referred to as aspects of the theoretical framework of human social capital (Putnam 2000, Bourdieu 1986, Nyqvist et al. 2013). The evidence in this review suggests that interventions that support social capital are promising as measures to promote mental wellbeing in old age, but there remain gaps in evaluation and in the quality of evaluations undertaken to date. By making efforts to support social contacts and relationships already established by older individuals, as well as aiming to enhance the development of new relevant social contacts when possible, important prerequisites for mental health in later life are created and secured. Bronfenbrenner’s ecological model (Bronfenbrenner 1979) could be a useful tool for the theoretical illustration of older people’s psychosocial wellbeing (Forsman 2012, Greenfield 2012). According to this model, preferences, abilities and attitudes at the individual level form an important basis for mental health and experienced wellbeing in later life, at the same time as the social relationships at the interpersonal level, social contacts at community level and social participation at a societal level are central covariates of mental health in later life. Interventions that look at all of these issues have been identified in the review, including a cluster of evaluations, largely from Spain to promote continued participation of older people in higher education. This type of activity is well established in the UK, perhaps most immediately through the Open University.
There is also a growing evidence base which emphasises the role that arts and musical activities can play in promoting the wellbeing and independence of older people. In this evidence review, several studies explored the effectiveness of varying art forms – such as musical activities, singing, dance, storytelling or story writing, festivals – on mental wellbeing outcomes. The beneficial effects of art based programmes on various aspects of psychosocial wellbeing among older people is evident, however, the evidence base is heterogeneous and often from small scale studies, but this is an area where evaluation has taken place in the UK, for instance through the New Dynamics of Ageing Scheme. Nonetheless the strength of the evidence as presented in this review should be considered in the context of its multiple limitations. Art based group interventions constitute a new and emerging research field (Mental Health Foundation 2011); this makes interpreting the synthesised findings based on a low number of studies, or comparing the emerging effects of one art form against another difficult. Windle and colleagues (Windle, Francis and Coomber 2011) have also in their review on programmes for prevention of social isolation and loneliness among older people evaluated art based group programmes. In the review from 2011, these programmes were categorised as wider community engagement initiatives, which in the analyses were compared to one-to-one and group service interventions. According to Windle and colleagues, there is good evidence that one-to-one interventions such as befriending reduce loneliness and improve mental wellbeing. However, it is also pointed out that interventions need to be adapted to the needs of the targeted older individuals.
For social group interventions and wider community initiatives, there was similarly good evidence on positive effects on various aspects of wellbeing in later life. These findings are supported by the current review. Another key point frequently emphasised in the reviewed literature is the importance of ensuring the involvement of older adults themselves in the planning of initiatives to enhance mental health and wellbeing, especially since the personal needs, preferences, and abilities vary to a great extent at the individual level (World Health Organization 2013, Futureage 2011). This is an area where the evidence is less definitive that would be desired in this review. More research is needed on the effectiveness of different ways of planning interventions, such that the older adults themselves are given an opportunity to be involved in intervention planning, community services and national policies. The limited participation of 135 men in these studies is a concern and potential research gap (See also the Barriers and Facilitators Review). Based on the evidence review findings, there are opportunities to make use of new technologies and the social media, although the strength of the evidence is moderate and to some extent inconsistent. Nonetheless many studies illustrate how training to use the internet and computers, as well as positive aspects experienced through attainment of internet usage skills and inclusion in the online world, can contribute to mental wellbeing and independence. A key issue here is, however, may be the digital exclusion of older adults from the virtual world, this being a form of social exclusion in itself, although this may reduce over time (Note: This is also discussed in Review 2 on Barriers and Facilitators. Since older adults typically adopt new innovations at a slower pace (Carey and Elton 2010) the number of ICT users in the older population is generally lower worldwide although it is increasing in older age groups over time (Ofcom 2009, Pew Research Centre 2013) and they have received less attention in ICT-related research. One gap is that much of current research is focused primarily on online health information and health service development (Rios 2013) rather than looking at broader psychosocial and independence aspects of digital inclusion and there may be both positive and negative impacts of increased use of these technologies (van der Wardt, Bandelow and Hogervorst 2012).