Helping older people become more enabled can have a big impact on their quality of life and burden of disease, and supports an efficient and sustainable healthcare system.
People aged 65 and over use a higher proportion of health and medical services than younger age groups.1 2 3 4 They are often overweight, do little or no exercise and do not eat enough fruit and vegetables.1 87 per cent of older people have at least one chronic disease and most have more than one.4 5
Healthy ageing is the process of developing and maintaining the functional ability that enables wellbeing in older age.
Functional ability is the ability to do things that matter to the person, such as self-care, mobility, decision making, activities, learning, work and meaningful relationships. The loss of functional ability increases the risk of hospitalisation, and the need for aged and family care.
To support functional ability, older people need to develop and maintain their physical and mental skills, and optimise their environment and the services they have access to. The process of maintaining functional ability, including relearning skills or developing new ones, is sometimes called ‘reablement’.7 8
Determinants and components of enablement
Determinants of enablement are personal attributes, background and environmental factors that affect how well a person can look after their health. They can have a greater influence on older people due to the cumulative impact of advantage or disadvantage over a lifetime.9
The health services that people use are also affected by where they live, their finances, cultural needs and beliefs, and past experience with health professionals and the health system. Beliefs about their role in their healthcare is shaped and reinforced by factors such as:
- family background
- education level
- life experiences.
When working with older people, you may need to focus more on working with these factors to build enablement, rather than changing them. But that does not mean that older people cannot change their attitudes, learn new things or become more confident in managing their health. Many older people are just as adaptable as young people with the right support.
It is not up to me to make decisions about my health – that is my doctor’s job.
I would never question the doctor or nurse, it is disrespectful.
Back in the day you just did what the doctor told you, but now we are a team.
I am too old to learn all this new stuff; I wish they would stop pushing it on me.
All this new technology is marvellous, we have got this whizz-bang device at home now that lets me measure all my vitals myself and send them off for checking.
I used to think seeing a shrink means you are weak, but since I finally went to one I feel strong and in control.
What do older people need?
Negative stereotypes about ageing and older people can have a negative impact on their health, including reduced physical and mental functioning, increased cardiovascular stress, increased risk of disability and reduced longevity.6 10 11 Research shows that generalisations like ‘old people are forgetful’ can actually lead to reduced memory performance.
On the other hand, pointing out positive stereotypes and the benefits of ageing can have a positive impact on the health of older people. When older people have a positive perception of ageing, they have improved physical functioning.6 10
Over a third of Australians aged 65 and over were born overseas, with the majority from non-English speaking countries in Europe and Asia.1 Older people from culturally and linguistically diverse (CALD) backgrounds often face additional barriers to accessing healthcare.
- Financial: older people from CALD backgrounds often have a lower socioeconomic status than other Australians.
- Language: 65 per cent of Australians speak English poorly or not at all.
- Cultural: different cultural practices or norms mean people can feel uncomfortable or misunderstood in a health setting.1
Older people may also have diverse cultural and immigration experiences that impact their world view, and affect their confidence, motivation and ability to care for their own health. This can include traumatic experiences such as genocide and war, or being a refugee or part of the Stolen Generations.
Older Australians are more likely to have religious beliefs than younger Australians, which can influence their healthcare needs and choices. In 2016, over 70% of Australians over 65 identified as Christian and 3% dentified as another religion.12
Mental health needs
Men aged over 85 have the highest suicide rate in Australia, with men who live alone most at risk.13 The onset on mental illness is rare in older people, but many experience psychological distress during times of significant change, which can affect their life and impact their ability to manage their own health.14
These may include:
- redundancy or retirement
- changes to health and abilities
- loss of independence
- death of a spouse
- changes to living arrangements
- increased social isolation.
Older people often believe they need to handle the distress themselves rather than get help. People who are prepared to get help may prefer medication to talking therapies. Overall, they use mental health services half as much as younger people, but prescription medications for mental health twice as much.4
To improve mental health in older people
- Find out what is going on in their life and if they are dealing with a change that could affect their mental health.
- Ask about their psychological wellbeing as part of your routine practice, to normalise the issue.
- Recognise that older people may be resistant to ask for help, due to their age or cultural beliefs.
- Promote positive coping behaviours.
- Encourage them to keep mentally active by reading, doing puzzles, learning new skills or doing further education.
- Recommend peer support and encourage them to maintain social connections by volunteering or joining a club, sports team or community group, and arranging regular meetings with friends.
- Recommend or refer mental health services for them and their family, such as a psychiatrist, psychologist or specialist mental health services for older people.
- Review the NSW Mental Health Commission’s Living Well in Later Life: a statement of principles.15
We need to move away from doing things ‘for’ older people to doing things ‘with’ older people.
Approaches for older people
The strategies in this guide can all be applied to working with older people, as well as families, carers and guardians. It is important to personalise your approach, as different techniques will suit different people.
Families, carers and guardians
Good communication with families, carers and guardians becomes increasingly important as people age, particularly if the older person’s physical or mental abilities are affected. The people in their life can directly influence their enablement, through shared decision making and practical or emotional support.
Comorbidity and aging
Older people often have more than one risk factor or chronic disease, so lifestyle changes that benefit their overall health are important. They may also need to address problems that are affecting their social and psychological wellbeing.
Approaches such as health coaching can provide older people with the skills they need to improve their overall health and wellbeing.17
They may also benefit from working with health professionals who can provide behaviour change advice and motivation, such as:
- exercise psychologists
- practice nurses.
Older people and their families may benefit from learning about polypharmacy (taking five or more medications) to help them understand their medications and risks. This knowledge makes them more likely to take their medications as prescribed and communicate with health professionals about the different medications, drugs and supplements they take.
Health literacy is an important part of consumer enablement at any age. You can support health literacy in older people by using techniques such as teach-back, encouraging them to ask questions, and providing information that is easy to read and understand.
Most people know what they should do to be healthier, such as eating healthy foods and exercising regularly, but they struggle with the motivation to change. They may also have trouble incorporating healthy habits into their life. Motivational interviewing can strengthen the motivation and commitment of older people to create and maintain positive behaviours.
Organised and informal peer support with people with a similar condition or experience can significantly improve enablement in older people, increasing their health literacy and supporting their emotional wellbeing. Peer support provides social, emotional and practical benefits that give older people the skills and confidence to manage their health.
Try not to assume that older people cannot use technology. Many have used computers throughout their working lives and are likely to own a smartphone. Even if they have limited experience using technology, they can usually learn new skills when encouraged and supported by healthcare professionals.
Technology such as videoconference consultations and remote monitoring can be excellent options for older people, especially if access is difficult because of where they live, physical disability or if they no longer drive. The technology in healthcare section of this guide provides more information that may be useful.
- Australian Institute of Health and Welfare (AIHW). Older Australians at a glance. Canberra, ACT: AIHW; 2017.
- Government of Western Australia. Burden of disease by age group in Western Australia, 2011. Perth, WA: Department of Health; 2017.
- AIHW. Australian burden of disease study: impact and causes of illness and death in Australia, 2011. Canberra, ACT: AIHW; 2016.
- AIHW. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra, ACT: AIHW; 2016.
- AIHW. Chronic disease. Canberra, ACT: AIHW; 2018.
- World Health Organization. What is Healthy Ageing? Geneva, Switzerland; WHO; 2018.
- Love JG. Enablement and positive ageing: a human rights-based approach to older people and changing demographics. The International Journal of Human Rights 2017;22(1):90-107.
- Cognitive Decline Partnership Centre. Reablement. Sydney, NSW: University of Sydney; 2018.
- Levy BR, Hausdorff JM, Hencke R, et al. Reducing cardiovascular stress with positive self-stereotypes of aging. The Journal of Gerontology. 2000;55(4):205-13.
- Levy BR, Pilver C, Chung PH, et al. Subliminal strengthening: improving elders’ physical function over time through an implicit-age-stereotype intervention. Psychological Science. 2014;25(12):2127-35.
- Levy BR. Age-stereotype paradox: opportunity for social change. The Gerontologist. 2017;57(S2):118-26.
- Australian Bureau of Statistics (ABS). Religion in Australia: 2016 Census Data Summary. Canberra, ACT: ABS; 2017.
- Simms J. Healthy ageing. Australian Family Physician. 2017;46:26-9.
- AIHW. Mental health of older Australians. Canberra, ACT: AIHW; 2015.
- Cramm JM, Hartgerink JM, Steyerberg EW, et al. Understanding older patients’ self-management abilities: functional loss, self-management, and well-being. Quality of Life Research. 2013;22(1):85-92.
- Mental Health Commission of NSW. Living Well in Later Life: The Case for Change. Sydney: Mental Health Commission of NSW; 2017.
- Mental Health Commission of NSW. Living Well in Later Life: A Statement of Principles. Sydney: Mental Health Commission of NSW; 2017.