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Visions Journal

A reminder that this article from our magazine Visions was published more than 1 year ago. It is here for reference only. Some information in it may no longer be current. It also represents the point of the view of the author only. See the author box at the bottom of the article for more about the contributor.

The State of Seniors' Health in British Columbia

Martha Donnelly

Reprinted from "Seniors' Mental Health" issue of Visions Journal, 2002, No. 15, pp. 4-5

It should be no surprise to anyone who is a keen observer of society, that the number of seniors is rising dramatically in BC, Canada and the world as a whole. In fact, the over-85s in Canada are growing four times faster than younger segments of the population. BC has one of the longest life expectancies in Canada. This is possibly related to better lifestyles, including less smoking and more physical activity. There is evidence that we are not only living longer, but healthier into our older years.

Unfortunately, however, there are a number of seniors with significant mental health problems.1 Established figures range from 15 to 30% — the 15% figure representing only the more serious problems. Some seniors come to older age with chronic mental illnesses including schizophrenia, bipolar disorders, substance abuse, or recurrent depressions, but most seniors’ mental health problems arise in old age. These problems range from anxiety, mood disorders and substance abuse, to delirium (acute confusion) and dementia.

The Canadian Study of Health and Aging2 showed that eight per cent of over-65 year-olds and 34.5% of over-85 year-olds suffer from dementia, the main causes being Alzheimer’s and vascular dementia which is dementia caused by strokes. Most dementias have as their primary symptom memory problems that are difficult for both the patient and caregiver to deal with. However, psychotic disorders and behavioural problems also occur with dementia, particularly in the middle and severe stages. Depression co-exists with dementia in 20 to 30% of cases. Frontal lobe dementias appear with behaviour problems and personality changes that predate the memory problems, and may be more difficult for caregivers to adapt to.

Depressive symptoms and disorders in old age are common, as are grief and adjustment disorders with depressed mood. Unfortunately depression is under-diagnosed and undertreated in seniors, even more so in a multicultural population. Suicide rates among older men are high, especially in those who have physical health problems. The interaction between physical and psychiatric problems in old age is a particular challenge for mental health professionals. Because of this, family physicians and mental health professionals must work closely together.

Compared to a younger adult population, young seniors who are physically healthy and have no cognitive impairment require little difference in approach to assessment and treatment. However, the over-85s, those with combined medical and psychiatric problems, or seniors with cognitive impairment often need comprehensive geriatric assessment by an interdisciplinary team — in particular an outreach team, where mental health professionals can see them in their own homes or facilities when needed. Outreach workers not only assess and case-manage, they also educate, liaise with other community resources, and act as advocates for those patients who cannot advocate for themselves.

The Geriatric Psychiatry Outreach Team has become a mandatory community service across the province. This was not always so, and prior to the 1980s, seniors’ mental health services consisted largely of inpatient programs in provincial mental health hospitals. The development of community geriatric psychiatry in Canada and BC has been a relatively recent development over the past 25 years. In 1983, the Canadian Psychiatric Association’s section on Geriatric Psychiatry recommended that guidelines be written which defined mental health services for seniors. These were completed in 1988 in a document developed by the Mental Health Division of the Health Services and Promotion Branch of the Department of National Health and Welfare. Titled Guidelines for Comprehensive Services to Elderly Persons with Psychiatric Disorders,3 the document became known as the “silver bullet,” and formed a framework for local service development across the country.

In 1992, BC developed its own mental health planning framework for seniors, 1 which defined a comprehensive service system. In February 2002, a report was written entitled Guidelines for Elderly Mental Health Care Planning for Best Practices for Health Authorities.3 In these guidelines, the outreach team was defined as a core service, but a wide variety of services of a biopsychosocial nature were also defined.

The document established six principles of care, and all recommendations followed from these principles, which are:

  1. Client and family centred:

    • maintaining the dignity of older adults and treating them with respect

    • involving the person and the family in care planning and management

    • being culturally sensitive

    • being sensitive to ethical issues and end-of-life issues.


  2. Goal-oriented:

    • reducing distress to the person and the family

    • improving and/or maintaining function

    • mobilizing the individual’s capacity for autonomous living

    • maximizing and maintaining independence at the highest level possible.


  3. Accessible and flexible:

    • being user friendly

    • being readily available

    • taking into account geographical, cultural, financial, political and linguistic obstacles to obtaining care

    • integrating services to ensure continuity of care and coordinating care by all levels of service providers

    • providing service to each person wherever most appropriate.


  4. Comprehensive:

    • taking into account all aspects of a person’s physical, psychological, social, financial and spiritual needs

    • making use of a variety of professionals, resources and support personnel to provide a comprehensive range of services in all settings, including the community, facilities and acute care.

  5. Defined, specific services:
    • recognizing that the needs of older adults with mental health problems are qualitatively different than mentally well older adults

    • recognizing that the needs of older adults with mental health problems are qualitatively different from the younger population with a mental health problem

    • designing appropriate and relevant services, especially for this population.


  6. Accountable programs and services:

    • accepting responsibility for assuring the quality of service delivered and monitoring this in partnership with the client and family

    • responding to reasonable expectations from the clients, family, and those providing service

    • anticipating and responding to changing demographics

    • incorporating relevant evaluation strategies and research findings to determine optimal methods of service delivery.


Several major report recommendations related to issues of education for all levels of staff who care for seniors with mental health problems, as well as education for clients, families and informal caregivers. Other recommendations focused on issues of coordination between various parts of the system, in particular, the need to create links for transitions between acute care, facility care and community-based services, as well as the need to create links to tertiary care when needed. The Guidelines recognized that each community has developed its own community capacity, and is at a unique stage in terms of service development. The report thus supported the need for individual community creativity in developing a full range of services.

Seniors’ mental health services must include a focus on family well-being, including both individual and group support for caregivers. It must be recognized that informal caregivers are the backbone of support for seniors with mental health problems. In order to remain healthy themselves, caregivers need to be educated and given concrete support, including respite. This formal support should not end until the caregiver feels that their informal supports are sufficient. As the province moves to an even more intensive initiative to keep seniors at home, or to provide assisted living, we must increase home supports to help seniors and their caregivers feel confident.

Formal mental health services must also increasingly collaborate with community organizations to provide education to consumers, caregivers, and the general public about mental health problems and solutions. The Canadian Mental Health Association, Alzheimer’s Society, Parkinson’s Foundation, VON, caregivers networks, and the Public Trustee’s Office are all crucial partners.

Seniors’ mental health promotion needs more research to demonstrate effective programs and policies. More seniors need to be active participants in planning, implementation and in evaluation of these programs. In the Elderly Mental Health Best Practices document, one of the recommendations relating to client and family-centred care included a statement of the need to “develop and foster a culture of caring across the spectrum of care that acknowledges the need for a meaningful life (rather than just living), and recognizes people’s relational needs. A culture of caring would prevent alienation, anomie and despair that mentally ill elderly people feel and would promote optimal mental health.”4

Perhaps the most difficult areas that seniors’ mental health professionals have to tackle are risk assessments, competency assessments, assessment for possible abuse, and protecting vulnerable adults from self-neglect, neglect or abuse. Unless there is proof to the contrary, all individuals are legally considered competent to make personal, health, living arrangement, financial, and lifestyle decisions. We as Canadians champion autonomy as one of our highest values, and because of this, health professionals must allow clients to live at some degree of risk before challenging their autonomy. However, acceptable levels of risk are difficult to define and must include some appreciation of previous personal values and lifestyle choices. It would be ideal if all people, young and old, considered the possibility of future incapacity and made clear advance directives, including choosing representatives to make decisions for them if and when they are not able to. New health care consent laws and guardianship laws do give directions for competency assessments and define processes for substitute consent, enforced support and assistance, or guardianship when needed.

Advocacy to continue the development of mental health services for seniors is needed. The BC Psychogeriatric Association (BCPGA) is an interdisciplinary professional organization created in 1997 to specifically support interdisciplinary education and research in the area of mental health for seniors, as well as advocate for seniors’ mental health services within the province. The organization has annual educational meetings, which revolve around the province, having been run in Nanaimo, Victoria, Richmond, Penticton and Nelson. The 2003 spring meeting will be in Prince George. The BCPGA lobbied the government to create a best practices document, and several of its members formed the working group that eventually wrote the report. The principles of elderly mental health care in this document are in fact revised from the BCPGA’s own charter.

In tough economic times, when health care faces hard choices, it is important to provide evidence to support best practices. Perhaps the most compelling evidence is qualitative in nature, in the stories of consumers and their family members who have suffered from the effects of serious mental health problems. Their pain and their personal growth can translate into powerful advocacy for more and better services. We also, however, need combined qualitative and quantitative research to prove the effectiveness of particular services and approaches. This research should be the next area of growth or focus in seniors’ mental health — and will hopefully happen soon enough to support the depth and breadth of services we have already developed.

About the author
Martha is the Director of the Division of Community Geriatrics, Department of Family Practice, and Head of the Division of Geriatric Psychiatry, within the Department of Psychiatry, at the University of British Columbia. She was co-Chair of the Ministry of Health Services’ Elderly Mental Health Care Working Group which produced the recentlyreleased publication Guidelines for Elderly Mental Health Care Planning for Best Practices for Health Authorities
  1. BC Ministry of Health and Ministry Responsible for Seniors, Mental Health Services, Continuing Care, Hospital Care, and Facilities, Planning and Construction. (1992). Services for Elderly British Columbians with Mental Health Problems.

  2. Canadian Study of Health and Aging Working Group. (1994). Canadian Study of Health and Aging: Study methods and prevalence of dementia. Canadian Medical Association Journal, 150, 899-913.

  3. Health and Welfare Canada. (1988). Guidelines for Comprehensive Services to Elderly Persons with Psychiatric Disorders. Ottawa.

  4. BC Ministry of Health Services. (2002). Guidelines for Elderly Mental Health Care Planning for Best Practices for Health Authorities. Available online at:

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