Mental Illness

Currently under review

What is mental illness?

Anxiety and depression are the most common mental illnesses in older adults. [4] However, some older people experience more severe, long-term mental illnesses lasting more than two years, which affect multiple areas of life. These include psychotic disorders such as schizophrenia, bipolar disorder, major depressive or anxiety disorders, and severe personality disorders, often accompanied by addiction issues. [5]

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Why does mental illness matter in aged care?

Promoting the emotional and psychological wellbeing of older people is central to person-centred aged care. [6] However, mental illness significantly affects the quality of life, overall health, and wellbeing of many older adults, particularly those in aged care. [7] The 2021 Royal Commission into Aged Care Quality and Safety highlighted concerns about the difficulty older people with mental illness face in accessing professional support. [8] Since then, improving mental health care has become a priority across the aged care sector. [9]

With the number of older adults with mental illnesses in aged care expected to grow, [10] it is important that aged care providers have systems in place to identify mental health needs and deliver appropriate services. [11] The Aged Care Quality Standards address this within Standard 5: Clinical Safety. Specifically, Action 5.5.6 requires providers to:

• Actively promote an older person’s mental health and wellbeing
• Respond promptly to signs of mental health deterioration
• Provide supportive responses to distress, self-harm, and suicidal thoughts while minimising risks to psychological and physical safety. [6]

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What the evidence tells us

How common is mental illness in aged care?

Mental illness affects around 8-11% of Australians aged 65 and older, [12] with rates significantly higher in aged care settings. In 2022, 23% of home care recipients were assessed as having at least one mental illness, with higher rates among those with dementia, individuals living alone, and First Nations people. The rate increases to 58% among those entering residential aged care, likely reflecting the complex health challenges that necessitate higher levels of support. Within residential care, mental illness was more common among urban residents, individuals without dementia, and those who previously lived alone. [11] However, there is evidence that people with mental illness face limited access to good-quality residential facilities or encounter barriers to aged care during the admission application process. Reasons given for this include service concerns over potential dangers posed, need for greater staff attention, and difficulties in obtaining psychiatric support for this population after admission. [10]

Impact of mental illness on older people

Mental illness can negatively affect an older person’s overall health, ability to function, and quality of life. [13] It often coexists with medical conditions and having one mental disorder increases the risk of developing another. [14,15] It can also lead to increased social withdrawal, loneliness, and distress, which further contribute to mental health deterioration. [16] The impact extends beyond the individual, as families and aged care staff may experience emotional strain when mental health conditions are not well managed. [17]

At the end of life, psychological distress can make it harder for older adults to enjoy their final days. It can increase physical pain, interfere with relationships, and contribute to increased requests to hasten death. [18] People with a serious mental illness in a residential facility are also significantly less likely to have an advance directive documenting their choices about care at the end of life. [19]

Risk factors for mental illness in later life

Multiple factors influence mental health in older adults, including life experiences, physical and social environments, and stressors related to ageing, such as loss of functional abilities. [20] Changes in life circumstances, such as moving into residential aged care, can also impact on mental health when they involve a loss of autonomy, control, independence, privacy, and other psychosocial factors essential to wellbeing. [21] Older people can also experience emotional distress or coping difficulties on being diagnosed with a life-limiting illness or as a symptom of that illness or medication side-effect. [22]

Although most people adjust to these changes, older people with existing mental illness can be significantly impacted by:

• Grief and bereavement
• Loss of independence
• Caring for someone with a chronic illness
• Living in poor conditions
• Experiencing abuse or neglect
• Having a chronic or neurological illness
• Limited access to quality support and services. [20]

Social isolation and loneliness, which affect around one in four older adults, are increasingly recognised as risk factors for depression and anxiety. [20] People can become isolated due to changes in social networks through retirement, bereavement, or declining physical mobility that limits participation in community activities. The impact is even greater for individuals with pre-existing mental illnesses, who may face additional barriers to social engagement, such as stigma, reduced functional capacity, or lack of accessible opportunities for meaningful interaction. [4]

Access to services

Mental illness in older adults is often misinterpreted as a natural part of ageing, leading to delayed diagnosis and treatment.[23] This misconception may partly explain why access to mental health services remains inadequate for many older Australians. [17] Primary Health Networks (PHNs) are responsible for commissioning psychological services in residential aged care, yet many facilities do not engage psychologists, with only 14% employing them directly. [24] Government-subsidised psychological support is also underused, with just 3% of residents accessing these services compared to 10% of older adults living in the community. [21] Instead, there may be a reliance on pharmacological treatments, with more than a third of residents prescribed psychotropic medications such as antidepressants, antipsychotics, or benzodiazepines, soon after admission. [25] Addressing these gaps requires greater investment in psychological services and prioritising non-pharmacological interventions. [17] It may also benefit from clear referral pathways for escalating care and access to specialised care delivered by clinicians with training in geriatric mental health (e.g. psychogeriatricians, psychologists or psychiatrists). [23]

Common mental illnesses

Depression

While it is natural to feel low or sad at times, people with depression usually experience these feelings for longer and with greater intensity. It is estimated that over half of aged care residents experience depressive symptoms, with a quarter (27%) having major depression. [26] Those most at risk appear to be people experiencing multimorbidity, pain, functional disability, social isolation or loneliness. [14,22] Loss of autonomy on entering residential care is also a factor, alongside the quality of the care environment, including that of lighting, noise levels, and access to gardens. [26]

Signs of depression include crying, changed eating habits or sleeping patterns, loss of interest in social connections, personal care, or hobbies, and cognitive changes such as difficulty concentrating or making decisions. [4,27]

Depression is common in people nearing the end of life where it can affect their perceived quality of life, increase distress, and influence care decisions. [22] However, recognising depression in this context can be challenging, as symptoms like fatigue, appetite loss, and sleep disturbances often overlap with the effects of terminal illness and age-related decline. Pain, nausea, and breathlessness can also heighten psychological distress. [28] Hypoactive delirium, which shares some similarities with depression, should also be considered and ruled out to ensure an accurate diagnosis. [28] More distinct indicators of major depression in people with terminal illness or age-related decline include loss of pleasure, excessive guilt, hopelessness, and feelings of being a burden. [22]

Screening for depression

Screening should be part of ongoing care rather than a one-time check as identifying depressive symptoms early allows for timely support and better outcomes. Several validated tools are commonly used to screen for depression in older adults. Some require training to use but others are simple and can be used in routine care. These include the Geriatric Depression Scale (GDS) and the Nursing Homes Short Depression Inventory (NH-SDI). The Cornell Scale for Depression in Dementia (CSDD) is designed for people with dementia who may struggle to respond to standard questionnaires. [29] A positive score on a screening tool should then initiate a more detailed assessment with a mental health professional, with the aim of reaching a formal diagnosis. [30]

Non-pharmacological management of depression

How depression, once diagnosed, is managed will depend on several factors, including:

• Depression severity
• Cognitive status
• Physical ability
• The time frame available (i.e. prognosis)
• The person’s other treatments
• Specialist availability. [22]

Most importantly, the choice of treatment needs to be person-centred and tailored to the needs and preferences of the older person, particularly those with dementia. [31] Optimally, non-drug approaches should be trialled first before looking to medications. [25]

Psychological (or ‘talking’) therapies show the greatest promise in reducing depressive symptoms in older people, at least in the short term. [32] Despite this, they remain underused in aged care settings in favour of medication. [33] Cognitive behavioural therapy (CBT) appears most effective, both when delivered face-to-face as well as online. [33,34] It also reduces symptoms of depression for people with dementia. [35] There is some evidence supporting the psychological therapies of goal-oriented therapy, reminiscence therapy, life review, and behavioural activation. [31,32,36]

People with severe depression but no cognitive impairment may respond well to daily structure, psychoeducation, creativity, and contact with others. Those with less severe depression might benefit from exercise, relaxation, and nature-based activities such as gardening and horticulture. [31] For older people in home care settings, digital solutions such as telecare and mobile applications show promise in improving access to mental health professionals. [34,37] This highlights that there is no ‘one-size-fits-all’ therapy and therapies must be matched to the unique circumstances and needs of each person. [34]

Medications for depression at end of life

Psychotropic medication use in residential aged care is widespread and may be overprescribed. Around 28% of aged care residents in one Australian study were prescribed antidepressants within their first three months of care, with nearly 20% newly initiated on these medications after entry. [25] The use of antidepressants in older adults, particularly those with dementia or nearing the end of life, appears to offer limited benefits while posing significant risks. Antidepressants in older adults with both dementia and depression showed no significant reduction in depressive symptoms across different antidepressant classes. [38] Similarly, tricyclic antidepressants while effective for depression, substantially increased the risk of falls and fractures due to their anticholinergic and sedative effects. This suggests their risks may outweigh their benefits in older adults. [39]

Given the limited effectiveness of antidepressants and their associated risks, non-pharmacological approaches should be prioritised where possible to minimise medication-related harm in end-of-life care.

Anxiety disorders

Anxiety disorders extend beyond temporary worry or fear. For those affected, anxiety persists across various situations and may intensify over time. [40] These disorders are common among older adults, [20,41] with particularly high rates in Australian aged care facilities, affecting around 10 to 20% of residents. [42] Despite this prevalence, routine screening for anxiety is uncommon in these settings, leading to underdiagnosis and undertreatment. [42]

A thorough assessment is essential to identify the underlying causes and guide appropriate management of anxiety. [22] Older adults at greater risk of anxiety disorders often experience severe pain, cognitive impairment, multiple chronic conditions, depression requiring antidepressant use, and a lower perceived quality of life. [43,44] In the context of end-of-life care, anxiety may stem from fears about death, practical concerns, unresolved conflicts, or existential struggles, such as questioning life’s meaning and purpose. It can also arise as a symptom of an underlying condition or a side effect of medication.

Barriers to providing anxiety care in residential facilities include the complexity of screening individuals with dementia who have difficulty communicating, medication management issues such as polypharmacy and compliance for those with multimorbidity and accessing psychotherapy services. Other deterrents include a lack of staff training, time, and interest in non-pharmacological approaches, as well as the misconception that anxiety is not common in residential care. [45]

Screening for anxiety

Aged care staff can use a screening tool to determine if a person should be referred for a formal mental health assessment with a health professional. The most used tools for detecting anxiety in older people include the Geriatric Anxiety Inventory (GAI) and the Hospital Anxiety and Depression Scale – Anxiety subscale (HADS-A). To date, these tools are considered the most reliable and have been validated. [46] Meanwhile, the Rating Anxiety in Dementia (RAID) is commonly used with people living with dementia. [47]

Screening for anxiety in aged care can be challenging as symptoms of medical conditions or medication side effects can also appear to be anxiety-related, for example breathlessness, palpitations, or agitation. [47]

Non-pharmacological management of anxiety

There is limited evidence on effective anxiety treatments in aged care. However, potentially helpful non-pharmacological therapies include reminiscence therapy (especially when combined with music), relaxation therapy, and problem-solving therapy. Music therapy, massage, animal-assisted therapy and therapeutic touch show promise, while exercise, robotic animals, and lifelike dolls do not appear to be effective. [48,49]

For people without dementia, cognitive behaviour therapy or psychoeducation delivered by trained facilitators appears particularly effective for reducing anxiety symptoms. [33] For people with dementia, music therapy and activity-based interventions have been tested but the evidence of effectiveness remains inconclusive, [50] although listening to preferred music may benefit anxiety. What is clear is that approaches need to be tailored to each person’s cognitive and functional abilities and based on knowledge of the activities the person enjoys engaging in. [45]

Medications for anxiety at end of life

There are very few studies looking at medications for treating anxiety in residential aged care settings and none focused on treating anxiety in frail older adults. [51] Given the risk of harm associated with medications in the older population, more research appears needed before anxiety drugs can be considered a core treatment. [45]

Severe mental illnesses

The ageing population has led to an increasing number of older people in aged care settings with serious mental illnesses (SMIs) such as schizophrenia, bipolar disorder, and treatment-resistant major depression. [10] Older people with a pre-existing SMI are more likely to die in a residential aged care facility than those without a mental illness. [52] However, they often face considerable barriers in accessing appropriate healthcare services as they age, including specialist palliative and end-of-life care. [53] This may be partly due to a lack of mental health expertise within the palliative care workforce. [54]

Caring for people with SMI at the end of life is complex. Psychiatric symptoms such as delusions, psychosis, denial of illness, and social withdrawal or apathy can hinder participation in care. [54] Many are unable to create an advance directive or appoint a substitute decision-maker due their illness and limited support networks. Additionally, care staff may be hesitant to initiate advance care planning discussions, influenced by stigma or assumptions about mental capacity. As a result, their preferences for end-of-life care may not be known or respected, with decisions made reactively by healthcare proxies or default medical teams. [54]

The physical care of people with SMI is also complex due to multimorbidity and significant functional impairments. [55] Evidence suggests that the physical health needs of older people with schizophrenia are often overshadowed by their psychiatric history, with profound implications for dignity and quality of life. [56] They receive significantly less opioid analgesia for pain relief at the end of life, possibly due to difficulties communicating their needs or a tendency to deny them. [53]

Older people with SMI are also more likely to die in care homes rather than hospitals or hospices, reinforcing the need to ensure their palliative care needs are adequately addressed in aged care facilities. [57] Standard end-of-life care tools and interventions may be unsuitable for this population, yet there are currently few tailored approaches to guide decision-making for people with SMIs. [5]

Care of people with dementia and mental illness

Depression is common in people with dementia, and the two conditions are closely linked. People with dementia are twice as likely as others to have depression, and long-term depression can increase the risk of developing dementia later in life. This overlap makes it hard to tell the difference between depression and dementia because depression can cause memory and thinking problems that look like early dementia. [58]

When depression and dementia occur together, they can make symptoms worse, leading to faster memory loss, poorer health, and earlier admission to aged care. Carers of people with dementia may also experience high levels of stress and depression. [58]

Even though antidepressants are often given to people with dementia, research shows they may not help at any stage of dementia. A review of eight studies found no strong evidence that antidepressants across different classes reduce depression in this group. This suggests that doctors may need to reconsider using these medicines, especially for people near the end of life. [38] Talking therapies such as cognitive behavioural therapy (CBT) may provide some benefit and could be a better choice than medication. [35]

Dementia and past trauma can also be linked. Some people with dementia may have experienced traumatic events in their past, which can lead to posttraumatic stress disorder (PTSD). [59] A history of psychological trauma is associated with higher rates of psychotic symptoms, agitation, aggression, irritability, disinhibition, and night‐time behaviours. [60] However, certain care practices, such as personal care routines, loud voices, bright lights, or strong smells, can trigger distressing memories and result in behaviours linked to past trauma that look like dementia symptoms. Training aged care staff to recognise and respond to PTSD in dementia care can improve the quality of support for these individuals. [59]

Screening tools can help identify depression in people with dementia. The Cornell Scale for Depression in Dementia (CSDD) is one tool that considers both patient responses and caregiver observations to assess depression. [29] However, tools for diagnosing PTSD in people with dementia are limited. [59]

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Implications for home care

Social isolation, loneliness, loss and grief can put older people living in the community at increased risk of developing depression. These experiences can also make worse an existing mental health condition. [4] Home care services and workforce need to be alert to these risk factors when providing care and document and/or escalate any concerns around signs of deteriorating mental health.

Page updated 27 February 2025