PHIAC took account of a number of factors and issues in making the recommendations.
1.1 Older people's mental wellbeing is affected by a range of factors, from an individual's makeup, personal circumstances and family background to the community in which they live, and society at large. PHIAC recognises that this guidance, though based on a review of the effectiveness and cost-effectiveness of interventions to improve mental wellbeing, can only be one element of a broader, multilevel strategy to promote the mental wellbeing of older people.
1.2 NICE's guideline on four commonly used methods to increase physical activity (published in March 2006) stated that there was insufficient evidence to recommend walking schemes to promote physical activity among adults over 16 years, other than as part of a properly designed and controlled research study to evaluate effectiveness. However, for this guidance, PHIAC considered the evidence on walking schemes to promote mental wellbeing. There was enough evidence of positive and beneficial effects using standardised measures of psychological wellbeing to enable the committee to recommend walking schemes to promote older people's mental wellbeing. The recommendations in this guidance are consistent with those in the earlier guidance which stated that professionals should continue to promote walking (along with other forms of physical activity) as a way of incorporating regular physical activity into people's daily lives.
1.3 PHIAC was concerned that if local resources are not available to meet the needs of all older people, the most disadvantaged should have priority of access. When determining level of need, some of the standard dimensions of disadvantage that relate to socio-economic status may not apply. Poor mental wellbeing can also affect older people from professional backgrounds and those who might not be perceived as economically disadvantaged. For example, socially isolated older people living in wealthier urban suburbs may have significant needs, particularly if there is limited service provision in these areas. Older people who are most disadvantaged will include those with physical or learning disabilities, those on very low incomes and those living in social or rural isolation, including older people from minority ethnic groups as well as those without family support and community networks. This view is based on a principle of equity and of addressing health inequalities rather than on evidence, which was lacking.
1.4 PHIAC recognised that the recommendations do not stand alone and that they should be implemented in conjunction with meeting healthcare needs as well as further health promotion, disease prevention and treatment.
1.5 The review identified a broad range of interventions and included evidence rarely found in traditional systematic reviews, notably qualitative research. However, most studies were of poor quality and used small samples that might not accurately represent the target population. In addition, few studies included information about the effective components of an intervention.
1.6 The close association between mental wellbeing and physical health is supported by the inclusion of social, mental and physical wellbeing components in most standardised quality-of-life measures or general health questionnaires. PHIAC recognised that the distinctions between mental wellbeing and physical health in some of the evidence identified may be artificial.
1.7 The review showed that a preventive occupational therapy programme in the USA was both effective and cost effective in improving older people's mental wellbeing. PHIAC noted that the standards of practice for occupational therapy in the USA (American Occupational Therapy Association 2005) are consistent with the professional competency standards detailed in the post-qualifying framework for occupational therapy practice in the UK (College of Occupational Therapists 2006).
1.8 No evidence was found of effective or cost-effective interventions to promote mental wellbeing in older people living in residential care or for those whose physical and mental health needs are complex. PHIAC agreed that though there was insufficient evidence to support drafting specific recommendations for older people in residential care homes, they should not be excluded as potential beneficiaries. PHIAC proposed that part or all of this guidance may be applied to this group if those responsible for their care decide the guidance is appropriate and would benefit their clients.
1.9 PHIAC agreed that providers need to be flexible in their approach to age-related inclusion criteria. The principles of equitable participation may be used to apply this guidance to people younger than 65 years, for example where one half of a couple is younger than 65 years.
1.10 There was a lack of UK-based evidence on how to promote mental wellbeing among older people, in particular those considered to be isolated, vulnerable and disadvantaged. US-based evidence does, however, relate to socially disadvantaged groups and minority ethnic groups of older people. Groups under-represented in the UK evidence identified include older people who:
live in all types of residential care
have restricted physical abilities
have learning difficulties
live in rural areas
are lesbian, gay and transgender.
1.11 PHIAC noted that many of these groups have high unmet needs and complex co-morbidities. The absence of specific recommendations for them indicates a lack of research. PHIAC noted that the gap in evidence for these groups needs to be addressed in future research. Commissioners and managers of services need in the meantime to consider how proposed interventions could be effectively delivered to these population groups and build in locally relevant feedback mechanisms for service users as standard practice. The committee recognised the value of alternative sources of evidence from local practice and voluntary organisations. Although such evidence will not have been tested robustly the committee recognised that such work may provide valuable information.
1.12 Much of the evidence in the peer-reviewed literature relates to clinical measures of anxiety or depression. It was excluded to avoid overlap with other NICE guidance and because clinical measures are inappropriate to demonstrate improved or sustained mental wellbeing or quality of life for public health guidance.
1.13 PHIAC recognised that an intervention not considered to be cost effective from a health perspective may be cost effective with respect to associated long-term social consequences. Almost all studies of interventions to promote mental wellbeing in people aged 65 years and over have examined the effects achieved over the short term, reporting within weeks or months, up to a maximum of 1 year. It should be noted that assumptions that extrapolate short-term effects to the long term are subject to considerable uncertainty.
1.14 PHIAC noted that an intervention, policy or strategy in current practice not covered by this guidance should not be assumed to be ineffective and be discontinued. The recommendations in this document are based on the evidence from peer-reviewed literature available at the time of writing and PHIAC recognised that some interventions may not yet have been evaluated.
1.15 PHIAC recognised that many older people are carers themselves. The committee considered the importance of carers as a particular group having dual responsibility: to maintain their own mental wellbeing and that of the older people they care for. The economic value of carers' unpaid support of frail, sick, or disabled relatives has increased in the past 4 years. The committee recognised that the context of carers' daily lives can increase their vulnerability to social isolation and poverty, and can have a marked effect on their ability to sustain a good quality of life for themselves and the older people they care for.
1.16 PHIAC recognised that for the recommended interventions to be implemented effectively, levels of staffing and training requirements will need to be considered.