Older Veterans in the UK: A review of current research.

For the first time in its history, the most recent Census asked individuals to record whether they had ever served in the UK Armed Forces. Of the 1.85 million ex-Armed Forces respondents, older Veterans, defined as being over the age of 65, made up more than half of this number (53%) and those aged 80 or above contributed a third (31.8%) [1]. Comparatively for non-Veterans, individuals aged 80 or above made up just 5.1% of the population. Despite accounting for most of the Veteran community in England and Wales, it appears as though older Veterans are an overlooked population in military research. Considering this, the following news feature provides an overview of research activity related to ‘older’ Veterans and highlights potential gaps and areas for future research attention.

Aged Veterans Fund

In recognition of the shortfall in understanding the needs of the older Veteran population in the UK, the Aged Veterans Fund (AVF) was launched in 2016. This was a £30 million investment from the Armed Forces Covenant Fund Trust which, through a portfolio method, funded 19 projects spanning practical support to primary research with the aim of improving the health, wellbeing and social support needs of older Veterans. Perhaps as a result of the health-centric aims of the AVF, the most common topic amongst recent literature on older UK Veterans is that of mental health and wellbeing.

Mental Health

Positively, for older Veterans, military experience may act as a protective factor against trauma related symptoms. Researchers from the Kings Centre for Military Health Research found that military experience positively impacted Veterans’ wellbeing in later life through the use of adaptive coping skills [2]. The findings from this study indicate that despite experiencing higher levels of occupational stress and trauma, older Veterans are more likely to report increased resilience and self-confidence than their age-matched non-Veteran counterparts.

However, the same study also highlighted that Veterans over the age of 65 reported higher levels of alcohol consumption than those who had not served in the military. As discussed in a previous News Feature, there is an established drinking culture within the Armed Forces which is often still apparent once individuals have left the military. When coupled with more free time, perhaps due to retirement, older Veterans may thus be a population significantly at risk of alcohol related health difficulties even when reporting increased self-confidence and resilience levels.

The prevalence of alcohol misuse in older Veterans is also seen in a study by Finnegan and Randles (2022) [3] who explored the mental health status of UK Veterans. The researchers found that amongst individuals over the age of 68, alcohol misuse was the most common mental health condition. This was followed by anxiety and depression, although the presence of both anxiety and depression decreased after the age of 77 and each was negatively correlated with dementia.

Mental wellbeing amongst Veterans does differ from that of the general population when considering figures for post-traumatic stress disorder (PTSD) with UK Veterans twice as likely to report PTSD than non-Veterans [4]. However, emerging evidence indicates that this too may be mitigated by age. Rhead et al. (2022) demonstrated that ex-Service personnel over the age of 65 were less likely to show symptoms of PTSD and other common mental health disorders than both younger Veterans and the general population [5]. However, just 8% of the participants in this study were female and findings from research on UK help-seeking Veterans has suggested that the same mitigation may not be present in older female Veterans. Hendrikx et al. (2021) [6] explored the mental health needs of UK women Veterans and found that whilst women Veterans reported a high prevalence of mental health difficulties overall, those over the age of 60 had the highest risk for both common mental health disorders and PTSD.  

Although the fastest growing sector of research on older Armed Forces leavers concerns mental health and wellbeing, the body of evidence remains small and lacks consistent evidence, further highlighting the need for additional research in this area. Furthermore, as mental health issues are also apparent in the older non-Veteran population, future research should explore whether mental and physical health issues experienced by Veterans in later life are because of military experiences, or whether health declines are part of the natural ageing process.

Loneliness

Unfortunately, recent research has highlighted a high prevalence of loneliness amongst the Veteran population in the UK [7] with evidence from The Royal British Legion suggesting that 370,000 Veterans over the age of 50 feel lonely [8]. With the detrimental effect of loneliness on both physical and mental health, this is a concerning figure. As many as 70% of the Armed Forces community state loneliness and social isolation as a common problem [9] yet these issues may be especially problematic for older Veterans. A systematic narrative review by researchers at the University of Northumbria identified differences in the experiences of loneliness between younger and older Veterans with older Veterans more likely to have fewer social connections and report increased levels of loneliness [10]. Whilst reasons such as moving to new areas, injury and disability, and leaving the Armed Forces have previously been cited as loneliness triggers [9], older Veterans in this study felt that a lack of connections (including family and friends) who could relate to their military experience was the most concerning risk factor for loneliness. Veterans described situations of feeling alienated due to a lack of connections with individuals sharing in the Veteran identity. This is supported by research showing that connecting with individuals who share this Veteran identity is not only favourable to reducing loneliness, but also to increase wellbeing in older Veterans. A study by Brewster et al. (2020) [11] explored how the Veteran identity creates a shared point of connection, with individuals stating that certain memories and experiences were difficult to share with people who do not “hold Veteran status”. As life in the military, especially deployment related experiences, can be largely unparalleled to experiences of non-Veterans, this shared sense of identity highlights the need for Veteran-specific interventions to target loneliness in ex-Service personnel over the age of 65.

Initiatives such as Age Scotland’s Comradeship Circles that promote social connectedness by unifying small groups of Armed Forces personnel and their families through weekly telephone calls are just one example of ways to forge connections through a shared sense of identity to prevent loneliness in older Veterans.

Care

Whilst there is not yet a definitive answer as to whether Veterans experience older age significantly differently from non-Veterans, what is clear is the benefit that community spaces create for older Veterans. This is also true for care homes. The majority of residential care homes endeavour to learn about those who live there and cater to their personal needs, but the uniqueness of military experiences adds weight to the argument for Veteran specific care homes. The Armed Forces Covenant states that Armed Forces personnel should not be disadvantaged in the provision of services and recognises that in certain circumstances, special consideration to meet this obligation may be required. The Royal Chelsea Hospital and Care for Veterans are examples of care facilities that respect military traditions and routines, allowing Veterans to retain a sense of their personal history and forge connections with other Veterans.

The Royal Hospital Chelsea encourages individuals to wear uniform and residents are divided into Companies with allocated Captains whilst Care for Veterans marks military significant days including Remembrance Day and VE Day with special services as part of residential activities. These care homes are specifically aimed at creating a collective environment and building a collective identity that the research evidence suggests is pivotal to older Veterans [12].

With individuals up to 5.5 times more likely to be lonely if they feel that they have nobody to talk to and share with [9] Veteran specific care homes may be able to limit the loneliness and mental health decline of older Veterans, acting as a protective contributor to the overall health and increased quality of life of older Veterans.

The 2021 census data revealed that the proportion of Veterans residing in care homes was smaller than non-Veterans. One explanation for this could be the reported beneficial role that military service has on protecting the physical health of older Veterans. One study that explores the physical health of geriatric Veterans found that the exercise and physical activity these individuals engaged in during their time in the Armed Forces was a key contributor to their good physical health in older life [13]. It's possible then that this favourable health status enables older Veterans to maintain independence and not require residential care for longer than their civilian counterparts.

However, there may also be alternative explanations for this discrepancy. Considering that the same study highlights how certain military-related occupational practices and a lack of safety equipment may actually contribute to poor health in older Veterans, caution must be exercised when stating that older Veterans are less likely to reside in care homes as a result of their military engagement. 

Another potential reason for this statistic could be that some Veterans do not self-identify as a Veteran, and this may be especially true for older LGBTQ+ Veterans who served in the Armed Forces during the LGBTQ+ ban, who may have potentially negative experiences in the military [14]. As such, the data collected in the census would not be a true representation of Veterans in care homes. Or perhaps it is due to the finding that ex-Service personnel are less likely to seek treatment [13] perhaps due to the self-reliance and resilience that is instilled in them in the military. For older Veterans, this may be reflected in not utilising care homes and support systems even if required as demonstrated in a report on older Royal Navy Veterans [15]. This research found that referrals to support services occurred most frequently when individuals had reached “crisis point”, which is consistent with a plethora of UK research on the behaviour of help-seeking Veterans [16] [17] [18].

Care requirements may be further complicated for injured Veterans. Caddick et al. (2018) [19] conducted a systematic review to establish how Service-related limb loss is experienced in older (defined in this study as Vietnam-era) Veterans and highlighted that long-term care requirements for physically disabled older Veterans were complexified by reduced mobility and injury related pain. However, the same review highlighted how in some instances, Veterans did not want to be identified as disabled and would rather not associate with other disabled Veterans to highlight themselves as ‘war heroes’. The literature appears to suggest that specialised training for healthcare, including training to navigate conflicting identities, would help to prolong mobility and independence, reduce mental health declines, and thus increase quality of life for older Veterans.

Whilst advantageous in growing the knowledge base on injured older Veterans, the review predominantly draws on research from the US and emphasises the lack of literature on UK Veterans. It is possible that the NHS may not be sufficiently equipped for the sometimes-specialised needs of ex-Service Members, particularly injured veterans. As Caddick et al. (2018) highlight, UK Policymakers and healthcare providers must thus be cautious when attempting to implicate recommendations from US-based studies concerning the topic of care given the stark differences in healthcare frameworks and structures between the UK and the US. 

Like other research areas, the literature on care for older Veterans is limited and whilst steps are being taken to support the older Veterans in this space, more needs to be done to understand their needs and experiences. This is especially relevant given the nearly 2,500 UK casualties from Afghanistan and Iraq between 2003 and 2011, many of whom have a traumatic brain injury (TBI) [20] [21] and will likely require specialised care in later life. The consideration for this generation of Veterans' care needs is further amplified when we account for the increased risk of dementia among those with TBIs  [22]. Whilst the ADVANCE study is generating evidence that will be able to contribute to the future planning of supporting these injured ex-Service men and women, exploring the needs of the current generation of older Veterans is also required to understand their unique needs now.

Summary

Although gaining some traction, the body of literature and research concerning older UK Veterans is still in its infancy, and there is more to do to increase understanding of the needs of this population. With the publication of more census data pertaining to employment trends, financial situations and activity of Veterans within the criminal justice system expected in 2024, a more comprehensive overview of the population of older Veterans in England and Wales should be obtainable. However, the Census data is limited to those residing in England and Wales and omits data from Veterans in other devolved nations. To obtain a comprehensive profile of older UK Veterans and their needs, future research should also consider the population of older Veterans in Scotland and Northern Ireland. 

Future research should continue to explore the mental and physical health of older Veterans and the specific needs that these individuals may have, both care- and non-care related, to maximise the quality of life for older UK Veterans. Furthermore, research should endeavour to address the underrepresentation of research on older female Veterans, LGBTQ+ Veterans, Veterans from ethnic minority groups, and injured Veterans, as evidence suggests that the needs of these sub-populations may differ from the white heterosexual male population who dominate the current ex-Service personnel literature. Focussing on these areas, in tandem with the new data from the census release concerning employment, financial and criminal justice trends, can help to further inform policy, community and clinical practice that can support older Veterans and their families.

1. Office for National Statistics (2023). Characteristics of UK armed forces veterans, England and Wales: Census 2021.
2. Williamson, V., et al., The impact of military service on the mental health of older UK veterans: A qualitative study. International Journal of Geriatric Psychiatry, 2019. 34(10): p. 1412-1420. Available from: link
3. Finnegan, A. & Randles, R. (2022). Prevalence of common mental health disorders in military veterans: using primary healthcare data. BMJ Military Health, p. e002045. Available from: link
4. Combat Stress (2018). New Research Reveals Higher Rate of PTSD Among Veterans. [Internet]. Combat Stress. Available from: link
5. Rhead, R., MacManus, D., Jones, M., Greenberg, N., Fear, N. T., Goodwin, L. (2022). Mental health disorders and alcohol misuse among UK military veterans and the general population: a comparison study. Psychological Medicine, 2022. 52(2): p. 292-302. Available from: link
6. Hendrikx, L. J., Williamson, C., Baumann, J., & Murphy, D. (2023). Understanding the mental health needs of a community-sample of uk women veterans. Illness, Crisis & Loss, 31(2), 385–402. Available from: link
7. SSAFA, (2021). A Qualitative Investigation of the Experience of Loneliness and Social Isolation in SSAFA Beneficiaries, Volunteers, and Employees during COVID-19. SSAFA. link
8. Royal British Legion (2014). A UK Household Survey of the Ex-Service Community in 2014 - Executive Summary. Royal British Legion. link
9. Royal British Legion (2018). Loneliness and Social Isolation in The Armed Forces Community. Royal British Legion. link
10. Wilson, G., Hill, M., Kiernan, M. D. (2018). Loneliness and social isolation of military veterans: systematic narrative review. Occupational Medicine (London), 2018. 68(9): p. 600-609. link
11. Brewster, L., McWade, B., Clark, S. J.A (2021). A point of connection? Wellbeing, the veteran identity and older adults. Ageing & Society, 2021. 41(9): p. 1984-2005.
12. Demos (2018). Supporting Military Veterans in Residential Care: A practical guide. Demos. Available from: link
13. Williamson, V., Harwood, H., Greenberg, K., Stevelink, S., Greenberg, N. (2019). Impact of military service on physical health later in life: a qualitative study of geriatric UK veterans and non-veterans. BMJ Open, 2019. 9: p. e028189. Available from: link
14. Etherton, T. (2023). LGBT Veterans Independent Review. UK Government. Available from: link
15. The Institute of Public Care (2020). Understanding the Needs of Older Merchant Navy Veterans. The Institute of Public Care. Available from: link
16. Randles, R. & A. Finnegan (2022). Veteran help-seeking behaviour for mental health issues: a systematic review. BMJ Mil Health, 2022. 168(1): p. 99-104. link  
17. Williamson, V., Greenberg, N., Stevelink, S. (2019). Perceived stigma and barriers to care in UK Armed Forces personnel and veterans with and without probable mental disorders. BMC Psychology, 2019. 7(1): p. 75. Available from: link
18. Williamson, V., Greenberg, N., Diehle, J., Jones, N., Dunn, R. (2018). The impact of military service on health and well-being. Occupational Medicine, 2018. 69(1): p. 64-70. Available from: link
19. Caddick, N., Cullen, H., Clarke, A., Fossey, M., Hill, M., McGill G., Greaves, J., Taylor, T., Meads, C., Kiernan., M. D. (2019). Ageing, limb-loss and military veterans: a systematic review of the literature. Ageing & Society, 2019. 39(8): p. 1582-1610. Available from: link
20. Hawley, C.A., de Burgh, H. T., Russell, R. J., Mead, A. (2015). Traumatic brain injury recorded in the UK Joint Theatre Trauma Registry among the UK Armed Forces. J Head Trauma Rehabil, 2015. 30(1): p. E47-56. https://doi.org/10.1097/HTR.0000000000000023
21. Denby, E., Murphy, D., Busuttil, W., Sakel, M., Wilkinson, D. (2020). Neuropsychiatric Outcomes in UK Military Veterans With Mild Traumatic Brain Injury and Vestibular Dysfunction. The Journal of Head Trauma Rehabilitation, 2020. 35(1): p. 57-65. Available from: link
22. Leung, K. K., Carr, F. M., Russell, M. J., Bremault-Phillips, S., & Triscott, J. A. C. (2022). Traumatic brain injuries among veterans and the risk of incident dementia: A systematic review & meta-analysis. Age and Ageing, 51(1), afab194. https://doi.org/10.1093/ageing/afab194