NHS England’s National Clinical Director for Older People’s Mental Health, and the Chair of the Royal College of Psychiatrists’ Old Age Faculty, highlight the need for age appropriate psychiatry for the elderly:
Mental health services for older people took root from clinical interest in the particular needs of older people compounded by the fact that their needs were not being well served by general adult services.
This culminated in the creation of the professional specialism of old age psychiatry twenty five years ago.
The rise of the specialty reflected interest from public and professionals and was akin to the creation of geriatric medicine, the traditional barefoot doctors typified by holistic practitioners dedicated to a group of patients eschewed by mainstream professionals. This was partly based on the assumed lack of any specific treatment for people in this age group.
Some facts about mental health in older people are revealing:
In a 500 bed general hospital, on an average day, 330 beds will be occupied by older people of whom 220 will have a mental disorder, 100 each will have dementia and depression and 66 will have delirium.
For every 1,000 people over the age of 65, 250 will have a mental illness, 135 will have depression, of which 115 will have no treatment.
85% of older people with depression receive no help from the NHS, and older people are a fifth as likely as younger age groups to have access to talking therapies but six times as likely to be on medication.
The number of older people being treated in the improving access to psychological therapies (IAPT) programme rose from 4% to 6.5% (2008/9-2013/14), still short of the articulated goal.
While 50% of younger people with depression are referred to mental health services, only 6% of older people are.
Around 10% of older people experience loneliness which can be a symptom course of depression – loneliness has the same health effects as smoking 15 cigarettes a day.
20% of men and 10% of women are drinking alcohol in harmful amounts – the latter is a 100% increase over the past twenty years.
Fast forward two decades and specialist services began to be disbanded, protected by the banner of equality – which none would dare challenge. Services were absorbed into generic provision with the inevitable consequence that the professional and dedication of staff were diluted.
Everyone was to receive an age appropriate service but what about these specific clinical groups? An older man with dementia has little in common with a younger person having a first psychotic break down. And a woman of 63 with chronic bipolar disorder does not have different needs when three years later she is 66 and should come under the ambit of old age services.
Many clinicians will remember the egregious ‘birthday service’ when, consequent on the inevitable march of time and on a calendar date, a patient was transferred from young adult services to old age services – so called “graduates”.
Many consultants employed a pre-emptive referral where the routine six month follow up spanned someone’s 65th birthday and a pre-emptive note for their next review was put in place in the new service. Many an older person was surprised with the sudden vanishing of a plethora of support workers and services to a single consultant and one CPN.
As was wisely commented upon at the time – the only thing worse than a service trying to discharge people when they are 65 is another service reluctant to take them just because of the mode of referral.
The British Journal of Psychiatry has recently published a study comparing the ability of general adult and old age mental health services to meet the needs of older people with enduring mental illness. Using a standard needs assessment schedule in a group of 74 older patients, the number of unmet needs was found to be twice as many in the group managed by general adult services compared with bespoke old age services.
This is clear evidence of the need for age appropriate old age psychiatry services for older people with mental health problems.
Most people will accept that age, in and of itself, is unsatisfactory as the single criterion for access to services in later life. This is not about professional protectionism. The Old Age Faculty of the Royal College of Psychiatrists has articulated what the specialty has to offer:
people with dementia of any age;
people of whom there is complex co-morbidity of physical and mental illness, for example older people in general hospitals with confusion;
people with a functional mental illness (in whom aging in and of itself is influencing the clinical picture and is amenable to specific interventions).
By the provision of age appropriate mental health services we can improve the outcomes for older people, and that is where there is true equality and where that should flourish – we should encourage and support it.
Alistair Burns is NHS England’s National Clinical Director for Older People’s Mental Health.
James Warner is Chairman of the Old Age Faculty at the Royal College of Psychiatrists.
Selected further reading:
Annual Report of the Chief Medical Officer 2013: Public Mental Health Priorities: Investing in the Evidence
Age discrimination in mental health services: making equality a reality – Royal College of Psychiatrists’ position statement PS2/2009
Developing an ideal old age Service P Connolly and N Perera Royal College of Psychiatrists 2013