Who cares wins
This report, compiled by the Working Group for Liaison Mental Health Services for Older People, Faculty of Old Age Psychiatry, Royal College of Psychiatrists, draws attention to the neglected clinical problem of mental disorder affecting older people admitted to general hospitals and calls for the development of specialist liaison mental health services for older people. It takes account of the best level of evidence where it applies to older people. Older people occupy two-thirds of NHS beds and 60% of older people admitted to general hospital will have or develop a mental disorder. This mental disorder will predict a poor outcome for the older person and the service.
The present delivery of mental health services for older people in general hospitals is by the process of consultation. The superior method of multidisciplinary liaison is established for working age adults as a developed speciality. This approach should be established for older people and a failure to do so represents an ageist policy.
Better management of these disorders improves outcome and this has major implications for the care of older people, the efficiency of acute hospitals and the utilisation of health and social care resources. We believe that any strategy to improve the performance of acute hospitals is seriously deficient if it ignores the mental health needs of older people.
We urge acute hospital trusts, older peoples' mental health services and commissioners of health and social care to regard carefully the care of mentally disordered older people in general hospitals and work together to improve their outcome.
- This report is intended to draw attention to the neglected clinical problem of mental disorder affecting older people admitted to general hospitals, and calls for the development of specialist liaison mental health services for older people. It is based on the best available evidence.
- Liaison psychiatry for working age adults is a developed speciality with at least 93 funded consultant liaison psychiatrists in the British Isles. These services have an established multidisciplinary model of service delivery with recommended staffing levels and training programmes. None of these standards exist for older people. Failure to deliver this quality of service for older people represents an ageist policy.
- This inequality of service is both short sighted, as the population ages, and discriminates against older people.
- The care of older people must be person centred respecting their unique individual characteristics, with attention to both their physical and psychological needs.
Section I – The Case of Need
- Two-thirds of NHS beds are occupied by people aged 65 years or older. Up to 60% of general hospital admissions in this age group will have or will develop a mental disorder during their admission.
- A typical district general hospital with 500 beds will admit 5000 older people each year and 3000 will suffer a mental disorder. On average, older people will occupy 330 of these beds at any time and 220 of these will have a mental disorder. This means that the acute hospital will have at least four times as many older people with mental disorder on its wards as the older people’s mental health service has on theirs. Three disorders; depression, dementia and delirium, will account for 80% of this mental disorder co-morbidity, such that, 96 patients will have depression, 102 dementia and 66 delirium.
- Mental disorder in this population is an independent predictor of poor outcome. These poor outcomes include increased mortality, greater length of stay, loss of independent function and higher rates of institutionalisation.
- The cost of these disorders to sufferers and carers is substantial and the cost to services considerable. For example, in 2001, in the United States estimates indicated that delirium complicated hospital admissions for 2.3 million older people each year, involving more than 17.5 million hospital days and accounting for more than $4 billion dollars of Medicare expenditure.
Section II – Can interventions improve outcome?
- Mental disorder affecting older people admitted to general hospitals is poorly detected and managed. Controlled clinical studies have demonstrated the potential to prevent and treat these mental disorders and improve outcome.
- For example, preventative interventions can reduce the incidence of delirium by 30-40% in at risk patients. This disorder carries a particularly poor prognosis. Specialist multidisciplinary care can reduce length of stay following hip fracture for those with mild or moderate dementia and increase the numbers returning to independent living. Depression responds to antidepressants and psychological treatment.
- Liaison mental health services have the potential to reduce length of stay.
- Improved outcomes have important implications for older people, carers and the utilisation of health and social care resources.
Section III – Service Models
- The report describes several models that can be adapted to provide liaison mental health services for older people. They have advantages and disadvantages that need to be considered when planning a local service.
- No single model will meet all needs and a range of local factors will influence the choice of model for a local service.
- For a district general hospital the most appropriate model is the multidisciplinary liaison mental health team and all services should plan this development. It is best placed to meet the needs of older people and to deliver the core functions of a liaison mental health service particularly in association with a shared care ward.
- Whichever model is adopted it should fulfil the minimum requirements of a liaison service. These include raising awareness of the importance of mental health, facilitating the acquisition of the basic skills of mental health assessment and treatment by general hospital staff through education and training, assisting with the management of serious and complicated cases of mental disorder and championing the cause of older people with mental disorder in the general hospital.
- The usual delivery of mental health assessment and advice for older people admitted to a general hospital is the process of consultation, that is, case by case referral to the mental health department. Consultation has several limitations including slow response, no capacity to develop better standards of mental health practice in general hospitals and being essentially reactive.
- In contrast, liaison mental health for working age adults is a developed speciality with at least 93 funded consultants in liaison psychiatry within the British Isles. These services have an established multidisciplinary model of service delivery with recommended staffing levels and training programmes.
- The liaison approach is proactive, working collaboratively with general hospital departments and providing a major focus on education and training to improve the mental health skills of general hospital staff.
- Liaison mental health services have been shown to offer several benefits in comparison with consultation. Services offering only consultation should develop a liaison style of working.
- Liaison services should be based in the general hospital and become integrated with general hospital services in order that attention to the mental health aspects of clinical management become part of routine general hospital care.
Section IV – Characteristics of a Liaison Mental Health Team
- Liaison mental health is a specialised area of work and staff need proper induction, training and clinical supervision. They must have dedicated time to fulfil their duties, adequate secretarial and administration support and be managed as a specialist service.
- Liaison services need adequate office space based in the general hospital and the necessary resources to support their activity.
- Liaison services should have a clinical lead involved with service planning with dedicated time to perform these duties
- Liaison services should have an identified consultant psychiatrist with dedicated time in their job plan to fulfil these duties
- Consultation- liaison mental health should not be devolved to junior staff or practitioners working in isolation.
- Services offering consultation should plan to move to a liaison model of working.
Section V - Education and Training in General Hospitals
- Education is a core business for liaison mental health services, and will need to be sufficiently resourced to allow time for this essential function.
- Education can be provided by several methods and delivered in many forums. The subject matter and staff group will influence the approach.
Section VI - Strategic Planning
- There are a number of national policies that would indicate that liaison mental health services for older people have an important part to play in the health care agenda.
- All health and social care services must be aware of the standards and targets set for health care commissioners and providers of acute hospital care and understand how liaison mental health can contribute positively to achieving these goals.
- Planning a liaison service will require a business case which will need to consider national and local issues, an option appraisal of service models with project management and evaluation.
- Service development will need the support of all stakeholders.