Relationships between old age psychiatry and geriatric medicine

Position Statement 31 ‘Relationships between old age psychiatry and geriatric medicine’ (PS31) is a joint statement of the Faculty of Psychiatry of Old Age of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and the Australian and New Zealand Society for Geriatric Medicine (ANZSGM).

Purpose

The Royal Australian and New Zealand College of Psychiatry’s (RANZCP) Faculty of Psychiatry of Old Age and the Australian and New Zealand Society for Geriatric Medicine (ANZSGM) recognise the need for old age psychiatry and geriatric medical services to work closely together to ensure the best treatment and care of older people, many of whom face complex combinations of mental and physical ill health. The following is a statement of agreement between the two bodies regarding best policy and practice in this regard.

Key messages

• Old age psychiatry and geriatric medical services should be widely available and, where possible, co-located.
• Old age psychiatry and geriatric medical services should cooperate to ensure the best treatment and care of older people, many of whom have complex combinations of mental and physical ill health.
• It is essential that governments ensure appropriate levels of funding to enable health services to provide the appropriate services to older people.
• Older people and their carers should have access to high quality, well-integrated community, residential and hospital services which include access to old age psychiatry and geriatric medicine specialists on-hand or via telehealth. It is important that health services ensure appropriate settings are available for people with both behavioural and acute medical needs.

Background

The statement represents an ongoing revision of one prepared in October 1990. The aim of the 1990 position statement was not to prescribe identical services in all parts of Australia and New Zealand. Rather, it established a set of principles to help the two subspecialties work better together, adapting to local circumstances. These principles still apply, with their longevity reinforcing their sound basis.

Relationships between services

1. Both old age psychiatry and geriatric medical services should be available in all health care areas, and preferably available face-to-face in communities with more than 50,000 inhabitants. Where old age psychiatry and geriatric medical services have defined catchments, their boundaries should correspond.
   i. Where old age psychiatrists or geriatricians are not readily available, arrangements should be made for visits by specialists and/or telehealth. The use of telehealth services is to be encouraged. Where no such arrangements are possible, it is expected that geriatric medical services, adult mental health services, private psychiatrists and general practitioners will liaise to provide a substitute service.
2. Wherever possible, old age psychiatry and geriatric medical and community services should be co-located to promote ease of access and continuity of care for older people, carers and referring agencies.
   i. It is imperative, however, that old age psychiatrists, and old age psychiatry services maintain close professional and educational links with their colleagues in general psychiatry. Similarly, geriatricians, and geriatric medical services, should maintain close professional and educational links with colleagues in general medicine and other medical specialities.
3.  Where co-location is not practicable, old age psychiatry and geriatric medical services should be integrated functionally to ensure the clinical outcomes described below. This may be achieved through governance structures or agreed working relationships.
4. Where the two services are co-located, referring persons or agencies should have the option of referring explicitly to either old age psychiatry or geriatric medicine or both (if applicable).
5. Irrespective of service structure, cross-referral and clinical reviews between services should be freely available to optimise care.
6. Criteria for the division of responsibility between the two services must be known and accepted both internally and externally.
7. Responsibility for patient care must be based on assessed needs. When a patient is referred from one service to another, clinical accountability rests with the original service until the other accepts primary responsibility.
8. In general, delirium is best managed by acute care physicians and geriatricians.
9. Old age psychiatry services are usually best placed to provide assessment and treatment to people whose dementia is complicated by very severe behavioural and psychological symptoms. It is important that health services ensure appropriate settings are available for people with both behavioural and acute medical needs.
10. As a core requirement, memory clinics should have accessible clinical input from old age psychiatrists and geriatricians.
11. Government funded support services should be supported and integrated within the client’s overall clinical care plan. This includes Dementia Support Australia (DSA) in Australia. Old age psychiatric services and geriatric medical services should work collaboratively in the development of dementia services at the local level. Services which specialise in managing dementia-related behaviour, for example DSA in Australia, are complementary, but not a replacement for, comprehensive geriatric or psychogeriatric assessments.
12. It is important that these health services for older people be adequately funded. Resources, such as staff and physical facilities, should be allocated on the basis of local need in line with the RANZCP Position Statement 22 on Psychiatry Services for the Elderly and ANZSGM Position Statement Number 8: Comprehensive Geriatric Assessment and Community Practice.[1-3]
    Reciprocal arrangements for rotations by advanced trainees in each other’s disciplines are highly desirable and training committees should provide clear guidance about standards of training and supervision.
13. Reciprocal arrangements for rotations by advanced trainees in each other’s disciplines are highly desirable and training committees should provide clear guidance about standards of training and supervision.
14. Wherever possible, representatives of both disciplines should contribute to medical appointment committees and to planning processes where the outcome impacts on the other sub-specialty.

Responsible committee: Faculty of Psychiatry of Old Age 

References

1. Royal Australian and New Zealand College of Psychiatrists. College of Psychiatrists (2015) Position Statement 22: Psychiatric services for older people. Royal Australian and New Zealand College of Psychiatrists, Faculty of Psychiatry of Old Age; 2015.
2. McKay R, Casey J, Stevenson J, McGowan H. Occasional Report: Psychiatry services for older people. Royal Australian and New Zealand College of Psychiatrists, Faculty of Psychiatry of Old Age; 2015.
3. Australian and New Zealand Society for Geriatric Medicine. Position Statement Number 8: Comprehensive Geriatric Assessment and Community Practice. 2011.

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.