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Psychiatry services for older people

October 2015

Position statement 22


Summary

Good mental health is essential to successful ageing. A holistic, age and culturally appropriate approach to addressing mental health in older people should be informed by the principles of recovery, independence, dignity and quality of life. 

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recognises that, in the context of the increasing proportion of Australia and New Zealand’s population who are over 65 years of age, it is essential that the appropriate mental health responses are in place. Good mental health is essential to successful ageing, and older people require the same full spectrum of mental health interventions as other people, from prevention to early intervention and clinical care. The RANZCP advocates for a holistic, age- and culturally-appropriate approach to addressing mental illness in older people, informed by the principles of recovery, independence, dignity and quality of life.

Background

The phenomenon of population ageing in Australia and New Zealand is well-established and has profound implications for health care provision. Over the next 30 years the proportion of people aged 65 years and over is projected to increase from 14% to 20% in Australia, and from 13% to 24% in New Zealand. Over the same time period the number of people aged 85 years and over is expected to approximately triple, to 1.2 million in Australia and 230,000 in New Zealand (Aschbrenner et al., 2011; Australian Bureau of Statistics, 2013).

It is important to recognise that the majority of older people do not have mental illness or dementia. However, even mild mental illness can have a significant impact on an older person’s health, function, quality of life, use of health services and outcomes of health interventions da Silva et al., 2013; Sarma and Byrne, 2013; Prina et al., 2013). Furthermore, older people who have a mental illness are also more likely to have significant social and physical health problems (Joint Commissioning Panel for Mental Health, 2013). The importance of treating mental illness in older people is demonstrated in the very high rates of suicide in older men both Australia and New Zealand, with suicide rates for men over 85 years old in Australia considerably higher than any other age group Aschbrenner et al., 2011; Australian Bureau of Statistics, 2013; Ministry of Health, 2012).
Serious concerns have been raised locally and internationally regarding the preparation of mental health services to meet the needs of older people (McKay et al., 2012; Jeste and Palmer, 2013).

Definition

Mental health is much more than the absence of mental illness. Good mental health maximises each older person’s quality of life, the quality of life of those around them, and their contribution to society.

Psychiatric services for older people, previously termed psychogeriatric services, have been subsumed by service terms which include old age psychiatry services, older persons’ mental health and mental health services for older adults.

The underlying philosophy of all these services is the promotion of successful ageing and improvement of the mental health of older people. With current health resource limitations, the priority is to improve the mental health of older people with distress or impairment related to functional and/or organic mental disorders. For organisational purposes ‘older’ is often accepted as being 65 years and over, although local, individual or cultural circumstances may require a flexible approach (Joint Commissioning Panel for Mental Health, 2013).

The generally accepted core entry criteria for mental health service for older people may be one of the following:

  • People with serious mental disorder, aged 65 or over, newly presenting to local mental health services or who have not been under the care of other local mental health services for a regionally-specified amount of years.
  • People with serious mental disorder and significant aged-related physical illness or frailty which compounds or complicates the management of the mental disorder.
  • People with serious mental disorder and significant psychological or social difficulties related to the ageing process where their needs may best be met by a service for older people.
  • People of any age with a primary dementia and serious behavioural and/or psychological symptoms.

Evidence

Successful ageing is intrinsically linked with maintaining good mental health. It is therefore essential that older people are valued, and their potential to be happy and productive is maximised. Older people should have the opportunity to make important contributions to their own welfare as well as that of younger generations.

Mental illness is common in elderly people, but often unrecognised by individuals, family and health care professionals, who may wrongly attribute symptoms of treatable mental illness to the irreversible effects of ageing or to physical or environmental changes. As such, relatively few older people with mental illness are referred for specialised psychiatric treatment (Jeste and Palmer, 2013).

The ageing population in Australia and New Zealand will mean that there will be increasing demand for mental health services for older people, including:

  • Older people with long standing mental illness are being joined by those with mental illness that develops for the first time in later life. Such illnesses include depression, anxiety and bipolar disorders, schizophrenia and other psychotic illnesses, alcohol and substance misuse disorders and dementia (Joint Commissioning Panel for Mental Health, 2013; Büchtemann et al., 2012).
  • The prevalence of cognitive impairment or dementia, which may also be associated with early-onset mental illness, increases exponentially in older age (Australian Institute of Health and Welfare, 2012).
  • Increasing numbers of men over 85, a group at considerably heightened risk of suicide (Australian Bureau of Statistics, 2013; Ministry of Health, 2012).
  • More people living in residential aged care facilities, where there are unacceptably high rates of depression and other mental illness; and often inadequate access to treatment (Australian Institute of Health and Welfare, 2012; Snowdon et al., 2011).
  • Increasing numbers of older people who may be exposed to polypharmacy and excessive prescribing of psychotropic medications (Hollingworth et al., 2011).
  • The average age of carers will also be older, and themselves are at significantly increased risk of depression and excess mortality (Molyneux et al., 2008; Perkins et al., 2013).
  • Older people presenting with physical health issues and comorbid mental illness in settings such as emergency departments, general hospitals, outpatients and general practice (Shah et al., 2011; Goldberg et al., 2012; Knapskog et al., 2013; Weyerer et al., 2013).

Most older people wish to live in their own homes and do so. Home-based mental health treatment for older people can reduce entry to hospital and residential care, improve quality of life, and reduce healthcare costs (Klug et al., 2010). However, the lack of access to appropriate mental health services and options for community-based accommodation and care increase the risk of inappropriate entry to residential aged care exposure to poor standards of care provision (Aschbrenner et al., 2011; Bowersox et al., 2013; Calati et al., 2013). Effective treatment improves function and quality of life, and can result in transfer to less costly, more appropriate community-based care (Aschbrenner et al., 2011).

Most interventions that are effective in younger people remain effective in later age, including when cognitive impairment is present. This includes treatment with pharmacotherapy, electroconvulsive therapy and psychotherapy (Calati et al., 2013; Jeste and Maglione, 2013; Riva-Posse et al., 2013; Wilkins et al., 2010; National Institute for Health and Clinical Excellence, 2012). Advanced knowledge or skills may be required to adapt treatments and enhance suitability for older people, and there will be increasing demand for specialist old age mental health services (Sarma and Byrne, 2013). Further information regarding the evidence base of interventions and systems for their delivery may be found in the occasional report developed to inform this position paper (Mckay et al., 2015).

Recommendations

  • Older people require the same spectrum of mental health care as the whole population, from mental health promotion and early intervention, through to community mental health care (including crisis services, continuing care, home care and residential care), acute inpatient care, liaison services in non-mental health hospital settings, and subacute and/or extended care.
  • Mental healthcare for older people should be evidence based and provided in settings most appropriate to the person’s needs (Draper et al., 2006).
  • National benchmarks should be established, setting standards for the availability and quality of mental health services for older people across the spectrum of care.
  • All mental health care for older people should incorporate the following principles:
    • Promotion of independence, dignity and quality of life for people with mental health problems, their families and carers (New South Wales Health, 2006).
    • Care informed by and aligned with current best practice in mental health aged care and disability services including recovery, person centred care and enablement (Australian Mental Health Ministers Advisory Council, 2013; Jacoby et al., 2008; Masala and Petretto, 2008; McKay and Draper, 2012; RANZCP, 2013).
    • General practitioners should be supported as the primary providers of health services for older people, with access to specialist clinicians and education, including on the interaction between the biological, psychological and social effects of ageing.
    • Liaison between mental health, social services and community providers should be facilitated to enable close coordination and continuity of care (Sarma and Byrne, 2013).
    • There needs to be recognition and respect for the roles and needs of older Aboriginal and Torres Strait Islander peoples, Māori, with awareness that concepts of mental health are integrated into broader concepts of wellbeing within these cultures (McKay et al., 2012; Hill et al., 2010; Community Liaison Committee of the RANZCP, 2000).
  • Mental health services for older people should not be subsumed into a broader ‘adult mental health’ or ‘ageless service’. The needs of many older people are distinct from young people (Joint Commissioning Panel for Mental Health, 2013).
  • Specialised psychiatry services for older people are:
    • Multi-disciplinary, coordinated and complementary to other providers across the spectrum of care.
    • Responsible for defined catchment areas allowing detailed knowledge of all services for older people in the area, ideally aligned to that of the geriatric medical service and to other public mental health and older persons’ social services (Chiu, 2005).
    • Adaptive and responsive with ongoing evaluation of different models of care to guide future service delivery for the changing cohorts of older people.
    • In close functional relationships with both adult mental health and geriatric medical services, underpinned by agreed policies or shared management systems which facilitate seamless, patient-centred care with optimal clinical outcomes.
    • Enhanced with ongoing investment in academic fellows, teaching and research.
    • Committed to creating valuable experiences and/or preferred training posts both at the Proficient and Advanced stages of RANZCP registrar training.
    • Key contributors to innovations to improve the mental health knowledge and skills of all health care and social service staff working with older people (Beck et al., 2011).

 

Responsible committee: Faculty of Old Age Psychiatry

Aschbrenner K, Grabowski DC, Cai S, Bartels SJ, Mor V (2011) Nursing home admissions and long-stay conversions among persons with and without serious mental illness. Journal of Aging and Social Policy 23(3): 286–304.

Australian Bureau of Statistics (2013) ABS 3303.0 -Causes of Death, Australia, 2012, Commonwealth of Australia, Canberra. Available at: www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3303.02012?OpenDocument (accessed 11th April 2014).

Australian Institute of Health and Welfare (2012) Dementia in Australia. Cat. no. AGE 70. Canberra: Australia.

Australian Mental Health Ministers Advisory Council (2013) A national framework for recovery-oriented mental health services: Guide for practitioners and providers. Commonwealth of Australia. Canberra. Available at: www.ahmac.gov.au/cms_documents/National%20Mental%20Health%20Recovery%20Framework%202013-Guide-practitioners&providers.pdf (accessed 21st April 2014).

Beck C, Buckwalter K C, Dudzik P M, Evans L K (2011) Filling the void in geriatric mental health: The Geropsychiatric Nursing Collaborative as a model for change. Nursing Outlook 59(4): 236–241.

Bowersox NW, Szymanski BJ, McCarthy JF (2013) Associations Between Psychiatric Inpatient Bed Supply and the Prevalence of Serious Mental Illness in Veterans Affairs Nursing Homes. American Journal of Public Health 103(7): 1325–1331.

Büchtemann D, Luppa M, Bramesfeld A, Riedel-Heller S (2012) Incidence of late-life depression: A systematic review. Journal of affective disorders 142(1): 172–179.

Calati R, Salvina Signorelli M, Balestri M, Marsano A, De Ronchi D, Aguglia E (2013) Antidepressants in elderly: Metaregression of double-blind, randomized clinical trials. Journal of Affective Disorders 147(1–3): 1–8.

Chiu E (2005) Principles and Best Practice Model of Psychogeriatric Service Delivery. In: Draper B, Melding P, Brdaty H. (eds) Psychogeriatric Service Delivery: An International Perspective. Oxford, UK: Oxford University Press.

Community Liaison Committee of the RANZCP (2000) Involving Families Guidance Notes. New Zealand Ministry of Health. Available at: www.health.govt.nz/system/files/documents/publications/involving-families-guidance-notes.pdf (accessed 15 April 2015).

da Silva SA, Scazufca M, Menezes PR (2013) Population impact of depression on functional disability in elderly: results from ‘São Paulo Ageing & Health Study’ (SPAH). European archives of psychiatry and clinical neuroscience 263(2): 153–158.

Draper B, Brodaty H, Low L F (2006) A tiered model of psychogeriatric service delivery: an evidence‐based approach. International Journal of Geriatric Psychiatry 21(7): 645–653.

Goldberg SE, Whittamore KH, Harwood RH, Bradshaw LE, Gladman JRF, Jones RG (2012) The prevalence of mental health problems among older adults admitted as an emergency to a general hospital. Age and Ageing 41: 80–86.

Hill L, Roberts G, Wildgoose J, Perkins R, Hahn S (2010) Recovery and person-centred care in dementia: common purpose, common practice? Advances in Psychiatric Treatment 16(4): 288–298.

Hollingworth SA, Lie DC, Siskind DJ, Byrne GJ, Hall WD, Whiteford HA (2011) Psychiatric drug prescribing in elderly Australians: time for action. Australian and New Zealand Journal of Psychiatry 45(9): 705–708.

Jacoby R, Oppenheimer C, Dening T, Thomas A Brooker D (2008) Person centred care. In: Jacoby R, Oppenheimer C, Dening T, Thomas A . (eds) Oxford Textbook of Old Age Psychiatry. Oxford: Oxford University Press.

Jeste DV, Maglione JE (2013) Treating Older Adults With Schizophrenia: Challenges and Opportunities. Schizophrenia Bulletin 39(5): 966–968.

Jeste DV, Palmer BW (2013) A call for a new positive psychiatry of ageing. The British Journal of Psychiatry 202(2): 81–83.

Joint Commissioning Panel for Mental Health (2013) Guidance for commissioners of older people’s mental health services. Available at: www.jcpmh.info/resource/guidance-for-commissioners-of-older-peoples-mental-health-services/ (Accessed 15th April 2014).

Klug G, Hermann G, Fuchs-Nieder B, Panzer M, Haider-Stipacek A, Zapotoczky HG, Priebe S (2010) Effectiveness of home treatment for elderly people with depression: randomised controlled trial. The British Journal of Psychiatry 197(6): 463–467.

Knapskog AB, Portugal MDG, Barca ML, Coutinho ES, Laks J, Engedal K (2013) A cross-cultural comparison of the phenotype of depression as measured by the Cornell Scale and the MADRS in two elderly outpatient populations. Journal of Affective Disorders 144(1): 34–41.

Masala C, Petretto D R (2008) From disablement to enablement: conceptual models of disability in the 20th century. Disability & Rehabilitation 30(17): 1233–1244.

McCrone P, Dhanasiri S, Patel A, Knapp M, Lawton-Smith S (2008) Paying the Price. The cost of mental health care in England to 2026. Kings Fund.

McKay R, Casey J, Stevenson J, McGowan H (2015) Psychiatry services for older people: A report on current issues and evidence to inform the development of services and the revision of RANZCP Position Statement 22. Available at: www.ranzcp.org/Files/Resources/College_Statements/Position_Statements/RPT-FPOA-Psychiatry-services-for-older-people-revi.aspx (accessed 15 April 2015).

McKay R, Draper BM (2012) Is it too late to prevent a decline in mental health care for older Australians? Medical Journal of Australia 197(2): 87–88.

McKay R, McDonald R, Lie D, McGowan H (2012) Reclaiming the best of the biopsychosocial model of mental health care and ‘recovery’ for older people through a ‘person-centred’ approach. Australasian Psychiatry 20(6): 492–495.

Ministry of Health (2012) Suicide Facts: Deaths and intentional self-harm hospitalisations 2010. Wellington, New Zealand: Ministry of Health.

Molyneux G, McCarthy G, McEniff S, Cryan M, Conroy R (2008) Prevalence and predictors of carer burden and depression in carers of patients referred to an old age psychiatric service. International Psychogeriatrics 20: 1193–1202.

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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.