Older people in residential and nursing homes have complex physical and mental health problems and are a highly vulnerable group.

This position statement has been endorsed by the Royal College of Nursing and is produced jointly by the Faculty for Psychiatry of Old Age of the Royal College of Psychiatrists and the British Geriatrics Society Special Interest Group on Cerebral Ageing and Mental Health in consultation with the Royal College of General Practitioners reflecting:

a) A desire to build on an earlier Position Statement by the Faculty of Old Age Psychiatry (Jones 1998).

b) Collaborative working between geriatricians, old age psychiatrists and general practitioners in setting standards for better care of older people.

c) A recognised need to drive up quality for a particularly vulnerable group of older people.

In this context no attempt is made to deal with the ongoing debate about funding of care, and neither are the different models of health and social care provision across the United Kingdom and Ireland specifically addressed. Recommendations made should be applicable in all jurisdictions and it is hoped that this document will be useful as a Clinical Governance framework for improving practice.

Background
More and more people are living to old age and the greatest rise is in those over 80; the number of people in England expected to live into their 80's is likely to double over the next 20 years (DoH 2001) and similar trends are likely in the rest of the UK and Ireland. In tandem with these demographic changes we can expect ever larger numbers of older people going into residential and nursing homes and it is known that the levels of physical and mental ill health in residents entering homes are increasing (Furniss 2002).

The need for appropriate assessment before admission to long-term care has long been promoted but although assessment prior to admission is usual practice for publicly funded residents, research has found wide variation in the assessments used (Sturdy and Carpenter 1995). The situation with those who are self-funding is even more worrying as they often do not have a pre-admission assessment. Challis et al. (2000) described the existence of a large group of self-funded low dependency new admissions to nursing homes. Several studies show considerable overlap in the case mix of residential and nursing homes (Rothera et al. 2003), which may be partly due to changes in physical and mental health needs following placement; the same authors call for a better system for monitoring changes in health status following placement. In similar vein there is considerable overlap between specialist elderly mentally infirm homes and non elderly mentally infirm homes in relation to the prevalence of dementia and the often accompanying behavioural disturbance. Dementia affects about three quarters of older people in non specialist elderly mentally infirm homes (McDonald et al. 2002) which are not designed or staffed for dementia care and management of behavioural problems.

In the past, large numbers of residents currently in residential and nursing homes would have received long-stay hospital care (geriatric or psychogeriatric) but medical responsibility now lies with primary care resulting in a rise in workload for general practitioners. The shift from specialist to primary care has led to concerns about the quality of medical care provided to residents and in a controlled observation study Fahey (2003) concluded that older people living in nursing homes, in particular in one UK city, received poorer care than those living at home in terms of under use of beneficial drugs, over use of inappropriate or unnecessary drugs, and poor monitoring of chronic disease. Several other studies have expressed concern about the use and review of medicines in residential and nursing homes (Heston et al. 1992, Passmore et al.1995, Furness et al. 2000, Dale et al. 2001, Furness 2002, Oborne et al.2003). The majority of people living in long-term care have some form of dementia and the prevalence of depression varies between 12% and 32% (Heston et al. 1992). Co-morbidity is common and residents often suffer from a range of chronic physical conditions.

Policy Context
A wide range of policy initiatives are now being applied to older people in general and to the long-stay population in particular. These include:

a) The National Service Framework for older people (Department of Health 2001)

b) Forget-me-not: Mental Health Services for Older People (Audit Commission 2000).

c) Standards of Care for Specialist Services for Older People (British Geriatrics Society 2002).

d) The Health and Care of Older People in Care Homes; a report of a joint working party of the Royal College of Physicians (London), The Royal College of Nursing and the British Geriatrics Society (2000).

e) The setting up of a National Care Standards Commission in April 2002.

These policy initiatives raise the profile of the health and care needs of a very vulnerable group and hopefully will lead to much needed improvements.

Recommendations for good practice
Central to improving standards is Clinical Governance which can and should provide a force for improvement in the health care of people in residential and nursing homes. The Clinical Governance requirement that individual residents experience the best possible health (Bowman 2001) seems a reasonable starting point. A key issue for professionals is who provides and who is responsible for care (Bowman 2003) and key to the process are general practitioners, geriatricians and old age psychiatrists. Hopefully this document, together with the policy initiatives described earlier, will guide those who commission medical and nursing services for older people in care homes in ensuring that residents experience the very best standards of care, otherwise Bowman (2003) may be proved right in his comment that re-engagement of specialist care may require several further uncomfortable reports. It is outside the scope of this document to determine how commissioners will ensure engagement and adequate training of health care professionals in chronic disease management or the care of frail older people. Suffice it to say that these are essential pre-requisites for ensuring adequate standards of care.

General recommendations

• Medical care in relation to nursing and residential homes should be delivered through new partnerships, at local and national levels, between geriatricians, old age psychiatrists, general practitioners and the primary care teams. (Philp 2001).
• Education must be a key component of these new partnerships. Effective learning is most likely to occur where all parties work collaboratively together toward shared objectives, where learning is firmly set in the context of service delivery and where the contribution of all members of the collaboration is equally valued. Geriatricians and old age psychiatrists should seek to work with individual practices, GP training schemes and medical schools. Topics covered should include diagnosis and management of common conditions from specialist and from generalist perspectives, when and how to refer to a specialist, and medicines management including the importance of regular medication review. General practitioners will provide most of the medical care but both specialist services must continue to lead on innovation and setting standards in the best care of older people with physical and mental illness.
• Geriatricians and old age psychiatrists (and the specialist nurses who work with them) have a responsibility to work with primary care colleagues and public health specialists in the planning of continuing care services, locally and regionally.
• The training of staff in both public and private care homes should be regarded as essential. Local collaboration between multi-disciplinary old age psychiatry, geriatric and primary care teams should ensure that the expertise available will cover essential topics such as:

  a) Promotion of autonomy and dignity
  b) Promoting an ethos of rehabilitation and prevention of unnecessary disability
  c) Monitoring changes in health status following placement
  d) The importance of recreation and a stimulating environment

• Monitoring of chronic disease

  e) Continence problems
  f) Falls prevention
  g) Detection and treatment of depression
  h) Management of dementia
  i) Dealing with difficult behaviour
  j) Medicines management including under use of beneficial drugs as well as over use of inappropriate or unnecessary drugs
  k) Palliative care

Pre-admission

• All older people whether in hospital or in the community should receive a thorough multidisciplinary assessment, including a full medical assessment, prior to a permanent move to residential or nursing care. The medical assessment must be performed by a suitably experienced doctor - a geriatrician, an old age psychiatrist or (in England and Wales) a general practitioner with Special Interest (GpwSI ) in older people. Intermediate care beds in England offer a route for this to be achieved.
• Older people who are financially independent should, as a routine, be offered pre-admission assessment and advice similar to that provided for publicly funded residents (Challis et al. 2000). Where possible, this should be a routine part of a GPs advice to an older person who is talking about moving into a care home.

Post-admission

• Commissioners should ensure that residents with complex physical and mental health needs have at least the same access to specialist services post-admission, as people living in their own home, and geriatricians and old age psychiatrists should ensure that their services respond effectively to the particular needs of care home residents.
• An up to date, comprehensive and accessible health record held at the care home for each resident, which contains information about advance directives, should be regarded as good practice by all those who commission care home services. Geriatricians and old age psychiatrists should collaborate with these arrangements, especially when the record travels with the residents to medical appointments outside the home for example, to general practice surgeries or hospital departments.

It is recognised that in England the Single Assessment process will eventually facilitate this process and also make the records of the multidisciplinary assessments undertaken subject to greater audit and scrutiny.

Conclusion
Engaging geriatricians and old age psychiatrists in the care of older people in residential and nursing homes is a common theme in the literature and seen as central to improving the care provided to this vulnerable group. Education, shared learning and development involving specialist services, primary care practitioners and staff in residential and nursing homes are key to driving up standards. Systems put in place should be embedded in a Clinical and Social Care Governance Framework within the organisations which commission care home services for this group of frail older people.

Produced by Dr Noeleen Devaney on behalf of the Faculty of Old Age Psychiatry and the British Geriatrics Society Special Interest Group on Cerebral Ageing and Mental Health in consultation with Dr Joe Neary on behalf of the Royal College of General Practitioners. The statement has been endorsed by Pauline Ford on behalf of the Royal College of Nursing

Publication in this newsletter authorised by:

Jackie Morris
Duncan Forsyth