psychogeriatrics

A report on psychiatric services for older people in general hospitals makes recommendations to improve the care of older people.

Those interested in psychiatric illness in older people need look no further than the wards of a general hospital to find high levels of psychiatric morbidity. Dementia, delirium and depression are particularly common, and in some general hospital wards, over 70% of patients have a diagnosable psychiatric illness.

What are psychiatrists doing about this?
Old age psychiatry, like many parts of the NHS, has become increasingly community focused, possibly to the detriment of general hospital inpatients. We set out to determine what old age psychiatrists think about their services to older people in general hospitals through a postal survey.

We found that psychiatrists are kept busy by general hospitals, with a quarter of all referrals to old age psychiatry from this source and referral rates rising. Most services operate a traditional, sector-based service model, often based away from the general hospital site, with assessments provided almost exclusively by doctors on a consultation basis, relying on general hospital staff to detect and refer appropriately. However, some services are provided on a more proactive basis, with general hospital based liaison psychiatry staff (including psychiatrists, psychiatric nurses, occupational therapists and others) developing educational programmes for general hospital colleagues as well as assessing and managing referrals. Shared care wards, jointly operated by geriatricians and psychiatrists to meet the needs of patients requiring both physical and psychiatric care, were also described.

Are psychiatrists happy with their current services?
It seems not; over two thirds described their service to general hospitals as being poor or needing improvement. Although many wanted to adopt general hospital based liaison psychiatry models, important barriers to service development included a lack of interest from mental health trusts managers, and the separate managerial arrangements of acute and mental health trusts.

What benefits can liaison psychiatry services offer?
We found that those psychiatrists operating a liaison model were able to respond more quickly to referrals, meaning less time spent waiting for assessments. This may be explained by a perception that community referrals should be assessed more urgently, as patients are in more danger than they would be on general hospital wards, although the vision of a junior hospital doctor bearing down on a delirious patient with a large syringe of haloperidol casts doubt on this.

There are other potential benefits from liaison psychiatry. One American study has shown that the introduction of a liaison psychiatry service reduced the overall length of stay by two days. If this could be reproduced in the NHS the potential cost savings are large. Most importantly, the overall quality of patient care should improve as the general hospital skills mix more accurately reflects the needs of patients.

Where do we go from here?
There is pressure for change from psychiatrists, who feel they could do better but are frustrated in their attempts to improve matters. Our report makes a range of recommendations across policy and planning, service models and care pathways, training, and research and development, and we need to build partnerships with clinical and managerial colleagues to implement these recommendations.

Interested readers can download a copy of our report from the Internet, and anyone wanting to hear more can attend the second annual conference on Liaison Psychiatry for Older People in Leeds on 12th and 13th June 2003. At our first conference last year, delegates asked where the geriatricians and managers were, so come along and bring a colleague!

The report – “Between Two Stools: Psychiatric services for older people in general hospitals” can be downloaded from:
www.leeds.ac.uk/medicine/divisions/psychiatry/research/oldliaison_br.htm

Further information about “Liaison Psychiatry for Older People: Directions and Developments 2003”, including a downloadable registration form, can be found at: www.leedsmentalhealth.nhs.uk/andrewsims/

John Holmes
Senior Lecturer in Liaison Psychiatry of Old Age
University of Leeds