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Colleagues around England have voiced considerable disquiet at their being asked for an opinion from an old age psychiatrist before the local Social Services or joint Health and Social Care placement panel would consider any patient with cognitive impairment being referred for institutional care (care home placement).

This has largely been seen as a means of delaying the discharge planning process and a failure to recognise the core skills of a geriatrician and the multi-disciplinary assessment that occurs in our departments. There appear to be several 'urban myths' influencing this unnecessary additional delay to the discharge from hospital of this vulnerable group:

Myth 1: a care home cannot accept a client who has dementia unless it is registered as a dementia care home;

Myth 2: care home residents who have not been given a diagnosis of dementia (i.e. undiagnosed but suffering from dementia) cannot have dementia and so can reside in a care home that is not registered as a dementia care home;

Myth 3: assessment of capacity and consent requires the input of an old age psychiatrist;

Myth 4: if a resident of a care home enters hospital without a diagnosis of dementia, but is then diagnosed as having dementia, they cannot return to that care home if it is not registered as a dementia care home despite the fact that the home had previously been successfully caring for that individual;

Myth 5: individuals with behavioural and psychiatric symptoms of dementia cannot be discharged to a specialist dementia care home without assessment by an old age psychiatrist;

Myth 6: all the above are compatible with guidance from the Commission for Social Care and Inspection (CSCI) and the registration process for a care home.

The Nursing Home and Residential Home sector is dominated by the care of people with dementia. Sometimes residents will have been given a formal diagnosis of dementia, and sometimes not. We need to recognise that this is the reality of care, and that, when someone is given a formal diagnosis of dementia, they should not automatically have to move to a home providing specialist psychiatric care. Where possible, the care needs of patients should be met through tailoring provision appropriately, rather than having to move home. In other words, levels of care should be determined by needs not by diagnosis. Residents in care homes should have the same access to specialist care as those living in the community. Thus, whilst all care homes require access to education and training to help them better understand and manage residents with dementia; not all care homes need to be specially registered as 'dementia homes'. At a national and local level the British Geriatrics Society (BGS) and Faculty of Old Age Psychiatry should work in collaboration to promote excellence in the care of all older people in care homes by using their influence as experts in health and social care of older people.

An individual who requires transfer to a care home purely on account of their dementia and/or BPSD will require a care home with an appropriate number of beds registered in the appropriate specialist category. However, where a degree of dementia already exists (or develops whilst they are resident in a care home) and this does not constitute the main reason for care or involve providers meeting specialist needs, then the resident need not be in a specially registered bed.

On behalf of England Council and the UKMC I have liaised with CSCI and colleagues in the Faculty of Old Age Psychiatry in order to develop a statement on behalf of the BGS that I hope colleagues will find helpful in their local negotiations to ensure that our colleagues in old age psychiatry are not unnecessarily burdened to 'second' our opinion, whilst also ensuring that older people with dementia are not denied timely discharge from hospital to appropriate care facilities. The document should be used in conjunction with the BGS compendium document dealing with the wider context of hospital discharge of frail older people. The scope of the document produced is confined to the safe and appropriate discharge of older people with cognitive impairment from hospital to a care home. It is a given, within the context of this document, that discharge to any other care setting has been deemed inappropriate as the result of a comprehensive geriatric assessment (CGA) and that the CGA will have determined the following:

• The level of cognitive impairment
• The underlying diagnosis (cause of their cognitive impairment)
• Whether there are or have been any symptoms of delirium
• Presence of persistent behavioural and psychiatric symptoms of dementia (wandering, aggression, shouting, etc) to a degree which requires specialist dementia care or need to be addressed appropriately in some other way
• Whether this is the most appropriate care setting to be discharged to, taking into account potential strengths and risks of alternative social care supports, including the position of spouse, partner, carer or immediate family
• Any other medical conditions are stable
• Appropriate follow up is arranged as necessary with either primary care, geriatric services or old age psychiatry services
• Appropriateness of medication (including anti-dementia drugs)
• Exclude or identify any degree of depression
• Access to any state benefits

Geriatricians should be able to recognise, diagnose and manage most aspects of cognitive impairment, as it is not just one of the 'geriatric giants' but is implicated in most aspects of geriatric medicine (falls, Parkinson's, stroke, etc). CGA will identify the individual's care needs based on the medical diagnosis, their degree of social functioning and/or likely rate of decline, as well as the availability/appropriateness of other social care options. It will not always be necessary for separate assessments to be undertaken by both the geriatric and old age psychiatry services. Where the complexity of the individual's management is such that the geriatrician requires further expert advice, this should be available from the local old age psychiatry liaison service.

Collaboration between health and social services is also required to ensure that both services work together and appreciate the professionalism of each others assessments. An integrated plan which may also come within the scope of the Single Assessment Process (SAP) should be agreed and incorporate the views of key stakeholders (family / carers, and, if possible, the individual) other than the health and social care professionals.

Given the future demographic trends, which will result in increasing numbers of dementia sufferers, the BGS must work in collaboration with other interested parties from health and social care to demystify dementia, dementia care, and the discharge planning process from hospital to care homes.

Duncan Forsyth
Vice-Chair England Council