Organization of services

The vast bulk of psychiatric disorder is coped with by patients themselves, their relatives, and their carers; some cases are recognized and treated in primary care, but only the minority reach secondary care. GPs have sometimes been criticized for not knowing about such problems in patients on their list, but there are indications that GPs avoid making these diagnoses if they feel, as is often, unfortunately, the case, that local psychiatric services for the elderly are overstretched.

Multidisciplinary teams in old-age psychiatry, as in general adult psychiatry (see Chapter 26), include doctors, nurses, psychologists, social workers, and occupational therapists. They work in liaison with primary health-care teams, social services, and gerontology departments.

Many of the problems identified in a comprehensive assessment are social rather than psychiatric, and require practical interventions accordingly. For example, a depressed patient living alone in poor accommodation will be unlikely to make a good recovery with antidepressant medication alone. Attending a day centre might combat loneliness and improve nutrition, and a social worker would advise about housing and social security benefits.

Physical problems also need to be addressed. Undiagnosed medical illness, inappropriate medication, and dietary deficiencies are common in this age group.

Hospital admission is frequently valuable to treat illness or, commonly, to relieve a social crisis. However, hospitalization should not be undertaken too lightly. Many old people survive in their own homes through a complex network of informal care and company from relatives, friends, church, the voluntary sector, and domestic pets, and this network may prove impossible to reassemble following an admission. If the patient does go into hospital, a gradual discharge with increasing periods of home leave is the rule.

Occupational therapy assessment is often important, to see whether the patient can manage day-to-day tasks such as cooking, cleaning, and shopping.

Inpatient facilities include assessment wards for functional psychiatric illness and for dementia patients. These are separate from the wards for younger adults, but some facilities may be shared with physicians for the elderly.

Respite admissions at regular planned intervals are particularly valued by relatives, and provide patients themselves with care and company, and an opportunity for thorough medical and nursing review.

Day hospital care is often preferable to inpatient admission, and also less costly.

Home care, a 'package' of 'community care', not only supports people with continuing difficulties, but can also be used as a treatment, with increased support at times of crisis.

Most care is now provided in the community. However, old-age psychiatry remains a 'Cinderella' specialty with many unmet needs; it is clear that the health and social services would be entirely unable to cope were it not for unpaid carers and the voluntary sector.

A major change has been the new responsibility of local authority social services to 'purchase' appropriate care for individuals. This care may range from provision of home helps, laundry, and meals-on-wheels, to residential accommodation. Such measures can no longer be directly prescribed by health services, so good local, day-to-day working relationships with social workers are vital. Integrated teams of health and social services staff are now the norm.

Supported accommodation, such as warden-controlled housing, can be very helpful in maintaining independent living. Alternatives include nursing or residential homes, almost all privately run now. Long-stay hospital provision for dementia patients is now almost extinct.

Reference

Burns, A., Guthrie, F., Marino-Francis, E. et al. (2005). Brief psychotherapy in Alzheimer's disease: randomized controlled trial. British Journal of Psychiatry 187, 143-147.

Further reading

Jacoby, R. and Oppenheimer, C. (2002). Psychiatry in the Elderly (3rd edn). Oxford: Oxford University Press.

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