Opportunities arise within the NSF for Older People to foster collaboration between primary care and specialist mental health services. Two areas are discussed: the requirement for a single assessment process and the development of locally agreed protocols and/or care pathways for the recognition and assessment of dementia and depression in primary care. A less obvious opportunity for collaboration is that of liaison services for mental health problems, for which monies could be provided within intermediate care developments, explain Dr N Jawaid and Professor R Baldwin

The elderly populations of the developed countries have grown in the last few decades and mental health problems are not uncommon in this age group. The incidence of Alzheimer's disease rises steeply with age while anxiety and affective disorders remain as significant disorders¹.

Although the National Service Framework for Older People (NSF)¹ came somewhat as an after thought following the publication of the National Service Framework for Mental Health¹, it provides an opportunity to raise the profile of older people services and recognizes the principles of individualized care packages for elderly people.

In the NSF, attention is given to the treatment of depression and dementia, along with some mention of services for people with young-onset dementia. However, there have been concerns raised by the Old Age Psychiatry Faculty of the Royal College of Psychiatrists about the lack of emphasis in the NSF liaison psychiatry services, of failing to mention services for older patients with schizophrenia, and the lack of provision of NHS continuing care beds for older patients with challenging behaviour.

This leading article will discuss the mental health aspects of intermediate care and the implications of the NSF for primary-care practitioners with respect to screening procedures, single assessment processes, and shared protocols for mental health.

The single assessment process applies to health and social services and has been established in recognition of the complex needs of elderly people. It recommends that individualized coordinated assessment should replace the current fragmented system. A comprehensive assessment of elderly people, however, will need services from, and the cooperation of, geriatricians, old age psychiatrists and their teams, primary care, and social services.

The single assessment process emphasizes timely diagnosis and subsequent treatment of underlying conditions through the use of appropriate assessment tools and screening procedures. The idea of a single assessment is appealing but needs to be carefully thought through. No screening instrument is perfect, and most require further assessment of positive cases and have resource implications.

The role of an old age psychiatrist is not clearly defined in the Government's document and what constitutes an 'assessment' is rather ambiguous, with the possible danger that a psychiatric diagnosis may be missed. It is suggested that almost any member of a multidisciplinary team can carry out an assessment. Given that the prevalence of depression among older people in the community is around 15per cent⁴ and of dementia 5 per cent, the workload implications for primary care are enormous.

The key role of the old age psychiatrist will be to recommend appropriate screening tools, e.g. Mini Mental State Examination (MMSE), Abbreviated Mental Test score (AMT), and Geriatric Depression Scale (GDS), for the assessment of the main metal health problems in old age, such as depression and dementia. All of the tools mentioned are suitable for screening⁵. There will also be a requirement to provide a comprehensive assessment and management plan of referred cases through locally and nationally agreed guidelines and protocol to promote facilities for teaching and training of medical and relevant non-medical staff.

For primary-care physicians, the emphasis will be on overseeing the use of appropriate screening tools and the exercise of professional judgement to decide whether a positive screen should be taken further. Primary-care services will also play a useful role in structuring, storing, and sharing patient-related information with other professionals and agencies.

Intermediate care is designed to bring a new range of acute and rehabilitative services to bridge the gap between acute hospital, primary, and community care2. Locally agreed protocols and care pathways will determine its precise shape and structure.

The stated aim of intermediate care is to prevent and reduce prolonged hospital admission. However, there are concerns that an underlying agenda is to free hospital beds rather than provide special care for elderly people⁶. Shared-care protocols between GPs and hospital-based specialists (mostly geriatricians), are recommended with an emphasis on physical health. There is, however, the potential problem that patients may be discharged from hospital before they are medically stable. There is omission of liaison psychiatric services against clear evidence of a high percentage of elderly people having physical and mental co-morbidity with the latter carrying detrimental effects on the former and evidence of the positive effects of psychiatric interventions both in hospital and community settings⁷.

The specialist old age psychiatry services should emphasize the key role of the psychiatrist in intermediate care development as mental health problems such as depression, delirium, and dementia are an important cause of emergency hospital admission and are a reason for prolonging hospital stay.

However, the process of developing partnerships for older people services and overcoming inter-professional barriers could be highly contentious and complex. At present the evidence of health gains in intermediate-care are relatively underdeveloped and there is need for more research in this field including the relationship between psychiatric morbidity and outcome.

Mental illness frequently goes unrecognized in primary care¹. Depression is common in elderly people and severely affects the quality of life. The use of appropriate screening tools can aid in early diagnosis in higher risk patients in primary care. There is also good evidence that the use of standardized cognitive tests by GPs can aid in the detection of early cases of dementia.

Earlier detection is now especially relevant with the advent of cholinesterase inhibitors. Screening is most efficient when targeted on high-risk individuals -for depression this means the frail, isolated, recently bereaved, or those just admitted to residential or nursing home care.

The Faculty of Old Age Psychiatry emphasizes that packages of care for older people with psychotic illness such as schizophrenia are similar to those for working age adults. It is unreasonable that older patients with schizophrenia have their care packages discontinued when they reach 65 years of age often with a recommendation for 'day care'. Local protocol will have to ensure continuity of services and appropriate continued care.

A further challenge is to improve access for ethnic elders with mental illness. High rates of hypertension in African-Caribbean patients and diabetes in Asians result in high levels of dementia, but there are cultural and service barriers both at primary and secondary-care levels⁸.

Psychiatrists have been instrumental in delivering local protocols for the use of cholinesterase inhibitors. However, now that these are part of routine practice it is perhaps time to relax the stringent monitoring arrangements, to allow more time to be devoted to the assessment of dementia and depression and the treatment of the latter.

The NSF poses a further challenge for the speciality, namely to help coordinate a system of easy referral and collaboration between old age psychiatry, geriatric medical services, primary-care groups, and social services, although ultimately this will have to be determined by local protocol.

The majority of the people with mental health problems in later life are treated in primary care. Primary care plays a vital role in the commissioning and provision of services. Local agreement and protocols should determine the choice of assessment scale and care pathways for depression, dementia, and 'graduate' schizophrenia. NICE guidelines for the treatment of dementia with cholinesterase inhibitors are already published and the Royal College of Psychiatrists is now preparing guidelines for the treatment of depression. NICE is also commissioning guidelines for the primary-care management of depression. The role of the old age psychiatrist will be to act as a resource so that guidelines are evidence-based and appropriate to local needs and conditionsl

Dr N Jawaid is Specialist Registrar, and Professor R Baldwin is Consultant in Old Age Psychiatry, York House, Manchester Royal Infirmary, Manchester, M13 9WL

References

1. Jorm AF, Jolley D. The incidence of Dementia, a meta-analysis. Neurology 1998; 5: 728-33

2. Department of Health. National Service Framework for Older People. 2001; HMSO, London

3. Department of Health. National Service Framework for Mental Health. 1999; HMSO, London

4. Baldwin RC. Mood disorders in the elderly. In: MG Gelder. New Oxford Textbook of Psychiatry. Oxford University Press, Oxford

5. Burns A, Lawlor B, Craig S. Assessment Scales in Old Age Psychiatry. 1999; Matin Duntiz, London

6. Evans JG, Tallis RC. A new beginning for care of elderly people. Br Med J 2001; 322: 807-8

7. Banerjee S, Shamash K, Macdonald AJ, Mann AH. A randomized controlled trial of the effect of intervention by a psychogeriatric team on depression of frail elderly people at home. Br Med J 1996; 313: 1058-61

8. Rait G, Burns A, Chew C. Age, ethnicity, and mental illness: a triple whammy. Br Med J 1996; 313: 1347-8

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