It is apparent that the prevalence of dementia among ethnic elders of Indian subcontinent origin, 'black' groups and the Chinese is essentially similar to that amongst the indigenous elderly population of the UK. However, ethnic elders are poorly represented in many psychiatry services for geriatrics. Dr Ajit Shah highlights why this discrepancy may have arisen and what measures should be taken within both primary and secondary care to resolve it.

The core ingredients of psychiatry services for ethnic minority elders are complex but should include:
a definition of ethnic minority elders
demography
epidemiology
primary care issues
secondary care issues
the core components of a geriatric service.

Definition

A useful working definition of ethnic minority individuals are those with a cultural heritage distinct from the majority population¹. The traditional cut-off age for geriatric psychiatry services used in the United Kingdom is 65 years. The definition of ethnic elders should include both these variables. The cut-off age of 65 years will ensure that ethnic elders can receive care from the same service as indigenous elders and avoid fragmentation and marginalization of services for them. Each service needs flexibility in assessing the age cut-off.

Demography

Service planning is assisted by the size, age distribution and projected population trends of ethnic minority elders. Three per cent of ethnic minority individuals compared to 17 per cent of the indigenous population within the UK are elderly, according to the 1991 census¹. This is likely to increase in the 2001 census. The ethnic elderly composition is as follows: 41 per cent of 'Indian sub-continent origin', 34 per cent 'black Caribbean', 'black African' or 'black other' origin, 5 per cent 'Chinese' origin, and 14 per cent from other ethnic groups². v Ethnic elders from some groups including Asia, China and Vietnam live with several family members in the same household. It is therefore often erroneously assumed that the extended family provides adequate care³. Ethnic minority groups are concentrated in metropolitan and industrial areas with over 25 per cent living in nine London boroughs and two districts outside London (Leicester and Slough)².

Epidemiology

Data on the epidemiology of mental disorders among ethnic elders are invaluable in planning services, but they are sparse. In the few published studies^4-6 available it is apparent that the prevalence of dementia among ethnic elders of Indian subcontinent origin, several 'black' groups and the Chinese is essentially similar to that amongst the indigenous population of older people within the UK. Whereas, the prevalence of dementia in the 'black African' group and the Chinese group (in those who do not speak English) was actually higher. Some data on the severity of illness and resultant disability in dementia is also beginning to emerge for ethnic elders^6-8.

One study has shown that the prevalence of depression among 'black Africans' in Liverpool was higher than indigenous elders⁵ and was thought to be associated with seeing their families infrequently. The prevalence of depression was also high among 'Indian sub-continent' origin elders in Bradford⁴. Depression scores were higher among elderly Bengalis in east London⁹, but not among Gujaratis in north London¹⁰ and Leicester⁷. These studies also provide some helpful data on severity of illness, resultant disability and life-events in depression.

Epidemiological data on other psychiatric disorders in ethnic elders are sparse. Levels of anxiety and simple phobias are low among Gujaratis in Leicester⁷ and north London¹⁰. The reasons for this are unclear. Unfortunately, at present there are no studies examining the mode and nature of clinical presentation of mental illness in ethnic elders. There are no studies of non-cognitive symptoms of dementia; even though non-cognitive symptoms (such as disorders of behaviour, mood, perception and thought content) commonly lead to a clinical presentation of dementia among indigenous elders.

Primary care

Elders from many ethnic groups are aware of services provided by GPs and utilize them effectively with a high consultation rate. However, ethnic elders are poorly represented in many psychiatry services for geriatrics⁷. This discrepancy may be due to factors related to patients and their families or primary care. Patients and their family members may not recognize symptoms of mental illness and may assume them to be a function of old age. This may be further enhanced by difficulties the patient may have in communicating symptoms to family members or the GP due to lack of appropriate vocabulary and language barriers. Both the patient and family member/s may believe nothing can be done, they may be unaware of services or may feel services are inadequate, inaccessible and culturally insensitive. All this may be further complicated by the fear of stigma attached to a diagnosis of mental illness. Also, due to cultural values, family members may elect to look after the patient rather than seek formal help.

Several factors in general practice may also explain the low representation of ethnic elders in geriatric psychiatry services. GPs may not recognize mental illness, and if diagnosed they either may treat it themselves or they may elect not to refer the patient to secondary care due to a lack of adequate or appropriate services.

Secondary care

Geriatric psychiatry services for ethnic elders have been sparsely evaluated. Almost all of the criticisms levied at primary care also apply to secondary care. There is a general lack of awareness and utility of various components of the geriatric psychiatry service among ethnic elders7. However, there is recent evidence from two west London services that this may be improving with better access and utility of various components of geriatric psychiatry services^3,11.

Several key components of an ideal geriatric psychiatry service for ethnic elders are illustrated in Table 1. The psychiatry service for ethnic elders should be integrated with the same service for the indigenous elderly population in order to avoid fragmentation and marginalization of the entire service. The core needs of ethnic elders should be considered to be the same as those for indigenous elders, but they should be considered to have 'special' or 'tailor-made' variations within this overall framework. Any such service should not only work closely with social services, but also with a range of voluntary sector organizations catering for ethnic minority individuals. v Ethnic elders should be able to access all the components of a traditional geriatric psychiatry service including inpatient care (acute, rehabilitation and respite), day hospital care, out-patient care, memory clinics, liaison services (for example to medical units and nursing homes) and community care in a multi-disciplinary setting. Ethnic elders should be assessed in an identical fashion to indigenous elders as far as possible. The traditional approach of all new (first) assessments, for example, occurring at home should apply to these patients. Multidisciplinary staff should have some working knowledge of the patient's culture and also have the ability and expertise to be culturally sensitive This can be assisted by efforts to employ a proportion of staff from the same background as ethnic elders likely to be treated by the service, and by training staff on a regular basis on transcultural issues.

There should be a clear protocol for dealing with all referrals and any such protocol should accommodate the specific needs of ethnic elders. Unless the patient speaks good English, there is usually a need to utilize services of professional interpreters to improve communication. Unless absolutely necessary, interpretation by family members and other non-clinical or clinical staff should be avoided as it can introduce bias in the communication process¹². Communication can be further improved by regular and frequent contact with patients and relatives using interpretation services. Therefore, we should develop translation service with interpreters receiving relevant health training.

Availability of written information in ethnic minority languages on the psychiatry service for the elderly, social services, various voluntary sector services, diagnosis and treatment of mental disorders in old age can further supplement this. Many ethnic elders may not be literate even in their mother tongue and the use of audio and video recording has been also suggested for this group⁷.

Geriatric psychiatry service facilities should ideally be located in or close to a general hospital within the catchment area to ensure easier access to general hospital facilities. There may be a need to locate additional satellite centres close to population clusters as ethnic elders often live in such clusters³. Individual components of geriatric psychiatry services should be designed to meet the needs of the ethnic elders they may serve. For example there may be a need for availability of appropriate food or labels on doors in a specified language.

Conclusion

The various components described above are not comprehensive or exhaustive. Clearly, different services with different groups, proportions and geographical distribution of ethnic elders will need to be developed appropriately. However, it is clear that ingredients of a satisfactory service are flexibility, ability to adapt to change, availability, ethnic sensitivity and the availability of appropriate communication tools. All components of any such service should be subject to rigorous audit and research. There should also be rolling programme of staff training in transcultural issues.

Dr Ajit Shah is a Consultant Psychiatrist and Honourary Senior Lecturer at the West London Mental Health NHS Trust, Uxbridge Road, Southall, London

References

1. Manthorpe J, Hettiarathy P. Ethnic minority elders in Britain. International Review of Psychiatry, 1993; 5: 173-80

2. Office of Population Census and Surveys. Census. Ethnic Group and Country of Birth Great Britain. London, Office of Population Census and Surveys, 1993

3. Odutoye K, Shah AK. The clinical and demographic characteristics of ethnic elders from Indian sub(c)continent newly referred to a psychogeriatric service. International Journal of Geriatric Psychiatry, 1999; 4: 446-53

4. Bhatnagar K, Frank J. Psychiatric disorders in elderly from the Indian subcontinent living in Bradford. International Journal of Geriatric Psychiatry, 1997; 12: 907-12

5. McCrakken CFM, Boneham MA, Copeland JRM, Williams KE, Wilson K, Scott A et al. Prevalence of dementia and depression among elderly people in black and ethnic minority groups. British Journal of Psychiatry, 1997; 171: 269-73

6. Lindesay J, Jagger C, Mlyni-Szmid, Simor Wale A, Post S, Moldino F. The mini-mental state examination (MMSE) in an elderly immigrant Gujarati population in the United Kingdom. International Journal of Geriatric Psychiatry, 1997; 12: 1155-67

7. Lindesay J, Jagger C, Hibbert MJ, Peets M, Moldino F. Uptake and availability of health and social service among Asian Gujarati and white elders. Ethnicity & Health, 1997; 6: 59-69 v 8. Rait G, Burns A, Baldwin R, Morley M et al. Validating screening instruments for cognitive impairment in older south Asians in the United Kingdom. International Journal of Geriatric Psychiatry, 2000; 15: 54-62

9. Silveira E, Ebrahim S. Mental health and health status of elderly Bengalis and Somalis in London. Age & Ageing, 1995; 24: 474-80

10. Ebrahim S, Patel N, Coates M, Greig C, Gilley J, Bangham C et al. Prevalence and severity of morbidity among Gujarati Asian elders: a controlled comparison. Family Practice, 1991; 8: 57-62

11. Redelinghuys J, Shah AK. The characteristics of ethnic elders from the indian sub-continent using a geriatric psychiatry service in west London. Ageing & Mental Health, 1997; 1: 243-47

12. Shah AK, Elanchenny N. Dementia services for ethnic minority elders with dementia. In: Dementia Topics for the Millennium and Beyond, Ed. S Benson). London, Hawker Publications. 2002; 27-35

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