- Email: [email protected]
Organization of old age psychiatric services
Old age psychiatric services
Organization of old age psychiatric services
In terms of service activity in psychiatry, older people are an important group. In the UK, people over the age of 65 make up around a third of all mental health activity in admissions, re-admissions and community contacts.1 However, their profile of disorder and needs differs from that in younger age groups. The challenges presented by dementia and comorbid physical illness and disability require particular professional skills. Services need to be able to deal with the complex mix of social, psychological, physical and biological factors found in the elderly mentally ill. The World Health Organization consensus statement on psychiatry for the elderly has affirmed that assessments should be carried out in the patient’s home.2 Unlike many principles, this appears to be the reality of clinical practice, with 9 out of 10 referrals seen at home rather than in out-patient clinics.3
Sube Banerjee Jenifer Chan
Abstract In terms of service activity in psychiatry, older people are an important group. People aged more than 65 years make up around a third of all mental health activity in the UK in terms of admissions, re-admissions and community contacts. However, the profile of disorder and needs differs from that in younger age groups. The challenges presented by dementia and co-morbid physical illness and disability require particular professional skills. Services need to be able to deal with the complex mix of social, psychological, physical and biological factors found in the elderly mentally ill. The development and delivery of such services is discussed in this contribution. Even given resource constraints and other challenges, there can be few more exciting parts of medicine with which to be involved, and where there is greater likelihood of clinically significant advances in treatment and care in the next 10–15 years, than old age psychiatry. The biological advances in understanding the causes of dementia are being rapidly transformed into therapeutic approaches as diverse as disease-modifying medication, immunization, and stem-cell therapy. The rate of transformational change in understanding and action in this area is stunning. In service terms we need to gear ourselves up to identify cases early, when there is the possibility of prevention of future harm; for example, in terms of crises, institutionalization, depression, carer burden, loss of function, and possibly further cognitive decline. The next generation of disease-modifying compounds will further challenge us to identify and intervene in presymptomatic states as well as in those already affected by dementia. Services must develop to meet local needs and will need to build on local strengths. In service development it is seldom the case that one size fits all, so there will be local variation in what works best. The announced National Dementia Strategy gives real hope that things can change. Finally, the focus on dementia should not be at the expense of older people with other serious mental disorder. Services should be considered failures if they do not ensure that older people with depression, schizophrenia, mania and other mental dis orders also receive good quality care. This will mean investing in good quality comprehensive older people’s mental health services rather than tokenistically opening services for working age adults to older people.
The National Service Framework The National Service Framework for Older People (NSFOP) was launched in 2001.4 It sets out a national set of standards to improve the quality of care provided to older adults and to end age discrimination in the NHS. One of the eight standards is mental health in older people (the others are rooting out age discrimination, person-centred care, intermediate care, general hospital care, stroke, falls and promoting an active healthy life). The main aim of the mental health standard is to ‘promote good mental health in older people and to treat and support older people with depression and dementia’. The standard set is that ‘older people who have mental health problems have access to integrated mental health services, provided by the NHS and councils to ensure effective diagnosis, treatment and support, for them and their carers’. The service specifications it contains require the early identification and treatment of older people with depression and dementia and endorse the use of antidementia medication according to guidance from the National Institute for Clinical Excellence.5 The main criticisms of the NSFOP are the lack of any ring-fenced funding for service development and the absence of performance indicators requiring primary care trusts (PCTs) to make further investment in old age psychiatric services. This has meant that, while well-intentioned, it has achieved very little for older people’s mental health. In a response to this there has been further detailed work on the preferred content of service provision, including that completed by NICE and SCIE in terms of their dementia clinical guideline6 (summarizing best practice) and policy development by the Care Services Improvement Partnership (CSIP) and published in Everybody’s Business.7 A potentially positive development is the ministerial announcement in August 2007 that dementia is now a national health priority and that there is to be the development of a National Dementia Strategy and Implementation Plan. This is the first such explicit prioritization of issues to do with older people’s mental health and it follows from the publication of the Dementia UK report8 and a critical National Audit Office report on dementia services in England.9 The Dementia UK report provides the best available estimates for dementia prevalence, cost and population projections. This report found that currently: • there are 700,000 people with dementia in the UK • dementia costs the UK economy £17 billion per year.
Keywords care; dementia; depression; organization; services; treatment
Sube Banerjee MSc MD FRCPsych is Professor of Mental Health and Ageing at the Health Services Research Department, Institute of Psychiatry, London, UK. Jenifer Chan MRCPsych is a Specialist Registrar in Old Age Psychiatry on the Maudsley Rotation, London, UK.
PSYCHIATRY 7:2
49
© 2008 Elsevier Ltd. All rights reserved.
Old age psychiatric services
With population ageing, in just 30 years it is estimated that: • the number of people with dementia will double to 1,400,000 • the costs of dementia will treble to more than £50 billion per year.10
The most complicated part of the strategy will be delivering the service improvements needed rather than agreeing the priorities. The strategy will be published in late 2008.
Service organization National Dementia Strategy and Implementation Plan
The first comprehensive old age psychiatric service to be established was probably that working from Goodmayes Hospital in east London.11 The underpinning principles upon which this service was based included: • ease of accessibility • flexibility • assessments being made at the patient’s home • management of the patient in close cooperation with general practitioners and other interested parties. This model of service, with its comprehensiveness and strong community focus, remains the basis for old age psychiatric services provided in the UK and, through the evangelism of Professor Tom Arie and his many trainees, in a large number of other countries. Services necessarily vary in response to the organization and service provision of local authority social services and the voluntary and private sectors. The main elements of old age psychiatric services are listed in Table 1. Models of service delivery in these areas vary markedly; there is a lack of comparative evaluation (in terms of effectiveness and cost) of different models of care.
The strategy will focus on three broad inter-related themes: • improving awareness • early diagnosis and intervention • improving quality of care for dementia. Each of the themes will concentrate on the needs of family carers of people with dementia, as well as those with dementia themselves. Improving awareness There is a generally low level of public and non-specialist professional understanding of dementia. There is a widespread mis-attribution of symptoms to ‘old age’ and a resultant unwillingness by some of those suffering from dementia, and their families, to seek help. This can be echoed in non-specialist professional groups, with a false view that there is little or nothing that can be done to assist people with dementia and their carers. There also remains within society a problem of stigma and fear associated with dementia, which can delay early diagnosis and the accessing of good quality care. It is proposed therefore that the programme of work should focus on: developing a better understanding of dementia by the public and professionals alike; ensuring that better information is provided on how to seek help and what help and treatment is available; and tackling the stigma and misunderstandings that currently exist.
Community assessment and treatment services With the particular ideological and clinical spurs to development discussed above, old age psychiatry has developed some of the most comprehensive and innovative examples of true multidisciplinary working in the whole of psychiatry.12 The only team member common to inpatient and community old age psychiatric services is often the consultant. Community teams vary from those consisting only of community psychiatric nurses (CPNs) with other professional input by internal referral, to those including the full-time involvement of other professionals, including social workers, occupational therapists, psychologists, physiotherapists, case managers, and speech therapists.13,14 The traditional model of old age psychiatric service delivery combines assessment either at home following a general practitioner request for a consultant domiciliary visit or, more rarely, in an outpatient clinic. Follow-up may then be by further consultant home visits, out-patient attendance or CPN follow-up. Outpatient assessment and follow-up may be particularly problematic in elderly populations (Table 2). For these reasons many services have almost entirely stopped hospital-based, clinic-based or general practitioner practice-based outpatient assessment and follow-up, or reserved it for selected groups of patients only.
Early diagnosis and intervention Currently only one-third of people with dementia receive a formal diagnosis at any time in their illness. When diagnoses are made, it is often too late for those suffering from the illness to make choices. Alternatively, diagnoses are often made at a time of crisis; a crisis that could have been avoided if diagnosis had been made earlier. The strategy will be designed to ensure that effective services for early diagnosis and intervention are available in future on a nationwide basis. There is evidence that such services are cost effective, but will require extra local investment to be established. Improving quality of care for dementia There are problems with the quality of care provided for people with dementia from diagnosis to the end-of-life. Successive reports have emphasized the need to enhance joint health and social care mental health teams in the community. During emergency and acute care we need improved systems to manage people with acute confusion and dementia, and to prevent unnecessary admission to hospital because of a lack of alternatives. We need better liaison services that enable effective management in hospital and care homes. In care homes and more generally in the health and social care workforce, we need to build better skills and understanding of dementia so that these become core skills for all those working with older people.
PSYCHIATRY 7:2
Main elements of old age psychiatric services • Community assessment and treatment services • Acute inpatient wards • NHS old age psychiatric continuing care provision (long stay) • Day care Table 1
50
© 2008 Elsevier Ltd. All rights reserved.
Old age psychiatric services
reduce care home placement by 28%, with a median delay to placement of 557 days compared with those not receiving the intervention.24 There is also a strong quality argument for the prevention of institutionalization; people with dementia (and their carers) generally want to stay in their own homes, and their quality of life is higher at home than in care homes. Finally, services that enable early intervention have been shown to have positive effects on the quality of life of people with dementia25 and their family carers.26 The problem we have is that in current systems only around 30% of people with dementia have a formal diagnosis made, or contact with specialist services, at any time in their illness.9 Such diagnosis and contact, when made, often only occurs late in the illness and in crisis when the opportunities for harm prevention are limited. If dementia is not diagnosed, then the person with dementia and their family carers are denied the possibility of planning for their future or of availing themselves of the help, support and treatments (social and psychological, as well as pharmacological) that are available. Contrary to social misconceptions, there is a great deal that can be done to help people with dementia and their carers, and while there are undoubtedly potential negative reactions to diagnosis as well as positive outcomes,27 the balance is very much in favour of early diagnosis, and the earlier such intervention is available in the illness the better.6 All primary care trusts will be commissioning a number of services that might make the diagnosis of dementia, such as general practitioners, old age psychiatric community teams, geriatric medicine, and neurology services. Current systems are non-prescriptive about where and by whom diagnoses of dementia should be made. There is, however, a marked reluctance on the part of primary care to be directly involved in the diagnosis of dementia for reasons that include: therapeutic nihilism; risk avoidance; concerns about competency; and concerns about resources.28 The current focus is on the severe and complex end of the spectrum, leaving early diagnosis and intervention largely unaddressed. The service structures needed to provide early diagnosis of dementia and intervention for people with dementia and family carers are increasingly well understood but have not been supported by policy and commissioning guidance to date. There is a strong case for commissioning a new system to work in a complementary way with existing primary and secondary care services. This would have three necessary components: • establishment of a national network of memory services • support for existing community mental health teams for older people • enhancement of social services for older people with mental health problems. Such services only exist in a very few areas and even then do not have the capacity to see the large number of incident and prevalent cases that are in the community. These multi-disciplinary and inter-agency teams would provide people with their diagnosis while they have capacity, so enabling choice and forward planning. The teams would also provide information, and direct medical, psychological and social help to people with dementia and their family carers to enable them to set a different, better course in their illness. They would prevent future crises by encouraging more effective and earlier help-seeking and so reduce unwanted transition into care homes. The Department of Health has piloted
Factors that make outpatient assessment and follow-up problematic in the elderly • It may be impossible to assess the patient’s true level of functioning without seeing them in their own home • Risk needs to be assessed in the patient’s own environment • Being able to inspect the home is valuable • Patients may have difficulties or be unwilling to attend clinics due to disability, cognitive impairment or lack of insight • Transporting elderly people with dementia to unfamiliar surroundings may exacerbate disorientation and behavioural disturbance and so compromise the assessment • Decreased access to information (e.g. medicine bottles and district nursing or social service notes) and to informants such as neighbours Table 2
The Guy’s model: the activity of the team and outcome of patients treated by community teams using the ‘Guy’s model’ has been evaluated in some detail.15 This model is based on the premise that, with appropriate induction, training and supervision, a team member from any professional background can make an accurate initial assessment that will allow for a diagnosis and management plan to be formulated by the multidisciplinary team as a whole. This assumption has been the subject of careful research which demonstrates that non-medical team members are as accurate as doctors in assigning psychiatric diagnoses16 and formulating treatment plans17 for those on whom they have completed new assessments. Experience in the specialty rather than professional background appears to be of most importance. This has led some to conclude that first assessments can be made safely and effectively by appropriately trained professionals other than doctors.18 One indication of the reality of community assessment in old age psychiatry is given by the finding that less than 5% of admissions to inpatient beds were completed without prior community assessment,3 and that two-thirds of new referrals to old age psychiatric services result in community treatment rather than admission.19 Memory services for early identification and treatment of dementia The literature strongly points to the value of early diagnosis and intervention in improving quality of life and delaying or preventing transitions into care homes. According to the best estimates available in the Dementia UK report, care home placement costs the UK £7 billion per year, with two-thirds paid by social services and one-third by older people and their families. Data suggest that early provision of in-home support can decrease institutionalization by 22%,20 and reductions of 6% even in more severe cases with a highly active control have been reported for case management in dementia.21 Behavioural disturbance, hallucinations and depression in dementia are three of the four most important factors in predicting institutionalization,22 and older people’s mental health services are designed to treat these symptoms. The value of carer support is clearly shown by the finding that having a co-resident carer exerts a 20-fold protective effect on entering a care home.23 A brief programme of carer support and counselling at diagnosis alone has been demonstrated to
PSYCHIATRY 7:2
51
© 2008 Elsevier Ltd. All rights reserved.
Old age psychiatric services
r elatively high costs and low throughput. It also seems important to ensure that day hospitals are not duplicating a service that could be provided at no cost (at least to health services), or at a lower cost, by social service or voluntary sector day centres (such as meals, company and social support).
this service model with positive results. Start-up costs, including training are estimated at 6 months’ running costs for the team. Such services could be provided by older people’s mental health services, geriatricians, neurologists or general practitioners with a special interest. Acute inpatient wards A unit for the inpatient assessment and treatment of people with functional or organic mental disorders who cannot be managed in the community is a central component of all old age psychiatric services. Inpatient units may be separated into organic wards (dementia and sometimes delirium) and functional wards (the rest) or may be integrated; there is no evidence to support one or the other approach. However, there may be difficulties in identifying the form of disorder an individual has on admission, and there is a substantial degree of comorbidity of organic and functional disorder in the elderly. Additionally, there may be particular concerns if the quality of care varies between the two units, which may occur if there is a perceived difference in attractiveness of working with one group or the other. With the reprovision of mental health care away from the asylums, acute old age psychiatric inpatient units have increasingly been sited in district general hospitals (DGHs) rather than in specialist hospitals.29 This may have advantages in terms of ease of access to medical help, which is of importance to the old age psychiatric population given their high level of physical morbidity. However, problems may arise when old age psychiatry is the only psychiatric specialty in a DGH with the provision of on-site psychiatric cover. Any division of old age psychiatry from the rest of psychiatry can lead to isolation and marginalization, and a lack of flexibility in medical and nursing cover.
Strengths in old age psychiatric service provision A major strength in old age psychiatric service delivery is the committed and skilled multidisciplinary workforce. Team members in all settings have had to embrace the ability to improvise and work with other local services in order to provide care in an environment of increasing need with no increase in resources. This has led to a willingness to experiment and change that has stood the specialty in good stead in incorporating and delivering the marked technological developments that have occurred in the past 5 years. Allied with this has been the growth of a strong and effective user and carer movement for dementia. For example, it is difficult to overestimate the immense positive contribution made by the former US president Ronald Reagan and his family when he admitted to having Alzheimer’s disease. This individual testimony, along with the growth of national Alzheimer’s societies, has influenced not only public attitudes and understanding of dementia but, in the USA at least, has led to massive governmental investment in research and (to a lesser extent) in service delivery. Dementia has even been the subject of a feature film (Iris, the story of the novelist Iris Murdoch). We may be in the unusual situation of a mental disorder becoming de-stigmatized, or at least having the stigma associated with it reduced and made more accurate. The stigma against dementia has been as real within medicine as in the community, and this is reflected in the traditionally low status applied to old age psychiatry within psychiatry and more broadly within medicine.
NHS old age psychiatric continuing care The provision of long-stay or continuing care psychiatric places has undergone marked changes with the closure of the asylums. Current NHS psychiatric continuing care provision makes up only a tiny and diminishing proportion of all long-term care. NHS continuing care may be provided in many settings in hospitals or in the community, alone or in collaborative ventures between health services, housing associations and the voluntary and independent sectors. NHS continuing care is essentially provided only to those who cannot be placed elsewhere. This results in the small number of remaining NHS continuing care beds being occupied by the most challenging of patients, requiring high levels of skilled staffing. These placements are free and not means tested – unlike normal care homes – and are generally expensive to run because of the high needs of the residents.
Challenges for old age psychiatry Reviewing old age psychiatric services in the light of the NSFOP and the lack of investment that has flowed from it, it is clear that there are significant challenges facing services (Table 3). Changes in workload – nationwide, all elements of old age psychiatric services have experienced an increase in referrals and throughput. This increase has accelerated with the introduction of antidementia drugs. Changes in working practice – the changes in the nature and quality of documentation and recording of activity required by
Day care Day care is an important element of community care for older people with mental health problems, and may be provided by social services, the voluntary sector or health services. Although many services include high-cost old age psychiatric day hos pitals, there is no good evidence to inform whether purchasing a day hospital is a reasonable use of scarce resources. The available data seem to consist largely of assertion and anecdote rather than evidence.30,31 What is clear is that the cost–benefit equation is likely to be least compelling for those day hospitals with
PSYCHIATRY 7:2
Challenges facing old age psychiatric services • Changes • Changes • Changes • Changes • Changes
in in in in in
workload working practice severity and dependence treatment expectation
Table 3
52
© 2008 Elsevier Ltd. All rights reserved.
Old age psychiatric services
general adult services (such as the Care Programme Approach, risk assessment, clinical governance structures and activity under the Mental Health Act 1983) have equally affected old age psychiatric services. Changes in severity and dependence – as referrals to services have increased, their nature has changed. The decrease in in patient acute beds in old age psychiatry has meant that the overall level of severity of disorder on the wards has increased. As in general adult wards, only those at the most severe risks can be admitted. The consequence of this is that the community teams have to deal with higher levels of risk and disturbance. Together with the increase in severity, there has been an increase in the physical dependency of the patients on the wards. The net effect of these changes has been to increase the workload of the nurses on the wards and in the community. Changes in treatment – the introduction of antidementia drugs is having a major effect on services. Their use has been sanctioned by NICE even though NICE’s decision to restrict use to those with moderate dementia is widely contested. NICE requires initiation and maintenance to be carried out in secondary care; the general nature of services nationwide means that old age psychiatry is the main provider of these medications. Changes in expectation – there are cohort effects in the expectations of users and carers of old age psychiatric services. Newer (younger) referrals and their carers have higher expectations of what can and should be provided by the health service.
in a true partnership with social care, primary care, user and carer groups, and patients and carers themselves. ◆
References 1 Philpot M, Banerjee S. Mental health services for older people in London. In: Johnson S, Ramsey R, Thornicroft G, et al., eds. London’s mental health. London: King’s Fund, 1998. 2 Wertheimer J. Psychiatry of the elderly: a consensus statement. Int J Geriatr Psychiatry 1997; 12: 432–35. 3 Wattis J, Wattis L, Arie T. Psychogeriatrics: a national survey of a new branch of psychiatry. Br Med J 1981; 282: 1529–33. 4 Department of Health. National Service Framework for Older People. London: Stationery Office, 2001. 5 National Institute for Clinical Excellence. Guidance on the use of donepezil, rivastigmine and galantamine for the treatment of Alzheimer’s Disease. Technology Appraisal Guidance no. 19. London: NICE, 2001. 6 Dementia, the National Institute for Health and Clinical Excellence/ Social Care Institute for Excellence clinical guideline. London: NICE/ SCIE, 2006. 7 Department of Health. Everybody’s Business. London: Care Services Improvement Partnership, 2005. 8 Knapp M, Prince M, Albanese E, et al. Dementia UK: the full report. London: Alzheimer’s Society, 2007. 9 National Audit Office. Improving services and support for people with dementia. London: Stationery Office, 2007. 10 Comas-Herrera A, Wittenberg R, Pickard L, Knapp M. Cognitive impairment in older people: future demand for long-term care services and the associated costs. Int J Geriatr Psychiatry 2007; 22: 1037–45. 11 Arie T. The first year of the Goodmayes psychiatric service for old people. Lancet 1970; ii: 1175–82. 12 Banerjee S. Services for older adults. In: Thornicroft G, Szmukler G, eds. Textbook of community psychiatry. Oxford: Oxford University Press, 2001. 13 Wattis J. The pattern of psychogeriatric services. In: Copeland JRM, Abou-Saleh MT, Blazer DG, eds. Principles and practice of geriatric psychiatry. Chichester: Wiley, 1994. 14 Rosenvinge H. The multi-disciplinary team. In: Copeland JRM, Abou-Saleh MT, Blazer DG, eds. Principles and practice of geriatric psychiatry. Chichester: Wiley, 1994. 15 Brown P, Challis D, von Abendorff R. The work of a community mental health team for the elderly: caseload, contact history and outcomes. Int J Geriatr Psychiatry 1996; 11: 29–39. 16 Collighan G, Macdonald A, Herzberg J, Philpot M, Lindesay J. An evaluation of the multidisciplinary approach to psychiatric diagnosis in elderly people. Br Med J 1993; 306: 821–24. 17 Lindesay J, Herzberg J, Collighan G, et al. Treatment decisions following assessment by multidisciplinary psychogeriatric teams. Psychiatr Bull 1996; 20: 78–81. 18 Herzberg J. Can multidisciplinary teams carry out competent and safe psychogeriatric assessments in the community? Int J Geriatr Psychiatry 1995; 10: 173–77. 19 Wattis JP. Geographical variation in the provision of psychiatric services for old people. Age Ageing 1988; 17: 171–80. 20 Gaugler JE, Kane RL, Kane RA, Newcomer R. Early community-based service utilization and its effects on institutionalization in dementia caregiving. Gerontologist 2005; 45: 177–85.
The future of old age psychiatric services Even given the resource constraints and other challenges detailed above, there can be few more exciting areas of medicine in which to be involved, or where there is greater likelihood of clinically significant advances in treatment and care in the next 10–15 years. The biological advances in understanding the causes of dementia are being rapidly transformed into therapeutic approaches as diverse as disease-modifying medication, immunization and stem-cell therapy. Services need to be able to identify cases early where there is the possibility of preventing future harm in terms of crises, institutionalization, depression, carer burden, loss of function and possibly further cognitive decline. The next generation of disease-modifying compounds will further challenge clinicians to identify and intervene in presymptomatic states as well as with those already affected by dementia. Finally, the focus on dementia and the opportunities presented by the National Dementia Strategy should not be at the expense of older people with other serious mental disorder. Services should be considered failures if they do not ensure that older people with depression, schizophrenia, mania and other mental disorders also receive good quality care. This will mean investing in good quality comprehensive older people’s mental health services rather than tokenistically opening services for working age adults to older people. Services must develop to meet local needs and will need to build on local strengths. In service development it is seldom the case that one size fits all, so there will be local variation in what works best. The goal must be to improve the quality of life for older people with mental disorder and for their carers; this can be done only by improving the quality of care. This means working
PSYCHIATRY 7:2
53
© 2008 Elsevier Ltd. All rights reserved.
Old age psychiatric services
21 Challis D, von Abendorff R, Brown P, Chesterman J, Hughes J. Care management, dementia care and specialist mental health services: an evaluation. Int J Geriatr Psychiatry 2002; 17: 315–25. 22 Gilley DW, Bienias JL, Wilson RS, et al. Influence of behavioral symptoms on rates of institutionalization for persons with Alzheimer’s disease. Psychol Med 2004; 34: 1129–35. 23 Banerjee S, Murray J, Foley B, et al. Predictors of institutionalisation in older people with dementia. J Neurol Neurosurg Psychiatry 2003; 74: 1315–16. 24 Mittelman M, Haley WE, Clay OJ, Roth DL. Improving caregiver wellbeing delays nursing home placement of patients with Alzheimer disease. Neurology 2006; 67: 1592–99. 25 Banerjee S, Willis R, Matthews D, et al. Improving the quality of dementia care - an evaluation of the Croydon Memory Service Model. Int J Geriatr Psychiatry 2007; 22: 782–8.
PSYCHIATRY 7:2
26 Mittelman MS, Roth DL, Clay OJ, Haley WE. Preserving health of Alzheimer caregivers: impact of a spouse caregiver intervention. Am J Geriatr Psychiatry 2007; 15: 780–89. 27 Iliffe S, Manthorpe J, Eden A. Sooner or later? Issues in the early diagnosis of dementia in general practice: a qualitative study. Family Practice 2003; 20: 376–81. 28 Iliffe S, Wilcock J, Haworth D. Obstacles to shared care for patients with dementia: a qualitative study. Family Practice 2006; 23: 353–62. 29 Shulman K, Arie T. UK survey of psychiatric services for the elderly: direction for developing services. Can J Psychiatry 1991; 36: 169–75. 30 Howard R. Day hospitals: the case in favour. Int J Geriatr Psychiatry 1994; 9: 525–29. 31 Fasey C. The day hospital in old age psychiatry; the case against. Int J Geriatr Psychiatry 1994; 9: 519–23.
54
© 2008 Elsevier Ltd. All rights reserved.
Organization of old age psychiatric services
In terms of service activity in psychiatry, older people are an important group. In the UK, people over the age of 65 make up around a third of all mental health activity in admissions, re-admissions and community contacts.1 However, their profile of disorder and needs differs from that in younger age groups. The challenges presented by dementia and comorbid physical illness and disability require particular professional skills. Services need to be able to deal with the complex mix of social, psychological, physical and biological factors found in the elderly mentally ill. The World Health Organization consensus statement on psychiatry for the elderly has affirmed that assessments should be carried out in the patient’s home.2 Unlike many principles, this appears to be the reality of clinical practice, with 9 out of 10 referrals seen at home rather than in out-patient clinics.3
Sube Banerjee Jenifer Chan
Abstract In terms of service activity in psychiatry, older people are an important group. People aged more than 65 years make up around a third of all mental health activity in the UK in terms of admissions, re-admissions and community contacts. However, the profile of disorder and needs differs from that in younger age groups. The challenges presented by dementia and co-morbid physical illness and disability require particular professional skills. Services need to be able to deal with the complex mix of social, psychological, physical and biological factors found in the elderly mentally ill. The development and delivery of such services is discussed in this contribution. Even given resource constraints and other challenges, there can be few more exciting parts of medicine with which to be involved, and where there is greater likelihood of clinically significant advances in treatment and care in the next 10–15 years, than old age psychiatry. The biological advances in understanding the causes of dementia are being rapidly transformed into therapeutic approaches as diverse as disease-modifying medication, immunization, and stem-cell therapy. The rate of transformational change in understanding and action in this area is stunning. In service terms we need to gear ourselves up to identify cases early, when there is the possibility of prevention of future harm; for example, in terms of crises, institutionalization, depression, carer burden, loss of function, and possibly further cognitive decline. The next generation of disease-modifying compounds will further challenge us to identify and intervene in presymptomatic states as well as in those already affected by dementia. Services must develop to meet local needs and will need to build on local strengths. In service development it is seldom the case that one size fits all, so there will be local variation in what works best. The announced National Dementia Strategy gives real hope that things can change. Finally, the focus on dementia should not be at the expense of older people with other serious mental disorder. Services should be considered failures if they do not ensure that older people with depression, schizophrenia, mania and other mental dis orders also receive good quality care. This will mean investing in good quality comprehensive older people’s mental health services rather than tokenistically opening services for working age adults to older people.
The National Service Framework The National Service Framework for Older People (NSFOP) was launched in 2001.4 It sets out a national set of standards to improve the quality of care provided to older adults and to end age discrimination in the NHS. One of the eight standards is mental health in older people (the others are rooting out age discrimination, person-centred care, intermediate care, general hospital care, stroke, falls and promoting an active healthy life). The main aim of the mental health standard is to ‘promote good mental health in older people and to treat and support older people with depression and dementia’. The standard set is that ‘older people who have mental health problems have access to integrated mental health services, provided by the NHS and councils to ensure effective diagnosis, treatment and support, for them and their carers’. The service specifications it contains require the early identification and treatment of older people with depression and dementia and endorse the use of antidementia medication according to guidance from the National Institute for Clinical Excellence.5 The main criticisms of the NSFOP are the lack of any ring-fenced funding for service development and the absence of performance indicators requiring primary care trusts (PCTs) to make further investment in old age psychiatric services. This has meant that, while well-intentioned, it has achieved very little for older people’s mental health. In a response to this there has been further detailed work on the preferred content of service provision, including that completed by NICE and SCIE in terms of their dementia clinical guideline6 (summarizing best practice) and policy development by the Care Services Improvement Partnership (CSIP) and published in Everybody’s Business.7 A potentially positive development is the ministerial announcement in August 2007 that dementia is now a national health priority and that there is to be the development of a National Dementia Strategy and Implementation Plan. This is the first such explicit prioritization of issues to do with older people’s mental health and it follows from the publication of the Dementia UK report8 and a critical National Audit Office report on dementia services in England.9 The Dementia UK report provides the best available estimates for dementia prevalence, cost and population projections. This report found that currently: • there are 700,000 people with dementia in the UK • dementia costs the UK economy £17 billion per year.
Keywords care; dementia; depression; organization; services; treatment
Sube Banerjee MSc MD FRCPsych is Professor of Mental Health and Ageing at the Health Services Research Department, Institute of Psychiatry, London, UK. Jenifer Chan MRCPsych is a Specialist Registrar in Old Age Psychiatry on the Maudsley Rotation, London, UK.
PSYCHIATRY 7:2
49
© 2008 Elsevier Ltd. All rights reserved.
Old age psychiatric services
With population ageing, in just 30 years it is estimated that: • the number of people with dementia will double to 1,400,000 • the costs of dementia will treble to more than £50 billion per year.10
The most complicated part of the strategy will be delivering the service improvements needed rather than agreeing the priorities. The strategy will be published in late 2008.
Service organization National Dementia Strategy and Implementation Plan
The first comprehensive old age psychiatric service to be established was probably that working from Goodmayes Hospital in east London.11 The underpinning principles upon which this service was based included: • ease of accessibility • flexibility • assessments being made at the patient’s home • management of the patient in close cooperation with general practitioners and other interested parties. This model of service, with its comprehensiveness and strong community focus, remains the basis for old age psychiatric services provided in the UK and, through the evangelism of Professor Tom Arie and his many trainees, in a large number of other countries. Services necessarily vary in response to the organization and service provision of local authority social services and the voluntary and private sectors. The main elements of old age psychiatric services are listed in Table 1. Models of service delivery in these areas vary markedly; there is a lack of comparative evaluation (in terms of effectiveness and cost) of different models of care.
The strategy will focus on three broad inter-related themes: • improving awareness • early diagnosis and intervention • improving quality of care for dementia. Each of the themes will concentrate on the needs of family carers of people with dementia, as well as those with dementia themselves. Improving awareness There is a generally low level of public and non-specialist professional understanding of dementia. There is a widespread mis-attribution of symptoms to ‘old age’ and a resultant unwillingness by some of those suffering from dementia, and their families, to seek help. This can be echoed in non-specialist professional groups, with a false view that there is little or nothing that can be done to assist people with dementia and their carers. There also remains within society a problem of stigma and fear associated with dementia, which can delay early diagnosis and the accessing of good quality care. It is proposed therefore that the programme of work should focus on: developing a better understanding of dementia by the public and professionals alike; ensuring that better information is provided on how to seek help and what help and treatment is available; and tackling the stigma and misunderstandings that currently exist.
Community assessment and treatment services With the particular ideological and clinical spurs to development discussed above, old age psychiatry has developed some of the most comprehensive and innovative examples of true multidisciplinary working in the whole of psychiatry.12 The only team member common to inpatient and community old age psychiatric services is often the consultant. Community teams vary from those consisting only of community psychiatric nurses (CPNs) with other professional input by internal referral, to those including the full-time involvement of other professionals, including social workers, occupational therapists, psychologists, physiotherapists, case managers, and speech therapists.13,14 The traditional model of old age psychiatric service delivery combines assessment either at home following a general practitioner request for a consultant domiciliary visit or, more rarely, in an outpatient clinic. Follow-up may then be by further consultant home visits, out-patient attendance or CPN follow-up. Outpatient assessment and follow-up may be particularly problematic in elderly populations (Table 2). For these reasons many services have almost entirely stopped hospital-based, clinic-based or general practitioner practice-based outpatient assessment and follow-up, or reserved it for selected groups of patients only.
Early diagnosis and intervention Currently only one-third of people with dementia receive a formal diagnosis at any time in their illness. When diagnoses are made, it is often too late for those suffering from the illness to make choices. Alternatively, diagnoses are often made at a time of crisis; a crisis that could have been avoided if diagnosis had been made earlier. The strategy will be designed to ensure that effective services for early diagnosis and intervention are available in future on a nationwide basis. There is evidence that such services are cost effective, but will require extra local investment to be established. Improving quality of care for dementia There are problems with the quality of care provided for people with dementia from diagnosis to the end-of-life. Successive reports have emphasized the need to enhance joint health and social care mental health teams in the community. During emergency and acute care we need improved systems to manage people with acute confusion and dementia, and to prevent unnecessary admission to hospital because of a lack of alternatives. We need better liaison services that enable effective management in hospital and care homes. In care homes and more generally in the health and social care workforce, we need to build better skills and understanding of dementia so that these become core skills for all those working with older people.
PSYCHIATRY 7:2
Main elements of old age psychiatric services • Community assessment and treatment services • Acute inpatient wards • NHS old age psychiatric continuing care provision (long stay) • Day care Table 1
50
© 2008 Elsevier Ltd. All rights reserved.
Old age psychiatric services
reduce care home placement by 28%, with a median delay to placement of 557 days compared with those not receiving the intervention.24 There is also a strong quality argument for the prevention of institutionalization; people with dementia (and their carers) generally want to stay in their own homes, and their quality of life is higher at home than in care homes. Finally, services that enable early intervention have been shown to have positive effects on the quality of life of people with dementia25 and their family carers.26 The problem we have is that in current systems only around 30% of people with dementia have a formal diagnosis made, or contact with specialist services, at any time in their illness.9 Such diagnosis and contact, when made, often only occurs late in the illness and in crisis when the opportunities for harm prevention are limited. If dementia is not diagnosed, then the person with dementia and their family carers are denied the possibility of planning for their future or of availing themselves of the help, support and treatments (social and psychological, as well as pharmacological) that are available. Contrary to social misconceptions, there is a great deal that can be done to help people with dementia and their carers, and while there are undoubtedly potential negative reactions to diagnosis as well as positive outcomes,27 the balance is very much in favour of early diagnosis, and the earlier such intervention is available in the illness the better.6 All primary care trusts will be commissioning a number of services that might make the diagnosis of dementia, such as general practitioners, old age psychiatric community teams, geriatric medicine, and neurology services. Current systems are non-prescriptive about where and by whom diagnoses of dementia should be made. There is, however, a marked reluctance on the part of primary care to be directly involved in the diagnosis of dementia for reasons that include: therapeutic nihilism; risk avoidance; concerns about competency; and concerns about resources.28 The current focus is on the severe and complex end of the spectrum, leaving early diagnosis and intervention largely unaddressed. The service structures needed to provide early diagnosis of dementia and intervention for people with dementia and family carers are increasingly well understood but have not been supported by policy and commissioning guidance to date. There is a strong case for commissioning a new system to work in a complementary way with existing primary and secondary care services. This would have three necessary components: • establishment of a national network of memory services • support for existing community mental health teams for older people • enhancement of social services for older people with mental health problems. Such services only exist in a very few areas and even then do not have the capacity to see the large number of incident and prevalent cases that are in the community. These multi-disciplinary and inter-agency teams would provide people with their diagnosis while they have capacity, so enabling choice and forward planning. The teams would also provide information, and direct medical, psychological and social help to people with dementia and their family carers to enable them to set a different, better course in their illness. They would prevent future crises by encouraging more effective and earlier help-seeking and so reduce unwanted transition into care homes. The Department of Health has piloted
Factors that make outpatient assessment and follow-up problematic in the elderly • It may be impossible to assess the patient’s true level of functioning without seeing them in their own home • Risk needs to be assessed in the patient’s own environment • Being able to inspect the home is valuable • Patients may have difficulties or be unwilling to attend clinics due to disability, cognitive impairment or lack of insight • Transporting elderly people with dementia to unfamiliar surroundings may exacerbate disorientation and behavioural disturbance and so compromise the assessment • Decreased access to information (e.g. medicine bottles and district nursing or social service notes) and to informants such as neighbours Table 2
The Guy’s model: the activity of the team and outcome of patients treated by community teams using the ‘Guy’s model’ has been evaluated in some detail.15 This model is based on the premise that, with appropriate induction, training and supervision, a team member from any professional background can make an accurate initial assessment that will allow for a diagnosis and management plan to be formulated by the multidisciplinary team as a whole. This assumption has been the subject of careful research which demonstrates that non-medical team members are as accurate as doctors in assigning psychiatric diagnoses16 and formulating treatment plans17 for those on whom they have completed new assessments. Experience in the specialty rather than professional background appears to be of most importance. This has led some to conclude that first assessments can be made safely and effectively by appropriately trained professionals other than doctors.18 One indication of the reality of community assessment in old age psychiatry is given by the finding that less than 5% of admissions to inpatient beds were completed without prior community assessment,3 and that two-thirds of new referrals to old age psychiatric services result in community treatment rather than admission.19 Memory services for early identification and treatment of dementia The literature strongly points to the value of early diagnosis and intervention in improving quality of life and delaying or preventing transitions into care homes. According to the best estimates available in the Dementia UK report, care home placement costs the UK £7 billion per year, with two-thirds paid by social services and one-third by older people and their families. Data suggest that early provision of in-home support can decrease institutionalization by 22%,20 and reductions of 6% even in more severe cases with a highly active control have been reported for case management in dementia.21 Behavioural disturbance, hallucinations and depression in dementia are three of the four most important factors in predicting institutionalization,22 and older people’s mental health services are designed to treat these symptoms. The value of carer support is clearly shown by the finding that having a co-resident carer exerts a 20-fold protective effect on entering a care home.23 A brief programme of carer support and counselling at diagnosis alone has been demonstrated to
PSYCHIATRY 7:2
51
© 2008 Elsevier Ltd. All rights reserved.
Old age psychiatric services
r elatively high costs and low throughput. It also seems important to ensure that day hospitals are not duplicating a service that could be provided at no cost (at least to health services), or at a lower cost, by social service or voluntary sector day centres (such as meals, company and social support).
this service model with positive results. Start-up costs, including training are estimated at 6 months’ running costs for the team. Such services could be provided by older people’s mental health services, geriatricians, neurologists or general practitioners with a special interest. Acute inpatient wards A unit for the inpatient assessment and treatment of people with functional or organic mental disorders who cannot be managed in the community is a central component of all old age psychiatric services. Inpatient units may be separated into organic wards (dementia and sometimes delirium) and functional wards (the rest) or may be integrated; there is no evidence to support one or the other approach. However, there may be difficulties in identifying the form of disorder an individual has on admission, and there is a substantial degree of comorbidity of organic and functional disorder in the elderly. Additionally, there may be particular concerns if the quality of care varies between the two units, which may occur if there is a perceived difference in attractiveness of working with one group or the other. With the reprovision of mental health care away from the asylums, acute old age psychiatric inpatient units have increasingly been sited in district general hospitals (DGHs) rather than in specialist hospitals.29 This may have advantages in terms of ease of access to medical help, which is of importance to the old age psychiatric population given their high level of physical morbidity. However, problems may arise when old age psychiatry is the only psychiatric specialty in a DGH with the provision of on-site psychiatric cover. Any division of old age psychiatry from the rest of psychiatry can lead to isolation and marginalization, and a lack of flexibility in medical and nursing cover.
Strengths in old age psychiatric service provision A major strength in old age psychiatric service delivery is the committed and skilled multidisciplinary workforce. Team members in all settings have had to embrace the ability to improvise and work with other local services in order to provide care in an environment of increasing need with no increase in resources. This has led to a willingness to experiment and change that has stood the specialty in good stead in incorporating and delivering the marked technological developments that have occurred in the past 5 years. Allied with this has been the growth of a strong and effective user and carer movement for dementia. For example, it is difficult to overestimate the immense positive contribution made by the former US president Ronald Reagan and his family when he admitted to having Alzheimer’s disease. This individual testimony, along with the growth of national Alzheimer’s societies, has influenced not only public attitudes and understanding of dementia but, in the USA at least, has led to massive governmental investment in research and (to a lesser extent) in service delivery. Dementia has even been the subject of a feature film (Iris, the story of the novelist Iris Murdoch). We may be in the unusual situation of a mental disorder becoming de-stigmatized, or at least having the stigma associated with it reduced and made more accurate. The stigma against dementia has been as real within medicine as in the community, and this is reflected in the traditionally low status applied to old age psychiatry within psychiatry and more broadly within medicine.
NHS old age psychiatric continuing care The provision of long-stay or continuing care psychiatric places has undergone marked changes with the closure of the asylums. Current NHS psychiatric continuing care provision makes up only a tiny and diminishing proportion of all long-term care. NHS continuing care may be provided in many settings in hospitals or in the community, alone or in collaborative ventures between health services, housing associations and the voluntary and independent sectors. NHS continuing care is essentially provided only to those who cannot be placed elsewhere. This results in the small number of remaining NHS continuing care beds being occupied by the most challenging of patients, requiring high levels of skilled staffing. These placements are free and not means tested – unlike normal care homes – and are generally expensive to run because of the high needs of the residents.
Challenges for old age psychiatry Reviewing old age psychiatric services in the light of the NSFOP and the lack of investment that has flowed from it, it is clear that there are significant challenges facing services (Table 3). Changes in workload – nationwide, all elements of old age psychiatric services have experienced an increase in referrals and throughput. This increase has accelerated with the introduction of antidementia drugs. Changes in working practice – the changes in the nature and quality of documentation and recording of activity required by
Day care Day care is an important element of community care for older people with mental health problems, and may be provided by social services, the voluntary sector or health services. Although many services include high-cost old age psychiatric day hos pitals, there is no good evidence to inform whether purchasing a day hospital is a reasonable use of scarce resources. The available data seem to consist largely of assertion and anecdote rather than evidence.30,31 What is clear is that the cost–benefit equation is likely to be least compelling for those day hospitals with
PSYCHIATRY 7:2
Challenges facing old age psychiatric services • Changes • Changes • Changes • Changes • Changes
in in in in in
workload working practice severity and dependence treatment expectation
Table 3
52
© 2008 Elsevier Ltd. All rights reserved.
Old age psychiatric services
general adult services (such as the Care Programme Approach, risk assessment, clinical governance structures and activity under the Mental Health Act 1983) have equally affected old age psychiatric services. Changes in severity and dependence – as referrals to services have increased, their nature has changed. The decrease in in patient acute beds in old age psychiatry has meant that the overall level of severity of disorder on the wards has increased. As in general adult wards, only those at the most severe risks can be admitted. The consequence of this is that the community teams have to deal with higher levels of risk and disturbance. Together with the increase in severity, there has been an increase in the physical dependency of the patients on the wards. The net effect of these changes has been to increase the workload of the nurses on the wards and in the community. Changes in treatment – the introduction of antidementia drugs is having a major effect on services. Their use has been sanctioned by NICE even though NICE’s decision to restrict use to those with moderate dementia is widely contested. NICE requires initiation and maintenance to be carried out in secondary care; the general nature of services nationwide means that old age psychiatry is the main provider of these medications. Changes in expectation – there are cohort effects in the expectations of users and carers of old age psychiatric services. Newer (younger) referrals and their carers have higher expectations of what can and should be provided by the health service.
in a true partnership with social care, primary care, user and carer groups, and patients and carers themselves. ◆
References 1 Philpot M, Banerjee S. Mental health services for older people in London. In: Johnson S, Ramsey R, Thornicroft G, et al., eds. London’s mental health. London: King’s Fund, 1998. 2 Wertheimer J. Psychiatry of the elderly: a consensus statement. Int J Geriatr Psychiatry 1997; 12: 432–35. 3 Wattis J, Wattis L, Arie T. Psychogeriatrics: a national survey of a new branch of psychiatry. Br Med J 1981; 282: 1529–33. 4 Department of Health. National Service Framework for Older People. London: Stationery Office, 2001. 5 National Institute for Clinical Excellence. Guidance on the use of donepezil, rivastigmine and galantamine for the treatment of Alzheimer’s Disease. Technology Appraisal Guidance no. 19. London: NICE, 2001. 6 Dementia, the National Institute for Health and Clinical Excellence/ Social Care Institute for Excellence clinical guideline. London: NICE/ SCIE, 2006. 7 Department of Health. Everybody’s Business. London: Care Services Improvement Partnership, 2005. 8 Knapp M, Prince M, Albanese E, et al. Dementia UK: the full report. London: Alzheimer’s Society, 2007. 9 National Audit Office. Improving services and support for people with dementia. London: Stationery Office, 2007. 10 Comas-Herrera A, Wittenberg R, Pickard L, Knapp M. Cognitive impairment in older people: future demand for long-term care services and the associated costs. Int J Geriatr Psychiatry 2007; 22: 1037–45. 11 Arie T. The first year of the Goodmayes psychiatric service for old people. Lancet 1970; ii: 1175–82. 12 Banerjee S. Services for older adults. In: Thornicroft G, Szmukler G, eds. Textbook of community psychiatry. Oxford: Oxford University Press, 2001. 13 Wattis J. The pattern of psychogeriatric services. In: Copeland JRM, Abou-Saleh MT, Blazer DG, eds. Principles and practice of geriatric psychiatry. Chichester: Wiley, 1994. 14 Rosenvinge H. The multi-disciplinary team. In: Copeland JRM, Abou-Saleh MT, Blazer DG, eds. Principles and practice of geriatric psychiatry. Chichester: Wiley, 1994. 15 Brown P, Challis D, von Abendorff R. The work of a community mental health team for the elderly: caseload, contact history and outcomes. Int J Geriatr Psychiatry 1996; 11: 29–39. 16 Collighan G, Macdonald A, Herzberg J, Philpot M, Lindesay J. An evaluation of the multidisciplinary approach to psychiatric diagnosis in elderly people. Br Med J 1993; 306: 821–24. 17 Lindesay J, Herzberg J, Collighan G, et al. Treatment decisions following assessment by multidisciplinary psychogeriatric teams. Psychiatr Bull 1996; 20: 78–81. 18 Herzberg J. Can multidisciplinary teams carry out competent and safe psychogeriatric assessments in the community? Int J Geriatr Psychiatry 1995; 10: 173–77. 19 Wattis JP. Geographical variation in the provision of psychiatric services for old people. Age Ageing 1988; 17: 171–80. 20 Gaugler JE, Kane RL, Kane RA, Newcomer R. Early community-based service utilization and its effects on institutionalization in dementia caregiving. Gerontologist 2005; 45: 177–85.
The future of old age psychiatric services Even given the resource constraints and other challenges detailed above, there can be few more exciting areas of medicine in which to be involved, or where there is greater likelihood of clinically significant advances in treatment and care in the next 10–15 years. The biological advances in understanding the causes of dementia are being rapidly transformed into therapeutic approaches as diverse as disease-modifying medication, immunization and stem-cell therapy. Services need to be able to identify cases early where there is the possibility of preventing future harm in terms of crises, institutionalization, depression, carer burden, loss of function and possibly further cognitive decline. The next generation of disease-modifying compounds will further challenge clinicians to identify and intervene in presymptomatic states as well as with those already affected by dementia. Finally, the focus on dementia and the opportunities presented by the National Dementia Strategy should not be at the expense of older people with other serious mental disorder. Services should be considered failures if they do not ensure that older people with depression, schizophrenia, mania and other mental disorders also receive good quality care. This will mean investing in good quality comprehensive older people’s mental health services rather than tokenistically opening services for working age adults to older people. Services must develop to meet local needs and will need to build on local strengths. In service development it is seldom the case that one size fits all, so there will be local variation in what works best. The goal must be to improve the quality of life for older people with mental disorder and for their carers; this can be done only by improving the quality of care. This means working
PSYCHIATRY 7:2
53
© 2008 Elsevier Ltd. All rights reserved.
Old age psychiatric services
21 Challis D, von Abendorff R, Brown P, Chesterman J, Hughes J. Care management, dementia care and specialist mental health services: an evaluation. Int J Geriatr Psychiatry 2002; 17: 315–25. 22 Gilley DW, Bienias JL, Wilson RS, et al. Influence of behavioral symptoms on rates of institutionalization for persons with Alzheimer’s disease. Psychol Med 2004; 34: 1129–35. 23 Banerjee S, Murray J, Foley B, et al. Predictors of institutionalisation in older people with dementia. J Neurol Neurosurg Psychiatry 2003; 74: 1315–16. 24 Mittelman M, Haley WE, Clay OJ, Roth DL. Improving caregiver wellbeing delays nursing home placement of patients with Alzheimer disease. Neurology 2006; 67: 1592–99. 25 Banerjee S, Willis R, Matthews D, et al. Improving the quality of dementia care - an evaluation of the Croydon Memory Service Model. Int J Geriatr Psychiatry 2007; 22: 782–8.
PSYCHIATRY 7:2
26 Mittelman MS, Roth DL, Clay OJ, Haley WE. Preserving health of Alzheimer caregivers: impact of a spouse caregiver intervention. Am J Geriatr Psychiatry 2007; 15: 780–89. 27 Iliffe S, Manthorpe J, Eden A. Sooner or later? Issues in the early diagnosis of dementia in general practice: a qualitative study. Family Practice 2003; 20: 376–81. 28 Iliffe S, Wilcock J, Haworth D. Obstacles to shared care for patients with dementia: a qualitative study. Family Practice 2006; 23: 353–62. 29 Shulman K, Arie T. UK survey of psychiatric services for the elderly: direction for developing services. Can J Psychiatry 1991; 36: 169–75. 30 Howard R. Day hospitals: the case in favour. Int J Geriatr Psychiatry 1994; 9: 525–29. 31 Fasey C. The day hospital in old age psychiatry; the case against. Int J Geriatr Psychiatry 1994; 9: 519–23.
54
© 2008 Elsevier Ltd. All rights reserved.