Who Cares Wins - Royal College of Psychiatrists

2: Can Interventions
Improve Outcome?
2.1 The majority of mental disorder co-morbidity affecting older people in general hospitals is due to
three disorders; dementia, depression and delirium (see Section 1) and these have been the
focus of research. Older people with medical illnesses and hip fracture have particularly high
levels of co-morbidity and form the populations for the majority of these studies. Recent years
have seen the publication of important controlled trials involving older people demonstrating
effective prevention and treatment. There is little information on the management of other mental
disorders affecting older people.
2.2 Also important are reports on the effect of providing different styles of consultation-liaison mental
health services to general hospitals.
2.3 A pre-requisite to instituting treatment or referral for a mental health assessment is the ability to
identify the problem. Reported detection rates for mental disorder in older people in general
hospitals indicate difficulties at this stage. Missed diagnosis rates for delirium of 32-67% (111) and
for cognitive impairment of 55% (112,113) are typical examples. A meta-analysis of the prognosis
of depression in older medical patients reported the detection rate for depression as “rare to
26%”, with a median of 10% (114).
2.4 Furthermore, there is an indication that general departments attempts to treat mental disorder are
inconsistent. For example, depressed older medical patients may be as likely to receive
benzodiazepines as antidepressants (115), as few as 25% of depressed older people with hip
fracture receive antidepressants (106) and there seems to be an over reliance on psychotropic
medication for the management of delirium (116). The use of psychological treatments is rare.
There may be several explanations for these observations but poor knowledge, attitudes and skills
combined with low confidence are likely to be significant factors.
Delirium
2.5 It is valuable to recognise the distinction between prevalent and incident delirium. Some older
people arrive at the hospital with delirium (prevalent) while others develop delirium during their
admission (incident). Studies aimed at prevention involve incident delirium and these have
identified the most important characteristics that predict the risk of developing delirium (117).
2.6 It is possible to identify those baseline characteristics which place individuals at high risk for
developing delirium (predisposing factors) and those factors causing high risk of precipitating
delirium (precipitating factors). A simple combination of 4 predisposing and 5 precipitating factors
has been used to produce a model that predicts the development of delirium for older people
admitted to medical wards (118)(Box 2).
2.7 However, it is important to recognise that these prediction rules will differ between different
populations of patients. For example, a slightly different set of risk factors has been found to
predict risk of delirium among older people admitted for surgery (69).
Box 2
Predisposing factors
• Vision impairment
• Severe illness
• Cognitive impairment
• Raised blood urea nitrogen/creatinine
Precipitating factors
• Use of physical restraints
• Malnutrition
• More than 3 medications added
• Use of bladder catheter
• Any iatrogenic event (harmful consequence of
a procedure or intervention)
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