Mohammed T. Abou-Saleh

662 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYKEY COMPONENTS OF PSYCHOGERIATRICSERVICESCatchment Area and ComprehensivenessVirtually all psychogeriatric services in the UK work to a definedgeographical catchment area and the vast majority aim to providea comprehensive psychiatric service to all people over the age of65 years 6,7 . Many services are now also trying to provide forpeople with early-onset dementia, although often without anydedicated resources 7 .The Multidisciplinary TeamFor some this is an outmoded concept, for others an ideal thatcannot be obtained, but for many psychogeriatricians it is anessential context for all their endeavours. Most multidisciplinaryteams for the elderly incorporate community nurses, a socialworker, one or more occupational therapists,aphysiotherapist, andoften a psychologist. Various patterns of working have evolvedand been described but they have in common an attempt toinvolve all disciplines in formulating treatment plans for thepatient.Home AssessmentThis lies at the heart of most psychogeriatric services. Surveys 6,7have shown that around two-thirds of referrals were seen at homeby a doctor, one-fifth by other members of the team and one-tenthin outpatient clinics. Just over one in 10 were seen as liaisonreferrals, although in some services this rises to a quarter or evenone-third, perhaps partly depending on the admission policies oflocal geriatric services. Less than one in 20 were admitted directwithout prior assessment.Community TreatmentThe rate of acute admissions was only one-third of the rate ofreferrals, reflecting the fact that most home assessments do notresult in admission but in treatment in the community. Homevisits by community nurses are probably the commonest form oftreatment in the community, although home visits by doctors andother members of the multidisciplinary team also play animportant part.Day HospitalsIn 1985, there were about 1.2 day hospital places/1000 elderlypeople, and this had not changed significantly by the mid-1990s.Some services and Health Regions had relatively more andothers less. The use of day hospitals varied from area to area,depending on the resource availability locally. Anecdotal evidencesuggests that government guidelines overestimate the need fordementia places. In many but not all cases of dementia, the need isfor care rather than treatment and so a proportion of this dayprovision can be provided by Social Services or voluntaryagencies. Here, however, issues will have to be addressed as towhat kind of care is of most benefit to older people with dementiaand their relatives, neighbours and friends. Elderly people withfunctional illness often have problems with psychiatric orpsychological management that demand the treatment resourcesof a true day hospital.Acute Inpatient BedsThe national rate of provision in 1985 was around 1/1000elderly served, and again did not vary much over the next 10years. This may be insufficient to cope with the increasingdemands caused by demographic changes and the relative lossof long-stay beds but a great deal depends on the communityservices available, since there is potential for considerable‘‘marginal shift’’ between community and inpatient resources.One study showed that around a quarter of acute psychiatricbeds for all age groups were occupied by elderly people withdepressive illness, and in many areas anecdotal evidencesuggests that a greater proportion of acute psychiatric bedsare being used for functional illness, principally depression. Aswith day hospital places, it appears that the old guidelines mayhave overestimated the needs for dementia assessment beds andunderestimated the needs for patients with depressive illnessand other functional illnesses. Because of the high prevalence ofphysical illnesses in mentally ill old people, it is recommendedthat acute beds should be on a general hospital site. Someservices are now beginning to differentiate the assessment andmanagement of behavioural problems in demented people,which can be carried out in the community or in communitybasedunits, from the management of patients with depression,who often have major associated physical illness or disability(and may need ECT) and are therefore better managed on anacute hospital site. The same may apply to atypical dementiapatients requiring high levels of investigation or to patients withdementia and delirium. This last group may be best helped ongeriatric medical wards.Long-stay BedsThe provision in 1985 was around 3.4 beds/1000 elderly. Sincethen a large number of beds appear to have been closed, withpatients discharged to the private sector, where developmentshave been funded through the Social Security budget. In 1996the number had reduced to around 1.1 beds/1000 elderly. Sinceprovision is largely (but not exclusively) for those with severedementia, whose main need is for care rather than treatment,this development appears to demand a cautious welcome.Patients are generally being cared for in smaller units. However,there must be reservations. The smaller units are harder toinspect and they are not necessarily in the patients’ communitiesof origin, since planning permission and housing costsenter into the commercial equation. They are subject tocapricious changes in the market, including government refusalto pay the ‘‘going rate’’. They are not under specialist medicalmanagement and there is some evidence that this managementmay be one of the factors that reduces the rate of decline indemented elderly people, a factor which, if confirmed, mightalso have relevance in the day care setting. The switch toprivate care has been engineered for political reasons and itsimpact is yet to be fully assessed. Psychogeriatric services willneed to retain a proportion of their long-stay beds forrehabilitation, for treatment of old people with resistantfunctional illnesses (especially depression) and for treatment ofbehavioural disturbances amongst demented people. A surveyof old age psychiatrists 8 showed the majority in favour ofaround 1.5 long-stay (including respite) beds/1000 elderly incommunity NHS units, with national rather than localeligibility criteria. The use of such beds for respite care tosupport carers in the community is now well established, andthere is a potential for developing community units as centresof excellence for dementia care, as well as bases for multidisciplinarycommunity teams.