Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0135Education and the Liaison PsychogeriatricianD. N. AndersonMossley Hill Hospital, Liverpool, UKThe elderly are under-represented among referrals to psychiatryfrom general hospital wards in relation to younger patients andbed occupancy. Less than 3% of general elderly admissions areseen by a psychiatrist and only 20–25% of all liaison contacts arewith older people, even though they occupy 40–50% of generalhospital beds and 30–50% might be expected to have or develop apsychiatric problem 1 . This represents 3000–5000 cases/10 000admissions and even if more were referred, only a fraction couldrealistically be seen by a psychogeriatrician 2 .The frequency of mental disorder in acute elderly medicaladmission populations is approximately twice that of the community3,4 . Depression, dementia and delirium are the commonsyndromes. Psychiatric problems are much more common onmedical and orthopaedic than general surgical wards 5–7 . Thefrequency of organic brain syndromes increases with age 8 butthere is less evidence that depression is age related 9 .The identification of mental disorder by general clinicians ispoor 10 , particularly the detection of depression 11 and delirium 12,13 .Clinicians appear to detect the syndrome of dementia morereliably than cognitive symptoms 14 but with depression it issymptoms that are more often recognized than the syndrome 15 .The possible adverse effects of a co-morbid psychiatric disorderupon the outcome of a medical admission makes the recognitionand treatment of these disorders important to both patient andclinical service 6,16,17 .A priority for the psychogeriatric consultation–liaison servicehas to be education (acting as it does at the interface betweenpsychiatry and general departments) that encourages goodpractice and alters attitudes to mental illness in old age. Withsuch morbidity it is essential to improve the ability of general staffto detect and prescribe appropriate treatment for the majority ofsimple disorders, while recognizing those cases that need thespecialist psychiatric service 18 . Currently, the treatment of mentaldisorder by general staff, particularly for depression, appearspoor 19 .There is indirect evidence that specialist consultation–liaisonpsychiatry for the elderly does influence the behaviour of generalclinical staff toward psychiatric problems. The introduction of aconsultation–liaison service is certainly associated with increasedrate of referral 1,20–23 . This increase is most marked for depression1,23 , perhaps the most neglected and inappropriately managedcondition, but close liaison produces a general improvement in thequality of referrals 23 .Research in the old age liaison field is in its infancy and hasconcentrated on quantifying levels of morbidity, examiningreferral rates and exposing clinicians’ difficulties in recognizingpsychiatric disorders. Preliminary work suggests that psychiatricinvolvement with older patients can have positive effects onoutcome 24 but this may not be targeted at the most appropriatecases 18 . If the management of mental disorder in this context is toimprove, then general services will need education. The process ofeducation is complex and multifaceted and a new researchdirection would involve a closer examination of the enablingrole of specialist consultation–liaison, identifying approaches andstyle of service with the greatest educational impact and the mosteffective methods of disseminating knowledge and expertise.It is the management of non-referred cases that will ultimatelyprove the measure of success. As the ageing population grows,this research is timely and these important areas of study need tobe explored.REFERENCES1. Anderson DN, Philpott RM. The changing pattern of referrals forpsychogeriatric consultation in the general hospital: an eight yearstudy. Int J Geriat Psychiat 1991; 6: 801–7.2. Anderson DN, Philpott RM, Wilson KCM. Psychogeriatric liaisonreferrals. Br J Psychiat 1988; 153: 413.3. Cooper B. Psychiatric disorders among elderly patients admitted tohospital medical wards. J R Soc Med 1987; 80: 13–16.4. Burn WK, Davies KN, McKenzie FR et al. The prevalence ofpsychiatric illness in acute geriatric admissions. Int J Geriat Psychiat1993; 8: 171–4.5. Incalzi RA, Gemma A, Capparella O et al. Effects of hospitalisationon affective status of elderly patients. Int Psychogeriat 1991; 3: 67–74.6. Holmes J. Psychiatric illness and length of stay in elderly patients withhip fracture. Int J Geriat Psychiat 1996; 11: 607–11.7. Millar HR. Psychiatric morbidity in elderly surgical patients. Br JPsychiat 1981; 138: 17–20.8. Ames D, Tuckwell V. Psychiatric disorders among elderly patients ina general hospital. Med J Aust 1994; 160: 671–5.9. Fenton FR, Cole MG, Engelsmann F, Mansouri I. Depression inolder medical inpatients. Int J Geriat Psychiat 1994; 9: 279–84.10. Bowler C, Boyle A, Branford M et al. Detection of psychiatricdisorders in elderly medical inpatients. Age Ageing 1994; 23: 307–11.11. Koenig HG, Goli V, Shelp F et al. Major depression in hospitalisedmedically ill men. Int J Geriat Psychiat 1992; 7: 23–34.12. Gustafson Y, Brannstrom B, Norberg A et al. Under diagnosis andpoor documentation of acute confusional states in elderly hip fracturepatients. J Am Geriat Soc 1991; 39: 760–5.13. Francis J. Delirium in older patients. J Am Geriat Soc 1992; 40:829–38.14. Harwood DMJ, Hope T, Jacoby R. Cognitive impairment in medicalinpatients. II: Do physicians miss cognitive impairment? Age Ageing1997; 26: 37–9.15. Jackson R, Baldwin B. Detecting depression in elderly medically illpatients: the use of the Geriatric Depression Scale compared withmedical and nursing observations. Age Ageing 1993; 22: 349–53.Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd