Liaison Psychiatry for Older People: a new service development with opportunities for research Dr Mick Dennis, Reader

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Liaison Psychiatry for Older People a new
service development with opportunities for
researchDr Mick Dennis, Reader Honorary
Consultant in Liaison Psychiatry for Older People
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Plan

• Background mental health problems in the general
  hospital
• NSFOP Who cares wins
• Service models
• Evidence base
• The new team in Swansea
• Research opportunities

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The complex challenge of providing mental health
care for physically ill older people in the
general hospital setting

• Older people occupy 2/3 of NHS beds
• Approximately 60 have, or will develop mental
  disorder
• Depression mean prevalence 29
• Dementia mean prevalence 31
• Delirium mean prevalence 20
• Mental disorder is frequently missed (gt50)
• 25-30 of all referrals to older peoples mental
  health services come from general hospitals

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• A typical district general hospital with 500
  beds
• Will admit 5000 older people each year.
• 3000 of these will have or develop a mental
  disorder

• In an average day
• 330 beds will be occupied by older people.
• 220 will have a mental disorder
• 96 will have depression
• 66 will have delirium
• 102 will have dementia
• 23 will have other major mental health problems.

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Selected studies of the prevalence of depression
in older medical inpatients
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Consequences of mental health problems on older
people in the general hospital - 1

• Untreated and poorly managed mental health
  reduces quality of life for patients and carers
  Co-morbid mental disorder has an adverse effect
  on outcomes
• Increased length of hospital stay
• Increased mortality
• Poor quality of life
• Increased carer strain
• Institutionalisation

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Holmes House (2000) Psychological Medicine, 30,
921-9
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Nightingale et al. (2001) Lancet, 357, 1264-5
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Consequences of mental health problems on older
people in the general hospital - 2

• Other effects of unrecognised and poorly managed
  mental health problems in the general hospital
• Disengagement with therapy
• Poor treatment adherence
• Complaints
• Increased staff stress, staff sickness,
  recruitment and retention problems
• Inappropriate use of psychotropic medication

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National Service Framework for Older People
(NSFOP, Standard 4, General Hospital Care)

• Clear guidelines for involving specialist mental
  health services in the general hospital
• Older people who have complex co-morbidities
  associated with old age are best treated by a
  dedicated specialised team
• Staff on wards to be trained to recognise and
  manage behavioural problems appropriately
• to have completed a skills profileand to have
  in place education and training programmes to
  address gaps identified

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Relevance of older peoples liaison psychiatry to
implementing the rest of the NSFOP

• Standard 1 Address age discrimination
• Standard 3 no intention to exclude people with
  mental illness from intermediate care
• Standard 5 psychological input to stroke,
  depression post-stroke, Vascular dementia
• Standard 6 MH issues in the aetiology of falls
• Standard 7 Endorses the early detection and
  management of mental illness no matter what the
  setting
• Standard 8 MH promotion

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Who Cares Wins (2005)

• Neglected problem.
• Underdeveloped services.
• Multi disciplinary team the most appropriate
  model
• Liaison approach is proactive with a focus on
  education and training.

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Service models for mental health care in the
general hospital setting

• Standard sector model
• An enhanced sector model
• The liaison nurse
• Outreach from psychiatric wards
• Shared care
• Hospital mental health team

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• What is the evidence concerning the effectiveness
  of liaison psychiatry services for older people ?

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Levels of evidence

• Level 1
• Systematic review of RCTs
• Level 2
• At least one well designed RCT
• Level 3
• Evidence obtained from non-randomised controlled
  trials
• Level 4
• Evidence from case series

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Evidence base for liaison services for older
people

• Level 2
• Reduce LOS
• Reduce costs
• Improvement in depression
• Patient satisfaction

• Level 4
• Improved physical functioning
• Decreased nursing home transfers
• Advice on suitability of psychotropic medication
  reduces adverse events and improves QOL

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Shared care wards

• Level 4
• Reduce LOS
• Reduce mortality

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Swansea 2007 The Hospital Liaison Psychiatry
Team for Older People

• John Coffey
• Bev Saunders
• Dr Mick Dennis

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Referrals

• Urgent referrals seen within 1 working day
• Routine referrals within 4 working days
• All Swansea hospitals (Morriston, Singleton
  Community Hospitals)
• Out of county (but not Neath/Port Talbot)

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What does a liaison service provide?

• Daily presence
• Speedy response
• Collaborative approach
• Assessment and management advice
• Advise on medication
• Regular reviews
• Liaise with family/carers/other agencies
• Arrange mental health follow up where indicated
• Training education

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DEPARTMENT OF OLD AGE PSYCHIATRYHOSPITAL MENTAL
HEALTH LIAISON SERVICE FOR OLDER PEOPLE
Dr Mick Dennis, Liaison Consultant
Psychiatrist Tel Direct line 01792 516517
Fax [phone] (secretary Trudi Poole ext
6517) John Coffey, Hospital Liaison Nurse
Manager Tel. [phone] ext 8606 Bev
Saunders, Hospital Mental Health Liaison Nurse
Tel. [phone] ext 8607
NB If the patient is currently known to
Mental Health Services for Older People,
the referral should be faxed to the relevant
Consultant Psychiatrist. Fax Numbers
Dr S Albuquerque
01792 516433 Dr E Clarke-Smith/Dr M Ellis
01792 222919 Dr T Crownshaw 01792
841461 Dr J Rule 01792
516433 If the patient resides in Neath
01639 862881 or if resides in Port Talbot
01639 862475

REFERRAL CRITERIA

Dementia Difficult behaviour Diagnostic
difficulty Risk to self and others Abuse New,
distressing or disabling psychotic symptoms Sleep
disturbance, not responding to usual measures
Depression Risk of harm to self or others Risk
of self-neglect Adverse effect on physical
health (including poor nutrition and fluid
intake) Psychotic depression and more severe
depression Compliance difficulties Diagnostic
problems More complex management issues (i.e.
resistive depression, discharge planning, etc)

• Delirium
• Difficult behaviour
• aggression/agitation/anti-social/significant risk
  to others/wandering
• Diagnostic difficulty
• - aetiology/complicating other mental disorder

Other referrals Alcohol/substance misuse, which
is complicating a mental health problem Late
onset schizophrenia Mania Organic personality
change Acute paranoid psychosis Problematic
abnormal reaction to physical ill health
Mental Capacity Assessment For advice where
there are uncertainties concerning capacity
after the treatment teams assessment
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The future The liaison mental health team for
older people (Liaison MHSOP)

• Multidisciplinary
• Psychiatrist
• Psychiatric nurses
• O.T.
• Social worker
• Operates like a sector CMHT but the population is
  the general hospital

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The Liaison MHSOP how does it work? (1)

• Consultation liaison i.e. proactive as well as
  reactive
• Referrals from general hospital staff, including
  AE MAU
• Rapid response
• Accurate, skilled assessment, monitoring, and
  treatment of mental disorder particularly for
  the complex case
• Targets areas where morbidity is high i.e.
  rehabilitation facilities, orthopaedic wards,
  geriatric medical wards

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The Liaison MHSOP how does it work? (2)

• Advise and supervise on non-specialist screening
  and management
• Assessment of all cases of self-harm
• Development and introduction of treatment
  protocols and care pathways
• Educational prevention, identification, and
  management
• Good communication
• Data for research and audit purposes

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The Liaison Mental Health team for Older People
important links

• Community mental health teams for older people
• General adult liaison services
• Educational institutions
• General hospital stakeholders
• Patients and carers

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Research Opportunities

• Service evaluation
• Liaison MHSOP
• Integrated Liaison MHSOP Community Care
• Disorder specific outcome evaluation
• Identification of mental disorder
• Screening tools
• Introduction and evaluation of training packages
• Collaboration in other areas of general
  hospital-based research of mental disorder in
  physically morbid populations