Psychiatry services for older people

Key messages

• Good mental health is essential to healthy ageing, and older people require the same full spectrum of mental health interventions as other people, from prevention to early intervention and clinical care.
• Mental healthcare for older people should not be subsumed into a broader ‘adult mental health’ or ageless services, reflecting the distinct needs of older people who require care from appropriately trained clinicians with specialised skills.
• Mental illness is relatively common in older people, but is often unrecognised by individuals, family and health care professionals, who may wrongly attribute symptoms of treatable mental illness to the irreversible effects of ageing or to physical or environmental changes.
• Psychiatrists have a key role in providing differential assessment, diagnosis and treatment to older people with mild to severe mental illness, including people for whom dementia is complicated by severe behavioural and psychological symptoms.
• Consultation-Liaison Psychiatry Services for older people in hospitals and the community are critical services that are cost effective and facilitate patient flow and access to care.
• Most interventions that are effective in younger people remain effective in later age, including when cognitive impairment is present.
• Current estimates regarding the prevalence of mental illness in older populations are methodologically flawed, resulting in significant under-estimation of the burden of disease.
• Serious concerns have been raised locally and internationally regarding the readiness of mental health services to meet the needs of a growing population of older people.

Definition

For organisational purposes ‘older’ is often accepted as being 65 years and over, although local, individual or cultural circumstances may require a flexible approach [1]. 

Psychiatric services for older people, previously termed psychogeriatric services, have been subsumed by service terms which include old age psychiatry services, older persons’ mental health and mental health services for older adults. The generally accepted core entry criteria for mental health service for older people may be one of the following:

• People with serious mental illness, aged 65 or over, newly presenting to local mental health services or who have not been under the care of other local mental health services for a regionally-specified amount of years.
• People with serious mental illness and significant age-related physical illness or frailty which compounds or complicates the management of the mental illness.
• People with serious mental illness and significant psychological or social difficulties related to the ageing process where their needs may best be met by a service for older people.
• People of any age with a primary dementia and serious behavioural and/or psychological symptoms.

Background

Good mental health is essential to successful ageing, and older people require the same full spectrum of mental health interventions as other people, from prevention to early intervention and clinical care. It is important to recognise that many older people do not have mental illness or dementia, and that ageing is not always associated with the development of severe mental illness.

However, untreated mental illness robs older people of their quality of life, physical health and independence at significant cost to individuals, family and community. It is essential that older people are valued, and their potential to be happy and productive is maximised. Older people should have the opportunity to make important contributions to their own welfare as well as that of younger generations. Family/whānau¹, friends, carers and the community play an important role in supporting older people in Australia and New Zealand, in particular those who may have mental illness or dementia. It is crucial that the role of family/whānau, friends and carers is acknowledged, and that they are appropriately supported and involved in the care pathway. 

The phenomenon of population ageing in Australia and New Zealand is well-established and has profound implications for health care provision. In keeping with other OECD nations, over the coming decades Australia and New Zealand are projected to experience an unprecedented increase in both the number and proportion of their older citizens. The 65 and over population in both countries will more than double by the 2050’s to approximately 8.7 million in Australia [2] and approximately 1.4 million in New Zealand [3]. By this stage older people will comprise around one-quarter of the population in both countries [2, 3]. However, serious concerns have been raised locally and internationally regarding the preparation of mental health services to meet the needs of older people  [4-6].

The ageing population in Australia and New Zealand will mean that there will be increasing demand for mental health services for older people, as older people with long standing mental illness are joined by those with mental illness that develops for the first time in later life. Such illnesses include depression, anxiety and bipolar disorders, schizophrenia and other psychotic illnesses, alcohol and substance misuse disorders and dementia [1, 7]. Older people may also face unique issues relating to elder abuse, with international estimates suggesting between 2% to 14% of older people are exposed to elder abuse [8, 9].

Both Australia and New Zealand are under-prepared to meet the mental health needs of this burgeoning population. While there are effective evidence based mental health treatments for older people in Australia and New Zealand, limited resources deny them equitable access. Action must start now to address this deficiency. Australia and New Zealand owe their older citizens and their families’ adequate support, respect and dignity.

Evidence

It can be challenging to determine the prevalence of mental illness in older people in Australia and New Zealand, as general population health surveys have excluded significant numbers of older people. This is evident in the Australian National Mental Health and Well-Being Surveys of 1997 and 2007, which excluded older people with dementia, those with English as a second language, and those living in residential aged care [10, 11]. This latter group comprise a significant proportion of those referred to aged persons’ mental health services in both countries. Research using 2007 Australian survey data found that, in the 12 months preceding the survey, 6% of those aged 65 to 85 met criteria for an affective, anxiety or substance use disorder [12].

The New Zealand Mental Health Survey of 2003/4 used a similar methodology to the Australian studies, and excluded all older people with cognitive and physical disabilities, those living in institutions, those unable to be interviewed in English, and those over the age of 85 years [10]. This survey found that the prevalence of mental disorders was 6% in the 75-85 age group. The lack of data on the prevalence of mental illness in older people in Australia and New Zealand demonstrates the need for a high quality survey of mental health and wellbeing in older people that reflects the true prevalence of mental disorder.

Even mild mental illness can have a significant impact on an older person’s health, function, quality of life, use of health services and outcomes of health interventions  [13-15]. Furthermore, older people who have a mental illness are also more likely to have significant social and physical health problems [1]. Mental illness in older people can often go unrecognised by individuals, family and health care professionals, who may wrongly attribute symptoms of treatable mental illness to the irreversible effects of ageing or to physical or environmental changes. As such, relatively few older people with mental illness are referred for specialised psychiatric treatment [4]. British research shows that increasing older people’s access to specialists reduces hospital admissions and improves health outcomes [16].

Evidence suggests that, among the cohort of older people, there are several groups that face higher risk of mental illness. One key example of this is permanent aged care residents. Australian Institute of Health and Welfare (AIHW) data from 30 June 2017 shows 85% of people in permanent residential aged care had at least one diagnosed mental health or behavioural condition, and 47% had a diagnosis of depression [17]. Other sub-groups that have been found to have a higher prevalence of poor mental health include people in hospital and/or with physical comorbidities, people with dementia, and older people who are carers [18]. Men aged 85 years and older are a group of significant concern, as they have the highest age-specific rate of suicide death of any demographic group in both New Zealand [19] and Australia [20].

Older people with mental illness face over-prescribing within the health system, and have prescription rates at 500% of that of the general population for anxiolytic, hypnotic, and sedative drugs [21]. The Health Quality and Safety Commission of New Zealand found that the percentage of people dispensed five or more long term medicines increased from 25.1% to 58.8% from the 65-74 age group to the 85+ age group [22]. Psychotropic medication has been associated with an increased risk of falls, as well as other adverse effects, so it is important that the necessity of each prescription is considered for each individual [23]. Recent AIHW data reveals that persons over the age of 75 are one of the least likely age groups to receive an MBS-funded mental health consultation, yet are the group most likely to be prescribed psychotropic medications [24].

Issues around mental health services for older people

Mental health services for older people should be evidence-based and provided in settings most appropriate to the person’s needs. Services should be multidisciplinary, coordinated, adaptive and complementary to other providers across the spectrum of care. Good mental health care for older people must incorporate the following principles:

• Promotion of independence, dignity and quality of life for people with mental health problems, their families and carers [25].
• Care informed by and aligned with current best practice in mental health aged care and disability services including recovery, person-centred care, quality and safety, family/whanau involvement, and enablement  [5, 26, 27].
• Liaison between mental health, social services and community providers should be facilitated to enable close coordination and continuity of care [15].
• Recognition and respect for the roles and needs of older Aboriginal and Torres Strait Islander peoples and Māori, with awareness that concepts of mental health are integrated into broader concepts of wellbeing within these cultures [5, 28].

The development of a sufficient workforce

Services and support for older people with mental illness must be underpinned by a range of medical and allied health professionals, including psychiatrists, geriatricians, general practitioners and others. Within the current aged care system, general practitioners provide primary care for mental health to older adults, while psychiatrists and other specialist services provide advice, support and treatment as required.

Research in both Australia and New Zealand suggests that there is insufficient emphasis placed on developing a specialist medical workforce to meet the needs of the growing group of older people. For psychiatry in particular, the Australian Commonwealth Department of Health psychiatry workforce review in 2016 concluded that a shortfall of psychiatrists was expected nationally by 2030, noting that some 42.8% of all psychiatrists were expected to reach retirement age by 2024 [29]. A recent survey of New Zealand Health Boards revealed that none had any plans to increase their medical staff time over the subsequent three years [30] . These shortages may lead to significant gaps in the old age psychiatry workforce and older person mental health services, particularly in light of the growing ageing population.

The RANZCP recognises the need for old age psychiatry and geriatric medical services in particular to work closely together to ensure the best treatment and care of older people, many of whom suffer from complex combinations of mental and physical ill health. Further detail on best policy and practice for old age psychiatry and geriatric medical services to work closely together to ensure the best treatment and care of older people is discussed in RANZCP Position Statement 31: Relationships between old age psychiatry and geriatric medicine.

Funding and planning to meet the needs of a growing older population

Issues in regard to planning, funding and resource allocation for older adults’ mental health services remain areas of concern for the RANZCP. While changes and reforms are ongoing in both Australia and New Zealand, clarity around models of care and care standards is often lacking. For example, a person-centred model of care is championed in New Zealand’s Healthy Ageing Strategy and, while the RANZCP strongly supports this evidence-based approach [31], implementing this model will require a transformation of services, and there is a lack of clarity about how this change will be achieved or funded. In addition to issues around resource allocation, there continue to be significant gaps in service provision for specific groups of older adults. Evidence from New Zealand [32] revealed a lack of care provision for older adults with intellectual disability, young-onset dementia, and addiction, and a recent follow-up survey revealed that no progress had been made in regard to services for these high-need older people [30].

Another significant gap is the availability of consultation-liaison psychiatry (CLP) services for older people. CLP teams are crucial to ensuring quality care and patient flow, and play a significant role in facilitating access to mental health care for older hospital patients as well as appropriate care after discharge. Failure to expand CLP services and ensure they have staff with specialist skills in working with older people represents a concerning risk within the health system. Research in the United Kingdom has demonstrated that investment in CLP services yields approximately a fourfold return on investment. A significant portion of the health benefits and financial savings associated with CLP services can be attributed to improvements in older people, particularly in geriatric medicine wards [33].

Meeting the mental health needs of Indigenous older adults

Currently there is inadequate attention on the mental health needs of older Aboriginal and Torres Strait Islander peoples and Māori. The indigenous peoples of Australia and New Zealand continue to experience significant barriers in accessing health services at all ages, and this is amplified for older individuals [34].Further attention also needs to be given to understanding the specific needs of these older adults, in order that service provision is better tailored to their needs. For example, older Maori may not wish to be placed in residential care and are more likely to prefer to be cared for by family/whanau [35]. Issues around service access and appropriateness need to be acknowledged and addressed in government policy in Australia and New Zealand. A key aspect of ensuring culturally appropriate and supportive care is the involvement of Aboriginal and Torres Strait Islander peoples and Māori in the planning of services and in the older age health workforce.

Recommendations

The RANZCP recommends that:

• Planning, funding, and resourcing of mental health services for the growing older adult population, including planning for a growing and culturally diverse workforce, is prioritised by governments in Australia and New Zealand.
• Mental health services for older people are not subsumed into a broader ‘adult mental health’ or ageless services.
• National benchmarks are established for mental health services for older people, setting standards for availability and quality across the spectrum of care.
• Effective and accessible mental health care is made available to meet the specific needs of Aboriginal and Torres Strait Islander and Māori older people, LGBTIQ+ and those from culturally and linguistically diverse backgrounds.
• General practitioners are supported as the primary providers of health services for older people, with access to specialist clinicians and education.
• Future national mental health surveys in both Australia and New Zealand are amended to include older people living with cognitive impairment, with English as a second language, and those living in residential facilities.

1 ‘Whānau’ (pronunciation: fa:naᵾ) is a Māori word used to describe an extended family group spanning three to four generations. The whānau continues to form the basic unit of Māori society (Rāwiri Taonui, 2012).

Responsible committee: Faculty of Psychiatry of Old Age 

References

1. Joint Commissioning Panel for Mental Health, Guidance for commissioners of older people's mental health services. 2013, Joint Commissioning Panel for Mental Health,: UK.
2. Australian Bureau of Statistics. Population projections, Australia, 2012 (base) to 2101. ABS cat. no. 3222.0. 2013.
3. Stats NZ (Tatauranga Aotearoa), 2013 Census QuickStats about people aged 65 and over.  Stats NZ: Wellington, New Zealand.
4. Jeste, D.V. and B.W. Palmer, A call for a new positive psychiatry of ageing. The British Journal of Psychiatry, 2013. 202(2): p. 81-83.
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35. RANZCP, New Zealand National Committee submission to the Ministry of Health on the Health of Older People Strategy. 2016: Melbourne, Australia.

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.