This month we spoke to Consultant Psychiatrist Dr Shehram Moghul (BM, MSc, MRCPsych). We discussed old age psychiatry services and the benefits that they can bring.

Old age psychiatry services - are they any use?

It's probably most useful to consider the patient population of old age psychiatry as comprising two main groups: organic and functional patients.

Of course real life is often not quite so neat...

Organic

In an ageing population the prevalence figures for dementia are daunting. Traditional estimates suggest 5% of those aged over 65 will be affected, rising to 20% of those aged over 80. This is also the age profile of the population that most often attends the GP for other conditions.

Dementia also complicates the management of other chronic conditions found in older people in primary care.

Most GPs are comfortable with knowing when to refer typical or established cases of dementia, however, sometimes the situation isn't as clear cut.

When it might be useful to consider referring to old age psychiatry services

• Where the cognitive deficit is mild or borderline (e.g. MMSE 26/30)
• When it only affects one domain e.g. short-term memory only
• When there is no effect on functioning
• Where the diagnosis is unclear e.g. a mixture of anxiety, low mood and complaint of memory problems
• Longer term follow up of those already on memory tablets
• Medico-legal issues around capacity e.g. LPA, testamentary capacity (although often NHS services will not feel this is their remit)

Old age psychiatry vs. neurological referral

• Often difficult to delineate
• Be wary of a short history of cognitive impairment e.g. noticeable within 3 months
• Relatively rapid decline - the MMSE typically declines by 3-4 points per year in Alzheimer's disease
• Early neurological symptoms/signs accompanying cognitive impairment e.g. lack of co-ordination, falls, seizures, incontinence, vision disturbance, significant weight loss. These are typically late signs in dementia
• Cognitive impairment in the context of Parkinsonian symptoms and signs

The potential benefits of referral to old age psychiatry services

• Clarifying or confirming diagnosis
• Early memory tablet treatment and long-term monitoring of this
• Early investigation e.g. brain scan if indicated
• Reassurance for those with benign or age related memory loss
• Support and help for both patient and family with navigating difficulties as dementia develops over subsequent years
• Help offload demands on the GP with involvement of a psychiatrist

NHS vs. private referral

A well-resourced NHS service is in a good position to offer all these services and benefits. However, sadly it is a reality that not all NHS services feel they are in a position to offer the services described and you will know if this is the case locally.

Common examples include a tendency for new referrals to be seen by practitioners who may not feel comfortable with diagnosing dementia, and longer waiting times (sometimes months) to see a psychiatrist to obtain specific medical review.

Some NHS services are also now offloading work hitherto performed by them e.g. long-term monitoring of anti-dementia drugs.

Functional

All GPs are proficient in diagnosing classical anxiety and depression. However, the elderly are more likely to be reluctant to disclose psychological distress. Often they somatise i.e. present with physical symptoms such as headaches, abdominal pain, vague neurological symptoms, and demands for multiple investigations.

There are many reasons e.g. generational stigma, fear of being thought of as 'mad', being sectioned or taken away to a rest home.

When it might be useful to consider referring to old age psychiatry services

• Sensitivity to common antidepressants e.g. selective serotonin reuptake inhibitors (SSRIs). More common in older people due to interaction with other tablets, GI disturbance, impaired renal/hepatic function etc.
• Physically infirm with multiple physical conditions where a delicate balance in medications needs to be achieved
• Suicidal thoughts - older people are more likely to be serious in intent than those in their 20s
• Psychological treatment - if carefully screened, older people can benefit from cognitive behavioural therapy (CBT) and other therapies, although individual therapy is more helpful than group therapy
• Failure to respond to a good course (at least 6 weeks) at an adequate dose of at least two different antidepressants

NHS vs. private referral

Again, a well-resourced NHS service is ideally placed to offer good services to these patients. However you will be aware if your local service is struggling to meet demand. Difficulties include a tendency for referrals to be seen by practitioners who are not in a position to diagnose or prescribe. This might leave you with a GP when your intention was for specialist medical input. The waiting time to see a psychiatrist may also be undesirably long.

Finally, one particular difficulty for elderly patients is accessing suitable psychological therapy. Not only are some local waiting lists longer than ideal (many months) but they often lead to group therapy. Elderly patients generally find this less helpful than individual therapy for many reasons (difficulty in hearing, uncomfortable with a group situation, etc).

Conclusion

Older people present different challenges in terms of diagnosis and treatment of mental health problems from younger patients. A proficient old age psychiatrist should have the knowledge and experience to manage the additional diagnostic and treatment challenges that issues like co-morbidity and polypharmacy brings. Older people can benefit from psychological therapy when carefully selected after assessment.

NHS services, when well-resourced, are ideally placed to meet these demands but some are struggling to do so. A private referral will usually mean directly seeing a consultant psychiatrist (or psychologist if appropriate) and within a timescale that suits both the patient and you as the referrer.

Priory has a nationwide network of hospitals and wellbeing centres that are well placed to support those suffering from mental health challenges related to old age, and we offer fast access to treatment to help improve our patients’ lives.