Abstract
This issue of the Journal celebrates the foundation of the Faculty of Psychiatry of Old Age (FPOA) of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) on 1 January 1999. The six papers that have been chosen for publication were solicited from both local and overseas authors. They offer the reader a stimulating blend of original research and scholarly review, and also provide a representative picture of some of the issues that are of concern to old age psychiatrists at the turn of the century.
Draper and Snowdon provide an organisational history of the FPOA and the Section that preceded it, placing the establishment of the Faculty in the context of overseas trends. They further emphasise the development of a College-accredited training scheme as a central objective of the FPOA. Opie et al. assess the effectiveness of a range of non-pharmacological therapies to manage behaviour disorders in dementia. These are among the most difficult problems that present to old age psychiatrists in clinical practice. Hassett presents original findings from a large study of individuals presenting with late-onset psychosis.
Weyerer et al. have studied the prevalence of alcohol-related problems among residents in old age homes in Germany and remind us of the persisting relevance of substance misuse into old age. McKeith and O'Brien, from Newcastle in the United Kingdom, provide an elegant review of clinical and research findings of Lewy body dementia that includes a highly relevant section on treatment, including the role of cholinesterase inhibitors. Finally, Stewart et al. from London report emerging evidence that vascular risk factors play a role in the aetiology of Alzheimer's disease, and that the differences between vascular and Alzheimer's dementias may not be as great as previously thought.
The clinical, teaching and research interests reflected by the contents of this special issue are but one aspect, albeit a significant one, of what the FPOA represents. Inevitably, the Faculty also has a social role. When issues that impact upon the elderly mentally ill need to be debated and brought to the attention of the wider community, then the FPOA will be expected to make itself heard, either directly or through its position on General Council.
Indeed, the FPOA has been founded at a time of great change in the delivery of health care to older Australians and New Zealanders. The reasons for these are largely demographic. The expectation of an increase in the number and proportion of people aged over 65 years in Australasia is well known to most readers [1]. In the wake of high postwar birth and immigration rates, both Australia and New Zealand will continue to experience rapid ageing, with particularly strong growth in the proportion of people aged over 80 years [2,3]. Given that dementia is an age-related disorder, the number of persons with dementia in Australia and New Zealand is expected to grow by over 100% over the next 30 years [1]. This will place greater pressures upon the range of services now utilised to provide care for persons with dementia, including those within the mental health sector.
The resultant growth in demand for aged care services that will emerge from the anticipated demographic trends, will not be met by a concomitant increase in funding, creating a situation in which vulnerable people may be further disadvantaged. We use the term ‘further’ deliberately, as it is our view and the view of many of our colleagues, that the elderly mentally ill are already disadvantaged when the issue of resourcing of acute services is considered.
Thus, in the state of Victoria where we practice, funding arrangements under which Aged Psychiatry Area Mental Health Services (APAMHS) operate manifest a naked ageism. The bed-day cost for aged psychiatry services is set at $269 per available bed-day. This compares to $297 per available bed-day in the adult sector, and $366 per available bed-day in the child and adolescent services [4]. A ludicrous situation, therefore, pertains whereby an individual suffering an acute manic episode requiring a 15-day admission, for example, will attract $420 less for their care in the month after their 65th birthday, even though their problems remain the same. These differences in funding occur despite the fact that the elderly tend, as a group, to be more disabled, have multiple comorbid medical illnesses and require more assistance with activities of daily living.
Other financial constraints add to the disadvantage inherent in the differential funding of aged psychiatry services. These include a yearly drive for ‘efficiencies’, the closure of large hospitals able to offer economies of scale, the decentralisation of inpatient beds to well-designed but more costly suburban treatment units, and the demand for decentralised services to pay facility charges for which separate funding has not been provided. The challenge remains to develop work practices that allow practitioners to do more with less and to retain quality staff while maintaining quality services. The practice of many services to reduce the involvement of psychiatrists, and transfer management responsibilities to allied health or non-clinical staff represents an obstacle to the constructive involvement of psychiatrists in the change process.
Similar problems exist in other parts of Australia and New Zealand. In the Hornsby region of northern Sydney, the psychiatric needs of 34 000 older residents are provided for by a service with access to only four inpatient beds on a general adult psychiatry unit, run by general psychiatrists [Llewellyn-Jones R: personal communication, 1999]. In New Zealand, the health reforms of 1993 have led to a situation where the money to treat and care for elderly patients with psychiatric disorders is used up well before the end of each financial year [2]. The Australian private psychiatric sector has its own limitations, which have not altered significantly since 1989, when Jorm and Henderson presented data showing that the elderly received fewer and briefer psychiatric consultations than younger individuals [6]. Information from the Australian Commonwealth Health Insurance Commission indicates that although those over 65 form 12% of the Australian population [1], they account for a mere 7.2% of patients receiving private psychiatric services currently funded by Medicare.
Age-related discrimination is not only relevant to resourcing issues. Although old age psychiatrists are familiar with the psychiatric complications of dementia, the recent Mental Health and Wellbeing Report [6], which is intended to guide Commonwealth and State governments in allocating resources to mental health services, actually excluded cognitive disorders from consideration. As a consequence, the high rates of affective, perceptual and behavioural disturbance known to exist in the elderly with dementia were not reported. The prevalence of mental disorder in the elderly was therefore found to be substantially lower than that for the general adult population. In fact, a wide range of epidemiological evidence indicates that overall prevalence of mental disorder in older persons differs little from that in younger age groups, once dementia and psychiatric complications of comorbid medical illnesses are included [7].
Growth in the field of psychiatry of old age in Australia and New Zealand over the past 15 years has been substantial. This is represented by the foundation of the Section and then the FPOA, in 1988 and 1999, respectively, the rising profile of Australasian old age psychiatry internationally [8] and expanding interest in the subspecialty among psychiatry trainees throughout Australasia. Despite these professional developments, however, older Australians and New Zealanders are still some way from enjoying what Murphy [9] defined as the challenge for our services, namely the provision of a comprehensive diagnostic, treatment and rehabilitation service for all elderly people with any disabling mental disorder. Many factors conspire to impede realisation of this ideal, not the least of which is an approach to resourcing that considers the needs of older persons with acute psychiatric disorders as inferior to those of people with similar illnesses aged under 65 years. Experience has taught most of us that few problems are solved simply through the expenditure of greater amounts of money. Nevertheless, the old, like the poor, are always and increasingly with us, and in the final reckoning, we all have a vested interest in arguing for equity of access to health services for older Australians and New Zealanders. Most readers of this Editorial will live to be old!
By moving to ensure that training in old age psychiatry is accredited and of a high standard, the RANZCP has taken a step towards promoting quality psychiatric care for older persons with mental disorders. It now behoves FPOA members to participate in training development and continuing education, while retaining a strong social advocacy role and continuing the strong tradition of psychiatric leadership in the organisation of services. In the long march towards universally accessible and equitable care for older people with psychiatric disorders, the establishment of the FPOA marks the end of beginning and the start of a long journey ahead.