Abstract
Age appropriate mental health services
For mental health services in the UK, older people are frequently defined as being over 65 years, although most people at that age are by no means old in terms of health, attitudes or behaviour.
Systematic development of old age psychiatry services began during the 1970s with a handful of psychiatrists who had seen the benefits of active treatment. 1 Almost immediately, these barely emerging services were hit by the financial effects of the oil crisis. By contrast, economic stability in the 1960s had allowed the more established disciplines of geriatric medicine and ‘general’ psychiatry to make some headway in creating modern clinical services. For example, as a proxy measurement of service development, in 1968 there were 178 geriatric medicine consultants 2 compared to about 6 in old age psychiatry. 3 For psychiatry, there were other influences generating change, such as the anti-psychiatry movement which was strongly focussed on younger people. 4 The needs of mentally ill older people were largely overlooked, and lagged behind in terms of resources.
There are good reasons for having dedicated old age services. First, the incidence of the various dementias begins to rise steeply at around 65 years, so clinical teams need specific skills to ensure accurate diagnoses and appropriate support and treatment. Second, as people age they are increasingly likely to have multiple diagnoses which require expertise to manage them alongside the mental illness. Third, discussion among mental health staff indicates that the age-group of patients with whom they wish to work is important to them. Usually, general adult psychiatrists do not desire to work with older people, nor old age psychiatrists with younger. Lack of enthusiasm about your patient group does not make for good therapeutic relationships. Fourth, negative responses from the medical profession generally towards mentally unwell older people have become deep-rooted over the decades. For example, 70 years ago an editorial in a respected medical journal commented: ‘All sympathy and desire to help seem to vanish. Nothing but irritation and an impatient desire to discharge the patient … exists’. 5 Forty years ago, old age psychiatrist Professor Tom Arie noted that many doctors and social workers ‘cannot formulate a “psychogeriatric problem” in any other terms but as to the need to get it instantly off their hands.’ 6 Recent experience as a liaison psychiatrist on medical and surgical wards suggests little has changed.
For treatment, many older patients will be best served by specific old age services because of physical frailty, confusion, co-morbidity, and social and psychological factors, but some may benefit from services used mainly by younger people. Thus, despite the need for psycho-social treatment options beyond the confines of traditional old age facilities and activities, the other reasons indicate that specific old age services have a valid clinical rationale. Age appropriateness is sometimes misunderstood to be age discrimination. These points indicate why specific services are to the patients' advantage and are no more discriminatory than having dedicated children's services.
Clinical benefits of providing dedicated mental health services for older people are well recognized. They are reflected in the peer-reviewed journals dedicated to the field including the International Journal of Geriatric Psychiatry and International Psychogeriatrics. Recent examples of good outcomes from specialist interventions include reducing length of stay for general hospital inpatients by adequate liaison services, 7 the benefits of supporting carers 8 and adequate end of life care in dementia. 9 Nevertheless funding has often not been forthcoming.
Funding old age mental health services
A report for the Department of Health in 2008 stated that ‘eliminating age discrimination in mental health services would require extra expenditure of around £2 billion’ annually. 10 That was despite the overall increase in National Health Service (NHS) funding during the preceding years. 11 New money had been provided for mental health services for working age adults, but not for older people. For example, the mental health component of the National Service Framework (NSF) for Older People in 2001 12 was unfunded, contrasting with the funded Mental Health NSF for working age adults in 1999. 13
In 2009, the National Dementia Strategy (NDS) aimed to dramatically improve dementia care. It was allocated £150 million over two years. However, with the total annual cost of dementia in England around £17 billion, 14 a less than 0.5% increase for each of two years did not suggest a serious commitment by the government. The allocated NDS money was not ‘ring-fenced’; many clinicians have seen little or no benefit from it. Much of the funding allocated to the NDS appears to have been used by Primary Care Trusts for other purposes. 15 That is not new; in 1985 health economist Professor Nick Bosanquet noted a similar phenomenon. 16 Repeated under-funding and disappearance of allocated money may help to account for the £2 billion shortfall which clearly did not develop overnight.
In 2009 there was no outcry at the inadequate allocation of new resources for the NDS, much as there had been little outcry for the previous 40 years, except from the Royal College of Psychiatrists Old Age Faculty (and its predecessors). 17 Official bodies, like Royal Colleges, have at times appeared reluctant to make a stand for older mentally ill people, fearful that highlighting inadequate service provision could be interpreted sensationally by the press as direct criticism of the government. 18
Repeated government orders to modernize, integrate, reorganize and re-invest have not had the desired consequences of miraculously improving NHS provision. 19 Nor are they likely to do so in the present climate of economic constraint. For older people, ongoing inadequacies of services are reflected by the similar content of both the damning Ombudsman's report on older people's mental and physical healthcare, Care and Compassion, 20 in 2011 and the ‘Sans Everything’ inquiry in 1968. 21 Personal autonomy, respect and dignity remain neglected. In the intervening decades, buildings, medical technology and much else have improved, but values and expectations by and towards older people have shifted little, and consequently so has the quality of care. Value has a double meaning, the financial and the mindset: the under resourcing of services and lack of quality of individual care are symptomatic of a society which does not value vulnerable older people. Shifting long-stay care, for example, out of large Victorian mental hospitals into smaller modern homes may have improved the environment, but it has not changed underlying problems: ‘The difference between the old psychiatric hospital scandals and nowadays [is] sweeping it under one big carpet or hundreds of small rugs’. 22
Attitudes and economics
Clinical experience tells us that stereotypes of older people are of increasing frailty and neediness, never to recover when the slippery slope of dependency begins. Reversible mental disturbance includes delirium which may occur in predisposed older people in the presence of relatively minor physical illness. Medical colleagues, older people themselves, and families appear astonished when they miraculously recover from physical illness and delirium and return to their own homes. At times though, delirium is misidentified as an irreversible dementia, and the older person may be inappropriately placed in long-stay care. Society has not yet adapted to the observations that older people can recover. This information is not new. Active treatment to assist recovery from physical illness in old age was advocated by Marjory Warren, a geriatrician, in 1943, 23 and for mental illness by Felix Post, a psychiatrist, in 1944. 24 Despite that, specialist rehabilitation facilities, for example to enable discharge home for elderly people who have required inpatient treatment for physical conditions co-existing with psychiatric illness, remain a rarity. 25 In addition, failure to provide rehabilitation and often relatively low-cost, community management for long-term multi-factorial disability has humane and economic implications, since it may result in unnecessary long-stay institutional placement or high-cost crisis re-admissions to acute hospitals. 26
The cost of healthcare is influenced by various factors, including medical technology, pharmaceutical developments, style of medical practice, expectations of society, proximity to death, and chronological age. Attributing the rising cost of healthcare to older people has been described as a political red herring. 27 Most common chronic conditions are managed relatively cheaply until shortly before death. 28 Around a quarter of the entire healthcare anyone consumes in their lifetime is in the last year of life at whatever age they die. If anything, healthcare expenses within the last year are higher for younger people dying than older people, 29 in part because the former are likely to be more intensively investigated and treated. Postponing death concentrates the cost of terminal illness in old age, but does not directly increase costs. 28 If most people live until their 80’s, expenditure for that age group will be high; it is not because they are living longer, but because they are dying older.
The ‘rectangular curve’ of longevity is well recognized, 30 indicating prolonged good health in old age and a lower proportion of life spent dependent, a compression of morbidity into a shorter time between dependence and death in extreme old age. Well described by philosopher and geriatrician Professor Raymond Tallis, he also commented that public perception is skewed by, amongst others, journalists and editors who want to sell newspapers. 31 We rarely hear of celebrations of healthy longevity. Those reports sadly appear less newsworthy than those highlighting the health-economic perils of old age. The latter reports are often one sided. They emphasise the use of resources by older people largely disregarding that many older people continue to contribute to society and to their family over many years, often despite chronic illness. A recent Women's Royal Voluntary Service survey indicated that people over 65 make a net contribution of £40 billion to the UK economy each year. 32 In addition, they have paid National Insurance through their working lives and some continue to pay taxes. Today, some need what the welfare state promised them, and for which they have already indisputably invested.
The ethics of healthcare economics in old age need review, including the implications of the rectangular curve, with allowance made for providing for terminal illness and decline in the last year or two of life. There are many ways of rationing healthcare; chronological age is only one of them. 33 Even the detailed study of the ethics of healthcare rationing in old age in the NHS by the Nuffield Trust warned that ‘easy answers in terms of age-based rationing can and should be resisted.’ 34 Some have suggested that funding should be on a whole life perspective. 35 Society does not complain that most of the education budget is spent on children and teenagers as part of whole life expenditure. A similar attitude should exist towards health spending in old age. For older people, we know the demographic projections and the epidemiology of diseases, so estimates of need and cost can be made. There is no excuse for not planning well in advance. The situation is not helped by short-term goals of political parties related to their term in government. High-tech medical interventions can be introduced rapidly and politicians can celebrate. These interventions may of course also dramatically benefit older people. However, less conspicuous medico-psycho-social interventions for psychiatric illness in old age which are often less tangible, less easy to measure and require a cultural shift by society still wait.
We strive to reach old age while aiming to keep it as remote as possible. As Professor Lewis Wolpert said ‘How can a 17-year-old, like me, suddenly be 81?’ 36 A rational response to funding would be that since we are almost all likely to become old, and may even lose our marbles, we should invest in old age mental health services. But this does not happen. Under-provision of services for old people may be related to psychological and existential influences, such as denial of the aging process, and discomfort at considering the possibility of one's own dependency, demise and inevitable death. Younger people avoid contemplating their old age especially at times when they may have the greatest professional influence on the development of health services, whether within healthcare professions, or outside, like politicians. Mental illness compared to physical, carries an additional fear and stigma, probably contributing to neglect of mental health provision.
Unlike other prejudices such as towards women, disabled people, gay people and ethnic minorities, ageism relates to the majority of the population, our own lives in the future. Progress has been made in changing discriminatory cultural beliefs, stereotypes and attitudes towards other groups, at least to some extent. But for old age, journalist Joan Bakewell commented ‘attitudes simply persist because no one has set out deliberately to change them.’ 37 Attitudes held by society permeate medicine and politics. For old age this is often in an unconstructive, unbalanced and defeatist way. Widespread change of attitudes is crucial to developing humane, funded policies. If we are mentally unwell in old age, we may not be able to say what we need or what is worrying us. If things do not change, the catastrophes of Sans Everything 38 almost half a century ago and Care and Compassion 20 in 2011, are likely to be repeated.
DECLARATIONS
Competing interest
None declared
Funding
None
Ethical approval
Not applicable
Guarantor
CH
Contributorship
Claire Hilton is the sole contributor
Acknowledgements
To Professor Tom Arie and Professor Dave Jolley for their comments
The phrase in the title: ‘Sans teeth, sans eyes, sans taste, sans everything’ is from William Shakespeare's As you Like It; II:vi (written c1599)