‘<i>Sans teeth, sans eyes, sans taste, sans everything</i>:’ resourcing mental health services for older people
Authors: Claire Hilton
Journal: Journal of the Royal Society of Medicine (2012)

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. 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 compared to about 6 in old age psychiatry. For psychiatry, there were other influences generating change, such as the anti-psychiatry movement which was strongly focussed on younger people. 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 agegroup 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’. 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.’ 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 DECLARATIONS