Plan

1. Liaison Psychiatry for Older People: a new service development with opportunities for researchDr Mick Dennis, Reader & Honorary Consultant in Liaison Psychiatry for Older People

2. Plan Background: mental health problems in the general hospital NSFOP & Who cares wins Service models Evidence base The new team in Swansea Research opportunities

3. The complex challenge of providing mental health care for physically ill older people in the general hospital setting • Older people occupy 2/3 of NHS beds • Approximately 60% have, or will develop mental disorder • Depression mean prevalence = 29% • Dementia mean prevalence = 31% • Delirium mean prevalence = 20% • Mental disorder is frequently missed (>50%) • 25-30% of all referrals to older peoples mental health services come from general hospitals

4. A typical district general hospital with 500 beds: • Will admit 5000 older people each year. • 3000 of these will have or develop a mental disorder In an average day: • 330 beds will be occupied by older people. • 220 will have a mental disorder • 96 will have depression • 66 will have delirium • 102 will have dementia • 23 will have other major mental health problems.

5. Selected studies of the prevalence of depression in older medical inpatients

6. Consequences of mental health problems on older people in the general hospital - 1 • Untreated and poorly managed mental health reduces quality of life for patients and carers Co-morbid mental disorder has an adverse effect on outcomes: • Increased length of hospital stay • Increased mortality • Poor quality of life • Increased carer strain • Institutionalisation

7. Holmes & House (2000) Psychological Medicine, 30, 921-9

8. Nightingale et al. (2001) Lancet, 357, 1264-5

9. Consequences of mental health problems on older people in the general hospital - 2 • Other effects of unrecognised and poorly managed mental health problems in the general hospital: • Disengagement with therapy • Poor treatment adherence • Complaints • Increased staff stress, staff sickness, recruitment and retention problems • Inappropriate use of psychotropic medication

10. National Service Framework for Older People (NSFOP, Standard 4, General Hospital Care) • Clear guidelines for involving specialist mental health services in the general hospital • ‘Older people who have complex co-morbidities associated with old age are best treated by a dedicated specialised team’ • ‘Staff on wards to be trained to recognise and manage behavioural problems appropriately’ • ‘to have completed a skills profile…and to have in place education and training programmes to address gaps identified’

11. Relevance of older people’s liaison psychiatry to implementing the rest of the NSFOP • Standard 1: Address age discrimination • Standard 3: no intention to exclude people with mental illness from intermediate care • Standard 5: psychological input to stroke, depression post-stroke, Vascular dementia • Standard 6: MH issues in the aetiology of falls • Standard 7: Endorses the early detection and management of mental illness no matter what the setting • Standard 8: MH promotion

12. Who Cares Wins (2005) • Neglected problem. • Underdeveloped services. • Multi disciplinary team the most appropriate model • Liaison approach is proactive with a focus on education and training.

13. Service models for mental health care in the general hospital setting • Standard sector model • An enhanced sector model • The liaison nurse • Outreach from psychiatric wards • Shared care • Hospital mental health team

14. What is the evidence concerning the effectiveness of liaison psychiatry services for older people ?

15. Levels of evidence • Level 1 • Systematic review of RCTs • Level 2 • At least one well designed RCT • Level 3 • Evidence obtained from non-randomised controlled trials • Level 4 • Evidence from case series

16. Level 2 Reduce LOS Reduce costs Improvement in depression Patient satisfaction Level 4 Improved physical functioning Decreased nursing home transfers Advice on suitability of psychotropic medication reduces adverse events and improves QOL Evidence base for liaison services for older people

17. Shared care wards • Level 4 • Reduce LOS • Reduce mortality

18. Swansea 2007: The Hospital Liaison Psychiatry Team for Older People • John Coffey • Bev Saunders • Dr Mick Dennis

19. Referrals • Urgent referrals seen within 1 working day • Routine referrals within 4 working days • All Swansea hospitals (Morriston, Singleton & Community Hospitals) • Out of county (but not Neath/Port Talbot)

20. What does a liaison service provide? • Daily presence • Speedy response • Collaborative approach • Assessment and management advice • Advise on medication • Regular reviews • Liaise with family/carers/other agencies • Arrange mental health follow up where indicated • Training & education

21. DEPARTMENT OF OLD AGE PSYCHIATRYHOSPITAL MENTAL HEALTH LIAISON SERVICE FOR OLDER PEOPLE Dr Mick Dennis, Liaison Consultant Psychiatrist Tel: Direct line 01792 516517 Fax: 01792 516579 (secretary: Trudi Poole ext 6517) John Coffey, Hospital Liaison Nurse Manager Tel. 01792 561155 ext 8606 Bev Saunders, Hospital Mental Health Liaison Nurse Tel. 01792 561155 ext 8607 NB If the patient is currently known to Mental Health Services for Older People, the referral should be faxed to the relevant Consultant Psychiatrist. FaxNumbers Dr S Albuquerque 01792 516433 Dr E Clarke-Smith/Dr M Ellis 01792 222919 Dr T Crownshaw 01792 841461 Dr J Rule 01792 516433 If the patient resides in Neath 01639 862881 or if resides in Port Talbot 01639 862475 REFERRAL CRITERIA Dementia Difficult behaviour Diagnostic difficulty Risk to self and others Abuse New, distressing or disabling psychotic symptoms Sleep disturbance, not responding to usual measures Depression Risk of harm to self or others Risk of self-neglect Adverse effect on physical health (including poor nutrition and fluid intake) Psychotic depression and more severe depression Compliance difficulties Diagnostic problems More complex management issues (i.e. resistive depression, discharge planning, etc) • Delirium • Difficult behaviour • aggression/agitation/anti-social/significant risk to others/wandering • Diagnostic difficulty • - aetiology/complicating other mental disorder Other referrals Alcohol/substance misuse, which is complicating a mental health problem Late onset schizophrenia Mania Organic personality change Acute paranoid psychosis Problematic abnormal reaction to physical ill health Mental Capacity Assessment For advice where there are uncertainties concerning capacity after the treatment team’s assessment

23. The future: The liaison mental health team for older people (Liaison MHSOP) Multidisciplinary Psychiatrist Psychiatric nurses O.T. Social worker Operates like a sector CMHT but the population is the general hospital

24. The Liaison MHSOP – how does it work? (1) Consultation & liaison i.e. proactive as well as reactive Referrals from general hospital staff, including A&E & MAU Rapid response Accurate, skilled assessment, monitoring, and treatment of mental disorder – particularly for the complex case Targets areas where morbidity is high i.e. rehabilitation facilities, orthopaedic wards, geriatric medical wards

25. The Liaison MHSOP– how does it work? (2) Advise and supervise on non-specialist screening and management Assessment of all cases of self-harm Development and introduction of treatment protocols and care pathways Educational: prevention, identification, and management Good communication Data for research and audit purposes

26. The Liaison Mental Health team for Older People– important links Community mental health teams for older people General adult liaison services Educational institutions General hospital stakeholders Patients and carers

27. Research Opportunities • Service evaluation • Liaison MHSOP • Integrated Liaison MHSOP & Community Care • Disorder specific outcome evaluation • Identification of mental disorder • Screening tools • Introduction and evaluation of training packages • Collaboration in other areas of general hospital-based research of mental disorder in physically morbid populations