The Case of Need forOPMH Liaison Services

John Holmes

Senior Lecturer in Liaison Psychiatry of Old Age

University of Leeds

To establish a convincing case of need:

• Evidence that mental health problems in older people are common in general hospitals

• Evidence that outcomes are adversely affected in this group

• Reasons why outcomes may be affected

• Solutions that address these reasons

Determining the prevalence

• Comprehensive search– 576 papers identified– 256 contained original data– 97 met appraisal criteria

How common is psychiatric illness in older people in general hospitals?

Diagnosis No. of studies

Total sample

Mean sample

size

Prevalence Mean prevalence

Depression 27 5173 192 5–53% 26%

Delirium 19 4818 254 7–61% 17%

Dementia 5 918 184 5–35% 13%

Cognitive impairment 22 10298 468 7–88% 30%

Schizophrenia 4 1147 287 1–8% 1%

Alcoholism 3 583 194 1–5% 4%

Total 61%

Some gaps in epidemiology in GH

• Self harm

• Somatisation

• Anxiety disorders

Self harm attendances in A&E

0

100

200

300

400

500

600

700

800

900

<15 15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

>74

Age (years)

110 of the 5038 attendances (2.2%) were by older people

University Hospitals of Leicester:

• Glenfield Hospital 570 beds• Leicester Royal Infirmary >1000 beds• Leicester General Hospital 680 beds• Total 2250• =1462 older people

– 380 with depression– 249 with delirium– 190 with dementia

Leeds Teaching Hospitals TrustDistribution of admissions 65 yrs

0

1000

2000

3000

4000

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6000

7000

8000

Geri Chest GenMed

Card Gastro Opth ENT GenSurg

Rheum Ortho Urol

So…

• There’s a lot of it about

• What about outcomes?– systematic review– 27 studies– Outcomes affected across the board

• LOS, mortality, institutionalisation, physical dependence, readmissions

Survival after hip fracture…

Time (days)

7505002500

Pro

por

tion

surv

ivin

g

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.1

0.0

Psych diagnosis

Depression (n-93)

Delirium (n=108)

Dementia (n=294)

Well (n=208)

(Nightingale et al 2001, Lancet, vol. 357, no. 9264, 1264-126)

As for length of stay…

Time (days)

2001901801701601501401301201101009080706050403020100

Pro

port

ion

in h

ospi

tal

1.0

.9

.8

.7

.6

.5

.4

.3

.2

.1

0.0

Diagnosis

Depression (n=93)

Delirium (n=108)

Dementia (n=294)

Well (n=208)

(Holmes & House 2000, Psychol Med vol. 30, 921-929)

To manage problems successfully we need:

– Accurate detection by general hospital staff– Optimal management by general hospital

staff• investigations• treatment• referral for specialist advice

Why are things so bad 2?

• We met with some general nurses:– To identify the attitudes, perceptions and

training needs of general nurses relating to older people with mental health problems.

– Data collection:• Focus groups with general nurses (CoE wards)

– Analysis• Grounded theory approach to develop themes

Theme 1• Older people with mental health

problems are identified through their behaviour.

• “I suppose when I think of people mentally, with mental health problems on an elderly ward, I’m thinking about people that get violent.”

• “It’s the dementias we see more of and they stand out more because they’re the one’s trying to get off the ward or mess with other people’s belongings or equipment on the ward.”

• “I think we all have it don’t we? The wandering patients, which is the biggest problem really . . “

• “Outbursts of aggression”

Theme 2

Physical care needs are prioritised over mental health needs •“you don’t die of confusion”•“you have to prioritise the life threatening conditions first.” •“that’s our problem on the ward, we prioritise the medical intervention, you know our focus, you know, hands on medical interventions.” •“if you’ve got 5 minutes, I don’t go and sit with a patient who I think might be getting more confused, to find out what the problem is, I think, ah, I’ve got 5 minutes, I am going to tidy up this bay because it’s a tip, because I don’t feel I have the skills to draw out from this patient.”

Theme 3  Nurses perceive themselves and medical staff as lacking the skills needed to recognise and manage mental health difficulties • “ And the root of the problem is basically our education, we don’t know enough about mental conditions for us to screen and identify and therefore treat, and that’s our problem, resources aren’t available for us to be able to do that.”•“And we don’t, we don’t know enough about psychiatric illnesses to pick up exactly what it is.”•“What sections what, who? I’ve walked round with the bleep, half thinking, please God, don’t let me have to go anywhere, cos I don’t know what I’m doing.” •“I did four weeks in a day hospital and then that was it. I played Bingo and listened to The Sound of Music, and did exercises and we threw a ball at each other.”

Theme 4General nurses believe older people with mental health difficulties do not get a good service in general hospitals. “In terms of managing somebody’s mental illness, we are doing them a disservice, and if it was a medical problem, you know, it wouldn’t be tolerated, but because it’s a mental health problem it is.”

“And the patients that are confused do get neglected, because you don’t give them the attention that you could give if you didn’t have your acutely unwell.”

“Like taking sticks off people, and moving the table away so they can’t even get their water; cos they throw it.”

Atkin et al. Int J Geriatr Psychiatry 2005; 20(11):1081-3.

… and our survey of old age psychiatrists revealed deficits in:

• Knowledge“How to engender some knowledge for the management of

psychiatry disorders in non psychiatry areas”

• Skills“Your questionnaire makes me aware of… …how much

mental disorder/psychopathology/unhappiness and distress is being missed or probably dealt with inappropriately”

• Attitudes“The general attitude is that anyone with a psychiatric label

should be put in a corner and ignored - almost universal on surgical and orthopaedic wards”

“Few referrals from surgery. I dread to think that they just over-sedate delirious patients with loads of haloperidol.”

An acute trust chief executive:

• Referral mechanisms SSD/Acute trusts/MHT do not address co-morbidity

• Organisational boundaries get in the way of appropriate service delivery

• Pressure on the acute system is not conducive to taking time and not rushing

• Systems too rigid to provide care in the appropriate place for each person

• Organisational cultures cause barriers more than a lack of resource

Why are things so bad?

• Different people interested in different outcomes:– Acute trusts– Mental health trusts– Primary care trusts– Users and carers

Back to our nurses…Some solutions identified:• Training wanted, to identify and manage

mental health difficulties.• Fast, direct access to a mental health

professional for patient management advice. • Improve referral system to psychiatry – faster

response, clear referral routes, nurses able to refer, improved follow up.

• Specialist wards for older people with complex needs.

So we need:

– To ensure that general hospital staff are equipped to deal with the basics of mental health care

• Training / education, ? supervision

and– To deliver specialist mental health care where

needs are more complex• Clinical service

and– Input into service design

• Stakeholder involvement

For adults of working age:

• Liaison psychiatry– Well established sub-speciality, Faculty of

the RCPsych– Specific policy drivers

• Health of the Nation• Self harm

– Input into many different specialities

• Ageist not to have the same for older people?

What about old age psychiatry services?

• Comprehensive– Generalist not specialist

• CMHTs, day hospitals, clinics

• Psychiatric wards– some general hospital based

• Community focused– Because that’s where people are

Potential models of general hospital care

• Standard sector model• Outreach from psychiatric wards• Enhanced sector model• Liaison nurse(s)• Liaison psychiatrist(s)• Shared care• Hospital mental health team

– (Clinical psychology)

Our survey

• Between Two Stools: Psychiatric services for older people in general hospitals– UK-wide– Old Age Psychiatrists

Services for general hospital patients 2002

0

50

100

150

200

Traditionalsector model

Enhancedsector model

Outreachfrom

psychiatricw ards

Liaisonpsychiatry

nurse

Liaisonpsychiatrist

Shared care Hospitalmental

health team

Other

Num

ber o

f res

pond

ents

But…

• General hospital referrals comprise 25% of the total referrals received by respondents

• Many respondents gave higher priority to community referrals– perceived as higher risk

• “The ones in hospital are safe and sound”

• 5% able to respond in the same working day• 68% able to respond in 5 or more working

days

And…

• 35% of respondents thought there were specialties who under-referred– in particular, orthopaedics, surgery, neurology

• Why?– Inability of staff to recognise psychiatric illness– Lack of awareness of psychiatric interventions

available– Need to discharge quickly, therefore don’t refer to

slow to respond services– Inappropriate referral to geriatricians rather than

psychiatric services

Barriers to service delivery and development

• Logistic– Travelling and parking– Workload

• Financial– No mechanism for measuring and charging– Limited resources– Domiciliary visit fees

• Organisational– Separate managerial arrangements of many trusts– Different priorities eg community– Lack of appreciation of the scale and impact of the problem

• Lack of good evidence for the impact• Culture and attitudes

What has changed?

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Traditional-sector

Enhanced-sector

Outreach MHwards

LiaisonPsychiatric

Nurse

LiaisonPsychiatric

Medical Team

HospitalMental Health

Team

Shared Care Other

Service model

Num

ber o

f hos

pita

lss

2002

2006

…and what do people want?

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Traditional-sector

Enhanced-sector

Outreach MHwards

LiaisonPsychiatric

Nurse

LiaisonPsychiatric

Medical Team

Hospital MentalHealth Team

Shared Care Other

Service model

Num

ber o

f hos

pita

ls

current

preferred

Non-elective LOS by PCTHRG T01 1999-2005

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West North-

West

South North-

East

East

Sta

y i

n D

ays

The Case of Need forOPMH Liaison Services

j.d.holmes@leeds.ac.uk

www.leeds.ac.uk/lpop

Liaison Psychiatry for Older People: Directions and Developments, Leeds, 17 May 2007