The pioneers of specialist psychiatric services for old people were motivated by the increasing need for psychiatric services for the age group, consequent upon increased life expectancy, the growing knowledge base about psychiatric disorders among old people, and the success of geriatric medicine. The special needs of older people were not always recognized by the generic services. Diagnostic problems included the differential diagnosis of dementia, the association of apparent cognitive impairment with some cases of depressive illness, and the non-specific presentation of disease in old people. The multiple pathology suffered by old people led to a need for new patterns of multidisciplinary working and for close liaison with physicians in geriatric medicine and social services^1–3. As in the early days of geriatric medicine, assessment and treatment in the community were emphasized not only because of ‘blocked beds’ but also because a more realistic picture of the patient’s health problems usually emerged. More recently, advances in psychosocial care⁴, interest in the spiritual needs of old people⁵ and the advent of new classes of antidepressant, antipsychotic and antidementia drugs (discussed elsewhere in this volume) have all had their impact on the organization and delivery of psychiatric services.

One of the key theoretical issues for the future development of community services is likely to be the distinction between care and treatment. ‘Care’ is a word with many connotations. Some are positive but, in the medical world at least, some are negative. For example, ‘care’ is seen as what is provided when there is no possibility of effective treatment, as in the ‘prescription’ of ‘tender loving care’ for the terminally ill person. ‘Care’ tends to be relegated to untrained (although not necessarily unskilled) workers employed by social care agencies and commissioned by social services departments, whereas ‘treatment’ is the province of highly trained personnel employed by the Health Service. The move to ‘Care in the Community’ has served to reclassify older mentally ill people, especially those with dementia, as not needing medical treatment. Thus long-term care of people with severe dementia, once shared by psychogeriatric and geriatric services within the NHS, is now provided in private institutions and is ‘means tested’, reducing the burden on the state but increasing the burden on afflicted families.

This situation is further complicated by the tendency of some health planners to equate primary care with low cost and community care, and secondary care with high cost and hospital care. Old age psychiatry services straddle the hospital–community divide and provide essentially secondary services, largely in a community setting. The new term, ‘intermediate care’, describes well some of these community services, but some who use the term believe that community psychiatric nursing services should be part of ‘primary care’, when in old age they work most effectively as part of secondary community care. Certainly, with the increasing prevalence of dementia, it is essential that primary care services and general hospital services become more proficient in recognizing and managing these conditions appropriately.

Catchment Area and Comprehensiveness

Until recently, virtually all psychogeriatric services in the UK worked to a defined geographical catchment area, and the vast majority aimed to provide a comprehensive psychiatric service to all people over the age of 65 years^6,7. Many services are now also trying to provide for people with early-onset dementia, although often without any dedicated resources⁷. In some areas, managers are seeking to save money by closing specialist wards for old people with functional mental illness and diverting those who need inpatient care onto wards designed for working age adults. Some old age psychiatrists feel they are being pushed towards developing ‘dementia only’ services.

The Multidisciplinary Team

For some this is an outmoded concept, for others an ideal that cannot be obtained, but for many psychogeriatricians it is an essential context for all their endeavours. Most multidisciplinary teams for the elderly incorporate community nurses, a social worker, one or more occupational therapists, a physiotherapist and often a psychologist