The planning and organization of services for older adults
Pamela S. Melding
Introduction
When does an individual become an older adult? When they show signs of ageing? When they retire from work? When their health becomes frail? When they feel old? When society says they are old? Any of these indicators could define an ‘older person’ anywhere between 40 and 90 plus years! However, it was for statistical simplicity that many jurisdictions chose the chronological age of 65 to mark the change in status from mature adulthood to ‘older person’, mainly to establish an age for expected retirement and entitlement to certain benefits, including access to geriatric health services. When this arbitrary discriminator was instituted in the midtwentieth century, 70 years was a good lifespan for most people. However, over the past 50 years, life expectancy steadily increased and is currently advancing at 6 weeks per annum, boosting the overall number of adults over 65 years and, particularly the over 80 years cohort.(1) Increasing life expectancy, due to improved health care and lowering birth rates, is causing worldwide ‘population ageing’. This phenomenon will affect all health and mental health services in future years.
Already, health care resource and cost implications of population ageing for health services are enormous. Older adults occupy about two-thirds of general hospital medical, surgical, and orthopaedic beds; they are the greatest users of primary care and prescription medicines. Internationally, late-life illness takes up a considerable proportion of government or insurance funded health care budgets. As an example of the enormous costs involved, in 2003/2004, the United Kingdom’s NHS spent around 43 per cent (£16.471 billion) of its hospital and community health services budget on people over the age of 65, and the cost of community and residential care for older people was 44 per cent (£7.38 billion) of all social welfare budgets.(2) These figures will rise dramatically over the next decades.
Mental Health Services have been slow to anticipate that population ageing will also increase the need for psychiatric services for older people. In many areas of the world, services are scarce, sporadic, or sub-standard. Even in developed nations, there is considerable variation in availability from one area to another. In the past decade, practically all OECD countries have promoted policies of de-institutionalization and community-based care for the elderly, in response to rising cost pressures associated with population ageing, plus a requirement to improve satisfaction for increasingly knowledgeable and assertive consumers, by providing better quality in all health services for older adults, including mental health.(3)
The need for services for older adults
Epidemiology
Whilst most people aspire to longevity, it can be a mixed blessing. Living longer increases risk of developing chronic degenerative diseases of body and brain, which can precipitate mental illness, possibly for the first time in life. Psychiatry services for older adults see a full range of new and chronic psychiatric disorders. However, the commonest new threats to mental health in late life are affective disorders and dementia.(4) Healthy, community-dwelling older adults are generally resilient, with a prevalence of major depressive illness of about 3 per cent, but studies of people in residential care find significant depressive symptoms in 14-42 per cent,(5) and in populations over 80 years, about 40 per cent.(6) Depression occurs in 15 to 40 per cent of medical inpatients(7) and in approximately 35.9 per cent of patients in geriatric rehabilitation units.(8) Among the many aetiological contributors to mental health problems in late life, physical illness and poor health are major risk factors, particularly for depression,(9) the risk increasing with disability.(10) Co-morbid physical disorders can mask depression or impede management with psychotropic medications. Although, pure anxiety disorders reduce in late life to about 1 per cent in community-dwelling older adults, anxiety co-morbid with other psychiatric disorders, particularly depression, is more common at approximately 4 per cent. Older people with anxiety disorders are high users of health care resources and may initially present with physical symptoms.(11) Affective disorders are often multi-dimensional, their treatment complicated, and frequently, they need joint management with geriatric colleagues.
Dementia affects 5-7 per cent of people at 65 and 20 per cent of those over age 80 years. By 2040, the number of people with the disorder will double in the developed countries of Europe and North America.(12) Older adults with dementia are an exemplar of consumers who require multi-disciplinary management. While geriatricians manage the majority of patients, those who exhibit behavioural and psychological symptoms of dementia (BPSD), approximately one-third, do best with additional specialist psychiatric
expertise and management.(13) People with dementia can live for many years as their disorder progresses, requiring increasing levels of support from family, social workers, nurses, residential care providers, and other community health care workers in addition to psychiatry services.
expertise and management.(13) People with dementia can live for many years as their disorder progresses, requiring increasing levels of support from family, social workers, nurses, residential care providers, and other community health care workers in addition to psychiatry services.
Why are specialist services required?
As indicated above, mentally or physically frail older adults have complex needs and frequently require a broad, multi-disciplinary approach in several domains, (a domain being a broad area of specialist services i.e. mental health, geriatrics, primary care, social services, etc.). This can be difficult to achieve if provision is by disjointed services. In many places in the world, lack of specialist services requires generic mental health services to treat older adults with dementia, depression, or other mental illnesses but this practice risks medical needs being unnoticed, or unappreciated. Frail older adults can find the experience of inpatient care in units with younger psychotic patients frightening and unacceptable. There are also different perspectives for working-age and geriatric psychiatry. Many working-age services promote a recovery model whereas care of older adults focuses on maintaining function, improving quality of life and paying more attention to the spiritual, environmental, and social influences on mental health. In addition, there is greater need to involve the social and family network of mentally frail elderly people than there is for working-age adults. For older adults, specialist services, with close collaboration with geriatricians and other geriatric providers, are preferred for optimal management.
Principles of good service delivery for older adults
Optimal service delivery starts by establishing the principles that services wish to adopt. These should govern the ethos of service delivery. For the World Health Organization (WHO), the mnemonic CARITAS (Latin for Compassion) summarizes a global consensus on specific values required for good service delivery for psychiatry of old age.(14) These principles, championed over many years by many international pioneers of mental health services for older adults, assert that optimal services are:
Comprehensive
They take all aspects of the patient’s physical, psychological, and social needs and wishes into account i.e. are patient-centred.
Accessible
They minimize the geographical, cultural, financial, political, and linguistic obstacles to obtaining care.
Responsive
They act promptly and appropriately to a wide variety of patient needs.
Individualized
They focus on each person in her/his family and community context aiming, wherever possible, to maintain and support the person within her/his home environment.
Transdisciplinary
They optimize the contributions of people with a range of personal and professional skills and facilitate collaboration with voluntary and other agencies.
Accountable
They accept responsibility for assuring the quality of the service delivered, monitoring this in partnership with patients and their families. They are ethically and culturally sensitive.
Systemic
They work flexibly with all available services to ensure continuity of care.
Summarizing, good services provide patient-centred care with easy access to a comprehensive range of services delivered by multidisciplinary personnel working in a collaborative, responsive, respectful, and accountable way.
Patient-centred care
The UK National Frameworks for Older People(15) and most OECD health administrations promote patient-centered care as a major means of improving quality of services and consumer satisfaction. Whilst most health professionals believe that they already practice patient-centred care, many patients would not agree. Predominantly, health systems for older people, particularly hospital-based, are far from patient-centered, being mostly organized around clinician or administrative requirements rather than patient needs. Patients encounter rigid appointment times, lack of evening or night services, inflexible boundaries between departments, inconvenient visiting hours, limited or expensive parking, and silo’d funding streams. Access or contact processes are obscure or difficult, information is inadequate, multiple assessments take place, and poor coordination between providers leads to treatment omissions or errors. Notably, older adults and their caregivers consider having multiple referrals to different specialists or providers and frequently repeating the same history to be a waste of time and resources.(16)
Consumer appraisals of their experience of services often result in common themes. Many experience poor communication—provider to patient, provider to caregiver, and provider to provider. Another common topic is lack of flexibility in developing management plans capable of involving several domains and dimensions of care (a dimension is a subset of a specialist domain, i.e. depression, dementia, continence, or mobility). As many elderly people have difficulties with mobility, or live far from services, transportation is another major issue.
In contrast, patient-centered services emphasize smoothing the progress of the patient ‘journey’ through the health system, eliminating duplication, matching care plans to patient needs, and generally making a demanding experience easier for the patient and their family. Unsurprisingly, the concept is appealing to patients and families. Increasingly, consumers, and their advocates, want to contribute to service planning, delivery, and evaluation.(17) So, what do older people want from their health care providers? Older people value their independence and being involved in the decision-making for their own care plans. Most want to remain in their own homes for as long as possible, but if that is detrimental for them, they want the right to relinquish decision-making, in various degrees, to other parties such as family members or their clinicians. They expect providers to treat them as an individual, to preserve their dignity, and to elicit and respect their preferences. Above all, they wish to be appropriately informed.(18) These desires are appropriate to all health care delivery for older adults, not just mental health. As most of us hope to grow old, we can empathize
with these wishes. Perhaps we need to remember that in planning and organizing services for older adults, we are potentially designing them for ourselves. The quality of care required is what we would be happy with, if we ever become clients.
with these wishes. Perhaps we need to remember that in planning and organizing services for older adults, we are potentially designing them for ourselves. The quality of care required is what we would be happy with, if we ever become clients.
Comprehensive and integrated services
Patient-centered care is more achievable with comprehensive or integrated services. The terms comprehensive and integrated are not interchangeable. A comprehensive service is one with a full range of inpatient and community services available within the same domain. An integrated service is one with a single point of entry capable of providing care plans that incorporate interventions and support in multiple domains and specific dimensions of care. Integrated services are characterized by a single point of entry, case management, geriatric, psychogeriatric and social assessments, and have multi-disciplinary teams.(3) They should have a seamless joining together of the various components of service, encompassing ‘systemness’ without diminishing component part identities.(19) Integration of different organizations is much easier if there are common administrative processes and financial systems. However, many mental health organizations have reporting and funding structures separate from other older adults’ services (e.g. The Mental Health Trusts in the United Kingdom). Quasi-integration can be achieved by building effective functional links with a wide variety of health care professionals outside mental health e.g. primary care, geriatrics, acute medical and surgical care, social care, community health care, and non-clinical resources. For these collaborations to work, it is essential that bureaucratic processes enable easy transfer of funding and information across different entities and do not thwart clinicians’ efforts to implement care plans for patients.
Integrated services are potentially more efficient as they should reduce duplication of assessments or investigations and service gaps. Currently, the majority of well-established services for older adults provide comprehensive rather than integrated services,(20) the latter being more ideology than practice, although this might be slowly changing. Research indicates that integrated care can delay institutionalization, reduce costs, and has benefits in consumer satisfaction(3) but is insufficient, as yet, to demonstrate that integrated services are more effective in achieving better health outcomes.
(a) The place of the common geriatric assessment (CGA)
An important tool for assisting integration is the common geriatric assessment (CGA). Different disciplines all have their own styles and foci for assessment but, despite individual differences, it is useful to have some common information for all teams and multi-disciplinary groups, regardless of who takes the main responsibility for the patient.(21) Advocacy for the comprehensive geriatric assessment (CGA) covering all the main domains and dimensions of physical illness, mental health, disability, and social assessment, is increasing internationally, notwithstanding a lack of research on their effectiveness in improving health outcomes. They aim to save a patient from multiple repetitions of the same information.(16) To be useful, CGAs require personnel to work across professional and agency barriers, which can have benefits in creating relationships with allied colleagues, essential for developing integrated services. There needs to be agreement amongst the providers as to the applicability of the information required, agreed processes by which the CGA generates onward referral to the appropriate domains of care and procedures for updating and review. In some jurisdictions, (e.g. United Kingdom) CGAs or single assessment processes (SAPs) are mandatory for all older adults’ services, in others, i.e. New Zealand and Australia, they are being trialed with a view to future obligatory use. SAPs and CGAs vary in their comprehensiveness and can aim at different levels, e.g. screening, proactive assessment, primary care, or secondary care services. They provide useful background information common to a range of providers but are not a substitute for specialized clinical assessment.
(b) The ‘core business’ of mental health services for older adults
Irrespective of whether a mental health service for older adults is part of a comprehensive or integrated system, their ‘core business’ is the:
Diagnosis and management of new cases of mental illness arising in late life, often associated with the ageing process.
Treatment of mental illness complicating physical illness and disability.
Management of older adults with long-term mental illness complicated by ageing.
Education and support for caregivers of older adults with mental illness.
Most psychiatry for older adults is about the management of chronic illness and care, rather than cure, is usually the main priority. An adaptation of the 5As model for patient-centred chronic illness management(22) is useful to describe the ‘core tasks’ of patient-centered psychiatry of old age. They are:
Assessment of multiple care needs
Advice on diagnosis and options for management
Agreement with patient and caregiver on a care plan
Assistance with implementation of care plan
Assertive follow-up when needed
The ‘core areas of expertise’ for specialist services for older adults are the:
Treatment of affective and psychotic disorders in late life
Assessment of neurocognitive disorders and the management of the behavioural and psychological symptoms of dementia (BPSD)
Rehabilitation of long-standing, chronic psychiatric disorders in patients whose disorder is complicated by physical illness or ageing
Management of delirium in medically ill or complicating dementia
Liaison with families, caregivers, and community providers
Core components of psychogeriatric service delivery
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