June
DEVELOPING AN IDEAL OLD AGE
SERVICE
Dr Peter J Connelly
Dr NilikaPerera
13
TABLE OF CONTENTS
INTRODUCTION
DEMENTIA CARE
1. Reducing stigma and raising awareness
5
2. Early identification and intervention in people with dementia
7
3. Intensive case management
10
4. Post diagnostic support
12
5. Community based support
14
6. People with dementia in care homes
17
7. Dementia in general hospitals
19
8. Young onset services
23
9. Late stage dementia
25
FUNCTIONAL AND OTHER SPECIALIST SERVICES
10. Functional illness services
29
11. Substance misuse in older people
36
12. Old age forensic services
38
13. Black and Minority Ethnic Elders
39
14. Academic Services
40
2
FOREWORD
The information in this paper has been provided either spontaneously or following specific requests
from the Old Age Faculty Executive. Neither the Faculty nor the College have evaluated these
services systematically and inclusion of a service description does not directly imply Faculty or
College endorsement of the service provided. However we do recognise that contributors
articulate forward-looking services and this is an ideal starting point for the future development of
Old Age Services. At present there are many gaps in the paper and we welcome any further
contributions. Any ideas, no matter how simple, esoteric, controversial or evidence based are
welcome. If you have a service model which works well for the people receiving it, it may well work
for others.
The dementia section of the paper is laid out in a general pattern of flow through a person’s stages
of illness, then some special situations such as general hospitals, care homes or young people,
and a section on academic input. The functional section, though separate, has obvious overlaps
with dementia services, but is less complete.
Please note that the separation of dementia and other forms of metal illness is to allow people to
easily identify a potential gap into which they can input a commentary on a particular service model
or extract a model already in the paper and implement it locally. It is not an endorsement of
separate “age-blind” services, or of old age psychiatry becoming dementia-only.
Anticipated reactions to this paper can be summarised as follows:
“My service does this already!” If so, please accept our apologies for not being included, but please
submit your service description to us. Colleagues will only benefit if you do so.
“We don’t have the resources to do this!” If this is the case then you will be able to demonstrate
that others are already delivering the service and this may help your case.
“It’s too much ‘blue sky’ and will never be funded!” Older people with mental illness are entitled to
the highest quality care and treatment we can provide. The fact that we have been unable to find a
service doing everything well suggests we must put pressure on policy-makers to improve matters.
This is the approach we have taken in our Guidance for Commissioners of Older People’s Mental
Health Services (to be published June 2013)
“I’m doing something novel and it’s not included!” Again, apologies, but submit something for
inclusion. We need to hear about it.
“This paper will be a great help to my plans for service development!” We hope so, and would
encourage contact with anyone who has provided information.
The paper is not finished. Perhaps it cannot be, because services are changing all the time.
However, we hope it provides a starting point from which genuinely novel, innovative and effective
services can be extended more widely across the UK, and will stimulate further strategic service
developments. Once more, thank you to all who have contributed. You should be proud of what
you have achieved.
PETER CONNELLY
Immediate Past Chair,
3
Faculty of Old Age Psychiatry,
Royal College of Psychiatrists.
4
INTRODUCTION
Later life psychiatry services commit themselves to providing excellent specialist care and services
to older age patients with a full range of functional and organic psychiatric disorders. The Old Age
Faculty of the Royal College of Psychiatrists recognises the importance and value of developing
services, looking at current practice and innovative care models to address the unique needs of
our patient group.
The timetable for implementation of national dementia strategies in Scotland and England ends in
2013 (*Wales published Feb 2012, no end date; NI published 8.11.2011). The focused four
strategies have been milestones in the development of dementia services. The purpose of this
paper is to consider a more aspirational type of service development with a view to influencing not
only the next round of dementia strategies from 2013 onwards, but also service development for
people with functional mental health problems. The paper reflects not only the equal weight the
Faculty gives to all aspects of older people’s mental health, as seen in the production of guides to
commissioners on services for people with dementia and those without, but the many fine
examples of people changing services in a highly pressured environment.
The paper does not set out to be prescriptive about what every service should look like. However
we recognise that although individual services often deliver excellent care in one part of the
spectrum offered to older people with mental health problems, it is much less common to find
services which deal equally well with all parts of the patient journey from symptom development to
end of life care and in all locations including the patient’s home, care home, general hospital and
mental hospital. The paper seeks to generate discussion and stimulate further ideas in the hope
that a service specification encompasses the full spectrum of service provision can be generated
within the next round of strategic development.
The Faculty is also aware of service changes which do not fit neatly into a patient pathway, but are
examples of change which may be of interest to readers. One example is described below.
SERVICE REDESIGN
Older adults mental health services in Central North West London Foundation trust recognised
some time ago that the criterion for access to services based on age was neither logical nor legal
and sought a new way to define the service. Following extensive consultation (including GPs,
commissioners, social service leads and Trust staff) they sought to revise the service criteria in a
way which capitalised on the skill set of their staff: managing dementia; managing psychiatric
disease with physical co-morbidity or frailty; and managing the psychological and social impacts of
ageing and dying.
Their revised criteria are:
* People of any age who have any primary cognitive disorder
* People who have mental disorders and who significant physical illness (e.g. stroke,
Parkinson's disease, severe Ischemic heart disease or COPD) or frailty. The definition of
significant illness is a matter of judgement - but any long-term illness which contributes to, or
complicates the management of, mental disorder could be considered significant.
* People around the age of 70 with social or psychological issues relating to ageing or
people approaching end-of-life
The service was renamed from "Old age psychiatry" to the more inclusive "Older people and
healthy ageing" These criteria were presented at the Royal College of Psychiatrists Old Age
Faculty Meeting in 2012.
Contact:James Warner j.warner@imperial.ac.uk
5
DEMENTIA CARE
1. REDUCING STIGMA AND RAISING AWARENESS
Background

Older people are more concerned about the possibility of developing dementia than they
are about cancer, heart disease or stroke.1,2

The longest gap in a patient journey is that between the onset of symptoms and presentation to
Primary Care.3

Even when a diagnosis is made there can be reluctance within Primary Care to disclose
this to the patient.4

98% of people on dementia registers in one service had their diagnosis made in Secondary
Care.
The changing demographics of the population mean that the number of people with dementia
will increase substantially over the next 20 years. However, although friends and relatives
have often raised the possibility of dementia to someone with late onset memory impairment,
people remain reluctant to approach their general practitioner when symptomatic. The
National Audit Office in England has reported that fewer than one third of general practitioners
regard themselves as confident in making a diagnosis of dementia with fewer still conducting
a diagnostic examination in a systematic fashion.
We seek to:

Work with agencies from the third sector including Help the Aged, Age Concern, Alzheimer
Scotland and the Dementia Services Development Centre to derive a package to help
increase community awareness of dementia.

Work with National Health Service Public Health Departments to target high-risk groups.

Work collaboratively to enhance the contribution made by stigma-reducing interventions to
ensure these are directed at older people with potential dementia.
Desired outcomes
Members of the public should understand that dementia is a common condition, and that it is not
an inevitable part of ageing;

They should be able to recognise the symptoms of dementia

They should understand that the earlier the diagnosis is made, the better

They should understand there are many positive things that can be done – as family
members, friends and professionals – to improve the quality of life of people with dementia
once diagnosed

They should recognize that the social environment is important, and that quality of life is as
related to the richness of interactions and relationships as it is to the extent of brain disease
6

They should realize that dementia is not an immediate death sentence – there is life to be
lived with the illness

They should understand that people with dementia make, and can continue to make, a
positive contribution to their communities

Stigma of dementia should be diminished so that people with dementia and their carers are
treated with dignity and respect, and do not experience discrimination, isolation, neglect or
abuse in their communities or in health and social care settings;
Service examples
1. Norfolk Clinical Academy for Dementia.
Norfolk & Waveney Mental Health NHS Foundation Trust has established the Norfolk Clinical
Academy for Dementia. In recognition of the projected increase in people suffering from
dementia and a likelihood of resources not keeping up with demand, the Academy seeks to train
and educate carers in other care settings, in order to expand capacity of the wider health
economy, improve quality of care provided and improve quality of life, both for patients and their
carers. It has already provided Dementia Awareness Training to over 1200 care staff, from the
acute as well as the independent sector, scattered throughout Norfolk.
Contact:
Hugo de Waal (dewaal@doctors.org.uk)
2. DH public awareness campaign
For more information on the DH public awareness campaign go to
http://www.nhs.uk/dementia/pages/dementia.aspx
References
1. Metlife foundation. (2011). "What America thinks". Available:
https://www.metlife.com/assets/cao/foundation/alzheimers-2011.pdf. Last accessed 31st
January 2013
2. yougov. (2012). Are you worried about dementia?. Available:
http://cdn.yougov.com/cumulus_uploads/document/xnbimbtb70/YG-ArchivesAlzheimersSoc-DementiaAwarenessWeek-220512.pdf. Last accessed 31st Jan 2013.
3. Alzheimer’s Society (2002). Feeling the pulse. A report for Alzheimer’s Awareness Week
2002. London
4. National audit office. (2007). Improving services and support for people with dementia.
Available:
http://www.nao.org.uk/publications/0607/support_for_people_with_dement.aspx. Last
accessed 31st January 2013.
7
2. EARLY IDENTIFICATION AND INTERVENTION IN PEOPLE WITH
DEMENTIA
Background

The number of people wanting to know their diagnosis of dementia is the same as those
who want to know a diagnosis of cancer.5, 6 7

Only 30% of people with dementia ever receive a diagnosis.4

This rate is half that of Sweden, France, Spain and Ireland.4

The proportion of GPs nationally who use a structured assessment of memory complaints
or who have confidence in making a diagnosis of dementia is falling

The HEAT target in Scotland supports a commitment to achieve improvements in the early
diagnosis and management of people with dementia. This achieved an increase in the
number of people on the Quality and Outcomes Framework (QOF) dementia register from
32000 in 2008/09 to 41,525 in 2011/12.8

People who take cholinesterase inhibitors have a significant delay in entry to a care home
compared to a matched population who do not take these drugs.9
Desired outcomes

Public and professional awareness and understanding of dementia to be improved

The benefits of timely diagnosis and care, the prevention of dementia should be promoted

Social exclusion and discrimination should be minimized

The system needs to have the capacity to see all those with dementia.
Service examples
1. Pre-diagnostic counselling, Sheffield
This model is taken from a description of the South Sheffield memory clinic. The clinic originally
saw people with a Mini Mental State Examination (MMSE) score between 25 and 30 in whom
dementia was suspected. Initially, this followed assessment by a Community Psychiatric Nurse
(CPN) and the memory clinic nurse visiting the patient at home to explain the nature of the
assessment and the ethos of the memory clinic, 2-3 days prior to attending the memory clinic.
This allowed discussion about the outcomes that may result from the clinic attendance. However
although pre-diagnostic counselling is still given, the CPN no longer visits in the community prior to
first attendance. This service has been expanded to cover the whole city.10
The contacts:
Jerry Seymour (jerry.seymour@rdash.nhs.net)
Clare Littlewood
Paul Boston (Paul.Boston@shsc.nhs.uk)
8
2.Open Access Memory Service, Perth and Kinross
In October 2010 an Open Access Memory Assessment Service was established in the
Strathmore area of Perth and Kinross (population >65 = 6000). Patients do not have to be
referred and have the options of being assessed during an open day or when the service has
visited their local health centre. In the first year of the service 230 people were assessed by
comparison to 68 referred for memory assessment by their GP over the same period. New
open access contacts account for 45% of all referrals to the Old Age Team in that period.
The service has a tiered approach with stage 1 and stage 2 being completed by nursing staff.
Stage 1: ten-minute low threshold cognitive assessment including scales for anxiety and
depression.
Stage 2: Those with potentially significant errors have more extensive evaluation including
input from relatives/carers.
Stage 3: People who appear to have cognitive impairment are assessed by a consultant
psychiatrist or senior trainee.
Of 230 initial attendees, 18 had a diagnosis of dementia and 21 a diagnosis of MCI. Of the GP
referrals 38 had a diagnosis of dementia and 5 MCI.
Compared to GP referrals open access patients were older, less intellectually and functionally
impaired and had less associated carer anxiety. A similar pattern was seen in comparing MCI
patients. Although at first sight case finding levels are low, they are as high as calculated using
EuroCoDe prevalence rates on the population of attendees. Less than a quarter had
discussed his or her symptoms with anyone else prior to attending. Satisfaction levels
amongst patients and carers were very high.
Comparison with published rates of detection in general practice suggests the basic
assessment is as good as GP judgement in picking up cognitive impairment but less good at
identifying those without impairment.
Since the patients with cognitive impairment presenting to the Open Access service are at an
earlier stage than those being referred from GPs, the service complements existing practice,
may enhance recognition of dementia and assists the service in meeting a key Dementia
Standard, namely, that all people with dementia are entitled to a diagnosis.
Contact:
Peter Connelly (peter.connelly@nhs.net)
3. Open access screening clinic Western New Forest
This open access screening clinic is run by a community psychiatric nurse (CPN) with a half
hour assessments of the patients. It has been running since 1999.
A sample of 100 cases showed half (53.5%) of attendees were reassured and discharged after
assessment, and 10% were recommended to attend again in 6 months time. In 28% of the
cases the GPs were advised to refer the attendee to the community mental health team
(CMHT) for further assessment. In all cases the referral was made by the GP.
Of those who were referred to the community mental health team, 96% received a diagnosis of
dementia (65.5% Alzheimer’s disease, 11.5% vascular dementia, In 19% of the cases the
notes were not specific about the subtype of dementia and only 4% of the cases the diagnosis
was inconclusive.
Contact:
Andy Barker (andy.barker@nhs.net)
9
4. Gnosall Clinic
The Gnosall Clinic model started in 2006 and provides close linkage between a consultant
psychiatrist and general practitioners within a health service managing a population of 8,000
people overall. In the model GPs or other clinicians are encourage to identify people with
possible dementia either through routine contact or when reviewing patients known to have
one or more vascular risk factors. Two questions are used initially “is the patient having trouble
concentrating and/or remembering things that have happened recently” and “when speaking
does the patient have more difficulty in finding the right words or tend to use the wrong words
more often than they used to”. Positive responses generate further testing, the clock drawing
test and the BASDEC cards to assess depression. A consultant psychiatrist sees patients
within the health centre and has immediate access to practice computerised records with in
depth multi-dimensional details of the patient’s previous and current health encounters and
treatment. Rapid feedback is given to the patients and practice staff. Where necessary
onwards referral can be made to the older peoples mental health team and if required a
specialised memory clinic although in practice these options are used only occasionally.
The clinic takes place on one session per month. The first 22 months, 41 patients were
assessed. The overall referral rate of 18 people per 1000 aged 65 and over per annum is well
in excess of that of published memory clinics.
Contact:
Prof Dave Jolley (dessjol@yahoo.co.uk)
References
5. H Miyata, M Takahashi, T Saito, H Tachimori, I Kai. (2005). Disclosure preferences
regarding cancer diagnosis and prognosis: to tell or not to tell? Journal of medical
ethics. 31 (8), 447-451.
6. Pinner, G. &Bouman, W. P. (2003). Attitudes of patients with mild dementia and their
carers towards disclosure of the diagnosis. International Psychogeriatrics. 15 (3), 279288.
7. Turnbull, Q., Wolf, A. M. & Holroyd, S. (2003). Attitudes of elderly subjects toward "truth
telling" for the diagnosis of Alzheimer's disease..Journal of Geriatric Psychiatry &
Neurology. 16 (2), 90-93.
8. The Scottish Government. (2012). HEAT standard. Available:
http://www.scotland.gov.uk/About/Performance/scotPerforms/partnerstories/NHSScotla
ndperformance/DementiaStandard. Last accessed 31st January 2013.
9. Rountree SD, Atri A, Lopez QL, Doodi RS. (2012). Effectiveness of antidementia drugs
in delaying Alzheimer disease progression. Alzheimers& dementia. S1552-5260 (12),
16-17
10. Sheffield health and social care trust. (2012). Memory services. Available:
http://www.shsc.nhs.uk/our-services/older-adults/dementia-services/memory-service.
Last accessed 31st January 2013
10
3. INTENSIVE CASE MANAGEMENT
Background

People with dementia who live alone have a twenty-fold increased risk of institutionalisation
by comparison with those who have a live-in carer.11

Evidence from Scandinavia (This study looked at patients with an average MMSE of 18)
and from Manchester shows that intensive case management of people with moderate
dementia delays admission to nursing home care.12

Evidence from United Kingdom (UK) of improved well being for the older people with a
diagnosis of dementia and carers with need reduction, improvements with aspects of daily
living and level of risk when receiving intensive care management support.13

Evidence from Australia suggests that the more intensive residential training program for
dementia carers has shown to be associated with increased patient survival at home and
decreased psychological morbidity in.14

Evidence from the United States (US) shows a correlation between earlier intensive input
and delayed entry to care by comparison to a population who did not receive intensive case
management.15

Many caregivers are not using support services, despite many reporting low levels of life
satisfaction and high levels of overload. Reasons for service non-use include lack of
knowledge of services, reluctance to use services and believing they did not need
services.16

Intense case management for patients with complex long-term conditions can contribute to
reduced hospital admissions and length of stay.17
Key features of this model include:

Early multidisciplinary assessment by all professionals likely to be involved in the care of
the patient with dementia and their carer.

Drawing up a comprehensive management plan in tandem with a patient with dementia and
their carer.
 Having small case loads in order to pay attention to fluctuating needs and risks; titrating
resources to needs

Appointment of a care navigator as a point of contact for the patient with dementia and their
carer as the illnesses progresses.

The development of an advanced care plan to look at future needs including potential
palliative care.

The introduction of a comprehensive risk assessment and management procedure to
ensure that only those at high risk are placed in institutional settings.
11
Service examples
No examples available at present.
A discussion paper on “Evaluating Active Case Management in Greater Manchester” is available at
http://www.pssru.ac.uk/pdf/MCpdfs/ACMGMfr.18
References
11. Benerjee S, Murray J, Foley B, Atkins L, Schneider J, Mann A. (2003). Predictors of
institutionalisation in people with dementia. Journal of neurology, neurosurgery and
psychiatry. 73 (9), 1315-1316
12. Elonieimi-Suklava U, Notkola IL, Hentinen M, Klvela SL, Sivenius J, Sulkava R. (2001).
Effects of supporting community-living demented patients and their caregivers: a
randomized trial. Journal of the American Geriatric Society. 49 (10), 1283-7.
13. Challis D, von Abendorff R, Brown P, Chesterman J, Hughes J. (2002). Care
management, dementia care and specialist mental health services: an evaluation.
International journal of geriatric psychiatry. 17 (4), 315-25
14. Brodaty H, Peters KE. (1991). Cost effectiveness of a training program for dementia
carers. International Psychogeriatrics. 3 (1), 11-22
15. Gaugler JE, Leach CR, Clay T, Newcomer RC. (2004). Predictors of nursing home
placement in African Americans with dementia. Journal of the American Geriatric
Society. 52 (3), 445-452.
16. Brodaty H, Thomson C, Thompson C, Fine M. (2005). Why caregivers of people with
dementia and memory loss don't use services. Geriatric psychiatry. 20 (6), 537-546
17. The Kings Fund. (2010). Avoiding hospital admissions. What does the research say?.
Available: http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-AdmissionsSarah-Purdy-December2010.pdf. Last accessed 31st January 2013
18. Challis D, Abell J, Reilly S, Hughes J, Berzins K, Brand C. (2008). Evaluating active
case management in Greater Manchester. Available:
http://www.pssru.ac.uk/pdf/MCpdfs/ACMGMfr.pdf. Last accessed 1st February 2013
12
4. POST DIAGNOSTIC SUPPORT
Background

Evidence from the US suggests that the level of stress acquired by caregivers in the early
stages of dementia may be the best predictor of a patient’s entry to institutional care. 19
At the point of diagnosis patients react very differently although shock and anger are common
early responses.
Although for some people the diagnosis provides an explanation for their symptoms, others
adjust poorly. The latter group may then become hard to engage in service planning and
delivery with increased carer stress.

Studies report a lack of specialist support particularly post-diagnosis.20

Major differences exist between patients' and carers' expectations following the diagnosis
disclosure of dementia and post diagnostic support services need to be tailored to address
this.21

Early tailored counseling and support may improve patients' and caregivers' opportunities
to adapt to the challenges of Alzheimer's disease and to maintain well-being.22
Desired outcomes

Structured post diagnostic counselling to appropriate patients and carers focussing on
o Understanding the illness
o Management of symptoms
o Planning for future: care and legal decisions
o Available community support

People with dementia and their carers to be provided with good-quality information on the
illness and on the services available – both at diagnosis and throughout the course of their
care.

Continuous support and advice to be provided for those diagnosed with dementia and their
carers.
13
Service examples
1. Primary Care Dementia Service
Norfolk & Waveney Mental Health NHS Foundation Trust was successful in a QIPP (the
Quality, Innovation, Productivity and Prevention (QIPP) agenda) bid to establish a Primary
Care Dementia Service, which has started work in the summer of 2011 and consists of 15
Primary Care Dementia Practitioners, covering most of Norfolk.
The objective is to meet the increasing demand faced by GPs with the increasing numbers of
people with dementia, by increasing the expertise in primary care through close liaison and
expert support.
The Primary Care Dementia Practitioners (PCDPs) are all qualified nursing staff, with a track
record of providing assessments and care to people with dementia.
PCDPs take referrals from primary care (but through a ‘single point of access’) and offer initial
assessments of people who are suspected to suffer from cognitive impairment. Additionally,
they take referrals (again: via the ‘single point of access’) from ‘community matrons’.
Community matrons work as generic community nurses in integrated-primary-care-teams,
which focus on patients with complex health needs, who are at risk of repeated admissions
particularly to the acute general hospitals, and require community-based case management.
In the many cases of older people with long-term physical conditions, where cognitive
impairment or established dementia is considered an important co-morbidity, these teams
refer to the PCDPs for further assessment and advice.
The Primary Care Dementia Service functions as a type of ‘brief intervention service’ and
limits its involvement: should a patient require longer term support then a referral will be made
to the Community mental health teams (CMHT). Equally: should more intensive support be
needed referral will be made to the Norfolk Dementia Intensive Support Team.
Contact:
Hugo de Waal (dewaal@doctors.org.uk)
References
19. Gaugler JE, Yu F, Krichbaum K, Wyman JF. (2009). Predictors of nursing home
admission for persons with dementia. Medical care. 47 (2), 191-8.
20. Bunn F, Goodman C, Sworn K, Rait G, Brayne C, Robinson L, McNeilly E, Lliffe S.
(2012). Psychosocial factors that shape patient and carer experiences of dementia
diagnosis and treatment: a systematic review of qualitative studies. PLoS medicine. 9
(10), e1001331
21. Kaniell-Miller O, Werner P, Aharon-Peretz J, Sinoff G, Eidelman S. (2012).
Expectations, experiences, and tensions in the memory clinic: the process of
diagnosis disclosure of dementia within a triad. International Psychogeriatrics. 12 (11),
1756-70
22. Sorensen LV, Waldorff F, Waldemar G. (2008). Early counselling and support for
patients with mild Alzheimer's disease and their caregivers: a qualitative study on
outcome. Aging & mental health.12 (4), 444-450.
14
5. COMMUNITY BASED SUPPORT
Background

Counseling and support preserved self rated health in vulnerable caregivers.23

Telephone support meets the caregivers need for information and education, assistance
required to navigate through the system, emotional support and caregiver support that is
convenient and hassle free.24

Ongoing access to ad hoc telephone support improves the health of caregivers.25

Predictors of nursing home placements are mainly based on underlying cognitive and/or
functional impairment, and associated lack of support and assistance in daily living.26

People who have regular contact with people with dementia do not have specialist training
in their needs.

Non pharmacological interventions involving family caregivers reduce neuropsychiatric
symptoms in community-dwelling persons with dementia and caregivers' adverse reactions
to neuropsychiatric symptoms.27
We seek to:

Implement the key recommendations of SIGN 86 and NICE 42.

Develop in particular carer-based interventions through the training, education and
supervision of informal carers throughout the course of a person’s illness.

Establish risk assessment and management procedures as part of intensive case
management of people with dementia.

Explore novel forms of respite such as home-from-home

Support the increased use of assistive technology. This must be backed up by a
sustainable bed model, which must encompass care home bed numbers.
Desired outcomes

All health and social care staff involved in the care of people with dementia to have the
skills needed to provide the best-quality care in the roles and in the settings where they
work.
15
Service examples
1. Later life home treatment service
Teeside (Tees, Esk and Wear valley NHS foundation trust) has an example of this. Details of
the mental health trust onhttp://www.tewv.nhs.uk.
Contact: details not available.
2. Crisis service
An All Age Crisis Service exists in Suffolk (Norfolf and Suffolk NHS Foundation Trust),
Manchester(Manchester Mental Health and Social care Trust) and Bolton (Greater Manchester
West Mental Health NHS Foundation Trust).
Many trusts are changing their Crisis teams to encompass all ages following the
implementation of the age-discrimination act.
Contact: details not available.
3. Intermediate care team
A 7-day service working as a Crisis/Home Intervention Team has been set up in Portsmouth.
Contact: details not available
4. Intensive support service
Norfolk & Waveney Mental Health NHS Foundation Trust has a team of just over 20 qualified
nurses and support workers, all with extensive experience of nursing people with dementia,
operational 7 days a week, from 8am till 10pm, so it is available from rising to bed time and
particularly when other services are not or less available.
The team can visit daily, up to twice a day for up to six weeks. Its overall aims and objectives
are:
1. To stabilise clinical challenging situations, improve quality of care and wellbeing
2. To avoid unnecessary admissions to secondary care or independent sector
3. To avoid breakdown of placements in independent sector
4. To facilitate discharge from acute general hospital wards as well as from the specialist
in-patient assessment unit
The team has been operational for just over a year and over that period in-patient occupancy
rates for the specialist dementia assessment unit dropped from approx 110% to 65%.
The in-reach function into the local acute general hospitals has only just started
Contact: details not available
16
5. Homecare
Somerset (Somerset Partnership NHS Foundation Trust) have “tenancy support workers” who
are people who will try to promote the independence of those with dementia in the community
by helping them with shopping and other activities of daily living rather than taking over the task
themselves.
This is following the re-ablement model.
Contact: No contact details.
6. Medication compliance service
A medication compliance service such as that available in Forth Valley may aid the stabilisation
of physical and mental problems at home.
Contact: No contact details
7. Live in carer service
Liverpool (Mersey Care NHS Trust) has developed a live-in carer service, which allows homebased respite to be provided to people with dementia.
Contact: No contact details
References
23. Mittelman MS, Roth DL, Clay OJ, Haley WE (2007). Preserving health of Alzheimer
caregivers: impact of a spouse caregiver intervention. American journal of geriatric
psychiatry. 15 (9), 780-9
24. Safil J, Ploeg J, Black ME. (2005). Seeking to understand telephone support for
dementia caregivers. Western journal of nursing research. 27 (6), 701-21.
25. Gougler JE, Roth DL, Hayley WE, Mittelman MS. (2008). Can counseling and support
reduce burden and depressive symptoms in caregivers of people with Alzheimer's
disease during the transition to institutionalization? Results from the New York University
ca. Journal of the American Geriatrics Society. 56 (3), 421-8
26. Luppa M, Luck T, Brähler E, König HH, Riedel-Heller SG. (2008). Prediction of
institutionalization in the elderly. A systematic review. Dementia and Geriatric cognitive
disorders. 26 (1), 65-78
27. Paolino N, O'Malley PG. (2013). Review: Nonpharmacologic caregiver interventions
improve dementia symptoms and caregiver reactions. Annals of internal medicine. 158
(4), JC4.
17
6. PEOPLE WITH DEMENTIA IN CARE HOMES
Background

Currently 40% of people who reach the age of 65 will enter a nursing home on at least one occasion.
Half of these will stay for more than one year.28

Dementia carries a five-fold risk of nursing home placement by comparison to a cognitively
intact age related population.29

In a care home the amount of non task-related face-to-face contact for an individual patient
may be as low as two minutes per shift.30

Lack of resources, especially care worker time and knowledge about managing challenging
behavior and dementia were judged to underlie potentially abusive consequences to
patients in care homes.31
There is a high rate of antipsychotic use in care home patients. The All Party Parliamentary
Group identified not only high use of these drugs but also a lack of staff training and minimal
face-to-face contact between staff and residents.
The latter report made five
recommendations: 32
 Dementia training should be mandatory for all care home staff
 Care homes must receive effective support from external services, including
GPs, community psychiatric nurses, psychologists and psychiatrists, which
should involve regular, pro-active visits to the care home.
 The use of antipsychotics for people with dementia must be included in
Incapacity training for all care home staff.
 Protocols for the prescribing, monitoring and review of antipsychotic medication
for people with dementia must be introduced.
 There should be compulsory regulation and audit of antipsychotic drugs for
people with dementia.
Desired outcomes

Quality of care in care homes to be improved for people with dementia.

Inappropriate use of antipsychotic drugs to be reduced.

Demonstrable improvement in the engagement of informal carers in the management of
people with dementia in care homes
Service examples
1. Joint clinics with GPs in care homes
A service in Camden and Islington has run clinics in care homes in association with GPs over
the last 5-6 years, attended by 8-10 nursing home staff of various backgrounds, four times
yearly over a morning. Findings of effectiveness of the service have been written33 with the
main outcome being a reduction in emergency referral, improved staff morale and improved
accessibility to advice for patients not attending the home clinics.
Contact: Dr Gianetta Rands at grands@doctors.org.uk.
18
2. Antipsychotic review
A service in Canterbury has managed to reduce or stop antipsychotic medication in 75% of
cases through a consultant led service working with local GPs in EMI residential homes in a
specific geographical area. A larger study of this work is underway.
Contact: Dr Deborah Connolly (dr.connolly@hmpt.nhs.uk)
3. Abuse in institutional settings
Although not specific to any service, a College Report (CR84) gives advice on a large number
of topics related to the abuse of patients, and very useful information to help recognise and
manage abuse when it is present.
Contact:
Sandra Evans (Sandra.Evans@eastlondon.nhs.uk)
References
28. Kleinjans, Kristin J. and Lee, Jinkook, The Link between Individual Expectations and
Savings: Do Nursing Home Expectations Matter? (April 24, 2006). University of
Aarhus Department of Economics Working Paper No. 2006-5. Available at SSRN:
http://ssrn.com/abstract=1147034 or http://dx.doi.org/10.2139/ssrn.1147034.
29. NHS Tayside. (2008). Tayside Older People's Strategic Framework. Available:
http://www.nhstayside.scot.nhs.uk/about_nhstay/commitees/01_nhs_tayside_board/bo
ard_meet/2008/20081113/docs_021479.pdf. Last accessed 1st of February.
30. Alzheimers Society. (2007). Home from home. Available:
http://alzheimers.org.uk/site/scripts/download_info.php?fileID=270. Last accessed 1st
February 2013.
31. Cooper C, Dow B, Hay S, Livingston D, Livingston G. (2013). Care workers' abusive
behavior to residents in care homes: a qualitative study of types of abuse, barriers,
and facilitators to good care and development of an instrument for reporting of abuse
anonymously. International Psychogeriatrics. 7 (1), 1-9.
32. All-Party Parliamentary Group on Dementia. (2008). Always a last resort Inquiry into
the prescription of antipsychotic drugs to people with dementia living in care
homes.Available: www.alzheimers.org.uk/site/scripts/download.php?fileID=322. Last
accessed 1st February 2013
33. Rands G, Okeowo A, Matthew-Bernanrd C, Kapfumvuti J, Skinner A. (2009). How
consultation liaison meetings improved staff knowledge, communication and care.
Nursing Times. 105 (42), 18-20.
19
7. DEMENTIA IN GENERAL HOSPITALS
Background

70% of acute hospital beds are occupied by people over 65.34Half of these have some
cognitive impairment.35

Cognitive impairment is not recognised regularly nor assessed systematically in in-patients,
nor reported to Primary or Secondary Care on discharge.35

People with dementia in general hospitals have longer lengths of stay, greater mortality and
increased risk of institutionalisation.36

Services for people with dementia in general hospitals lack clear leadership, an explicit care
pathway or preventative measures to reduce re-admission.36

There are also marked deficits in the knowledge and skills of general hospital staff who
care for people with dementia.36

Few general hospitals wards have staff trained in dementia care on their staffing
complement. There needs to be careful consideration of staffing levels which ensures that
skill mix, ratio and numbers of staff are adequate to support the complex needs and
numbers of people with dementia.37

It has been suggested that 70% of those with dementia in A&E will not have received a
formal diagnosis.38

People with dementia are more likely to be admitted to general hospitals than those of a
similar age without dementia. In part this relates to co-morbid problems e.g. nutrition,
infection, falling and in part due to the increased risk of delirium (acute confusion) at a
milder level of physical illness.

A recent Yorkshire and Humberside study found that 95% of acute hospital admissions of
people with a diagnosis of dementia only, or with a secondary admission of dementia, were
in an emergency, with over 60% being through A&E.39 Obviously some of these cases may
have significant medical problems. In Liverpool they are developing a specialist nursing
assessment service based in A&E with the intention of cutting the percentage of people
admitted to 20%.
Few hospitals are of dementia friendly design and the needs of people with dementia are not
met well.
The Royal College of Psychiatrists Report “Who Cares Wins” reveals, delirium and dementia
are under-recognised and under-managed in an acute hospital setting.
 For example, a study carried out in Perth showed that only 8% of people admitted to
a medical unit had a recorded diagnosis of dementia though another 26% were
identified as having some degree of intellectual impairment. Only 75% of these
patients had an intellectual assessment carried out and in less than a third of these
cases was the result reported to either a GP or a specialist Old Age Service.
20

Dementia is in the top three reasons for delayed discharge. However, rehabilitation
services and community liaison teams appear more focused on people with an MMSE
greater than 20.40 A parallel specialised service for those with scores under 20 is required.

The management of highly agitated people with delirium can be complex but often over-use
of antipsychotic medication or inappropriate treatment schedules leads to increased
confusion and prolonged length of stay. Proactive identification of established risk factors
is seldom done in a systematic way. Nor is delirium routinely managed using SHOPPING
principles (treat sensory impairment, hydrate, oxygenate, pain relief, peace and quiet,
investigation and treatment, no antipsychotics unless essential, go home early).

In cases where delirium does not resolve within four weeks or where dementia is present
there is an increased risk of re-admission to hospital and of admission to institutional
settings. Consequently, improved discharge procedures and more co-ordination of
aftercare is required to try to improve community based management and identify
potentially modifiable risk factors for re-admission.
The traditional model of liaison with general hospitals is now more than 25 years old. Though
popular, it does not meet the needs of the highly complex group of individuals with dementia
or delirium who are admitted to our acute hospitals. A variety of services to support people
with dementia in general hospitals exist. The most frequent model is of a psychiatric nursing
liaison service supported by a modest provision of consultant psychiatry sessions for complex
management cases.
Desired outcomes

Quality of care in general hospitals to be improved for people with dementia.

Develop a comprehensive brain care service in each general hospital, with a remit to
include community hospitals as appropriate.

Proactively identify people with delirium and dementia on or close to the point of admission.

Proactively identify risk factors for people who might develop delirium and manage people
with delirium using recommended guidelines.

Develop psychological service provision.

Provide an interface with community services including the transitional care of people with
dementia discharged from general hospitals and the management of risk associated with
re-admission.

Consider the necessity for a small number of joint care beds on acute hospital sites comanaged by Medicine for the Elderly and Old Age Psychiatry.
21
Service examples
1. Liaison services
No one has come forward with an example of a genuinely pro-active service although high
quality liaison has been described in Leeds, Liverpool, Manchester and elsewhere.
Leeds and Liverpool
Leeds and Liverpool services can demonstrate a reduction in acute bed days associated with
their involvement. However, neither service proactively identifies people with dementia or
delirium.
A pilot study in Liverpool demonstrated that proactive nurse identification brought forward
referral to specialist services by a mean of 12 days and reduced length of stay of people with
dementia by almost two thirds. Unfortunately this pilot was not funded on completion.
Contact:
Liverpool – Dr Dave Anderson
Leeds – Dr John Holmes
Grampian
Grampian (NHS Grampian) have well-established plans to provide for older people a service
similar in scale to that for younger adults.
Somerset
n Somerset (Somerset Partnership NHS Trust) a community based team providein-reach
services to community hospitals seeking to pro-actively identify people admitted to community
hospitals with dementia before a crisis arises. This service is involved in discharge planning
and brief aftercare of those discharged. There are similarities to transitional care in this
respect.
Sheffield
In Sheffield they are attempting the redesign of urgent care responses for people with delirium,
falling and transient ischaemic attack. The intention is to tackle mental health needs rapidly to
attempt to reduce the length of stay. Their strategy quotes the average length of stay of people
with dementia as 67 days by comparison to 9 days for people who are cognitively intact.
They also have an accelerated dementia discharge team based in general hospitals. This
group is involved in discharge planning at an early stage of admission and have a direct role in
co-ordinating community care post-discharge.
2. Healthcare assistant training
A package developed in Scotland and marketed through the Dementia Services Development
in Scotland has now been taken up by a wide number of hospital services. The purpose is to
provide training of ward based healthcare assistants to improve their ability to manage people
with dementia. This package is available to HCAs in any environment.
Contact: Shirley Law at Dementia Services Development Centre, Stirling.
22
3. Specialist nursing assessment service based in A&E
Liverpool has a nurse led service based in A&E with the aim of reducing admissions of patients
presenting with dementia to A&E. The service aims to reduce the admissions to 20% of
patients presenting with dementia.
Contact: not available.
4. Rapid assessment investigation and discharge (RAID)
41
The Rapid Assessment, Interface and Discharge (RAID) model is a unique service offering a
comprehensive range of mental health specialities within one multidisciplinary team, so that all
patients over the age of sixteen can be assessed and treated, signposted or referred
appropriately regardless of age, address, presenting complaint, time of presentation or severity.
This service has received accreditation from the Psychiatric Liaison Accreditation Network
(PLAN) (Royal College of Psychiatrists) and won the Health Service Journal (HSJ) award for
innovation in mental health (2010).
RAID aimed to see all accident and emergency referrals within 1 hour and all ward referrals
within 24 hours. Data collected illustrated that RAID met the 1-hour target in the majority of
cases and only missed this target in 7% of cases. RAID responded to ward referrals within 24
hours in 84% of cases. Data was independently collected and analysed regarding cost savings
and focused on three areas: reduced length of stay, reduced re-admissions and admission
avoidance at the point of the medical assessment unit (MAU). RAIDs own evaluation estimated
that RAID saved between 42-64 beds every day. Most of the savings came out of the older
adults wards. London school of Economics (LSE) carried out an independent review, which
concluded that: RAID has saved at least 44 beds/day, most of it came from older adults wards;
cost / return ratio was £1:4; the team improved quality and response time. Saving to social care
cost was estimated to be £60,000/week through increasing the number of older people being
discharged back to their own home rather than to residential care. The RAID model has shown
benefits in three areas of service delivery, demonstrating high levels of staff and patients
satisfaction, quality improvement, rapid response time and huge cost savings, whilst also
responding to referrals of a complex nature for patients of all ages.
Contact:
George Tadros: george.tadros@nhs.net
23
References
34. Department of Health. (2001). National Service Framework for Older People. Available:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/dig
italasset/dh_4071283.pdf. Last accessed 1st of February 2013.
35. Royal College of Psychiatrists. (2005). Who cares wins. Available:
http://www.rcpsych.ac.uk/pdf/whocareswins.pdf. Last accessed 1st February 2013
36. Department of Health. (2009). Living well with dementia: A National Dementia Strategy.
Available:http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/docu
ments/digitalasset/dh_094051.pdf. Last accessed 1st of February 2013
37. Royal College of Nursing. (2013). Dementia: Commitment to the care of people with
dementia in hospital settings. Available:
http://www.rcn.org.uk/__data/assets/pdf_file/0011/480269/004235.pdf. Last accessed 2nd
February 2013.
38. Department of Health. (2007). Urgent Care Pathways for Older People with Complex
Needs. Available:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/dig
italasset/dh_080136.pdf. Last accessed 1st of February 2013.
39. NHS East of England. (2010). Services to people with dementia and acute care: dementia
QIPP programme. Available: www.eoe.nhs.uk/downloadFile.php. Last accessed 1st
February 2013.
40. Mary Marshall (2005). Perspectives On Rehabilitation And Dementia. London: Jessica
kingsley. 138-139.
41. George Tadros, Rafik Salama, Paul Kingston, Nageen Mustafa, Eliza Johnson, Rachel
Pannell, Mahnaz Hashmi. The impact of an integrated rapid response psychiatric liaison
team on quality improvement and cost savings: The Birmingham RAID Model”. The
Psychiatrist, Jan, 2013; 37 (1), 4-11.
24
8. YOUNG ONSET SERVICES
Background

There are few dedicated services for younger people in the UK.42

Of these, diagnostic services are the most frequently provided.42

Voluntary sector support is the second most common service.42

Employment implications for young people with dementia can be severe.

Many patients are referred to neurology or adult psychiatry services. The coordination of
care and management in collaboration with other specialties, particularly neurology,
remains a crucial factor 43

Referrals to neurology services tended to be for diagnostic purposes, whereas referrals to
old age psychiatry were for other reasons, including behavioural assessment and long-term
management.44

The perceived need of younger people with dementia and their carers is for specialist ageappropriate services that are responsive to the different needs of a younger age-group.45

Primary progressive dementia in people under 65 is much less common than in the over
65s. Estimates vary, but the prevalence estimated by Harvey and colleagues at 54 per
100,000 between the ages of 30 and 65 and 98 per 100 000 between the ages of 45 and
65 years is not atypical. 46

The geography of many areas mitigates against the development of central services for this
group other than in an urban centre.

Services for younger people with dementia are often overlooked in mental health strategies
and older peoples strategies. It is important that this group have high quality service
provision.
Service examples
1. Old Age Faculty young onset forum
There were 58 responses to a Freedom of Information request regarding Young Onset
Dementia Service. As a result, the Faculty have set up a web based forum
(http://83.138.143.74/yods1/yaf_rules.aspx). Forum members will be invited to contribute a brief
description of their service and their ideas for service development.
One key task of forum members will be to update the College Report on Young Onset Dementia
Services which is overdue for review.
Contact:
Kitti Kottasz on kkottasz@rcpsych.ac.uk.
25
2. Huntington’s Disease service
There is a multidisciplinary Huntington’s Disease clinic for the Peninsula with a neurologist,
neuropsychologist, HDA advisor, genetics nurse and a nurse from HD specialist care
organisation in Launceston that hosts the clinic, with an average of 10 new pts and 10 followups a year.
This clinic has been run by 2 Trusts - mental health and acute - and they have been in
dialogue with commissioners from the 4 Primary Care Trusts (PCTs) in the Peninsula .The
service has been commissioned since April 2011, including a nurse outreach team from the
specialist provider.
Contact: Stephen Pearson, Clinical Lead
3. Psycho-educational services
In Berkshire there is a monthly evening YPWD psycho-education course for carers and a
parallel, adapted, course for patients. This has now been running for 3 years attended by
around 25 - 30 people. The key to it is having an exit strategy, which the educational focus
allows, and running the parallel patient group which is viewed as meaningful activity rather
than offering a sitting service. A website has been created www.ypwd.info
Contact: Jacqui Hussey on Jacqui.Hussey@berkshire.nhs.uk.
References
42. Connelly P, “Freedom of Information request survey of Young Onset Dementia
Services”. Faculty of Old age psychiatry. Royal college of psychiatrists.
43. Royal College of Psychiatrists. (2006). Services for younger people with Alzheimer’s
disease and other dementias. Available: the perceived need of younger people with
dementia and their carers is also for specialist age-appropriate services that are
responsive to the different needs of a younger age-group. The Alzheimer’s S. Last
accessed 2nd February 2013
44. Allen, H. & Baldwin, B. (1995) The referral, investigation and diagnosis of pre-senile
dementia: two services compared. International Journal of Geriatric Psychiatry, 10,
185–190.
45. Alzheimer’s Society (2001) Younger People with Dementia: A Guide to Service
Development and Provision. London: Alzheimer’s Society.
46. Harvey RJ, Skelton-Robinson M, Rossor MN.The prevalence and causes of dementia
in people under the age of 65 years. (2003). J NeurolNeurosurg Psychiatry. 74 (9),
1206-9
26
9. LATE STAGE DEMENTIA
Background
Palliative (or supportive) care

The progression of dementia towards the terminal phase is something which is traditionally
thought of as time when psychiatric needs reduce and fade while physical needs increase.

While it is true that physical dependency does increase, it is clear that psychiatric need, and
the need to manage distress persists through to the end of life in many people with
dementia.

Better palliative care for older people with dementia, but also more generally, is advocated
in a number of national documents or strategies.36,47,48,

The benefits of partnership between those who specialize in palliative care and those who
work in dementia care has also been acknowledged.49
Palliative (or supportive) care should be broadly understood to imply holistic biopsychosocial
and spiritual care from the time of diagnosis until death and beyond.50
The practice of specialist palliative care should sharpen the focus of dementia care in certain
areas, with implications for the practice of old age psychiatry more generally.
Palliative care for dementia is often poorly planned and co-ordinated. 51
The palliative care needs of people with dementia differ from existing groups for whom
specialist palliative services are provided.
 The declining condition of people with dementia lasts much longer than those with
cancer and is more continuous than those with organ specific disease.
 In addition to the management of pain, managing nutritional needs and managing
distress can prove more difficult than in other palliative areas.
Advance care planning can be of assistance in setting up palliative services tailored to the
needs of individuals. The Gold Standards Framework may help improve service delivery.

Palliative interventions have a variety of objectives:50
o to screen for and manage cognitive impairment
o to avoid unnecessary hospitalization
o to avoid unnecessary treatments (e.g. artificial feeding)
o to provide symptomatic treatment (e.g. of pain); to provide appropriate spiritual care.

Close working relations with colleagues in specialist palliative care is likely to encourage
and facilitate discussion of more complex cases regarding difficult treatment decisions
about swallowing, infections, pain, possible malignancies or other acute or sub-acute
events, contractures or seizures and so on.
o These patients may occasionally, warrant admission to a hospice.
27


Care homes may require specialist multidisciplinary teams, who not only deal in a reactive
way with problems, but also proactively seek ways to improve the palliative experience of
residents.
This might involve encouraging the care home staff to screen for symptoms such as pain
(perhaps using suitable assessment tools), to look for other psychiatric conditions such as
depression,

Specialist input will encourage care home staff to
o
o
o
o
engage with family and close friends in care planning
think of ‘ceilings of care’ (i.e. to avoid unnecessary hospital admissions)
minimise behaviour that might be found challenging (e.g. by making sure that the
needs of the person are fully understood in the context of life histories),
provide family and other close carers with emotional support through the course of
the illness and beyond in bereavement.
An alternative is that some of this work could be undertaken by primary care (GPs and district
nurses).
Another alternative is that palliative care nurse working into several homes could undertake
some of the work.
The Gold Standards Framework would provide a suitable basis for care.52.
.

Given the terminal nature of dementia and the threat that it poses to the integrity of the
standing of the individual as a person, spiritual issues (broadly conceived) can emerge.
Teams, in whatever setting, need to be open to discussion of these issues and supported
by those who are able to pursue such discussions further (i.e. chaplains representing a
multitude of faiths).
o This also draws attention to another requirement, which is that suitable
bereavement services need to be in place, recognizing that grief may anticipate, as
well as follow, death from dementia.
Contact: Prof Julian Hughes (julian.hughes@newcastle.ac.uk
Desired outcomes

Develop advance care planning for people with dementia in association with the intensive
case management model.

Develop services to provide specialist palliative care for people with dementia in the
community and in care homes.
28
Service examples
1. Home based advanced dementia service
Greenwich advanced dementia service
The Greenwich Advanced dementia service has looked after about 130 people with advanced
dementia at home and experience shows that about 75% can die well at home if supported.
Key needs include ongoing management of distress and ongoing adjustment of anti-psychotic
medicines etc.
The service saved around £2.5 million for an investment of about £200,000
The Westminister dementia voice project
The Westminster Dementia voice project is a OPMH based and worked well, saving £279,000
for the cost of one band 7 registered mental health nurse (RMN).
Contact:
Dr Adrian Treloar. (Adrian.Treloar@oxleas.nhs.uk)
The Croydon project
The Croydon project is hospice based and enables many people to die at home or in care
homes. Again this project shows good cost efficacy.
29
References
47. NICE-SCIE. (2006). Dementia: Supporting People with Dementia and their Carers
in Health and Social Care (NICE Clinical Guideline 42). Available:
http://www.scie.org.uk/publications/misc/dementia/dementia-fullguideline.pdf. Last
accessed 2nd February 2013.
48. Department of Health. (2008). End of life strategy. Available:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAn
dGuidance/DH_086277. Last accessed 2nd February 2013.
49. The National Council for Palliative Care. (2009). Power of Partnerships: Palliative
Care and Dementia,. Available:
http://shop.ncpc.org.uk/public/shop/default.aspx?Category=Publications&Page=3.
Last accessed 3rd February 2013
50. Hughes JC, Robinson L, Volicer, L. (2005). Specialist palliative care in dementia.
British Medical Journal. 330 (7482), 57-58
51. Lloyd-Williams M. (1996). An audit of palliative care in dementia. European Journal
of Cancer Care. 5 (1), 53-55.
52. The National GSF Centre. (2012). Improving care for all people near the end of life
provided by frontline generalist staff in any setting. . Available:
http://www.goldstandardsframework.org.uk/. Last accessed 3rd February 2013
30
FUNCTIONAL AND OTHER SPECIALIST SERVICES
10. FUNCTIONAL ILLNESS SERVICES
.
Background

Mental health problems increase with age
o Depression affects 1 in 5 older people living in the community and 2 in 5 living in
care homes.53
o Highest prevalence of depression is found in those over 75.54

Depression affects 10% to 15% of people above the age of 65 but recognition rates
are poor.55When recognised, fewer than half can expect appropriate pharmacological
treatment. Only one third of older people with depression discuss their symptoms with their
general practitioner and less than half of these will receive adequate treatment.56

Older people comprise about 25% of all UK suicides, and there is a much stronger
association between self-harm or completed suicide and mental health problems in old age
than in adults of working age.57

Twenty per cent of people over 85 will experience at least one psychotic symptom. 55,58
Late onset schizophrenia-like psychosis has the longest latency between onset of
symptoms and presentation to psychiatric services of any serious mental illness. These
patients are extremely socially isolated.
A key principle in the provision of services is that older people are as entitled as any other
group in society to high quality services delivered timeously and comprehensively by people
with the greatest expertise in that area.
Parallels can be drawn with Child and Adolescent Services where the needs of younger
people are recognised as being substantially different from other population groups.
For some groups e.g. prisoners, services have to be tailored to the location and life
circumstances of the individual.
Even where services are well integrated there is no expectation that every member of the
team has equivalent or interchangeable skills.
However services are configured, older people should be treated by those with the greatest
expertise in the aspect of treatment they require at the time
Models of care for younger adults may not meet the requirements of older people and while
age should not define an individual’s need it can provide a proxy for a set of physical and
mental health needs and a psychosocial context that is appropriately distinctive
31
Self help
Older people as a group do not have the same spectrum of social outlets as younger people and
many third sector agencies do not provide age related input across the age spectrum.
Older people should have access to self help including tailored computer based models and
information appropriate to their age, educational and cognitive level.
The Age UK “ Down but Not Out “ campaign provides materials and training to:59

Encourage older people with depression to seek help

Ensure older people with depression are correctly diagnosed

Ensure older people with depression get the treatment they need
Programmes that enable older people to be involved in planning and delivering activities are most
likely to be effective. Studies have shown that high social support beforehand during, adversityincreased resilience by 40-60% compared with those with low social support.60
Psychological services
It is important to remember that “the provision of psychological therapies is a multi professional
endeavour”.61 It may involve psychologists, psychiatrists, nurses, counsellors, social workers and
others who have undertaken appropriate training in specific models of psychological intervention
There is good evidence that the response rate to psychological input amongst older people is as
good as those of younger adults.62The spectrum of psychological service provision at all tiers
needs to reflect this.
Research indicates a under diagnosis and/or under treatment of depression in older people.63
Many older people with depressive symptoms are in contact with general community services;
usually primary care or social care workers, and half had been to hospital outpatients in the
previous six months. However, their rate of contact with specialist mental health workers was low.
Out patient services
The majority of people in contact with Older Peoples Mental Health Services will have one or more
outpatient appointments. These services need to be accessible and in some cases delivered in
the patient’s normal residence. Moderate antidepressant efficacy along with slower response time
than in younger people means patients remain in contact with services for longer.64
Outpatient services need to be backed up by robust community based provision e.g. community
psychiatric nurse and where appropriate allow for a joint pharmacological and psychological
approach.
Community based services
Many older people will have very chronic illnesses, which continue to impair their day-to-day
function and quality of life despite considerable symptom resolution.62
32
Existing measures of recovery are heavily weighted towards the expectations of younger adults. A
recovery based provision for older people is essential with individualised goal attainment targets
becoming the norm.
A multi-agency approach is key to identifying and intervening early in high-risk situations where
there are vulnerable people and un-supported carers under high levels of stress
It is essential for Older People’s teams to be able to work in an integrated way that brings together
primary and secondary health, social care and other relevant agencies.62
The teams are responsible for contributing to the Single Assessment Process and the
management of the care plan, including coordinating the input of the wider care network. The
specialist role and function of the CMHT will enable the appropriate specialised mental health input
at each stage of the Care continuum.
The Department of Health (DoH) Policy Guidance on CMHTs, although primarily discussing
working age services, suggested CMHTs should be able to:65
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Provide support and advice to primary care services
Establish effective liaison with referring agents
Provide prompt and expert assessment of mental health problems
Provide effective, evidence based treatments to reduce and shorten
distress and suffering
Reduce the stigma associated with mental health care.
Ensure that care is delivered in the least restrictive and disruptive manner
possible.
Stabilise social functioning and protect community tenure.
Ensure that inappropriate or unnecessary treatments are avoided
Establish a detailed understanding of all local resources relevant to support
of individuals with mental health problems and promote effective
interagency working
Assist patients and carers in accessing such support, both to reduce
distress but also to maximise personal development and fulfilment
Provide advice and support to service users, families and carers
Gain a detailed understanding of local population needs
Provide a culturally competent service
Crisis resolution and home treatment team
This is an extremely contentious area in which there is evidence of both direct and indirect age
discrimination.Crisis resolution teams has been associated with reductions in admissions.64Gradual
changes are being made in mental health trusts to make crisis and home treatment teams all age
inclusive services.
Crises amongst older people arise for different reasons than in working age adults and intensive
support may be required for longer, particularly where a person is living alone. Service
configuration needs to be able to respond in these areas.66
33
Service examples
1. Home Treatment Team. St Charles Hospital, Central North West London
Foundation Trust
A Home Treatment team (HTT) was developed to provide intensive management for older
people with severe functional mental illness or dementia who would otherwise have been
admitted to hospital. The team includes nurses, social workers, an occupational therapist, a
psychologist and an administrator. The team operates seven days a week between 8 am and 8
pm, combined with a 24-hour telephone advice service.
The impact of this team was evaluated over three years. Admissions to the inpatient units fell by
over 50% in the first two years. Length of stay (combining inpatient and HTT data) fell from 71
days in Year 1 to 35 days in Year 3. The number of people being discharged to residential care
(having been admitted from home) fell from 10% in Year 1 to 3% in Year 3.
Contact
James Warner: j.warner@imperial.ac.uk
In patients
Over 65s make up 15‐18% of A&E admissions.67In comparison to working age patients, later life
patients are slightly less likely to be detained under a civil section of the Mental Health Act, far less
likely to be detained under a criminal section of the Mental Health Act, less likely to have co-morbid
substance misuse or personality disorder, but more likely to have significant physical co-morbidity
and some degree of cognitive impairment.68 Their length of stay is likely to be longer as a
consequence.68. The National Audit of Violence in mental health in-patient services found higher
rates in wards for older people and the highest on wards for people with dementia.69
The needs of the two groups i.e. younger and older adults are clearly different.70
Many Older Peoples Services started by removing older adults from “all age” wards because their
needs were overlooked. A return to all age wards is unlikely to benefit older people.
Interfaces
Two keys principles apply:
1. There should be no sudden transition across an interface e.g. if a service has an age
related boundary then preparation should be made for transfer to ensure that the patient’s
family and carers are not suddenly exposed to an entirely new group of professionals. This
is particularly important when the patient will have less support available from the new
service than from their existing service.
2. Artificial boundaries should not be created where none exist currently e.g. in an “age
inclusive functional service” provision should not be determined by the patient’s current
MMSE or other measure of cognition. Inter-rater variation is well recognised with this
34
instrument and scores can fluctuate quite considerably. Having service changes based on
this is inappropriate.
Service overlap and conjoint management
The separation of dementia and functional services for older people is unhelpful and described in
the National Dementia Strategy as a “false dichotomy”.68
A number of people with mental health problems will not be suitable for management by a single
mental health service. Arrangements for conjoint management will be required.
In addition there will be some people for whom current service provision will not be the most
appropriate e.g. a patient under 65 with chronic and severe mental illness who has significant
cognitive impairment or a highly functioning 70 year old who develops a catastrophic depressive
illness in response to bereavement. Adequate arrangements need to be in place to ensure that
appropriate services can be accessed.69
References
53. Adults In Later Life with Mental Health Problems, Mental Health Foundation quoting
Psychiatry in the Elderly, 3rd edition, Oxford University Press, 2002
54. The kings Fund. (2008). Paying the price. Available:
http://www.kingsfund.org.uk/sites/files/kf/Paying-the-Price-the-cost-of-mental-healthcare-England-2026-McCrone-Dhanasiri-Patel-Knapp-Lawton-Smith-Kings-Fund-May2008_0.pdf. Last accessed 3rd February 2013.
55. Royal College of Psychiatrists. (2009). Royal College of Psychiatrists Consultation
Response. Available:
http://www.rcpsych.ac.uk/pdf/Response%20to%20Age%20Discrimination%20Review.p
df. Last accessed 3rd March 2013.
56. Chew-Graham C, Baldwin R, Burns A. (2004). Treating depression in later life. British
Medical Journal. 329 (7459), 181-2.
57. Royal College of Emergency Medicine. (2011). QUALITY CARE FOR OLDER PEOPLE
WITH URGENT & EMERGENCY CARE NEEDS. silver book. Available:
http://www2.le.ac.uk/departments/cardiovascular-sciences/people/conroy/docs/thesilver-book-subsections/SILVER_BOOK_FINAL_CLINICAL.pdf. Last accessed 1st
March 2013.
58. Targum SD. (2001). Treating Psychotic Symptoms in Elderly Patients. Journal of
clinical psychiatry. 3 (4), 156–163.
59. Age UK. (2012). Depression in later life: Down but not out. Available:
http://www.ageuk.org.uk/get-involved/campaign/depression-in-later-life-down-but-notout/. Last accessed 4th February 2013
60. Netuveli G, Wiggins RD, Montgomery SM, Hildon Z, Blane D. (2008). Mental health and
resilience at older ages: bouncing back after adversity in the British Household Panel
Survey..Journal of epidemiology and community health. 62(11): (11), 987-91
35
61. National Mental Health Development Unit. (2005). Everybody's Business. Available:
http://www.nmhdu.org.uk/our-work/mhep/later-life/everybodys-business. Last accessed
3rd February 2013
62. Abeles N. (1998). What Practitioners Should Know About Working With Older
Adults.Professional Psychology: Research and Practice, 29 (5), 413-427.
63. Gerrard j, Rolnick SJ, Nitz NM, Luepke L, Jackson J . (1998). Journal of Gerontology.
Clinical Detection of Depression Among Community-Based Elderly People With SelfReported Symptoms of Depression. 53A (2), 92-101
64. Calati R, Salvina Signorelli M, Balestri M, Marsano A, De Ronchi D, Aguglia E, Serretti A.
(2012). Antidepressants in elderly: Metaregression of double-blind, randomized clinical
trials. Journal of affective disorders. S0165-0327 (12), 00820-8
65. Department of Health. (2002). Community Mental Health Teams - Mental Health Policy
Implementation Guide . Available: www.doh.gov.uk. Last accessed 1st March 2013
66. Gyles, G. (2006). Crisis resolution/home treatment teams and psychiatric admission
rates in England. The British Journal of psychiatry. 189 (1), 441-445.
67. Faculty of the Psychiatry of Old Age of the Royal College of Psychiatrists. (2011). Inpatient care for older people within mental health services. Available:
http://www.rcpsych.ac.uk/pdf/FR_OA_1_forweb.pdf. Last accessed 13th February 2013.
68. Downing A, Wilson R. (2005). Older people's use of Accident and Emergency services.
Age Ageing. 34 (1), 24-30.
69. Anderson D, Banerjee S. (2009). The need to tackle age discrimination in mental health.
Available: http://www.rcpsych.ac.uk/pdf/Royal%20College%20of%20Psychiatrists%20%20The%20Need%20to%20Tackle%20Age%20Discrimination%20in%20Mental%20He
alth%20Services%20-%20Oct09.pdf. Last accessed 2nd March 2013.
70. Healthcare Commission (2008) National Audit of Violence. Royal College of
Psychiatrists.
71. Department of Health. Care Services Improvement Partnership. (2007). Age Equality:
What does it mean for older people’s mental health services? Guidance note on age
equality.. Available: www.mentalhealthequalities.org.uk/silo/files/everbodys-businessage-equality-guidance-.pdf. Last accessed 3rd March 2013.
36
11. SUBSTANCE MISUSE IN OLDER PEOPLE
Background

For people aged 65 and over in the United Kingdom, 68% of men and 45% of women drink
alcohol at least once a week.

21% of older men reported drinking more than 4 units of alcohol on at least one day a
week, and 7% more than 8 units; 10% of older women said they drank more than 3 units of
alcohol on at least one day in the week, and 2% of this age group drank at least 6 units.72, 73

Alcohol misuse or dependence affects 2-4% of older people.72

The percentage of men and women drinking over weekly recommended limits has risen by
60% in men and 100% in women between 1990 and 2006.72

The pattern of misuse is quite different from younger adults and age appropriate treatment
is important to outcome.69,74

A third of older people with alcohol use problems develop them in later life – often as a
result of life changes such as retirement or bereavement, or feelings of boredom, loneliness
and depression.75
Service examples
1. OASIS’: Older Adults Support in Southwark
It is estimated that in Southwark, there are over 800 older people with alcohol dependence
and at least three times this number with alcohol misuse.
However, only 5% of these people are seen by mental health of older adults services.
As a consequence of the high prevalence of alcohol misuse in this sector, over the past 10
years, some specific work was undertaken to explore this area more fully within North
Southwark Community Mental Health Team (NSCMHT) for Older People
OASIS was a commissioned, specialist home care rehabilitation service that provided flexible and
intensive support for older mental health service users with complex needs. OASIS rehabilitation
support workers developed their expertise in engaging with older people with dual diagnosis.
Between 2005 and 2009, this model of service provision was associated with a fall in the
percentage of alcohol-related admissions with dual diagnosis from up to 50% to fewer than 5%.
Although, owing to financial pressures, the OASIS service was withdrawn in 2009, the acquisition
of competencies around dual diagnosis continues to benefit both NSCMHT and other community
teams within the Mental Health of Older Adults (MHOA) Clinical Academic Group (CAG).
37
Dual diagnosis training is offered in a targeted and proportionate way to Community Teams, with
staff now having a basic grounding in:
 screening for the presence of concurrent mental health difficulties and substance misuse;
 developing and sustaining collaborative therapeutic relationships with dual diagnosis patients;
 systematically assessing the needs of dual diagnosis patients and constructing basic care
plans designed to address these needs;
 implementing simple, low intensity evidence based dual diagnosis interventions safely and
effectively in partnership with patients;
 recognising patients whose needs are sufficiently complex to require high intensity dual
diagnosis interventions and referring them to specialist services;
 understanding the prevalence, nature, and severity of substance misuse within the target
patient groups;
 developing awareness of the effects of substance misuse on the mental health, social role
performance, and interpersonal relationships of patients with concurrent mental disorder;
 using valid and reliable brief screening techniques to identify the presence of substance misuse
and measure its severity;
 using a motivational interviewing approach to explore the advantages and disadvantages of
reducing substance use and enhance readiness for change;
 using structured problem solving to identify personal strategies to facilitate and sustain a
reduction in substance use;
 using brief health education techniques to help individuals understand the effects of substance
misuse and encourage reflection on the need for change.
Contact:
Tony Rao. (Tony.Rao@slam.nhs.uk)
References
72. Royal College of Psychiatrists. (2011). Our Invisible Addicts. Available:
http://www.rcpsych.ac.uk/files/pdfversion/cr165.pdf. Last accessed 4th March 2013.
73. NHS Information Centre (2010) Statistics on Alcohol: England, 2010. The Health and
Social Care Information Centre.
74. Crome I, Bloor R (2006) Older substance misusers still deserve better treatment
interventions. Reviews in Clinical Gerontology, 16:45-57.
75. Royal College of Psychiatrists. (2011). Psychiatrists call for action to tackle substance
misuse in older people. Available:
http://www.rcpsych.ac.uk/press/pressreleases2011/ourinvisibleaddicts.aspx. Last
accessed 4th March 2013
38
12. OLD AGE FORENSIC SERVICES
The need for a separate specialist forensic service for older people was debated at the Stratford
Residential Meeting with no clear consensus.
There are many differences between younger offenders, older people with mental disorders who
are not offending and those who are, including criminological aspects of offending in late life, the
psychiatric problems of elderly mentally disorder offenders and their treatment needs. It is
important that the needs of this group are not overlooked in an ideal service.
There are currently no specialist NHS services for older forensic patients. All the expertise is in the
independent sector, which derives income from inpatient care, thereby having an inherent
disincentive to recommend care out of a secure bed. Adult (and older adult) low and medium
secure beds in England and Wales are commissioned by specialist commissioning groups (SCGs).
The needs of elderly mentally-disordered offenders are complex and fall within the expertise of old
age and forensic psychiatry, without being adequately met by either one.76
An NHS service could be developed as part of a supra-regional quaternary service – perhaps 3 or
4 in the UK, with its own (small number) of low secure in patient beds but acting mainly in an
advisory capacity, helping old age psychiatrists and forensic psychiatrists manage the majority of
patients in their own local services.
Consultant staff would need training in old age and forensic psychiatry, and other staff would have
a range of experience across these two specialties. Many older offenders need a very detailed
assessment, but once this has been carried out, the treatment and monitoring is less complex and
so they could return to their own areas if this could be supported in some way by the specialist
service.
The specialist service would have an important role in reducing costs in the independent sector by
helping patients move out of expensive secure beds when they no longer need them.
Contact:
Graeme Yorston
References
76. Nnatu O, Mahomed F, Shah A. (2005). Is there a need for elderly forensic psychiatric
services?.Medicine, Science and the Law. 45 (2), 154-160.
39
13. BLACK AND MINORITY ETHNIC ELDERS
This group are known to engage with services at a lower level than the general population.
Service configuration needs to take this into account.
In England and Wales the proportion of Black and minority ethnic older people over the age of 65
has progressively increased from 1% in the 1981 population census to 8.2% in the 2001 population
census77
People from Black and minority ethnic elder (BME) groups who experience mental health problems
are now recognised to be one of the most socially excluded groups in our society. 78 This form of
social exclusion is not just due to the direct impact of mental illness but is a result of the stigma,
prejudice and lack of access to services that could help this group of people back into mainstream
life.
People from BME groups are also more likely to experience racism, be unemployed or homeless,
have poor physical health and live in deprived neighbourhoods, all of which can contribute to
poorer mental health.
Evidence indicates that the prevalence of common mental health problems is fairly similar across
different ethnic groups, although rates are higher for Irish men and Pakistani women and lower for
Bangladeshi women.79 However, there is evidence to show that the impact of social exclusion,
racism and poverty leads to early ageing of individuals.
Planning of services for older people from BME groups therefore needs to begin at the 50 year age
range.
References
77. Shah, A. K., Oommen, G. &Wuntakal, B. (2005) Cultural aspects of dementia.
Psychiatry, 4, 103–106
78. National Institute for Mental Health in England (2003) Inside Outside: Improving Mental
Health Services for Black and Minority Ethnic Communities in England. NIMHE.
79. Weich S, Nazroo J, Sproston K, McManus S, Blandchard M, Erens B, Karlsen S, King
M, Lloyd K, Standfeld S, Tyrer P. (2004). Common mental disorders and ethnicity in
England: the EMPIRIC Study. Psychological Medicine. 34 1543–1551
40
14. ACADEMIC INPUT
Although there are many scientific advances in researching the cause of dementia there are many
gaps in the understanding of what pharmacological and non-pharmacological interventions can
help people with dementia and their carers. To combat this research networks have been set up in
all four nations.
The need for treatment interventions to be based on good scientific evidence applies as much to
dementia as to other illnesses. SIGN 86 and NICE42 identify a number of key research questions,
the answers to which would improve the day-to-day care of people with dementia.
The pharmaceutical industry increasingly looks towards pre-clinical Alzheimer’s disease as the
target for their next therapeutic agents. Their work will be supported by the large longitudinal
studies of the older population in parts of Scotland and elsewhere but this work impacts less
directly on the treatment of existing patients than future patients.
High quality audit is often assisted by a research culture and improved audit would be beneficial
and supporting the development of an ICP for Dementia.
Electronic Patient Records
The large volume of information contained in electronic patient records is a valuable potential
resource for observational studies of treatment response and adverse events, as well as potentially
facilitating more targeted recruitment to research studies. However, the complexity of record
systems, combined with perceived governance and procedural hurdles, has hindered work in this
area to date. The NIHR Biomedical Research Centre for Mental Health at the South London and
Maudsley NHS Foundation Trust has supported the building of a case register (the Clinical Record
Interactive Search 'CRIS' application) which provides researcher access to full but anonymised
records on over 185,000 mental health service users, including large numbers of people with
dementia and other late-life mental disorders. Search and database assembly functions are
included to facilitate use by clinicians, and over 70 research and audit projects have been
completed to date making use of this. In addition a procedure has recently received full approval
whereby service users will be routinely asked about consent for direct contact by a researcher in
the future, allowing records to be used for identifying eligible participants for studies and improving
patient access to research participation. Both the CRIS resource and the consent for contact
procedure are potentially transferrable on to other electronic patient record systems
Contact Dr Robert Stewart (robert.stewart@kcl.ac.uk)
41
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