The Case of Need for
OPMH Liaison Services
John Holmes
Senior Lecturer in Liaison Psychiatry of Old Age
University of Leeds
To establish a convincing case of need:
• Evidence that mental health problems in
older people are common in general
hospitals
• Evidence that outcomes are adversely
affected in this group
• Reasons why outcomes may be affected
• Solutions that address these reasons
Determining the prevalence
• Comprehensive search
– 576 papers identified
– 256 contained original data
– 97 met appraisal criteria
How common is psychiatric illness in
older people in general hospitals?
Diagnosis
Depression
No. of
Total
Mean Prevalence
studies sample sample
size
27
5173
192
5–53%
Mean
prevalence
26%
Delirium
19
4818
254
7–61%
17%
Dementia
5
918
184
5–35%
13%
Cognitive impairment
22
10298
468
7–88%
30%
Schizophrenia
4
1147
287
1–8%
1%
Alcoholism
3
583
194
1–5%
4%
Total
61%
Some gaps in epidemiology in GH
• Self harm
• Somatisation
• Anxiety disorders
Self harm attendances in A&E
110 of the 5038
attendances (2.2%)
were by older people
900
800
700
600
500
400
300
200
100
0
<15
1519
2024
2529
3034
3539
4044
4549
Age (years)
5054
5559
6064
6569
7074
>74
University Hospitals of Leicester:
•
•
•
•
•
Glenfield Hospital
Leicester Royal Infirmary
Leicester General Hospital
Total
=1462 older people
– 380 with depression
– 249 with delirium
– 190 with dementia
570 beds
>1000 beds
680 beds
2250
Leeds Teaching Hospitals Trust
Distribution of admissions 65 yrs
8000
7000
6000
5000
4000
3000
2000
1000
0
Geri
Chest
Gen
Med
Card
Gastro
Opth
ENT
Gen
Surg
Rheum Ortho
Urol
So…
• There’s a lot of it about
• What about outcomes?
– systematic review
– 27 studies
– Outcomes affected across the board
• LOS, mortality, institutionalisation, physical
dependence, readmissions
Survival after hip fracture…
1.0
.9
.8
.7
.6
.5
.4
Psyc h diagno sis
.3
Depression (n-93)
.2
Delirium(n= 108)
.1
Dementia (n=294)
0.0
Well (n=208)
0
250
500
750
Time ( days)
(Nightingale et al 2001, Lancet, vol. 357, no. 9264, 1264-126)
As for length of stay…
1.0
.9
.8
.7
.6
.5
.4
Diagnosis
.3
Depression (n=93)
.2
Delirium(n= 108)
.1
Dementia (n=294)
0.0
Well (n=208)
0
10
20
30
40
50
60
70
80
90
10 0
11 0
12 0
13 0
14 0
15 0
16 0
17 0
18 0
19 0
20 0
Time (days)
(Holmes & House 2000, Psychol Med vol. 30, 921-929)
To manage problems successfully we need:
– Accurate detection by general hospital staff
– Optimal management by general hospital
staff
• investigations
• treatment
• referral for specialist advice
Why are things so bad 2?
• We met with some general nurses:
– To identify the attitudes, perceptions and
training needs of general nurses relating to
older people with mental health problems.
– Data collection:
• Focus groups with general nurses (CoE wards)
– Analysis
• Grounded theory approach to develop themes
Theme 1
• Older people with mental health
problems are identified through their
behaviour.
• “I suppose when I think of people mentally, with
mental health problems on an elderly ward, I’m
thinking about people that get violent.”
• “It’s the dementias we see more of and they stand
out more because they’re the one’s trying to get off
the ward or mess with other people’s belongings or
equipment on the ward.”
• “I think we all have it don’t we? The wandering
patients, which is the biggest problem really . . “
• “Outbursts of aggression”
Theme 2
Physical care needs are prioritised over mental
health needs
•“you don’t die of confusion”
•“you have to prioritise the life threatening conditions first.”
•“that’s our problem on the ward, we prioritise the medical
intervention, you know our focus, you know, hands on medical
interventions.”
•“if you’ve got 5 minutes, I don’t go and sit with a patient who I think
might be getting more confused, to find out what the problem is, I
think, ah, I’ve got 5 minutes, I am going to tidy up this bay because
it’s a tip, because I don’t feel I have the skills to draw out from this
patient.”
Theme 3
Nurses perceive themselves and medical staff
as lacking the skills needed to recognise and
manage mental health difficulties
• “ And the root of the problem is basically our education, we don’t
know enough about mental conditions for us to screen and identify
and therefore treat, and that’s our problem, resources aren’t
available for us to be able to do that.”
•“And we don’t, we don’t know enough about psychiatric illnesses
to pick up exactly what it is.”
•“What sections what, who? I’ve walked round with the bleep, half
thinking, please God, don’t let me have to go anywhere, cos I don’t
know what I’m doing.”
•“I did four weeks in a day hospital and then that was it. I played
Bingo and listened to The Sound of Music, and did exercises and
we threw a ball at each other.”
Theme 4
General nurses believe older people with
mental health difficulties do not get a good
service in general hospitals.
“In terms of managing somebody’s mental illness, we are doing
them a disservice, and if it was a medical problem, you know, it
wouldn’t be tolerated, but because it’s a mental health problem it
is.”
“And the patients that are confused do get neglected, because you
don’t give them the attention that you could give if you didn’t have
your acutely unwell.”
“Like taking sticks off people, and moving the table away so they
can’t even get their water; cos they throw it.”
Atkin et al. Int J Geriatr Psychiatry 2005; 20(11):1081-3.
… and our survey of old age
psychiatrists revealed deficits in:
• Knowledge
“How to engender some knowledge for the management of
psychiatry disorders in non psychiatry areas”
• Skills
“Your questionnaire makes me aware of… …how much
mental disorder/psychopathology/unhappiness and
distress is being missed or probably dealt with
inappropriately”
• Attitudes
“The general attitude is that anyone with a psychiatric label
should be put in a corner and ignored - almost universal
on surgical and orthopaedic wards”
“Few referrals from surgery. I dread to think that they just
over-sedate delirious patients with loads of haloperidol.”
An acute trust chief executive:
• Referral mechanisms SSD/Acute trusts/MHT
do not address co-morbidity
• Organisational boundaries get in the way of
appropriate service delivery
• Pressure on the acute system is not
conducive to taking time and not rushing
• Systems too rigid to provide care in the
appropriate place for each person
• Organisational cultures cause barriers more
than a lack of resource
Why are things so bad?
• Different people interested in different
outcomes:
– Acute trusts
– Mental health trusts
– Primary care trusts
– Users and carers
Back to our nurses…
Some solutions identified:
• Training wanted, to identify and manage
mental health difficulties.
• Fast, direct access to a mental health
professional for patient management advice.
• Improve referral system to psychiatry – faster
response, clear referral routes, nurses able to
refer, improved follow up.
• Specialist wards for older people with
complex needs.
So we need:
– To ensure that general hospital staff are equipped
to deal with the basics of mental health care
• Training / education, ? supervision
and
– To deliver specialist mental health care where
needs are more complex
• Clinical service
and
– Input into service design
• Stakeholder involvement
For adults of working age:
• Liaison psychiatry
– Well established sub-speciality, Faculty of
the RCPsych
– Specific policy drivers
• Health of the Nation
• Self harm
– Input into many different specialities
• Ageist not to have the same for older
people?
What about old age psychiatry services?
• Comprehensive
– Generalist not specialist
• CMHTs, day hospitals, clinics
• Psychiatric wards
– some general hospital based
• Community focused
– Because that’s where people are
Potential models of general hospital care
•
•
•
•
•
•
•
Standard sector model
Outreach from psychiatric wards
Enhanced sector model
Liaison nurse(s)
Liaison psychiatrist(s)
Shared care
Hospital mental health team
– (Clinical psychology)
Our survey
• Between Two Stools: Psychiatric
services for older people in general
hospitals
– UK-wide
– Old Age Psychiatrists
Number of respondents
Services for general hospital patients 2002
200
150
100
50
0
Traditional Enhanced
sector model sector model
Outreach
from
psychiatric
w ards
Liaison
psychiatry
nurse
Liaison Shared care
psychiatrist
Hospital
mental
health team
Other
But…
• General hospital referrals comprise 25% of
the total referrals received by respondents
• Many respondents gave higher priority to
community referrals
– perceived as higher risk
• “The ones in hospital are safe and sound”
• 5% able to respond in the same working day
• 68% able to respond in 5 or more working
days
And…
• 35% of respondents thought there were
specialties who under-referred
– in particular, orthopaedics, surgery, neurology
• Why?
– Inability of staff to recognise psychiatric illness
– Lack of awareness of psychiatric interventions
available
– Need to discharge quickly, therefore don’t refer to
slow to respond services
– Inappropriate referral to geriatricians rather than
psychiatric services
Barriers to service delivery
and development
• Logistic
– Travelling and parking
– Workload
• Financial
– No mechanism for measuring and charging
– Limited resources
– Domiciliary visit fees
• Organisational
– Separate managerial arrangements of many trusts
– Different priorities eg community
– Lack of appreciation of the scale and impact of the problem
• Lack of good evidence for the impact
• Culture and attitudes
What has changed?
2002
2006
130
120
Number of hospitalss
110
100
90
80
70
60
50
40
30
20
10
0
Traditionalsector
Enhancedsector
Outreach MH
wards
Liaison
Psychiatric
Liaison
Psychiatric
Nurse
Medical Team
Service model
Shared Care
Hospital
Mental Health
Team
Other
…and what do people want?
current
preferred
130
Number of hospitals
120
110
100
90
80
70
60
50
40
30
20
10
0
Traditionalsector
Enhancedsector
Outreach MH
wards
Liaison
Psychiatric
Nurse
Liaison
Hospital Mental Shared Care
Psychiatric
Health Team
Medical Team
Service model
Other
Non-elective LOS by PCT
HRG T01 1999-2005
40
Stay in Days
35
30
25
20
15
10
5
0
West
NorthWest
South
NorthEast
East
The Case of Need for
OPMH Liaison Services
j.d.holmes@leeds.ac.uk
www.leeds.ac.uk/lpop
Liaison Psychiatry for Older People: Directions and Developments, Leeds,
17 May 2007