Good mental health care is a part of good geriatrics

Tom Dening is Professor of Dementia Research at the Institute of Mental Health at the University of Nottingham. He tweets at @TomDening shutterstock_162166118

Sir Simon Wessely (yes, we are going through a phase where the RCPsych Presidents get gongs – I suppose it’s cheaper than investing in mental health services) has made some eloquent points about the current state of mental health provision.

He didn’t specifically mention older people, though of course they have common mental disorders like depression. Also he didn’t talk about the complex world where physical and mental ill health conspire against people and bring them into contact with geriatrics or old age psychiatry, or both.

In this complex world, there are many aspects to be proud of but also some massive challenges. What’s good? There’s generally a good deal of respect between geriatricians and their psychiatry counterparts. Geriatricians readily recognise that their patients will often have mental disorders alongside their physical illnesses, and so they are aware of dementia and delirium, and some are quite good at recognising depression too. Following the tearaway success of the RAID service in Birmingham, and stimulated by the National Dementia Strategy, there has been much more attention to the experience of people with dementia in general hospitals. I think there’s still a long way to go on this – but there again most hospitals are working under so much pressure that they are fairly toxic places to be a patient in, irrespective of what condition you have.

What’s not so good? There’s still a feeling of relentless pressure on acute services. Frail older people pass through A&E and are farmed out to various wards. A large proportion of them have dementia, often with delirium on top, and the ward staffing establishment is often not sufficient to provide the additional care that they require. Why is it OK to have increased staff for high dependency units of various kinds but not to augment staffing levels on wards that care for people with dementia? Isn’t their care just as requiring of specialist skills? At present, it is the patient who gets the blame for being confused: that can’t be right.

And Sir Simon is right about mental health services – they are in a difficult state at present. Bed numbers have fallen for various reasons, but the chief of these is that it’s really the only way to save money. This is true across the age range, so the large numbers of dementia beds that used to exist no longer do so. I suspect this means more patients come to geriatric medicine as a result. For both types of service, discharging patients to suitable accommodation can be very difficult especially if there have been any problems with aggressive behaviour.

Finally, together, we should make hospitals better places to die in. There are half a million deaths a year in the UK and over half occur in hospitals. Helping people to die properly is a big part of our business.

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