From uncertainty to understanding: Can psychodynamic theories improve our care of older adults?

Dr Juliette Brown is a locum consultant psychiatrist in CMHT for Older Adults in Newham and in liaison psychiatry at Newham University Hospital, and is a member of the Association for Psychoanalytic Psychotherapy in the NHS. 

Dr Cate Bailey is a Specialist Registrar in Psychiatry working in Liaison Psychiatry at Homerton University Hospital, and is a member of the Association for Psychoanalytic Psychotherapy in the NHS.

‘Psycho-analysis is not a child of speculation, but the outcome of experience; and for that reason, like every new product of science, is unfinished. It is open to anyone to convince himself by his own investigations of the correctness of the theses embodied in it, and to help in the further development of the study’ Sigmund Freud, On Psycho-analysis (1)

Can psychodynamic theory improve our care of older adults? A century of psychoanalytic thought and a half century of work by old age psychiatrists and psychotherapists suggest that it can (2-3). Psychodynamic approaches help in making sense of complex, bewildering and frustrating clinical encounters through the recognition and observation of unconscious communication (4). By becoming aware of the inner and outer worlds of ourselves and our patients we can provide more thoughtful and effective care.

Old problems, new solutions

Alistair Burns is Professor of Old Age Psychiatry and Vice Dean for the Faculty of Medical and Human Sciences at The University of Manchester. He is the National Clinical Director for Dementia and Older Peoples’ Mental Health, NHS England. This blog was originally published on the NHS England website. He will be speaking at the upcoming BGS Autumn Meeting in London.

As now seems to be tradition, let’s start with some statistics.

Up to four out of ten people over the age of 65 experience mental health problems. Depression is both the most common and most treatable mental illness in old age, affecting one in five older people in the community. This figure doubles in the presence of physical illness and trebles in hospitals and care homes. Nor should we forget that older people also experience severe mental illnesses.

About one fifth of all suicides happen in older people. Risk factors include: being male, being widowed, increasing age, social isolation, physical illness – present in up to 80 per cent of cases – pain, alcohol misuse and depressive illness past or present.

Deprivation of liberty safeguards

In March this year, the Supreme Court handed down its judgement on two cases which will have significant impact in determining whether arrangements made for the care and/or treatment of an individual lacking capacity to consent to those arrangements amount to a deprivation of liberty.

Key points of the Supreme Court Judgement: The Court ruled that there is a deprivation of liberty in terms of Article 5 of the European Convention on Human Rights if the person is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements. Whether the person objects to the arrangement or not is irrelevant, as is the ‘relative normality of the placement in the context of the person’s needs.’

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 

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.

Links between depression and syncope in older people

Jaspreet Bhangu is a Clinical Research Fellow and Specialist Registrar in Geriatric Medicine in Dublin Ireland. His paper The relationship between syncope, depression and anti-depressant use in older adults was recently published in Age and Ageing journal.

The Irish LongituDinal study on Ageing (TILDA) is a large scale, nationally representative, study on ageing in Ireland. TILDA collects information on all aspects of health, economic and social circumstances from people aged 50 and over in a series of data collection waves once every two years. In addition to providing vital information for strategic planning and policy for older people in Ireland, it provides a rich scientific database to further study common diseases in older adults.  It has recruited over 8000 people and has captured important data on falls and syncope in older people.

Mental wellbeing of older people in care homes

The BGS is one of many organisations who support the National Institute for Health and Care Excellence (NICE) in their commitment to improve quality standards for mental wellbeing of older people in care homes.

NICE has published a new quality standard to help care homes tackle loneliness, depression and low self-esteem in older people. Also available is the NICE Pathway for mental wellbeing and older people overview, which sets out the guidance and resources in a simple format.

Is the Abbreviated Mental Test Score the best we’ve got?

Dr Thomas Jackson and Professor John Gladman discuss a recent review of screening tools for dementia in general hospitals.

Thomas Jackson says:

Geriatricians will often diagnose dementia for the first time in hospital as a crisis admission. Here the diagnosis is usually straightforward but we are left with a feeling that the crisis may have been preventable had a diagnosis been made earlier. Dementia is very much a hot topic at the moment. There has been the recent political drive to raise rates of diagnosis through an appeal by the Prime Minister and introduction of a financial incentive to improve dementia detection in hospitals (a Commissioning for Quality Innovation Payment or CQUIN). Getting the diagnosis of dementia right, and in a timely fashion, is important for the patient, their carers and medical professionals looking after them. Diagnosis gives reassurance to patients and carers about worrying symptoms, as well as allowing access to specialised health and social care services. Making the diagnosis in hospital enables healthcare professionals to ensure they get the best care.  However, we need the right tools to help us get things right. 

A specialist medical and mental health unit

Dr Rowan Harwood is‎ a consultant physician, professor of geriatric medicine at Nottingham University Hospital NHS Trust

Click here to go to video

There is a lot of criticism of how we manage cognitively impaired patients in acute hospitals. And advice on how to do it better. The hope has been that more expert and co-ordinated services would improve outcomes and save resources. But there has been little in the way of rigorous evaluation.

We developed a specialist medical and mental health unit with the ambitious objective of demonstrating best practice. We enhanced the ward environment, ward staffing and skill mix, including mental health specialist nurses, therapists and psychiatry, trained all staff to a high level in the person centred philosophy of care, and endeavoured to engage family carers more fully.

After 18 months of operation we ran a randomised controlled trial, published in the BMJ. This video abstract describes the intervention and trial results.To illustrate the challenges and capture the essence of compassionate person-centred care, we made a 23 minute documentary, called Today is Monday. Footage from this is used to illustrate the abstract.

The full 23-minute film is available for training purposes; interested readers are welcome to discuss this with me Rowan.Harwood@nuh.nhs.uk.

Strategic planning in Intermediate Care is needed to “unstick” the NHS

Prof John Young is a Consultant Geriatrician in Bradford, UK and National Clinical Director for Integration and Frail Elderly at NHS England. Here he reflects on the 2013 National Audit of Intermediate Care. The full audit report can be found here.

I have been closely involved with the National Audit of Intermediate Care since its inception in 2008. The journey has been challenging but highly rewarding. The audit now covers about half the NHS – remarkable when you consider the commitment required by local staff to collect and submit the data.

The audit is important because it describes services that are otherwise relatively hidden from view in our conventional perception of health and social care. Yet intermediate care, or “care closer to home,” has been quietly developing during the last ten years or so. The focus has always been that of older people with co-morbidities/frailty – just the group that is now so much in the forefront of health and social care thinking. And intermediate care services have always been a platform to develop new ways of working – particularly multi-agency working – and so it is highly relevant to our current interest in service integration.

What role can social media play in healthcare?

Victoria Betton is a social media & mental health PhD researcher, Deputy Director at Leeds & York NHS PFT. She tweets at @VictoriaBetton and blogs at digitalmentalhealth.co.uk

Social media is the term used for online platforms which enable people to consume information as well as produce their own content – from 140 character updates on Twitter through to sharing photos on Instagram, and much more besides. Whether we use social networks or not, they are increasingly incorporated into day to day life, and not just for younger people:  Age UK report that the number of 55-64 year old internet users creating a social network profile rose by almost half last year, and many use social networking to keep in touch with family and friends and to reduce social isolation.