Dementia is far from the only mental health problem for over-65s, yet the millions who struggle with depression are scandalously neglected. Stuart Shepherd reports
Popular misconceptions aside, most older people do not suffer from depression or any other mental health-related problems. However, they might be forgiven for feeling a little down in the mouth if they read Improving Services and Support for Older People with Mental Health Problems, the second report from the UK inquiry into mental health and well-being in later life, published earlier this year.
Because if at a point in the not-too-distant future an older person were to need even a little short-term support for a mental health issue - be it depression, anxiety or delirium - he or she would face the prospect of services slammed as inadequate 'in range, in quantity and in quality'.
Improving Services and Support reveals that depression severe enough to warrant intervention affects one in four older people living in the community. However, only one in three discusses the condition with their GP and of these just half are diagnosed and treated. One in three informal carers of older people, says the report, are also depressed. Meanwhile, diagnosed dementia - and only half the people who have it get a diagnosis - costs health and social care more than cancer, heart disease and stroke combined.
As its foreword points out, the report is simply adding to evidence already presented by a number of other organisations, putting its voice to the call for properly resourced care services that respect the dignity and needs of users.
The inquiry itself was launched, with the support of Age Concern, in 2003, following the publication of national service frameworks for mental health and older people and amid concerns that mental health in later life was being neglected.
Its first report, Promoting Mental Health and Well-Being in Later Life, published in 2006, made clear the neglect of both mental health and of older people in policy and resource allocation. It also confirmed that a decline in mental health is not an inevitable part of ageing and that lots can be done to prevent it.
As well as outlining the key facts and figures, this second report, Improving Services, identifies five main areas for action and makes 35 recommendations. The first is the establishment of a ministerial task force by 2008 to co-ordinate services to meet needs and promote good mental health in later life.
'The big theme from the inquiry overall is the significant mismatch between the needs of people who use the NHS and the ways the service and the education and training of the staff are organised,' says Age Concern England policy manager Philip Hurst. 'This is an issue for the whole service. Primary care sees the most older people with mental health needs; and in acute hospitals 60 per cent of older people, who occupy two-thirds of the beds, have, or acquire, a mental health need.'
With a task force in place and determining the direction of travel it is just possible that the 34 other recommendations - directed at the Department of Health; the NHS; acute trusts; commissioners; housing, regulatory and professional organisations; and voluntary groups - might get the attention called for.
'Government has broadly welcomed the report,' says Mr Hurst. 'But practical action stemming from that is not yet clear. This is an issue that needs to be tackled to meet the goal of turning the NHS into a well-being service that delivers personalised care. Given the number of older people in the system, neglecting their mental health needs will mean failure to achieve the vision for the NHS, he argues.
According to the report, the number of older people with mental health needs stands at 3 million and is set to grow by more than 30 per cent in the next 15 years. By 2051 there could be as many as 5 million older people with depression and 1.7 million with dementia.
'If there is no change to the way the service is currently delivered, it will break,' says Dr David Anderson, chair of the faculty of old age at the Royal College of Psychiatrists. 'Furthermore, we live in an age of cuts to specialist services, while very little attention is being paid to the mental health needs of older people in the acute sector.'
The level of cuts has varied considerably, from frozen community nursing to swingeing reductions in bed numbers to the closure of day services. In two or three trusts the college says the cuts were extreme - in one of them enough to warrant a report to the health secretary that prompted a departmental emergency review.
Dr Anderson says: 'Mental health services for older people were starting from a much lower base. The targeted investment in crisis intervention and assertive outreach that came with the national service framework for mental health - a framework not directed exclusively at working-age adults - was clearly ageist and excluded older people.
'In the meantime, there has been much dishonest use of terms such as remodelling and new ways of working where what you were getting in truth were service cuts. Interestingly, while this was happening across all the regions in England, there were no reports that any other country in the UK was affected.'
Improving Services recognises the high level of mental health problems suffered by older people in hospitals, the opportunity for instigating care that this presents and the reality that screening, diagnosis and management is poor. Evidence that conditions such as depression and delirium in this group can increase length of stay and mortality rates appeared in the RCP faculty of old age's 2005 working group report, Who Cares Wins.
'This is an enormous problem and it's hard to find another specialty that has so many implications for every other aspect of health and social care,' says Dr Anderson. 'And yet, despite all the evidence for the benefits of liaison psychiatry in the acute sphere - where there are more contacts with mental health than any single other service provider - nobody, including the commissioners, has it on their agenda.'
Concerns that specialist psychological therapies for older people might also slip off the agenda have been expressed recently by PSIGE, the faculty for old age psychiatry at the British Psychological Society.
'There is a shift at the moment towards generalising psychological therapies across the age range, with some services doing away with specialists,' says PSIGE chair Steve Boddington. 'Our recommendation on workforce planning is one qualified psychologist per 10,000 older people. Right now it's at one to every 25,000 and there are huge swathes of the country that have no provision at all.'
Mr Boddington also finds it telling that, while many overt age-discriminatory barriers have been removed, thanks in no small part to the first standard of the national service framework for older people, ageism still exists in practice. 'Primary care psychology services no longer have an upper age limit,' he says, 'but statistics from some PCTs show less than 2 per cent of referrals are for older people.
He praises a project that has seen psychologists from South London and Maudsley foundation trust work alongside GPs in Southwark to 'radically alter referral pathways for older people'. Funding for this three-year project will end soon however and mainstream funding from commissioners looks unlikely.
The loss of specialist older people's mental health services in both inpatient and community settings and the accompanying skills and expertise is clearly seen as discriminatory. The Care Services Improvement Partnership's Age Equality document published earlier this year as guidance notes to its earlier Everybody's Business service development guide helped clarify and bring this concern to the fore.
Phil Minshull, older people's mental health programme co-ordinator for North West England at the partnership and author of Age Equality, says: 'People were saying to me that if you have age equality or inclusivity you may not need specialist older people's services. My worry was that this might be thought of as a cost-saving measure, against the spirit of the guidance and offering no tangible benefits to the patient group.'
The guidance note points out the requirements within the NSF for older people for districts to have their own specialist teams. It also reminds readers of Age Concern's comments from 2006 on indirect or 'neutral' discrimination in services designed solely around the needs of young people which would clearly be unsuited to a frail older person with a severe depression.
Age Equality goes on to recommend the development of and access to services being determined on the basis of individual clinical need and the sharing of services where this benefits treatment and social inclusion.
The ethos of more equitable and balanced provision is being introduced to older people's mental health services in the East Sussex locality of Sussex Partnership trust. Self-help or 'Mindfulness' groups bring young and old people together - on the basis of need rather than age - to relieve stress and develop psychological techniques for managing depression.
Specialist psychology services for older people in community mental health teams are also being made more widely available, as is older people's access to psychological services aimed at those of working age. Therapists from the trust's working-age services deliver the resources and have worked collaboratively with older people specialists to develop appropriate skills. A Department of Health partnerships for older people's projects pilot is providing intensive home support in East Sussex to prevent unnecessary admissions, facilitate discharge from hospital and establish individual care regimes.
'We have also developed a joint mental health and primary care service for older people with milder mental health problems offering brief therapy interventions,' says John Beeton, service improvements and projects manager in East Sussex. 'It is needs-led, open to young and old and a further example of how we are trying to bring down the barriers between services.'
Further signs of encouragement come from the CSIP older people's mental health programme.
As Ruth Eley, who leads the programme's work on older and disabled people, explains: 'Age equality is at the heart of the programme and has two strands. First, promoting provision of services on the basis of need and not age and second making sure that mainstream services are skilled and competent in meeting the mental health needs of older people.'
The CSIP 'Let's Respect' campaign has initially been aimed at acute wards in general hospitals. Its toolkit - with presentation slides, a good practice guide and case studies - is designed to help nurses without mental health training recognise, understand and support older patients with depression, delirium or dementia.
'Managed learning networks encourage participants to explore particular themes in their workplaces and then share the lessons across the region,' adds Ms Eley. 'There is still work to be done, such as in areas where people with dementia are excluded from intermediate care, but equally there are examples of some very good redesign work coming through.'
The integrated community mental health team in Doncaster - part of Rotherham, Doncaster and South Humber Mental Health foundation trust - is a case in point.
'We used to have more than 120 beds,' says community mental health service manager for older people Wayne Goddard. 'They are now reconfigured and our service includes 40 assessment beds, 15 continuing care reassessment beds and a single point of access, the integrated community mental health team, providing home liaison, acute hospital liaison, memory clinics and talking therapies - all as part of a range of integrated care pathways.'
'About 50 per cent of care home residents will have some form of depression,' he adds. 'The integrated team works across 1,800 beds, helping staff to improve the quality of their care by showing residential staff how to work with memory loss, difficult behaviour and depression.'
The Doncaster team's work is one of the most notable signs that the health service is finally waking up to the mental health problems of over-65s - but the scale of the unmet need and projected rise in demand suggests that there is still a huge amount to do.
Mental health in older age
It is estimated that one in four elderly people suffer depression, yet the vast majority get no treatment for it.
A national campaign and pioneering trusts are showing how to meet the needs of this group in and out of hospital.
The spiralling number of elderly mentally ill means that more service change is urgently needed.
Let's Respect campaign: 'it had been waiting to happen for ages'
In the year since the launch of Let's Respect at St Helens and Knowsley trust, the care of older people in acute beds with depression, delirium or dementia has improved dramatically.
Let's Respect is a national campaign by the Care Services Improvement Partnership to improve the mental health of the elderly in hospitals. 'We timed our first presentation to coincide with the national launch,' says nurse consultant for older people's services Marie Barnes.
'The event was open invitation and we did the slide show. The images of older people in care settings are very powerful and really helped people connect with the issues.'
Not that there was any shortage of enthusiasm. The mental health special interest group formed afterwards now has more than 50 members including doctors, nurses, allied health professionals and social workers - all keen to learn and make things better for this vulnerable group of patients.
'It had been waiting to happen for ages,' says Ms Barnes. 'We now have a delirium-prevention programme auditing numbers of ward moves and night-time sedation, depression is assessed earlier and considered in discharge planning, and we have liaised with [private finance initiative scheme] architects about environmental design.
She adds that the trust's care of the elderly training module now also includes a half-day session on mental health.
Moving on: 'we try not to get hemmed in by rigid age restrictions'
Increasingly those working with people turning 65 believe the shift from working age mental health services to those for older people should be determined by individual patient need and choice rather than determining entitlement purely on the basis of chronological age.
This philosophy is reflected in West Sussex, a locality within Sussex Partnership trust, as Dr Al Amaladoss, lead consultant for older people's mental health/ explains.
'We take a fairly pragmatic approach and try not to get hemmed in by rigid age-related restrictions.
'Many patients will have grown old being looked after by members of a particular team so, unless there are particular needs that can be better addressed by an older person's team, they are best staying where they are.'
'This works well in the case of patients aged 68 or 69 who are in the care of the working age team and need to come in to hospital. If they need more physical care or wouldn't feel comfortable on an adult ward we will however admit them to one of our beds.
'Those over 65 and presenting for the first time or suffering a recurrence of an illness after a long interval would probably be assessed by the older people team.
'But it is always best if we can base the decision around the user's perception of their problem.'
Find out more
Details about the CSIP Let's Respect campaign