International Review of Psychiatry (1998), 10, 130± 133

Needs of special groups: the elderly

SUBE BANERJEE

The Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK

Introduction

This paper rests on the statement that the elderly,

usually somewhat arbitrarily de ® ned as those over

the age of 65, are an important group that has

particular needs which should be met. However, this

statement needs to be supported, it raises the ques-

tion: in what ways are the elderly of importance?

Leaving to one side all the positive social and cul-

tural aspects of the contribution the elderly make to

society, for the purposes of this paper this import-

ance may be divided into economic and clinical

® elds. On the clinical side the elderly have high rates

of physical health problems, disability and mental

disorder, which make them high users of all health

and social services.

The economic side to their importance also has

positive and negative sides. The positive is often

neglected: older people may work and provide ser-

vices (often at low or no cost); they pay and have

paid local and national direct and indirect taxes; and

they purchase goods and services, so feeding the

economy. The negative economic aspects of their

use of health and social care, however, are a matter

for open and more or less apocalyptic debate. Con-

sumption of resources may be consequent to ageing

itself (in the case of generally available bene® ts) or

to the clinical correlates of ageing (in the case of use

of community social services, residential care, pri-

mary health care services, community secondary

health care and in-patient admissions of all types).

Speci® cally within the scope of this paper, the

elderly at home and in residential care are high users

of primary health care services. With the massive

contraction in provision of NHS Continuing Care

beds over 99% of the elderly will have a general

practitioner responsible for the provision and co-or-

dination of their often complex health care needs.

Equally, the elderly are high consumers of com-

munity and in-patient secondary mental health care.

People over the age of 65 make up around a third of

all new admissions and re-admissions to mental

health beds in England, and this proportion appears

to be on the increase (Philpot & Banerjee, 1997). In

1968 people over the age of 65 made up 23% of all

admissions and 16% of all re-admissions to mental

health beds in England compared with 37% and

33%, respectively, in 1986 (Department of Health

and Social Security, 1988).

In this paper the management of depression will

be used as a case study to illustrate themes of

importance. The same fundamental issues will be

relevant to the other mental disorders of later life

such as dementia, anxiety disorders and alcohol

problems.

If it ain’t broke, don’t ® x it

It might be argued that because the elderly are such

high users of primary and secondary mental health

care services their needs must be being met. `If it

ain’ t broke don’ t ® x it’ (Lance, 1977) is an import-

ant maxim to bear in mind when considering service

delivery and any change in con® guration. So are

things `broke’ at present?

The past 15 years have seen enormous advances

in the descriptive epidemiology of old age mental

disorders. Research methodology and capacity have

matured and speci® c instruments have been devel-

oped with which the prevalence of mental disorder

in the aged can be estimated with known and ac-

ceptable validity and reliability. We can therefore

state with some con® dence that the prevalence of

dementia in the community as a whole is around 5%

in those over 65, with a doubling of prevalence for

in each successive ® ve year age band over the age of

65; an estimate that is remarkably stable between

developed countries (Hofman et al., 1991). Equally,

our understanding of the level of depressive disorder

in the community has crystallized. At any one time

around 15% of those over the age of 65 have

depressive disorders of such a nature and severity

that intervention would be warranted (Copeland et

al., 1987; Livingston et al., 1990).

If it `ain’ t broke’ then these needs are either being

met or are unmeetable. For depression the evidence

points towards the need for treatment not being

met. It is clear that specialist psychiatric services are

not meeting this need, only 6% of people over the

age of 65 with serious depression are in receipt of

old age psychiatric services (Waterreus et al., 1994).

This would be ® ne if they were being effectively

managed within primary care; however, less than

15% of people with depression of such a severity

that intervention would be warranted, are receiving

any form of active management of this depression

(Blanchard et al., 1994).

This suggests a profound discontinuity along the

pathway from disorder to recognition to treatment

of depression that our present models of organiza-

tion of primary and secondary health care services

0954± 0261/98/020130± 04 $7.00 Ó 1998, Institute of Psychiatry

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Social Services

Informal Care

Primary HealthCare

Secondary HealthCare

Needs of the elderly 131

Figure 1. Service matrix for the elderly menta lly ill.

do not effectively address. It is unclear where this

breakdown is, it may be a lack of recognition of

depression by primary care (Williamson et al., 1964)

or that recognition is not linked to action (Macdon-

ald, 1986). In addition, public education campaigns

such as the Royal Colleges of General Practitioners

and Psychiatrists’ Defeat Depression Campaign and

local medical education appear to have had little

impact.

This inactivity might be warranted if these people

with depression were untreatable, and the need

therefore unmeetable. However, this does not ap-

pear to be the case. Despite the evidence-base in old

age psychiatry being relatively sparse (Banerjee &

Dickinson, 1997), there is growing evidence that

depression in the elderly can be successfully treated

in general community samples (Blanchard et al.,

1995) and even in supposedly poor prognostic

groups such as the disabled elderly (Banerjee et al.,

1996).

The system therefore seems to be `broke’ for

depression in the elderly. In order to `® x’ this some

understanding of the determinants of this situation

is needed. Important contributory factors are likely

to include the knowledge, attitudes and behaviour

of: primary health care teams; old age psychiatry

services; the older people themselves; and those of

society more generally. The essence of successful

work with the elderly is effective multidisciplinary

and multi-agency working. Figure 1 summarizes the

inter-dependant matrix of services within which the

elderly mentally ill are cared for, and all of whose

components need to be mobilized if effective man-

agement plans are to be formulated. The adequacy

of communication between the constituent parts will

vary according to general professional relationships

and local factors. For instance, the line of communi-

cation and co-operation between primary and sec-

ondary care is fairly well established if often

stereotyped and unproductive. Another strong link

by practice and carer-focused legislation is that be-

tween social services and informal care. However,

the paths, for example, between primary health care

and social services may be less well trodden and

productive. More effective packages of care may be

formulated by viewing the system as a whole in this

way and identifying where there needs to be particu-

lar attention to the strengthening of communication

and co-operation in each particular case and in

general.

Primary health care and old age psychiatry

However, the focus of this paper is on the relation-

ship between old age psychiatrists and primary care

and on improving the care of the elderly mentally

ill. The apparent disjunction in the system from

disorder to recognition to action was outlined

above. In this section an attempt will be made to

illustrate what this means for older people with

depression and where change might best be fo-

cused by considering the pathway from depressed

state to resolution in frail elderly home care recipi-

ents (Banerjee, 1993). This is possible since it is a

population for which accurate estimates of the level

of active management (Banerjee & M acdonald,

1996) and of 6 month response to treatment

(Banerjee et a l., 1996) are available. This is sum-

marized in Figure 2.

At its most simple, the outcome of depression

over a period of time is either that the individual

recovers or does not recover. If intervention has

ef® cacy then the relative proportion falling into re-

covery or not recovery depends on whether the

disorder is recognized and effective action is taken.

So, if a population of 100 depressed home care

recipients is taken, the ® rst stage is to apply the 15%

rate of any active management for depression

(Banerjee & Macdonald, 1996) to divide the group

into a `treated’ and a `not treated’ group. The

second stage is to apply the spontaneous recovery

rate of 25% to the `not treated’ group and the 60%

recovery rate with active management to the

`treated’ group (Banerjee et al., 1996). When these

® lters are applied only 30 of the 100 recover (only 9

in the `treated’ group and 21 spontaneously recover-

ing in the `not treated’ group) compared with 70

who do not recover (6 in the `treated’ group and 64

in the `not treated’ group).

That only 30% of people with depression recover

in a 6-month period is a fairly good demonstration

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Recovered Not recovered Recovered Not recovered

Treated

Depression

Not treated

100

15% 85%

75%25%40%60%

9 6 21 64

132 Sube Banerjee

Figure 2. Outcom e of depression in the frail elderly.

of the system’ s being `broke’ . Where then should

effort be focused to address this situation? The

spontaneous recovery rate will be fairly resistant to

change and the gain from trying to improve the

ef® cacy of treatment would appear to be relatively

limited. What is clear from the ® gure is that the

main determinant of the poor population outcome is

the low rate of active management. This would

suggest that resources should be focused on increas-

ing the proportion which enter the `treated’ group,

since there is the greatest scope for improvement at

this point and any bene® t at this stage will cascade

down the system. This demonstrates the need to

attend to the processes of recognition of depression

in the elderly and of linking this recognition to

action.

Elements of an effective strategy

It is at this point that it is often concluded that

general practitioners (GPs) are failing to do their job

properly by not recognizing and treating these disor-

ders and that the solution is for them to adopt the

management strategies of old age psychiatry. This

blaming approach and the suggestions stemming

from it are likely to be unfeasible and unsustainable.

Secondary care can have a fairly narrow focus of

attention, so that it is often forgotten that the dis-

order that the psychiatrist is suggesting the GP

should take a lead in identifying and treating is only

one of a multitude of other similar injunctions from

hospital-based services referring to other disorders.

The mechanisms by which clinical decision-making

and behaviour change occurs are complex and be-

yond the scope of this paper. However, useful fac-

tors will include a shared ownership and

understanding of the problem and the solution

needed. A further factor that is sometimes over-

looked is that this shared explanatory model and

acceptance of the need for a particular intervention

is not simply a matter for the GP and the psy-

chiatrist, but also vitally includes the patient and his

or her formal and informal supports. Researchers

have a vital role to play, in that evidence of effective-

ness of intervention in terms of cost (including time)

and understandable clinical outcome is a necessary

prerequisite for positive change.

The following, then, are some of the elements of

a comprehensive strategy to address depression in

the elderly in particular and mental disorder in the

elderly in general. Much of this consists of current

practice, but by listing it in this way the dif® culties

in assuming that any change in behaviour has any

likelihood of being simple or cost neutral (in terms

of time, resources etc) are highlighted.

Public education

To inform and enable the older people themselves,

families, friends, carers, social services, health ser-

vices and the voluntary sector to understand the

nature, consequences and treatability of the dis-

order.

Focused education and training

For health services, social services and other care

providers such as the staff of residential care homes.

Screening

Assessments before and on entry into social service

care, regular reviews of those cared for, opportunis-

tic screening on consultation and programmed

health checks. Such screening could be carried out

by social services using validated instruments and

also by primary health care staff using clinical proto-

cols or screening tools.

Diagnosis

Screening is pointless without a subsequent clinical

diagnosis being made. Therefore primary and sec-

ondary care services need to be con® gured to re-

spond to the need for diagnosis, this may require

the transfer of skills from secondary to primary care

(not necessarily G Ps) and the willingness of sec-

ondary care to support and respond to prim ary

care needs.

Action

Effective action requires the formulation of a man-

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Needs of the elderly 133

agement plan, negotiating it with the patient and

other parties and then implementing it.

Active management

For the elderly this will need a maximization of

treatment of physical problems, co-operation to ad-

dress psychological and social needs, minimization

of handicap and maximization of compliance.

Review

The outcome of the management needs formal re-

view with modi® cation in the light of positive or

negative changes.

Research and evidence

There is a need to review and summarize that

evidence which we have and to keep this up-to-date.

This should lead to the identi® cation of areas where

evidence is lacking, coupled to this needs to be the

commitment to ® ght for funds to complete the work

needed. Without clear evidence it is unlikely that

clinical change will occur from the `bottom up’ and

it is equally unlikely that policy change will be

effected to enable enhanced service provision from

the `top down’ .

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