Abstract
Background: The worldwide ageing of the population is mirrored in the general hospital where the proportion of elderly patients is increasing. In Australia 31% of hospital discharges and 46% of bed days were over 65 years of age in 1997–98. In the US, over the last 15 years the proportion of elderly referrals to consultation liaison (CL) services has increased from around 20–30% to over 50%. Both CL and old age psychiatry are involved in service delivery in Australia without clear direction about which should be primarily responsible.
Objective: To determine the most appropriate model of mental health service delivery for the elderly in general hospitals.
Method: Literature review utilising Medline, PsychoInfo and Ageline databases supplemented by a manual search of references from relevant literature for studies of CL psychiatry in the elderly.
Results: Twenty-seven studies were found that described service delivery in general hospital, 15 by old age psychiatry services and 12 by CL services. The patient profiles, reasons for referral, diagnoses and management were similar in both types of service delivery. The majority of referrals were from orthopaedics after hip replacements. Many studies report low referral rates in the elderly, which may increase with the introduction of a specific old age psychiatry service.
The most frequently mentioned reasons for consultation are ‘depressive symptoms’, ‘confusion, dementia’, ‘discharge advice and placement’, ‘mental state evaluation/competency assessment’ and ‘behavioural problems’. Older patients are less frequently referred for assessment of suicide risk and psychogenic causes of physical symptoms. Organic mental disorders are reported in 44% (median) of referrals, with dementia accounting for 30% and delirium 14%. Depression is found in 27% of referrals, with around half of these cases due to major depression. Anxiety, adjustment and somatoform disorders occur in 8% of referrals, substance abuse 5%, personality disorders 4%, and schizophrenia/paranoid disorders 3%. No diagnosis was made in 7%. In comparison with younger CL referrals, fewer older patients are diagnosed with substance abuse, anxiety, somatoform and personality disorders or have ‘no diagnosis’.
The most frequent management recommendation was for psychotropic medication in 44% of referrals. The use of psychotherapy was variable and 'ward management and
The most frequent management recommendation was for psychotropic medication in 44% of referrals. The use of psychotherapy was variable and ‘ward management and advice’ was mentioned irregularly. Many older referrals are recommended to have a further medical review or investigations. The main difference found between old age and CL psychiatry was that in around 30% of referrals, old age psychiatry services are asked to give discharge advice, particularly about placement, and are more likely to arrange community psychiatric follow-up. This extended care approach is the most effective style of service delivery for the elderly.
Conclusion: There are a few differences reported in service delivery by CL and old age psychiatry services. Old age psychiatry services may be better placed to liaise with geriatric medicine and to treat the ‘old’ old, with multiple health problems who require long term community support. Collaboration between CL and old age psychiatry services is recommended.