Abstract
As the world’s population ages, an increasing number of older adults will require medical care, and this group currently occupies between 40 and 65% of general hospital beds in western countries. Up to 60% of older adults admitted to a general hospital will have or will develop a mental disorder during their admission, and mental disorder in this population is an independent predictor of poor outcome (Royal College of Psychiatrists, 2005). With the recent health reforms in New Zealand where 20 district health boards were amalgamated under a single national health entity, there is a pressing need to review models of care for older adults with comorbid psychiatric and medical needs in the general hospital. A recent survey in New Zealand revealed six different models of services for older adults. This editorial summarises these models and identifies opportunities for standardisation and integration of psychiatric care for medically ill older adults.
Psychiatry of Old Age and Consultation-Liaison Psychiatry
Psychiatry of Old Age (POA) is the psychiatric subspecialty focusing on the mental health of older adults. It is usually organised around inpatient units and multidisciplinary community teams, with a strong tradition of home-visiting, and adopting age-appropriate service entry criteria rather than age-defined or ageless criteria. Consultation-Liaison Psychiatry (CLP) is the psychiatric subspecialty that operates in the interface between physical and mental health. It focusses primarily on comorbidity in the general hospital and medical and surgical outpatients, providing a mix of consultation, liaison, psychological therapies, teaching and research.
Survey of psychiatric services for older adults in New Zealand general hospitals
A recent nationwide survey (Hopkins et al., 2023) received responses from all 22 mental health services providing psychiatric care to older adults in the 16 general hospitals in New Zealand with specialist CLP services (six tertiary hospitals: 480–1120 beds; nine regional hospitals: 190–370 beds; one district hospital: 170 beds). Six different service models were identified, having evolved either by POA in-reach into the general hospital from their base or by the expansion of generic or all-age CLP services within the general hospital.
POA in-reach. In this model, used in one regional and one district hospital, all older general hospital inpatients are covered by a sub-team of POA by in-reach from its base. The advantages of this model are that POA is a specialist team that already has an existing relationship with geriatric medicine, and transitions from the general hospital to POA inpatient and/or community care are usually seamless. The challenges with this model are trying to maintain prompt in-reach response times while also providing a community POA service; and having to develop effective liaison relationships across the general hospital when a separate CLP service already has them.
Split POA and CLP coverage. In this model, used in one tertiary and one regional hospital, geriatric inpatient wards are covered by a sub-team of POA by in-reach from its inpatient or community base, while adult and older patients in general wards of the hospital are covered by a generic CLP service. The advantages of this model lie with the POA team having a liaison relationship with geriatric medicine, a direct interface with the POA inpatient unit and a seamless transition from hospital to community care. However, this only applies to the geriatric inpatient wards and leaves the generic CLP service covering the generally larger number of older patients in the general wards of the hospital. Further, because CLP and POA are separate services, formal transfers of care are required when patients transfer from general wards to geriatric inpatient wards within the hospital or are discharged directly to the POA community service. This model also means two separate mental health services becoming involved in all general hospital pathways for older adults.
Shared POA and CLP coverage. In this model, used in two tertiary and two regional hospitals, a POA team in-reaches into the general hospital from their base for their open cases, while a generic CLP service covers all other older adults in the general hospital. While POA in-reach ensures continuity and seamless transition for their open cases, POA liaison is more challenging given open cases are scattered across the general hospital. POA in-reach activity and workload depend on how many open cases there are in the hospital at any one time. Since CLP and POA are separate services, formal transfers of care are required when CLP patients transfer to a POA inpatient unit or are discharged to community POA follow-up.
Generic CLP service. In this model, used in two tertiary, three regional and one district hospitals, a CLP service covers all adult patients aged 18 years and over (including older adults). The clear advantage of this model is there is ‘one team to serve them all’. However, this team faces serious challenges including maintaining ‘specialist’ standards for all its patient groups (with quite diverse needs), maintaining effective liaison relationships with specialist services for older adults (e.g. geriatric medicine, POA and aged residential care) and relying on a separate service (i.e. POA) for inpatient unit transfers, community follow-ups and specialist aged residential care assessments.
Separate CLP for older adults. In this model, used in one tertiary hospital, all older inpatients are covered by a separate, dedicated CLP team specialising in older adults. The clear advantage of this model is a specialist team dedicated to the unique needs of older adults, with strong liaison links with both geriatric medicine and POA. However, this model produces an arbitrary split between patients under and over 65 in the same hospital (the former is covered by an adult CLP team and the latter by a CLP team for older adults). Further challenges include providing leave and vacancy cover for a small separate team, the potential for demand to outstrip capacity, the inevitable tensions over funding (POA or CLP or joint) and the lack of integration with the adult CLP team.
Integrated CLP team for older adults. In this model, used in one regional hospital, there is a specialist CLP team for all older adult inpatients, integrated within a broader CLP or psychological medicine umbrella service. The clear advantage of this model is a specialist team dedicated to the unique needs of older adults that also has strong liaison links with geriatric medicine and POA and functional links with an adult CLP team to ensure ‘horizontal’ staffing cover for a small team. While the potential remains for demand to outstrip capacity, caseload adjustments are more likely with the adult and older adult CLP teams being components within the same service umbrella.
International comparisons
Recent international surveys have shown results very similar to New Zealand. In England (Walker et al., 2018), the vast majority of their 170 acute hospitals had all-age generic CLP services, while only 24% had dedicated specialist CLP services for older adults. In Ireland (Gallagher et al., 2015), consultation by POA in-reach on a sessional basis was the dominant model, with staffing consisting mainly of psychiatrists and registrars, infrequent coverage of the emergency department and few proactive or educational initiatives. The situation in Australia (Flavel et al., 2022), where coverage of older adults by a generic or all-age CLP service was the most common model (72%), but POA in-reach, coverage split or shared between CLP and POA in-reach, specialist CLP services for older adults and no service at all, were also described, closely mirrored New Zealand.
The case for specialist CLP for older adults
In the context of the global phenomenon of rapidly ageing populations, there are strong arguments for CLP for older adults being a separate sub-specialty of both CLP and POA. The mental health problems encountered in older adults are different to those of younger hospital inpatients (principally depression, delirium and dementia, but also a panoply of other older adult presentations), arise in different psychosocial contexts (the effects of ageing, long term co-morbid medical and psychiatric conditions, frailty and functional decline, grief, isolation and loneliness), and therefore require specific approaches to care and treatment. The key liaison linkages and service interfaces for CLP for older adults are specialist and include hospital pathways/guidelines for delirium, dementia and capacity assessment, POA inpatient units and community services, geriatric inpatient wards and community services, memory clinics, aged residential care and community advocacy/support organisations for older adults. The specific competencies for CLP for older adults require specialist training, including assessing mental health problems of later life, wishes for hastened death and suicidality, reversibility and need for rehabilitation and decisional capacity; prescribing psychotropic medications for older adults, managing behavioural and psychological symptoms of dementia; and operating in general medical settings, aged residential care and complex domestic situations involving squalor and elder abuse. The Royal College of Psychiatrists’ position statement on the provision of CLP services across the lifespan (Royal College of Psychiatrists, 2019a) treats young people, working age adults and older adults equitably, making it clear that comprehensive, specialist CLP services should be available to patients of all ages.
The case for integration
Integrated healthcare occurs when all components of a health system come together to work seamlessly for patients and is an especially important element in ensuring that patients with severe, complex or co-morbid conditions get the help they need (Royal College of Psychiatrists, 2019b). For example, patients with long-term chronic medical conditions, medically unexplained symptoms and urgent situations requiring immediate medical and mental healthcare (such as delirium and self-harm) are particularly likely to benefit from integrated healthcare. CLP is in a unique position to provide integrated healthcare, given it specialises in the assessment and treatment of patients presenting with complex medical and psychiatric co-morbidities.
Using a multidimensional model of integrated care (covering patient, unit, service and organisational levels and ranging from not at all, to fully integrated), a fully integrated CLP service for older adults would provide:
Patient consultations, formulation and management plans, follow-ups, discharge planning and signposting to other services.
Proactive screening for psychiatric disorders, regular attendance at ward ‘huddles’ and multidisciplinary team meetings, opportunistic ‘bedside’ teaching and more formal in-service activities.
Needs assessment for specific patient groups, pathway/guideline development, bespoke education packages and audit, quality improvement and research activities.
Added value to organisational governance, strategy, policy development and monitoring of quality standards.
Synthesis and recommendations
The case for specialist, integrated CLP teams for older adults with an explicitly age-appropriate needs-led approach is strong. These teams could sit alongside specialist CLP teams for working age adults, children and adolescents, addictions and the clinical and health psychologists working in physical health settings, all within a broader CLP or psychological medicine umbrella service; and be integrated vertically within the hospital, horizontally with geriatric medicine and allied health and externally with aged residential care, primary and secondary care services and community organisations (Thacker et al., 2017). In support of this, the Royal College of Psychiatrists’ Faculty of CLP recommends that one of the two psychiatrists in a CLP service for a 500-bed hospital be an old age psychiatrist (Royal College of Psychiatrists, 2019b). Integrated CLP teams for older adults are preferred over POA in-reach models and split or shared POA/CLP arrangements because of their greater coherence, responsiveness and relationships across the general hospital and their potential to improve outcomes and reduce healthcare costs for older adult inpatients with comorbidities. Although in light of the current evidence base (Cations et al., 2022), the effectiveness of this approach will need to be tested with further research.
Given the mosaic of different sized hospitals in New Zealand, one service model is unlikely to be universally applicable, but the principles of specialisation and integration remain highly relevant. Large tertiary hospitals are likely to be able to support specialist CLP teams for older adults. Regional hospitals are likely to be able to support staff working with a ‘special interest’ in older people within their CLP services. District and smaller (<100 beds) hospitals without CLP services will continue to rely on POA in-reach. Linkages inside and outside of the hospital with geriatric medicine, POA, allied health and community providers and agencies will be vital to all three tiers of services. The use of innovative methods such as telepsychiatry in large tertiary hospitals could be used to support regional, district and smaller hospitals to provide high-quality psychiatric care to medically ill older adults.
Narrowing the very sizeable gap between where we are now and the solutions we have proposed will require immediate, prospective planning, otherwise services are at risk of being overwhelmed by the very rapid increases in the population aged 65+ (and especially those aged 85+). The amalgamation of health services across New Zealand could support the development of CLP services including those for older adults and presents a remarkable opportunity if the reorganisation is undertaken and resourced commensurately.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
