What is the effectiveness of old-age mental health services?

Summary

The issue

The European Region had 15% of its population 65 years old or older and nearly 7% 75 or over in 2000, the world’s highest percentages. By 2030 these figures will increase to 24% and 12% respectively. The effect on health care will be amplified by a disproportionate increase in dementia, and depression, anxiety, schizophrenia, substance abuse disorders and delirium are also of major concern. Therefore effective services to treat mental illness in older people will become an ever-increasing imperative.

Findings

Old-age mental health services are usually defined as multidisciplinary, comprehensive, integrated service delivery to a defined catchment area. The quality of evidence relating to old-age mental health services is improving, but there are few studies evaluating overall models of old-age-specific mental health care. Effective models of general health care for older people include:

• a single entry-point system
• case management
• assessment and multidisciplinary teams
• use of financial incentives to encourage less expensive, community-based care.

The evidence for the effectiveness of old-age mental health service ranges from strong, for community multidisciplinary teams, to weak, for acute hospital care; this is mainly due to a lack of controlled studies rather than measured ineffectiveness. Old-age mental health models involving case management in the community have been shown to be effective, and there is limited evidence to support liaison in long-term residential care. However, both options are more staff-intensive than the alternative “assessment only” consultation service style. Integration of acute hospital and community care has also been shown to improve outcomes following hospital discharge. The limited evidence also suggests that old-age mental health services are more effective than geriatric medical and adult mental health services.

There is lower quality, albeit consistently positive, evidence of the effectiveness of acute hospital care. Controlled studies are required to determine whether alternative forms of community or hospital care are as effective. While community residences for long-term institutional care appear to offer better quality care than hospitals, it is unclear whether there are particular patients who require long term psychogeriatric hospitalization.

Policy considerations

The most widely accepted model is multidisciplinary, comprehensive, integrated service delivery to a defined catchment area, and this is the basis of the World Psychiatric Association (WPA) and World Health Organization consensus statement on the organization of care in old-age psychiatry. The strongest evidence supports the development of community multidisciplinary teams as a major service-delivery component, and this should be encouraged in all European countries, as should partnerships with consumers, nongovernmental organizations, primary care providers, social services, long-term residential care providers and other medical services.

• There is good evidence (level I/II) to support the effectiveness of multidisciplinary, individualized community services; primary/specialist care collaborations for treatment of late life depression; outreach services to residential care; integrated post discharge mental health services and treatments to prevent delirium in medical wards (but effects are modest).
• There is limited evidence (level III or II/IV) to support consultation/liaison mental health services to medical wards or long-stay psychogeriatric wards for less-dependent patients.
• There is weak evidence (level IV) to support day hospitals, general adult mental health wards, old-age mental health wards, or combined old-age mental health and geriatric wards.
• No benefit was found from geriatric medical post discharge services.