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Recognising mental health problems in older patients

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VOL: 96, ISSUE: 48, PAGE NO: 41

Jayne Sayers, BSc, RMN, is training coordinator for primary care, older adult psychology department, mental health services, Mental Health Services of Salford NHS Trust

A fifth of the population is aged over 60 and eight million people are over 65. For many older people, retirement offers the chance to engage in hobbies and activities they did not have time for during their working lives.

A fifth of the population is aged over 60 and eight million people are over 65. For many older people, retirement offers the chance to engage in hobbies and activities they did not have time for during their working lives.

The absence of physical ill health and psychological problems is crucial to enjoying life at this stage. Although mental health problems in older adults are not an inevitable part of the ageing process, their mental health problems are often not detected or treated.

Psychiatric epidemiological studies (Copeland et al, 1987; Evans and Katona, 1993) have shown that mental health problems are common in older people, especially depression and dementia. Many also have anxiety disorders or misuse alcohol. But they are often not offered any treatment or support for their mental health problems.

Studies have suggested that, on average, GPs identify only about half the psychological problems of patients presenting to them (Marks et al, 1979). Many present with physical rather than psychological complaints, and psychiatric disorders associated with physical disease are less likely to be acknowledged as needing treatment in their own right. This is more likely to be a problem with older patients as the prevalence of physical disorders rises with age.

The project
In view of this, Mental Health Services of Salford NHS Trust carried out a survey of the mental health needs of patients using older adult primary care services (Watts et al, 1996). The sample size, methodology and incidence of those in need of treatment is shown in Box 1.

The most significant result was the high incidence of patients in need of treatment that the sample revealed. Anxiety was the most common problem identified by all screening measures: 14% were shown to have mild anxiety and 12% had more severe anxiety.

Screening also identified 7% as experiencing mild depression and only 2% with more severe depression, while 9% were diagnosed with dementia.

Worryingly for primary care, 60% of the patients who took part in the survey said they had attended the practice for a physical illness. Only 6% indicated that they had sought help for a psychological or emotional problem. In total, 48% were found to have mental health needs and the survey emphasised the close correlation between physical and mental well-being.

Of the participants who had a mental health problem, 33% felt that talking to someone about their feelings would be the most useful treatment.

Practice staff proved accurate in identifying people with more severe mental health needs but were less accurate in detecting mild to moderate problems. There was also limited use of mental health screening, including the over-75 annual check.

The high proportions of patients with depression reported elsewhere (Evans and Katona, 1993) were not found in this study, but this may be attributable to different methodologies. This survey screened attendees at a single practice, as opposed to week-long study periods with 14 different practitioners. Furthermore, many studies have restricted themselves to identifying one diagnostic area only, such as depression, whereas a more holistic approach is likely to provide a more accurate picture of distress and the management/treatment required.

This survey supports other research findings that mental health problems in older adults are often not recognised or treated. In response to these findings, a training course focusing on mental health problems in older adults was developed for primary care staff in Salford.

In September 1999, after the successful implementation of a small-scale training initiative in Salford, a primary care mental health service for older adults within the psychology service was commissioned by Greater Manchester West NHS Education and Training Consortium.

The aim is to train primary health care nurses across the district, including Salford, Trafford, Bolton, Rochdale, Wigan and Bury. Training is currently up and running in all these areas.

The training programme is offered at two levels for practice nurses, district nurses and health visitors. It is specifically designed to raise awareness of mental health problems in older people, promote mental health and positive attitudes, and improve the recognition and management of these problems in primary care settings.

During week one of the four-week course, nurses explore the concept of mental health, the importance of mental health promotion in primary care and their role in encouraging inclusive practice. They also discuss the early recognition and management of anxiety and depression in older people by identifying potential psychosocial triggers and working through a series of case histories.

The second week highlights the importance of differential diagnosis in dementia in primary care and the need for carer support and regular review. The training format is multidisciplinary. During week three of the first level, participants meet the mental health teams from each respective area, promoting communication between primary and secondary care services and clarifying their respective roles.

The final week of level one discusses medication issues, with a pharmacist highlighting the risk of polypharmacy in older people and the need for regular review.

Level two builds on the knowledge gained during level one and begins with a member of the psychology team discussing the use of screening questionnaires and instruments and how they can be integrated into physical health assessments.

During the second week, the local mental health team shows nurses how to implement protocols to conduct suicide risk assessments that are appropriate to primary care settings and identify the point at which a patient needs to be referred to secondary mental health services.

Week three covers basic psychological approaches, with occupational therapists revealing how planning can significantly help to improve life for a patient with a functional illness. The counselling team demonstrates communication skills using role play.

The final session focuses on participants developing action plans, encouraging them to do something concrete with the training when they return to their clinical area.

Training in practice
All nurses must complete level one before moving on to the second level. The training takes place over four consecutive weeks and amounts to a total of eight hours for each level.

Each course is evaluated both by those who took part and by the training project team to ensure it meets the needs of primary health care nurses and remains focused within the national context of modernising and changing mental health services.

The evaluation of referrals received by secondary mental health services in the Salford area indicate that, in the 10 practices that are allowed to refer directly to community psychiatric nursing services, the number of referrals has halved over a two-year period. This may be due to the fact that specific protocols on dementia and depression mean that referrals are probably filtered out. In addition, a primary care liaison nurse who specialises in this area has been appointed to offer advice and support, which promotes timely and appropriate referrals as well as the more effective management of mild to moderate mental health problems at primary care level.

The courses have been well received and course evaluations have reported nurses' increased confidence in the recognition, referral and management of mental health problems in older people.

The annual screening of patients aged over 75 has been in operation since 1990. Practice nurses usually carry this out and it has been suggested that such screening should include questions to detect probable depression and dementia and assess social networks (Illiffe et al, 1991).

The Salford training package has shown that primary health care nurses can be trained in brief assessment tools and management techniques that are suitable for primary health care settings. The training project team hopes that this innovative approach to raising the profile of mental health needs in older people is only the beginning.

In the not too distant future, it is hoped that training will be extended to other groups of people working in primary care who have regular contact with older people, such as nursing assistants and administrative staff. Ageism and the assumption that mental health problems in older people are inevitable lead to a reluctance to refer older people for appropriate help. Mental Health Services of Salford NHS Trust has taken steps to redress this, but on a wider scale there is still much work to be done.

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