Mental health in old age

This section considers both mental illness in those aged 65 and older, and dementia in those of all ages.

Dementia

Dementia is the term used to describe a group of related symptoms associated with progressive memory loss. Dementia can be caused by a number of different diseases but the most common causes are Alzheimer's disease, vascular dementia, mixed dementia and dementia with Lewy bodies.

Symptoms associated with dementia include problems with understanding and judgement, communication and thinking speed, and a reduction in a person's ability to carry out daily activities such as washing, dressing and cooking. Other symptoms that may be related include changes in personality and mood including depression.

Dementia is a progressive condition, which means that the symptoms will gradually get worse. Most types of dementia cannot be cured, but detecting it early can aid with obtaining the right treatment and support and can help slow progression.

Dementia Although it is most commonly found in people aged over 65 years of age, age although people younger than this can suffer from early-onset dementia. It is predicted that the numbers of people affected with dementia will rise nationally. In Slough the numbers of people with dementia is estimated to rise year on year and by 2025 it is expected that 1261 people will have dementia.

Depression and anxiety

Everybody will experience times of feeling low or miserable but when these feelings persist or interfere in daily life then a person could be suffering from depression. Depression can range from mild depression which can make daily tasks harder to do to severe clinical depression which can be accompanied by suicidal thoughts or ideations.

Many older people experience psychological or emotional distress and depression associated with factors linked to old age, including isolation, loss of independence, loneliness, physical illness and/or disabilities and losses of many kinds, including bereavements.

Information provided by the Mental Health Foundation suggests that nationally; depression affects 1 in 5 older people living in the community and 2 in 5 older people in care homes. An estimated 2 to 4% have severe depression. Estimates based on McDougall et al’s (2007) study suggest that around 1,200 older people living in Slough are estimated to have depression with numbers rising slightly year on year.

What do we know?

According to the Alzheimer’s Society, there are around 850,000 people in the UK with dementia. One in six people aged 80 and over have dementia and two thirds of people with dementia are women.

There are 40,000 people under the age of 65 with dementia in the UK. There are 25,000 people with dementia from black and minority ethnic groups in the UK. The number of people with dementia is increasing because people are living longer. There are 670,000 carers of people with dementia in the UK. It is estimated that by 2025, the number of people with dementia in the UK will have increased to around 1 million.

The mental health of older people impacts upon acute general hospitals and care home populations as 50-80% of care home residents can be expected to suffer from dementia. To illustrate, a typical district general hospital with 500 beds will admit 5,000 older people each year and 3,000 will suffer a mental disorder in addition to the physical disorder for which they were admitted. On average, older people will occupy 330 of these beds at any time and 220 of these will have a mental disorder.

Facts, Figures, Trends

Dementia prevalence and projections

Community Health Profiles 2013 showed data for 2010-11, in which Slough was ‘significantly worse than England’ for the ratio of recorded to expected prevalence of dementia, meaning that there were estimated to be many people with dementia in Slough that were not being diagnosed.

Efforts to improve this have since been made and the rate of GP registrations of dementia has increased from 0.21% in 2010/11 to now 0.35% in 2014/15. Figure 1 illustrates the increasing number of cases registered with Slough GPs. This remains below the expected number for Slough though is expected to rise further following joint undertakings between Practice surgeries, the Slough Memory Clinic and Slough CCG.

As of September 2015 there were 544 older people (aged over 65) registered with their GP as being diagnosed with dementia in Slough.

Figure 1. Prevalence of Dementia (GP register) in Slough

Figure1

Given our ageing population, predictions have been made about the increasing prevalence of dementia in our communities. There is predicted to be an almost 50% increase in the total number of older people with dementia over the next fifteen years. It is also projected that the number of those aged under 65 with early-onset dementia is likely to increase by a third over this time.

In terms of reducing the risk of dementia, particularly vascular dementia, there is still much to do in Slough. Risk factors for vascular disease (including vascular dementia) such as diabetes, high blood pressure and obesity are a significant problem locally.

Of those in Slough diagnosed with dementia, a significant proportion are admitted to hospital each year. Over 2013/14 the figure was 80% which is an improvement on 84% seen in the previous year but remains higher than the England average of 65%. As a proportion of all emergency admissions for those aged over 65, admissions related to dementia constitute about 3.5%.

In terms of quality of life of those caring for people with dementia, a survey in 2014/15 of those caring for older family members showed that only 39% felt that they had as much social contact as they would like. This is similar to the results on average in England.Figure 1 shows the number of people in Slough predicted to have early onset dementia up to 2030.

National & Local Strategies (Current best practices)

The Department of Health’s Mental Health Strategy No Health without Mental health was published in 2011. This strategy sets out how the government, working with all sectors of the community, will improve the mental health and wellbeing of the population and provide high-quality services that are equally accessible to all. The strategy identifies six outcomes:

  • more people will have good health
  • more people with MH problems will recover
  • more people with MH problems will have good physical health
  • more positive experience of care and support
  • fewer people will suffer avoidable harm
  • reduced stigma and discrimination

The National Dementia Strategy, which was published in 2009, as 5 year plan for improving health and social care services for people with dementia and carers. There are 17 objectives, intended to ensure better knowledge and remove stigma, ensure early diagnosis and develop services.

Local Implementation of the Dementia Strategy has been overseen by a Partnership group, and actions have been focused on review of information to service uses and carers; housing provision; dementia friendly communities; workforce development; accurate data projections. Funding through the Dementia Challenge Fund has supported some of this activity.

Although the strategy has now reached the end of its 5 year term, the principles of the dementia strategy continue to be progressed along with the priorities set through the Prime Ministers Dementia Challenge in 2012. The Slough dementia strategy implementation group continues to pursue best practice through a multi agency approach and meets as a sub group of the Older persons Partnership Board.

A full schedule of guidance can be found at the National Institute of Health and Care Excellence (NICE) website.

Current local activity and services

Services are provided by Berkshire Healthcare NHS Foundation Trust. Some services are jointly provided with Slough Borough Council.
  • Slough Memory Services – based at Upton Hospital
    The Memory Clinic provides specialist assessment and treatment of memory problems at early to moderate stages of dementia as defined by National Institute of Health and Clinical Excellence (NICE). The Clinic offers assessment, prescription of anti-dementia drugs, medication management and monitors effectiveness of medications, as well as side effects. In addition to the outpatients clinics offered, the staff also facilitate support and therapy groups and provide access to a Dementia Advisor.
  • Slough Older Persons Mental Health Liaison service
    An Alzheimers society report in 2009 recommends commissioning of specialist older people’s mental health liaison teams to facilitate the management and care of people with dementia in hospitals. Since July 2014, this service in Slough has expanded and now includes a multi disciplinary team (consultant liaison psychiatrist, nurses, social worker, Occupational therapist and psychologist).
  • Older Persons Mental Health In Patients service- situated at Prospect Park Hospital, Reading
    Two wards, namely Rowan and Orchid, situated at Prospect Park Hospital in Reading, host 40 inpatient beds and care for older adults from the 6 localities in Berkshire, including Slough. The wards provide assessment and treatment to patients with severe and/or enduring conditions such as bipolar disorder, schizophrenia and dementia. Workers from Slough Home treatment team and community mental health team liaise closely with the wards to ensure continuity of care and smooth discharge planning.
  • Community Mental Health Team for Older persons
    This service is jointly provided by Berkshire Healthcare NHS Foundation NHS Trust and Slough Borough Council, to meet mental health and social care needs, and is based at Upton Hospital. The Service provides assessment and treatment to older people with complex mental health problems (both ‘functional’ mental health problems, and needs associated with Dementia), requiring the expertise of health and social care professionals who specialise in conditions associated with later life. Entry to the service is not defined by age, but is based on needs.

What is this telling us?

Dementia is a common condition which can have a significant effect on people and their families. Given the expected changes in demography in Slough, the prevalence of dementia is predicted to increase significantly over the next fifteen years.

Though dementia is currently thought to be under-diagnosed in Slough (the number of diagnosed cases of dementia is lower than that expected in the population), efforts have been made to improve recognition so that the rate of diagnosis has been improving.

What are the key inequalities?

The increasing older population means that the incidence of dementia and conditions affecting older persons will increase. In Slough the population profile means that whilst numbers of older people in Slough are increasing, the increase is less pronounced than in some of our neighboring authorities.

The ethnic profile of Slough means that numbers of service users from Black and Minority Ethnic (BME) groups are increasing. Engagement projects in Slough have shown that providing assessment, treatment and information in different languages and settings has been effective at engaging some BME patients and carers.
Efforts to reach out to the BME communities by the Slough OPMH include:

  1. Widespread use of interpreters
  2. Cognitive stimulation Therapy groups are provided in Punjabi
  3. Dementia Information groups offered in Punjabi
  4. Leaflets and letters available in different languages (Punjabi, Urdu, Polish)
  5. Audible translation is available on the service website
  6. A Part time dementia advisor is employed, who is able to communicate in different Asian languages

Patient engagement projects are undertaken including a Patient Story project to obtain the views of BME service users, and a survey conducted with a section of the BME community, regarding knowledge and myths of the Slough memory Clinic

Lethal Discrimination, Rethink 2013 highlights data showing physical health inequality for people with mental health problems. The report highlights how adults with diagnosed mental health conditions are likely to have poorer physical health and poorer access to physical health services. Whilst the report focuses on younger adults, it also highlights the need to ensure older adults with mental health problems are also supported to maintain good physical health with appropriate screening and intervention.

What are the unmet needs/ service gaps?

  • Training and in-reach for care home staff in managing mental health conditions and dementia has been identified as a need.
  • Housing: Local housing provision including ‘extra care’ housing is not set up to meet needs of people with dementia. There is a need to improve the range of options including use of telecare and telehealth to maintain people in their own homes.
  • Although improving, the low numbers of patients on GP registers may mean that patients are not receiving early diagnosis, treatment and support.

Recommendations for consideration by other key organisations:

  • Substantive funding for the dementia adviser post to be secured.
  • Carer’s needs to continue to be championed through a multi agency approach effectively promoting the rights of carers and offering carers access to services in accordance with the Care Act.
  • It is important to maintain a focus on depression, social inclusion and physical health, and ensure preventive approaches are in place.
  • Housing strategy to include focus on needs of older people with mental health problems including dementia.
  • To continue to monitor and reduce the inappropriate use of anti-psychotic prescribing and treatment of dementia service users in Slough.