Mental Health in Older People A Practice Primer

Mental Health in Older People

A Practice Primer

Published by NHS England and NHS Improvement

Christoph Mueller, Clinical Lecturer

Amanda Thompsell, Consultant Old Age Psychiatrist

Daniel Harwood, Consultant Old Age Psychiatrist

Peter Bagshaw, General Practitioner

Alistair Burns, Professor of Old Age Psychiatry

NHS England INFORMATION READER BOX

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Document Purpose

Guidance

Document Name

Older People's Mental Health The Practice Primer

Author

Older People's Mental Health and Dementia, NHS England

Publication Date

11th September 2017

Target Audience

GPs

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List

CCG Clinical Leaders, CCG Accountable Officers, GPs

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Dementia team

NHS England

Quarry House

Quarry Hill

Leeds

LS2 7UE



Document Status

This is a controlled document. Whilst this document may be printed, the electronic version posted on

the intranet is the controlled copy. Any printed copies of this document are not controlled. As a

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always be accessed from the intranet.

Promoting equality and addressing health inequalities are at the heart of NHS England¡¯s values.

Throughout the development of the policies and processes cited in this document, we have:

Given due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of

opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited

under the Equality Act 2010) and those who do not share it; and

Given regard to the need to reduce inequalities between patients in access to, and outcomes from healthcare

services and to ensure services are provided in an integrated way where this might reduce health inequalities.

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OFFICIAL

Document Title: Mental Health in Older People

Subtitle: A Practice Primer

Version number: 1

First published: 12th September 2017

Prepared by:

Alistair Burns ¨C Professor of Old Age Psychiatry, University of Manchester &

National Clinical Director for Mental Health in Older People and Dementia, NHS

England

Amanda Thompsell ¨C Consultant Old Age Psychiatrist, South London and Maudsley

NHS Foundation Trust

Christoph Mueller ¨C Higher Trainee and Clinical Lecturer in Old Age Psychiatry,

South London and Maudsley NHS Foundation Trust

Daniel Harwood ¨C Consultant Old Age Psychiatrist, South London and Maudsley

NHS Foundation Trust

Peter Bagshaw ¨C General Practitioner, CCG Clinical Lead and Director, South West

Clinical Network for Dementia

Classification: OFFICIAL

This information can be made available in alternative formats, such as easy read or

large print, and may be available in alternative languages, upon request.

Please contact 0300 311 22 33 or email england.contactus@ stating that this

document is owned by the Older People¡¯s Mental Health team, Operations &

Information Directorate.

3

Contents

Contents ................................................................................................................................ 4

1.

Foreword by Tom Wright CBE, Age UK ......................................................................... 5

2.

Introduction .................................................................................................................... 6

3.

What¡¯s different about mental health in older people?.................................................... 7

Taking a History ......................................................................................................... 7

Mental state examination ........................................................................................... 7

Physical examination ................................................................................................. 8

Investigations ............................................................................................................. 9

Indications for referral to specialist and older adult mental health services ................ 9

Prescribing................................................................................................................. 9

4.

Depression .................................................................................................................. 10

Symptoms of depression ......................................................................................... 10

Distinguishing Depression and Dementia................................................................. 11

Suicide ..................................................................................................................... 11

Bereavement ........................................................................................................... 11

Drug treatment ......................................................................................................... 12

Alternatives to drugs ................................................................................................ 14

Electroconvulsive Therapy (ECT) ............................................................................. 14

Management of depression in frail older people ....................................................... 15

5.

Anxiety disorders ......................................................................................................... 16

Treatment ................................................................................................................ 17

Insomnia .................................................................................................................. 18

6.

Bipolar affective disorder ............................................................................................. 19

Lithium Monitoring ................................................................................................... 20

7.

Psychotic disorders...................................................................................................... 22

Late-onset schizophrenia ......................................................................................... 22

Symptoms................................................................................................................ 22

Treatment ................................................................................................................ 23

Physical health monitoring ....................................................................................... 23

Indications for referral .............................................................................................. 24

8.

Delirium ....................................................................................................................... 26

9.

Charles Bonnet syndrome ........................................................................................... 27

10.

Alcohol ...................................................................................................................... 27

Management strategies ........................................................................................... 28

11.

Personality problems ................................................................................................ 29

12.

Hoarding disorder and Diogenes syndrome .............................................................. 29

13.

Elder abuse .............................................................................................................. 31

Appendices ......................................................................................................................... 32

¡°What a GP needs to know about¡­¡± ........................................................................ 33

Local summary of services and phone numbers (to self- complete) ......................... 38

National services available....................................................................................... 39

Further reading ........................................................................................................ 39

4

OFFICIAL

1. Foreword by Tom Wright CBE, Age UK

It is now widely accepted that the mental health needs of

older people have historically been under-recognised and

under-treated. Although the proportion of those affected is

broadly in line with other age groups, older people have not

been able to access the same level of support.

Research has also found that older people with common mental health conditions are

more likely to be on drug therapies and less likely to be in receipt of talking therapies

compared to other age groups. Older people themselves may be reluctant to seek

help ¨C with fewer than one in six older people with depression ever discussing it with

their GP.

Later life is a time when getting the right support is extremely important for wellbeing

due to the complex challenges older people often face. As our population ages, it is

crucial to ensure that older people¡¯s mental health not only attains parity with physical

health diagnostics and care, but parity with other age groups too.

At Age UK we are committed to addressing the mental health needs of older people

so that they can live fulfilling later lives. Over the past few years we have worked with

NHS England on a campaign to improve older people¡¯s access to talking therapies

with the aim of fighting stigma and misconceptions. We are also running a number of

pilots and services across the country, including in partnership with Mind, to enhance

psychological coping strategies, wellbeing and social connections among older

people.

Age UK warmly welcomes the initiatives NHS England is taking to concentrate on

mental health in older people, to which this Practice Primer is a valuable contribution.

Improving the identification and management of older people¡¯s mental health

conditions in primary care is a priority and the Primer shows that the majority of

mental health conditions are highly treatable, whether through medical or nonmedical approaches, including talking therapies and social prescribing.

This publication represents a hugely significant step in the right direction and we

hope that clinicians will find it an essential touchstone for their practice.

Tom Wright CBE

Group CEO, Age UK

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