Care of Elderly Patients With Functional Disorders: A U.K. Debate

To the Editor: There is an ongoing controversy in Great Britain regarding the care of elderly persons with functional psychiatric disorders who “graduate” from working age into old age and who are traditionally called in Britain “elderly graduates” (1). These individuals often suffer from severe psychotic illnesses. Formerly these patients spent their lives in Victorian mental hospitals, but with the implementation of community care (deinstitutionalization), most now live in the community. The current debate in Britain is in regard to which of the two age-spectrum services—adult general psychiatry or old-age (geriatric) psychiatry—should be responsible for the care of these patients. The Royal College of Psychiatrists in London has suggested that patients should have a needs assessment once they are 65 to determine which of the two services is more appropriate for the individual patient (2).

In a postal survey of 311 consultant psychiatrists in England, Green and colleagues (3) found that no coherent policy exists to determine which of the two services should look after these patients. During the 2002 annual meeting of the Royal College of Psychiatrists, the college's policy document on the care of these patients (2) was discussed. It was clear from the discussions of that meeting that there is very little research evidence to help decide which service should look after these patients and in what circumstances.

Only a few studies have investigated the needs of elderly patients with functional psychiatric disorders. Our analysis of a representative sample of elderly patients with psychosis in two South London sectors who participated in the PRiSM study (Psychiatric Research in Service Management) revealed problems with use of a needs assessment tool that had been validated with younger adults (4). Jolley and colleagues (2) suggested that each mental health provider should assess the care being delivered in their locality to elderly patients with functional psychiatric disorders when these patients reach the age of transition to the responsibility of specialist old-age mental health care. These authors argued that a needs assessment should be conducted that takes local services and resources into consideration.

We have completed a survey using a novel needs assessment schedule that was developed and validated with elderly patients with functional psychiatric disorders—the EPNS (Elderly Psychiatric Needs Schedule)—which is available from the first author (5). In this study we assessed the needs of an epidemiologically based sample of elderly patients with functional psychiatric disorders who were in contact with either old-age psychiatry or adult general psychiatry. Our objective was to explore which of the two services better meets the needs of these patients. Preliminary results suggested that the patients in contact with old-age psychiatry had significantly fewer unmet needs than those in contact with general adult psychiatry. However, this study had some methodological limitations: because it was conducted in an inner-city London area, the study should be repeated in suburban and rural areas.