The last century witnessed significant changes in contemporary demographics: average life expectancy increased and the emphasis in disease epidemiology changed from infectious diseases and acute illnesses to chronic diseases and degenerative illnesses (e.g., cardiovascular disease and cancer, respiratory diseases and injuries, diabetes, and Alzheimer's disease) [1]. These changes have led to major changes in medical practice as well, especially in developed Western countries, with the instigation of new specialized medical disciplines aimed at improving the health of older adults, including geriatric medicine, geriatric orthopedics, and psychogeriatrics. Although these three disciplines have evolved relatively independently, they all share a common denominator—the special expertise needed to maintain the well-being of elderly people. It is therefore not surprising that an interdisciplinary approach is increasingly needed, with regular psychogeriatric input to both medical and surgical clinical settings.
In Great Britain, liaison psychiatry for older adults (LPOA) has become established as a new discipline in psychogeriatrics over the last 8–10 years. It has been recognized by the following publications: the National Service Framework for Older People (Department of Health, 2001), which calls for a skill-mix ability to meet the complex needs of older people; the NICE (2004) guidelines for depression; the Royal College of Psychiatrists' (2005) document “Who Cares Wins,” which provides a comprehensive view of mental health care for older people in a general hospital setting; and, most recently, Everybody's Business (www.everybodysbusiness.org.uk, 2005), which stresses the value of psychiatric input in the medical care of elderly individuals.
Although LPOA services are established in several centers (Leeds, Newcastle, and London), a recent review reported that 73% of liaison services are provided via a generic sector-based psychiatry model. The role and composition of liaison services vary, with dedicated liaison psychiatry nurses for older people engaged in only 14% of services, whereas all services have a medical psychiatric input [2]. Nurse-led mental health liaison services for older people do not appear to be effective in reducing general psychiatric morbidity, although they may have a modest effect on depression [3].
Undoubtedly, the biggest contribution of liaison nursing teams lies in facilitating effective discharge planning and continuity of care [4]. The survey discussed in Reference [4] also revealed that, although input from occupational therapists is often needed by teams, it was routinely available to only less than 2% of liaison nursing teams.
Changes in health care delivery and increasing diversity of the elderly population in both urban and rural settings, together with high expectations from families and home care needs, place additional pressure on social services to meet the needs of the elderly population. This is further complicated per se by a lack of social workers with sufficient knowledge and experience to deal with medical and mental health problems, highlighting a need for the development of educational programs so that these demands can be met in field practice [5]. In this respect, interdisciplinary team training may be beneficial: it has been proven to change both attitudes across medical, nursing, and social work professions and team dynamics. However, it has no major influence on care planning measures [6].
Although it is expected that liaison services will deal with psychiatric conditions irrespective of age, it is becoming increasingly apparent that there are differences between adult and older adult liaison psychiatric services. Thus, comorbidity and previous contact with psychiatric services are more frequent for those seen by LPOA services than for those seen by adult liaison psychiatry services [7]. There is a higher prevalence of social issues in a vulnerable population of elderly male patients living alone who are referred to LPOA services and neurodegenerative disorders in nearly 70% of all patients referred to such services with associated behavioral problems (Mukaetova-Ladinska et al., unpublished data), although the prevalence of depression (10–15%) remains similar for both adult and older adult referrals ([7]; Mukaetova-Ladinska et al., unpublished data). There is underrepresentation of fatigue syndrome, deliberate self-harm, borderline personality disorders, and personality disorders in general. However, there is a high level of assessment for mental capacity, level of care, placement, acute confusional state, medication advice, and polypharmacy; in addition, there are previously undiagnosed cases of learning disability, including autistic spectrum disorders (especially the Asperger syndrome) [8].
Although LPOA is a relatively new discipline within liaison psychiatry, those of us who work within it have already identified a number of clinical needs quite distinct from those of adult liaison psychiatry. This is particularly so in terms of the detailed mental state examination, which includes domains such as mental function and capacity as well as complex and long-term management. This requires the use and adaptation of specific clinical tools (e.g., clinical rating scales usually used in liaison psychiatry) for the elderly population with varying degrees of cognitive impairment. There is therefore a need for further development of simple clinical aids that would be highly sensitive and specific to detect psychiatric disorders in older adults with a medical illness. These will need to be easy to administer, not time-consuming, and, in particular, independent of cognitive impairment and level of education.
In the future, LPOA services should also draw from the experiences of adult liaison services—many of the patients seen by the latter sector may eventually become involved with LPOA. This has relevance for the further development of services with respect to clinical expertise and potential changes in current clinical practice to include dealing with more psychosomatic illnesses, personality disorders, and unexplained medical syndromes that are currently underrepresented in our clinical load. This will require adaptation of the existing LPOA service profile (predominantly a biologic model dealing with neurodegenerative disorders as well as associated behavioral and social changes) to include psychologic support, requiring expertise in psychotherapy.
In this respect, liaison old age psychiatrists and their affiliated specialties need to become more integrated within the liaison psychiatry family. The EACLPP would be an ideal forum for this process, providing the opportunity to share experiences via participation in working groups, sessions, and symposia. This would facilitate a “working together” initiative and assist with the further development and integration of this new discipline.
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