Author: María Isabel Tornero
Origin/Affiliation: Early Career Geriatrician at Hospital Cien Pozuelos.
There is a day, September 21, dedicated to Alzheimer’s disease and some pages for the knowledge of geriatrics and public media publish information in reference every year. I want to honour not only this day but all the other days of the year those people in advanced age with a mental pathology, not only dementia, that don´t have an assigned day in the calendar.
It has been estimated that in 2030, 65.7 million people will suffer dementia and in 2050, 115.4 million. However, it is not only dementia. Major depression is present in 1-4% of people 65 or older and its prevalence increases with age. 10-15% of older adults have depressive symptoms clinically significative although not complying the criteria of major depression and around 10% suffer anxiety disorders. Psychosis is neither an isolated phenomenon in the older, with a 27% of those living in their community and up to 62% if those living in institutions.
The “psychogeriatric patient” is not only a psychiatric person with age, but one with a complex medical treatment in whom besides the (neuro)psychiatric illness coexist many other organic pathologies, polypharmacy, vulnerability and frailty, that can influence or be affected by the first and reduce the quality of life of the person and its environment (overload of the caregiver, institutionalization, negligence in the care, hospitalizations and death).
After reading these facts one asks herself, what are we doing about it? We are talking about an authentic social problem in an everyday older society, in which there is a high prevalence of psychiatric and neuropsychiatric disorders with all the consequences that these create in society social and economically. The World Health Organization (WHO) and the World Psychiatric Association (WPA) echoed this worry and in 1996 defined “Geriatric Psychiatry”, “Gerontopsychiatry” or “Psychogeriatrics”. A branch of Psychiatry centered in a multidisciplinary care of peoples ‘s mental health who are in retirement age, which varies from one country to another. In 1997, WHO and WPA agreed on publishing a document about psychogeriatric care where the principles of these cares were established (integral, accessible, quick, individualized, transdisciplinary, responsible and systematic) as well as the environmental components for its application based on a continues care system (Figure 1).
A-Community Mental Health Teams for Older People. B- Inpatient services. C- Day hospitals. D- Out-patient services. E- Hospital Respite Care. F- Continuing Hospital Care. G- Liaison Services. H- Primary Care. I- Community and social support services. J- Prevention. Figure 1: Surround with care.
Although we are on our way, we still have a long way to go.
The development of Psychogeriatrics is low in Europe and Spain is an example. To improve the quality of assistance we would have to begin by increasing its visibility through the citizen consciousness and incentivate the teaching of medical personnel helping the development of the subspeciality in medical, psychological, nursing, auxiliary, social workers, physiotherapy and nutritional environment.
Since in 1989 Psychogeriatrics was recognized as a subspecialty for the first time in United Kingdom, only 6 countries consider it but only like a part of the medical education and not a part of the other careers that should include the multidisciplinary team. The current efforts are in the hands of those professionals most sensibilized with the psychopathological world, which are few, besides those who are involved in master degrees on the subject.
In a structural level, although WHO’s recommendations, pyschogeriatric services have barely reached their development with a very wide variability in its typology, structure, organization, extension and team composition, besides the lack of conditioning of medical centres (Emergency services for instance). Nobody would think of a hospital without coronary unit or a post surgery room but it would be normal to find a third age person screaming all night, tied to a bed, alone and in the dark. Nobody realizes we are on the wrong path?
The scientific evidence in relation to the efficiency of the pyschogeriatric services is scarce. To summarize the evidences supplied by WHO is strong for the multidisciplinary community teams and weak for acute hospital units, with very little control studies done. This could encourage us to continue investigating and not quit.
We need more resources, not only economic and social, of course, but humans in quality and quantity. As a curiosity, in Spain there are 6 memory units known, 116 consulting offices for cognitive monographic impairment, some unaccounted consulting offices beyond dementia depending on Psychiatry and some unaccounted psychogeriatric hospitalization units but 306 associations of relatives of Alzheimer's patients. All of these speak to us of the deep social demand, to which no voice is being given.
As a conclusion, I find the important to have three basic pillars:
First, an excited and more qualified medical personnel who get…
A society that is consciousness of the problem to have....
A government that gives priority to this situation, finally.
What do you think?
Mª Isabel Tornero López,
Citizen and geriatrician.