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Editorials

205
Age and Ageing 2005; 34: 205207 The Author 2005. Published by Oxford University Press on behalf of the British Geriatrics Society.
doi:10.1093/ageing/afi073 All rights reserved. For Permissions, please email: journals.permissions@oupjournals.org
Liaison psychiatry for older peoplean
overlooked opportunity
Introduction
People aged 65 years and over occupy two-thirds of NHS
beds [1] and approximately 60% of older people admitted to
general hospitals will have a co-morbid mental disorder.
Most UK old age psychiatry services respond to mental
disorder in general hospitals by providing a consultation
service on a case by case basis [2]. This model relies on
general hospital staff detecting mental disorder and referring
appropriately. This is a problem. Mental disorder is poorly
detected [38] and psychiatric recommendations are not
implemented [9].
For adults of working age, specialist general hospital-
based consultation-liaison psychiatry services have developed
that work jointly and proactively with general hospital staff
to provide clinical services and training in basic psychiatric
management. This speciality has a clear career path, training
programme with a competency-based curriculum, an aca-
demic sector and sub-speciality status on the General Medical
Council specialist register. The Royal College of Psychia-
trists provides a model consultant job description that specifies
the structure and resources necessary for a service. There
are at least 93 funded consultant posts in liaison psychiatry
in Britain [10]. None of this exists for older people. Is this
ageism?
Morbidity and outcome
Mental disorder affecting older people is 34 times more
common in general hospitals than in the community. A
teaching hospital admitting 20,000 older people per annum
will encounter over 10,000 episodes of mental disorder per
year. Eighty per cent of the psychiatric morbidity is delirium,
dementia and depression. A systematic review of the literature
(details from the authors, unpublished data) shows the
mean prevalence for depression to be 29%, delirium 20%
and dementia 31%. A systematic review of elderly people
with hip fractures reported the prevalence range to be
947% for depression, 4361% for delirium and 3188%
for unspecified cognitive impairment [11].
Not only are these conditions common but they are also
independent predictors of poor outcomes. A further sys-
tematic review of the literature (details from the authors,
unpublished data) shows that mental disorders increase
mortality, length of stay, transfer to institutional care and
reduce independent function at discharge. Some of these
effects remain evident after discharge so that mental disorder
predicts mortality 2 years after hip fracture [12] and depres-
sion is associated with increased health care utilisation [13].
The cost of these effects is substantial and they are likely
to rise as the population ages and the in-patient population
becomes more frail and complex. More effective manage-
ment of co-morbid mental disorder could make an important
contribution to better outcomes for older people and
improve the performance of general hospital NHS trusts.
Improving outcome
Each mental disorder presents a different challenge but
there is now evidence from controlled clinical trials that
these conditions can be effectively prevented and treated
and that this improves outcome.
From studies identifying the major predisposing and
precipitating factors for incident delirium [14] it is now
possible to recognise those most at risk at the time of
admission and the factors that are liable to precipitate a
delirium. Employing this information, a clinically controlled
preventative intervention study of 852 medical admissions
over age 70 targeted moderate and high-risk patients and
achieved a 33% reduction of incident delirium compared to
usual care [15]. A randomised trial of elderly hip fracture
patients receiving proactive geriatric consultation reduced
episodes of delirium by one-third and severe delirium by
40% [16].
Conversely, a randomised trial of systematic detection
and specialist multidisciplinary care for established delir-
ium in medical patients proved no better than usual care
using a number of outcome measures [17]. In medical
wards the emphasis needs to be prevention and specialist
treatment of delirium seems to offer no advantage over
usual care. A systematic review of early detection and
management of potential aetiological factors can have
beneficial effects on cognitive and functional recovery of
surgical patients [18].
A randomised controlled trial of intensive multidiscip-
linary rehabilitation of elderly hip fracture patients achieved
reduced length of stay for patients with mild and moderate
dementia, and those with mild dementia were as success-
ful returning to independent living as patients without
dementia. Furthermore, patients with mild and moderate
dementia from the intervention group were more likely to
be living independently 3 months after fracture than the
usual care group [19].
Randomised trials have shown fluoxetine to be more
effective than placebo for the treatment of depression in
seriously medically ill older patients [20] and psychological
treatment to be superior to usual care for resolution of
depressive symptoms 6 months after admission [21].

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D. Anderson and J. Holmes
206
A prospective clinically controlled trial of routine con-
sultation-liaison psychiatry with elderly hip fractures was
associated with a reduced length of stay. In this comparative
study the intervention group had a mean length of stay
2 days less than the usual care group and the cost of the
service was offset by the shorter duration of admission [22].
Consultation or liaison?
The usual approach to the delivery of mental health services
to general hospitals in the NHS is consultation [2] where
general staff refer a patient to the psychiatry department and
a mental health professional (usually a doctor) provides an
assessment and advice. Patients are usually only reviewed if
referred again.
The consultation model has serious limitations. It is usually
slow to respond and considered low priority because it is
seen as add on work by community psychiatry staff, who
see the community as priority [2]. It is reactive, depends on
general staff to refer the right patients and adherence to
recommendations is poor. A randomised pilot study of psy-
chiatric consultation for depression reported that over 50%
of recommendations were never implemented, including
the prescribing of antidepressants, and that the outcome
was no better than usual care [9]. The consultation approach
does not educate general hospital staff.
The liaison model is dedicated work in the general
hospital. It is proactive, collaborating with general depart-
ments in shared care, taking part in joint meetings and
developing education and training programmes for general
staff to improve their basic psychiatric skills. The solution
to this considerable morbidity is not to refer more patients
for psychiatric assessment (currently around 35% of
elderly admissions are referred) but to improve the know-
ledge and expertise of general ward staff. Education is key
to tackling this problem.
A systematic review concluded that liaison was associated
with higher referral rate, more referrals of depression, better
diagnostic accuracy by referring doctors, more psychiatric
reviews and increased adherence to recommendations [23].
Conclusion
The presence of psychiatric co-morbidity in elderly general
hospital admissions is common and is an independent predic-
tor of poor outcome for patients and the general hospital.
There is now evidence from controlled trials that pre-
vention and treatment of these disorders is possible and
improves outcome. The provision of consultation-liaison
psychiatry provides the general hospital with a dedicated
specialist service to deal more intensively with patient mana-
gement and the ability to provide training and facilitate
more effective management of mental disorders by general
ward staff.
The issue of psychiatric co-morbidity will not go away.
If ignored the situation will get worse. Until consultation-
liaison psychiatry services for older people are suitably com-
missioned and provided, general hospitals will not have the
skill mix to meet demand and ensure the best care is delivered
where it is needed. Failure to provide these services is a
missed opportunity to improve the outcome for older
people admitted to general hospitals and for the general
hospitals themselves.
Key points
60% of admissions of older people to general hospitals
are accompanied by a co-morbid mental disorder.
Mental disorder is an independent predictor of poor
outcomes.
Controlled trials demonstrate that mental disorder can be
effectively prevented and treated and this improves
outcome.
The key to tackling co-morbidity is education that will
improve the basic psychiatric knowledge and skills of
general ward staff.
Liaison models are more effective than traditional
consultation for delivering psychiatry services and educa-
tion to general hospitals and should be developed as they
are for working age adults.
DAVID ANDERSON
1
*, JOHN HOLMES
2
1
Mersey Care NHS Trust, Mossley Hill Hospital, Merseyside, UK
2
University of Leeds, Leeds, UK
Email: helen.bickerton@merseycare.nhs.uk
*To whom correspondence should be addressed
References
1. Department of Health. National Service Framework for Older
People, 2001.
2. Holmes J, Bentley K, Cameron I. Between two stools: psychi-
atric services for older people in general hospitals. University
of Leeds, 2002.
3. Inouye SK. The dilemma of delirium: clinical and research
controversies regarding diagnosis and evaluation of delirium
in hospitalised elderly medical patients. Am J Med 1994; 97:
27888.
4. Ardern M, Mayou R, Feldman E et al. Cognitive impairment in
the elderly medically ill: how often is it missed? Int J Geriatr
Psychiatry 1993; 8: 92937.
5. Harwood DMJ, Hope T, Jacoby R. Cognitive impairment in
medical inpatients: II; do physicians miss cognitive impair-
ment? Age Ageing 1997; 26: 379.
6. Rapp SR, Parisi SA, Walsh DA et al. Detecting depression in eld-
erly medical inpatients. J Consult Clin Psychol 1988; 56: 50913.
7. Koenig HG, Meador KG, Cohen HJ et al. Detection and treat-
ment of major depression in older medically ill hospitalised
patients. Int J Psychiatry Med 1988; 18: 1731.
8. Jackson R, Baldwin B. Detecting depression in elderly medi-
cally ill patients: the use of the Geriatric Depression Scale
compared with medical and nursing observations. Age Ageing
1993; 22: 34953.
9. Shah A, Odutoye K, De T. Depression in acutely ill elderly inpa-
tients: a pilot study of early identification and intervention by
formal psychogeriatric consultation. J Aff Dis 2001; 62: 23340.
10. Swift G, Guthrie E. Liaison psychiatry continues to expand:
developing services in the British Isles. Psychiatric Bull 2003;
27: 33941.

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/
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Editorials
207
11. Holmes JD, House AO. Psychiatric illness in hip fracture. Age
Ageing 2000; 29: 53746.
12. Nightingale S, Holmes J, Mason J et al. Psychiatric illness and
mortality after hip fracture. Lancet 2001; 357: 12645.
13. Koenig HG, Kuchibbatla M. Use of health services by medi-
cally ill depressed elderly patients after hospital discharge. Am
J Geriatr Psychiatry 1999; 7: 4856.
14. Inouye SK. Prevention of delirium in hospitalised older
patients: risk factors and targeted intervention strategies. Ann
Med 2000; 32: 25763.
15. Inouye SK, Bogardus ST, Charpentier PA et al. A multicompo-
nent intervention to prevent delirium in hospitalised older
patients. N Engl J Med 1999; 340: 66976.
16. Marcantonio ER, Flacker JM, Wright RJ et al. Reducing delir-
ium after hip fracture: a randomised trial. J Am Geriatr Soc
2001; 49: 51622.
17. Cole MG, McCusker J, Bellavance F et al. Systematic detection
and multidisciplinary care of delirium in older medical inpa-
tients: a randomised trial. Can Med Assoc J 2002; 167: 7539.
18. Cole MG, Primeau FJ, Elie LM. Delirium: prevention, treat-
ment and outcome studies. J Geriatr Psychiatry Neurol 1998;
11: 12637.
19. Huusko TM, Karppi P, Avikainen H et al. Randomised, clini-
cally controlled trial of intensive rehabilitation in patients with
hip fracture: subgroup analysis of patients with dementia. Br
Med J 2000; 321: 110711.
20. Evans M, Hammond M, Wilson K. Placebo controlled treat-
ment trial of depression in elderly physically ill patients. Int J
Geriatr Psychiatry 1997; 12: 81724.
21. Mossey JM, Knott KA, Higgins M et al. Effectiveness of a psy-
chosocial intervention, interpersonal counselling, for sub-
dysthymic depression in medically ill elderly. J Gerontol 1996;
51A: M1728.
22. Strain JJ, Lyons JS, Hammer JS et al. Cost offset from a psychi-
atric consultation-liaison intervention with elderly hip fracture
patients. Am J Psychiatry 1991; 148: 10449.
23. Draper B. The effectiveness of old age psychiatry services. Int
J Geriatr Psychiatry 2000; 15: 687703.
Age and Ageing 2005; 34: 207209 The Author 2005. Published by Oxford University Press on behalf of the British Geriatrics Society.
doi:10.1093/ageing/afi078 All rights reserved. For Permissions, please email: journals.permissions@oupjournals.org
Depression as a risk factor for later dementia:
a robust relationship?
Clinicians and patients have long recognised the close asso-
ciation of depression and cognitive impairment [1]. Forty
per cent of community-dwelling depressed patients com-
plain of memory problems, compared with 1020% of
healthy elderly individuals [2, 3]. Previously attention has
concentrated on cases where depression and cognitive
impairment overlap in one of two common presentations.
In the first type of presentation, depression is considered to
be the driving force, and in this case the majority of cogni-
tive deficits remit with improvements in mood [4, 5].
Although the resultant cognitive impairment is sometimes
sufficiently serious to be called depressive pseudodemen-
tia, it is typically of mild to moderate severity and perhaps
more accurately labelled depression-related cognitive
impairment [6]. In the second type of presentation, it is the
cognitive disorder that is considered to be the driving force,
with depression heralding the development of an early
dementia. Autopsy-confirmed series show that as many as
72% of individuals complain of broadly defined mood
symptoms 2 years before the diagnosis of Alzheimers dis-
ease [7]. High rates of depression and anxiety are also well
recognised in the early and middle stages of most types of
dementia [8]. To what extent mood disorder in early demen-
tia is a reaction to perceived cognitive loss and to what
extent it is driven by biological factors is difficult to investi-
gate and thus remains speculative [9]. Considerable effort
has been expended in attempting to differentiate depres-
sion-related cognitive impairment from prodromal depres-
sion in early dementia under the assumption that these are
two mutually exclusive presentations [10, 11]. However, the
field has recently become more complex with the realisation
that these two pathways may overlap and that depression in
early or mid-life may be associated with dementia or cogni-
tive impairment many years later. Is it then possible that
depression has a causative role in the later cognitive decline?
In order to disentangle the complex relationship of psy-
chiatric complaints and cognitive impairment, it is necessary
to consider a number of other explanations [12]. From an
epidemiological perspective, depression might be an inde-
pendent risk factor for cognitive decline in late life, but
equally depression might be a very early symptom of unde-
tected dementia (an example of reverse causation). Equally
plausible, depression and dementia might share one or more
common risk factors or there might be no true association
at all. What is the evidence for each of these possibilities?
Taking the last hypothesis first, an early meta-analysis of
seven cross-sectional studies and seven cohort studies dem-
onstrated that depression was associated with dementia but
this review did not consider studies that used a broader def-
inition of cognitive impairment [13]. To date there have
been 37 cohort studies that have examined this association.
Of these, 27 studies report a statistically significant positive
association in which severity of depression is a risk factor for
increasing cognitive decline, six studies report a trend towards
a positive association, four studies report no relationship and
no studies report an inverse relationship (data available on
request). Thus the observation is unlikely to be erroneous, yet
could the explanation simply be accounted for by shared risk

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