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Essay 11: Services

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Discuss the differences between general adult and old age psychiatric services and why these services should remain separate

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Ok here's a rough plan, off the top of my head. Some of the points are probably plain wrong, others not terribly relevant to the question. I would be most grateful if people could make useful comments. I will try and tidy it up at a later point


- On criterion of age, psychiatric service divided into child/adolescent, general adult and old age

- cut off boundaries between general adult (GA) and old age (OA) services vary between 65, 70 and 75 between trusts

- Services differ in terms of retention or graduation of patients when reaching OA entry level age

- service = provision of facilities, people, protocols/systems for working, communications with other services

- GA deals with GA population, full range psychiatric disorders. Forensic/substance abuse/learning disabilities usually separate services

- Pts usually transferred via G.A to other services e.g. LD

Main arguments

1. Prevalence differs

a. Dementia obviously in domain of OA even if pts develop dementia prematurely

b. Depression: Probably equally relevant in both services

c. Schizophrenia: ? reduced prevalence in elderly population since early onset, usually run its course, reduced life expectancy. Different presentation?

d. Psychosis ?? prevalence. Note paraphrenia now under schizophrenia. ?Isolated delusional disorder increased in elderly

e. Organic induced psychiatric illness markedly increased in OA population

f. Delirium markedly increased in OA

g. ?Dual diagnosis increased in GA

h. Substance misuse increased in GA population

i. ?Alcohol misuse - again use argument about onset, life expectancy, reduced likelihood of reaching OA

Prevalence means OA Service

j. Personality disorders ?increased in GA relative to OA because of reduced life expectancy - need figures to back this up

Allocates a lot of resources for management of dementia

GA service

Allocates a lot of resources for management of substance misuse/schizophrenia/dual diagnoses

Pd ? Increased use of psychotherapy in GA population

2. Increased number of medical problems

a. ?Proximity to emergency medical facilities (may not be necessary)

b. Close connection medical/surgical wards - possible liaison service

c. Emphasis in old age liaison service on delirium + dementia diagnosis/management

d. Employment of staff trained in this area e.g. liaison nurses well versed in dementia scales etc

e. Medical staff skilled in interpretation of CT scans/MRI/Neuropsychological tests and relation to dementia

3. Organic aetiology

- Increased use of CT/MRI with increased cost relative to each patient

4. Polypharmacy

Increased polypharmacy leads to increased prevalence of iatrogenic psychiatric illness

Needs close coordination between GP, medical specialists and psychiatrists re: medication. ?Education of medical specialists re:psychiatric illness as SE's of medication

Liaison with medical services, re: safety of psychiatric medications in conjunction with medical illnesses and medication for those illnesses

5. Daytime activities

a. Old age - retired - more likely to require daytime structured activities

b. GA - needed for severely mentally ill and need relevantly trained staff

c. GA - need back -to work schemes/training; service needs to interact with employers

6. OT

GA: Preoccupied with living with/managing psychiatric illness e.g.

a. anxiety management

b. self esteem groups

c. anger management

OA: more focused on physical disability interacting with psychiatric illness, memory impairment and independent living

7. Social Workers/Social services

GA: Sorting out benefits

OA: Appropriating resources for nursing/residential

GA: finding accommodation for severeal mentally ill

8. Nursing staff

Nursing staff have relevant skills

- GA: need to be able to run like the wind :-)

9. Unique to General adult

- puerperal psychosis, postnatal depression, management of depression during pregnancy


Needs to be different services

Different prevalence of illnesses.

Old age dominated by dementia.

General adult dominated by schizophrenia, substance misuse, dual diagnosis.

- As a result consultants/registrars need a different set of skills in order to manage elderly and general adult populations in best way possible

[However only an additional year of training is required for dual accreditation]

- Consultants/registrars need to draw on a large team comprising individual with particular skills e.g. Social workers with a knowledge of residential homes etc

- Although this could be provided under one umbrella it would be very complicated and more likely to fail

- Specialists in the different fields need to build up relationships with different combinations of related services e.g. geriatric services/residential homes etc

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