Psychiatry of later life is a growing discipline, but there are still not enough practitioners in Ireland, says one expert, writes COLETTE SHERIDAN
WITH A GROWING number of older people and the associated increased level of age-related mental health problems and dementia, Psychiatry of Later Life (PoLL) is likely to become an important speciality within psychiatry and medicine.
This branch of psychiatry started to develop in Ireland in the late 1980s, having been available in the UK for some time before that. “Ireland went from having no service at all to having approximately 30 psychiatrists of later life in most geographical regions, with some private psychiatrists of later life as well,” says Dr Henry O’Connell, psychiatrist of later life in the Laois/Offaly region.
“But, based on A Vision for Change (which sets out the direction for mental health services in Ireland), there is a need for 46 psychiatrists of later life. And that number will go up. With all the cutbacks, my fear is that PoLL will be affected. It’s the one area for our ageing population that needs to be funded and developed in years to come.”
According to the Central Statistics Office, there will be about 909,000 people in Ireland over the age of 65 in 2026. Figures based on a paper by epidemiologist Eamon O’Shea suggest that there will be 70,115 people with dementia in 2026. In general, about 5 per cent of people over 65 have dementia including Alzheimer’s Disease.
“Age is one of the main risk factors for dementia. It is being diagnosed at an earlier stage these days. It’s not curable at the moment, but a lot of the symptoms can be treated. These would be behavioural and psychological symptoms. Things like depression, agitation and psychosis can be treated. Some of the dementia drugs may have an effect on stabilising or slowing the progression in some people.”
O’Connell says that he and his colleagues treat all sorts of patients. “Our work also revolves around managing older people who have psychological problems that arise for the first time in later life. Like dementia, the reasons for developing mental health problems in later life are multi-factorial. They can be linked to physical health problems like respiratory disease or arthritis or chronic pain.
“Also, if a person has been prone to low grade anxiety or low moods in younger years, it can be more apparent or more severe in later life. And there are social factors such as bereavement, changing roles and retirement.”
O’Connell says that, anecdotally, older people are less likely to present for a psychiatric assessment or treatment. “They may be stoic or might feel stigmatised by attending mental health services.”
He says that primary care GPs manage the vast majority of mental health problems in older people. “I would treat people who are not responding to primary care treatment.”
Older people “should be prioritised now and in future years. They have made a very significant contribution to our society and in later life, when they have health needs, these should be met. In later life, health needs can be a complex mixture of bio/psycho/social factors. Health services should be equipped to meet these.”
Prof Des O’Neill, a geriatrician at Tallaght Hospital, says that PoLL “is an absolutely invaluable resource that is hugely complementary to the work that geriatricians do. There is quite a lot of cross referral. If psychiatrists of older age come across patients that have significant medical problems, they call us. The best thing to do is to discuss the patient with the family doctor who tends to have a feel as to which services will best meet the needs of the older person.”
As well as cross-referral, geriatricians and psychiatrists of later life meet frequently to share knowledge. “We do joint radiology conferences with our older-age psychiatrist colleagues, looking at brain scans carried out in cases of dementia.”
O’Neill says that one of the biggest challenges concerns the diagnosis of depression in an older person. “It’s really quite important that people aren’t put on unnecessary medication.” He says that the type of damage caused by dementia can lead to a patient being apathetic and lacking in motivation.
Instead of putting this down to depression, it is “more likely to be a problem with what’s called executive function, which is how people plan and sequence events. It can be difficult for the older person to do these things. Apathy is quite appropriate behaviour given the cognitive skills of the patient. Older-age psychiatrists are very good at diagnosing depression and knowing when depression is not there.”
O’Neill would like to see more psychiatrists of later life. “They save discomfort by facilitating people to live at home, helping them to manage complex situations such as dementia. There is also an economic saving.”
He is concerned that some regions don’t have a PoLL service. The ideal scenario is a consultant-led multi-disciplinary team serving a population of 10,000 people over the age of 65.
