Ayrshire Central Hospital, Irvine
Gartnavel Royal Hospital, Glasgow
Royal Dundee Liff Hospital, Dundee
Leverndale Hospital, Glasgow
Hairmyres Hospital, East Kilbride, Scotland, UK
Correspondence: Dr Seamus McNulty, Department of Psychiatry, Ayrshire Central Hospital, Irvine KA12 8SS, Scotland, UK. E-mail: seamus.mcnulty{at}aapct.scot.nhs.uk
Declaration of interest None. The study was funded by the Chief Scientist Office of the Scottish Executive.
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ABSTRACT |
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Aims To measure the care needs of an epidemiologically based group of patients over the age of 65 years suffering from psychotic illness, using a standardised assessment.
Method All patients aged 65 years and over with a diagnosis of schizophrenia and related disorders from a defined catchment area were identified. Their health and social care needs were investigated using the Cardinal Needs Schedule.
Results The 1-year prevalence of schizophrenia and related disorders was 4.44 per 1000 of the population at risk. There were high levels of unmet need for many patients, including those in National Health Service (NHS) continuing-care beds.
Conclusions Many needs were identified, all of which could be addressed using the existing skills of local health and social care professionals. The investigation raises serious concerns about standards of hospital and community care for elderly patients with schizophrenia. The findings may be unique, reflecting long-standing problems within a particularly hard-pressed part of the NHS. However, it is not known whether a similar situation exists in other parts of the UK.
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INTRODUCTION |
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METHOD |
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Second, the views of individual patients are paramount in deciding whether they will accept a potentially effective intervention and therefore whether they currently have a need for care in this area (Marshall et al, 1995). This can be overruled only in special circumstances, for example when the patient is a risk to self or others.
Third, deciding what interventions could be effective requires expert professional knowledge. This may be considered a rather old-fashioned approach. However, needs assessment in psychiatry sometimes leads to creation of a wish list which fails to differentiate effective and ineffective interventions.
Fourth, if an illness can impair judgement, evaluation of quality of care must include those not in receipt of services as well as those who are receiving assistance. In our opinion, this is the most important principle in evaluating the care of people with any serious psychiatric or neuropsychiatric condition.
Study area
The investigation was carried out in the towns of Hamilton, Blantyre,
Larkhall, Stonehouse, Bothwell, Uddingston, Bellshill and Viewpark (referred
to below as Hamilton and Bellshill) with approval from the research ethics
committee of the Lanarkshire Health Board. The total population in 1998 was
155 696, with 20 292 persons aged 65 years and over. The major part of the
study area had previously formed the old Hamilton local government district,
which has been rated the eighth most-deprived district in Scotland (out of
56), based on deprivation indices
(Carstairs & Morris, 1991) applied to the 1991 census (McLoone,
2000). The overall Carstairs deprivation score for Hamilton
district was 0.61, with scores for individual towns ranging from 3.7 for
Blantyre to -2.3 for Uddingston and Bothwell. Viewpark had a Carstairs score
of 3.3 and Bellshill a score of 3.2 (the third and fourth highest levels of
deprivation for towns in Lanarkshire).
Until about 10 years ago Lanarkshire mental health services were dominated by Hartwood Hospital, a hugh, isolated Victorian asylum. This hospital is set for final closure in 2003. Services for elderly people with mental illness in Hamilton and Bellshill now include acute assessment beds in two local district general hospitals and a geriatric community unit. There are long-stay beds in Hartwood and Cleland Hospitals. As in other parts of the west of Scotland, the National Health Service (NHS) has contracted with a private nursing home to provide partnership beds staffed by registered mental nurses. The NHS consultants have direct admitting rights and remain the responsible medical officers. Community mental health teams (CMHTs) for elderly patients in Lanarkshire were established in 1995. At the planning stage they were envisaged as teams for the care of patients with dementia. When they began work their remit included all other mental illnesses, although without additional resources.
Study group
All participants were aged 65 years or over during the period 1 January to
31 December 1998. They had a home address in the study area during this period
or else they had been in continuous long-term care in one of the Lanarkshire
in-patient facilities and had been originally admitted from a Hamilton or
Bellshill address. The NHSprivate partnership home was situated in
Bellshill and all residents with a relevant diagnosis were included. Patients
had schizophrenia or a related disorder, operationally defined as any of the
following diagnostic categories from DSMIIIR
(American Psychiatric Association,
1987): schizophrenia, schizophreniform disorder, delusional
disorder, atypical psychosis and schizoaffective disorder. Those with learning
disability who fulfilled the above criteria were included. Potential
participants were identified from the following sources.
All psychiatric case notes of potential study participants were examined by the research psychogeriatrician (S.V.M.) using OPCRIT (McGuffin et al, 1991), a symptom checklist which generates standardised diagnoses. Four patients had no or inadequate case notes and for these people a semi-structured diagnostic interview was necessary. One of these patients refused all contact with the researchers and was excluded. Another was markedly cognitively impaired in addition to being deaf and blind. She did not cooperate with interview and was excluded from further analysis. The two remaining patients were not eligible: one had a bipolar affective disorder and the other had no psychiatric diagnosis.
Interview procedure
Patients were contacted only with the permission of their general
practitioner, consultant or keyworker. Subject to consent, the research
psychiatrist interviewed each patient and the research nurse interviewed the
carer (where available) using the Cardinal Needs Schedule
(Marshall et al,
1995). It comprises the following six scales.
Behaviour was assessed using the Rehabilitation Evaluation Hall and Baker (REHAB; Baker & Hall, 1988), a widely used standardised behaviour scale which rates living skills such as communication and self-care (general behaviour, scale 0-160), and disruptive or embarrassing behaviours such as violence, self-harm and shouting (disturbed behaviour, scale 0-14). Some questions had been slightly altered in an earlier study (Murray et al, 1996) to make them suitable for use in community settings.
The Manchester scale (Krawiecka et al, 1977) rates depression/anxiety on a scale of 0-8; positive symptoms (hallucinations, delusions and/or incoherence of thought) on a scale of 0-12; negative symptoms (psychomotor retardation, blunting of affect and/or poverty of speech) on a scale of 0-12; and side-effects of psychotropic medication, including tardive dyskinesia, on a scale of 0-10.
The Mini-Mental State Examination (MMSE; Folstein et al, 1975) is used to assess cognitive impairment (scale 0-30; higher scores indicate better cognitive function).
The Client Opinion Questionnaire is a structured interview that elicits the patient's views on current problems and needs.
The Carer Stress Questionnaire is a structured interview about problems encountered by the main carer.
The Additional Information Schedule collates information from the case notes and the carer on medical history, forensic history and other relevant clinical factors. These last three scales were specifically developed for the Cardinal Needs Schedule (Marshall et al, 1995).
These instruments together determine whether objective problems are present in eight clinical and eight social domains of functioning (Table 1). These become cardinal problems (a problem requiring action) if one, two or three of the following criteria are met: first, the patient is willing to accept help for the problem (the cooperation criterion); second, people caring for the patient are experiencing severe anxiety, annoyance or inconvenience as a result of the problem (the caregiver stress criterion); third, the problem is such that the health and safety of the patient and/or others are at risk (the severity criterion). Rules for deciding on the presence of a cardinal problem are not applied uniformly. For example, people who were unable to use community facilities would not have a cardinal problem in this area if they did not want help. On the other hand, behaviour that puts a patient at risk becomes a cardinal problem on the basis of severity even if the patient would not choose to accept any intervention. For each area of functioning the outcome for a cardinal problem must be one of the following:
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The process that is followed in determining objective problems, cardinal problems, needs, suspended needs and persistent problems despite intervention is summarised in Fig. 1. This provides a very conservative assessment of needs. Lockwood (2000) summarised needs as a measure of the extent to which mental health services are failing to provide suitable care.
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Statistical analysis
Total numbers of objective problems, cardinal problems, needs, suspended
needs and persistent problems despite intervention in the people interviewed
were calculated for each social and clinical domain. Statistical analyses were
performed using the Statistical Package for the Social Sciences, version 9.0
for Windows (SPSS, 1998). Mean
scores and 95% confidence intervals are presented for comparisons of key
socio-demographic, clinical and needs assessment variables. Levels of
statistical significance are based on independent-sample t-tests.
When re-analysed using non-parametric methods the levels of statistical
significance are very similar.
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RESULTS |
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Eighty-one patients had schizophrenia, three had delusional disorder, and six had an atypical psychosis. The 1-year prevalence for non-organic, non-affective psychosis was 4.44 per 1000. Mean age was 73.9 years (s.d.=7.8, range 64-99); 29 patients (32%) were male and 61 were female. The mean age at onset of illness was 51.1 years (s.d.=19.1, range 17-97); 53 (59%) had onset after the age of 45 years. Fifty patients (56%) were living in their own homes; 14 (16%) were living in local authority or private residential and nursing homes; 12 (13%) were in the NHSprivate partnership home; 8 (9%) were in long-stay wards of the mental hospitals; 5 (6%) were in the community hospital; 1 was in the acute admission ward.
Interviewed participants
Fifty-eight participants (64%) were interviewed. During the study year 12
(13%) of the 90 eligible patients died and one moved to another part of the
country before they could be interviewed. One patient (who had an OPCRIT
diagnosis of schizophrenia and a known history of alcohol misuse) could not be
traced despite visits to three different identified addresses. Eighteen
patients (20%) refused to participate, of whom 15 had a diagnosis of
schizophrenia and 3 an atypical psychosis. They were of a similar age to the
interviewed patients (mean 73.6 years v. 74.9 years; P=0.5).
However, all but one were female and all were living in their own homes.
Of the 58 people interviewed, 37 (64%) were female and 21 were male. The age range was 65-94 years with a mean of 75 years. Fifty-four patients (93%) had a DSM-III-R diagnosis of schizophrenia, 2 (3%) had a delusional disorder and 2 had an atypical psychosis. Twenty-four (41%) participants were living in their own home; 13 (22%) lived in a nursing or residential home; 11 (19%) lived in the NHSprivate partnership home; 5 (9%) were in long-term psychiatric wards; 5 were in-patients in the community hospital or acute admission ward.
Current symptoms and behaviour
One patient did not cooperate with the assessment of current symptoms and
side-effects. Thirty-seven of the remainder (65%) had clinically significant
positive psychotic symptoms and 32 (56%) had negative symptoms; 13 (23%) had
clinically significant depression and/or anxiety, 4 of whom reported suicidal
ideas in the previous week. Tremor was identified by the research psychiatrist
in 22 patients (38%) and rigidity in 18 (32%). Tardive dyskinesia was mild in
18 (32%) and marked in 17 (30%) of those who cooperated with clinical
examination.
Cognitive impairment was a prominent feature. For the 53 participants who completed the MMSE the mean score was 20 (range 1-30). Thirty-two (60%) of these people scored 25 or below, which was considered by Folstein et al (1975) to indicate clinically relevant cognitive impairment.
In 12 cases the REHAB scale was not completed because no carer was available for interview. The mean REHAB score for general behaviour in the remaining 46 participants was 75 (95% CI 66.6-83.4, range 14-124). Twenty-six (57%) had a general behaviour score above 70; using the original guidelines of Baker & Hall (1988), if these people were on a long-stay ward it would be doubtful that they could ever live in the community. Only 14 of these 26 high scorers were in long-term hospital or partnership care; 9 were in a residential or nursing home, and 3 were at home, cared for by their family. On the disturbed behaviour scale, 31 participants (67%) scored 1 or above, indicating some form of disruptive or embarrassing behaviour in the previous week.
Needs assessment
Table 1 shows that the 58
people interviewed had 101 needs for care in clinical domains and 51 in social
domains (mean total 2.6 per person). Eleven patients (19%) had no clinical
need, 11 had one clinical need, 22 (38%) had two, 10 (17%) had three, and 4
(7%) had four clinical needs. There was no need in any social domain in 27
patients (48%), 19 (33%) had a need in one domain, 6 (10%) had needs in two, 4
(7%) had needs in three, and 2 (3%) had needs in four social domains. Only 5
patients had no need whatsoever. One patient in a long-stay hospital ward had
a total of seven unmet needs.
The research team decided which interventions were most appropriate for needs in each domain using the guidelines in the Cardinal Needs Schedule. These are shown in the last column of Table 1.
Comparison according to residence
Clinical features and needs are compared in
Table 2 for community
residents, hospital in-patients and patients in the NHS-private partnership
home. These analyses must be interpreted with caution in view of the small
number of participants and because some variables are so complicated. For
example, a need relates to the severity of a problem, the patient's and
carer's attitudes, and what care professionals have done to help.
Nevertheless, these comparisons can provide some insight into the functioning
of local psychiatric services.
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Clinically significant differences in group means for some variables emerge; as can be seen from the confidence intervals, some differences were statistically significant in spite of the small numbers involved. Cognitive impairment and negative symptoms were much worse in hospital and partnership-home patients compared with community residents. Side-effects of medication were substantially more severe in the hospital patients compared with those living in the community. However, the community residents had the highest mean depression/anxiety scores (1.6): the difference appears clinically significant when compared with the mean for partnership-home patients (0.7; P=0.17) and both clinically and statistically significant compared with the hospital in-patients (0.3; P=0.04). Hospital in-patients had, on average, considerably more social needs for care (1.8) than those in the partnership home (0.4; P=0.005) and the community residents (0.8; P=0.009).
Comparison of CMHT input
Thirty-seven participants were living in the community, either in their own
homes or in nursing or residential homes.
Table 3 compares those
receiving (n=17) and not receiving (n=20) care from the
CMHT. The CMHT appears to be targeting a more seriously ill group. In
particular, the teams' patients had more-severe negative symptoms of
schizophrenia. On average, total needs were higher in those receiving care
from the CMHT (2.9 v. 1.8; P=0.027). However, the
substantial number of needs in those not receiving multi-disciplinary mental
health care should be noted.
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It is also a cause for concern that there were very few suspended needs. Among the whole group of patients who were not under the care of the CMHT there was no suspended need in any social domain and only one suspended clinical need. This indicates that little is currently being done to assist these patients in spite of their having, on average, more than two cardinal problems each.
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DISCUSSION |
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Reasons for shortcomings in care
Lanarkshire has the second highest level of need in Scotland (using
socio-demographic variables as a proxy measure) but by far the lowest per
capita spending on mental health services
(Accounts Commission for Scotland,
1998). There is a shortage of consultants both in old age and
general adult psychiatry throughout the UK
(Royal College of Psychiatrists,
1998). Lanarkshire has the lowest number of funded posts in
Scotland and this has resulted in a lack of continuity of care. Similar
shortages exist in all the mental health professions.
Depending on local policies, patients with chronic psychosis who reach the age of 65 years may go to either a new social work team, a new health care team or both. Three faculties of the Royal College of Psychiatrists (the faculties of rehabilitation psychiatry, old age psychiatry and general psychiatry) have described continuing uncertainty regarding whether old age psychiatrists should take over responsibility for these graduate patients (D. Jolley, personal communication, 2002). General adult psychiatric teams can struggle with the increasing complexities of the management of patients with psychosis as they age. Also, they are often forced to prioritise young patients with more-acute illness.
Accommodation
Fourteen needs related to inappropriate accommodation. Local authorities
face particular difficulties in housing the relatively small number of
patients with functional psychotic illnesses, who often end up in mainstream
nursing homes, living with patients with severe dementia despite having very
different nursing needs. The NHS-private partnership homes are a new
development in the care of people with severe psychiatric and neuropsychiatric
illnesses in Scotland. These facilities can only be welcomed when compared
with the wards of Victorian asylums. In this study, patients in the
partnership home had fewer social needs than any other group. Some
short-comings were identified which might have been due to lack of experience
with this model of service provision. These NHS-private partnership homes will
not be successful if, for example, there is insufficient input from trained
psychiatric nurses and consultants in old age psychiatry.
Implications for clinicians, managers and policy-makers
The demonstration project investigated by the Team for Assessment of
Psychiatric Services has shown that high-quality care can be achieved in this
patient group (Trieman & Wills,
1996; Trieman et al,
1999). However, our study provides evidence of serious
shortcomings. It remains to be seen whether similar problems exist in other
parts of the UK. These results raise serious questions about methods of
working and targeting of patient groups. Systematic needs assessment could
assist clinicians, managers and policy-makers in their efforts to provide
decent care for our elders with schizophrenia, who are among the most
vulnerable members of society.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication May 24, 2002. Revision received October 8, 2002. Accepted for publication October 21, 2002.
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