No More “Business as Usual” in Mental Health Services for our Treasured Population in Later Life
On United Nations Day for Older People, Consultant Psychiatrist for Later Life and Chair for the Faculty of Old Age Psychiatry Dr Tom Reynolds writes on the urgent need to prioritise care and safeguarding for older people with mental illness.
‘2020 has seen the emergence of COVID-19, which has caused upheaval across the world. Considering the higher risks confronted by older persons during the outbreak of pandemics such as COVID-19, policy and programmatic interventions must be targeted towards raising awareness of their special needs’ – UN Day for Older Persons, 1st October
Over six months since the COVID-19 pandemic hit Ireland we continue trying to organise the safest and the most efficient and effective ways to provide clinical services again in a healthcare environment that has changed radically, with the myriad of new challenges posed by our need to control the virus and prevent “overwhelming our health service”.
Psychiatric services for older people and care homes for older people continue to face that challenge equally and daily, but with particular caution as the tragic aftermath of COVID-19 is realised.
Much focus, rightly, has been and continues to be on Nursing Home care, but a concern for myself and colleagues from the beginning was the potential plight of the particularly vulnerable group of people in later life with mental illnesses, such as Depression and Anxiety as well as those with Dementia who are in our specialist care because of the psychiatric symptoms of their dementia. There were obvious concerns about the potential for outbreaks of COVID-19 for those older people admitted to our units for more specialised inpatient care, but there was also a grave concern about how those at home and their carers would cope with the increased stress of “cocooning”.
As time evolved, it became clear fairly early on from when the pandemic hit Ireland that there were serious reasons to also be concerned about how the long-term care sector may fare for older people receiving or requiring support for mental illness, not distress, but illness.
While there will be a detailed and multi-faceted look-back with more targeted critical analysis on how the various facets of our healthcare sector performed (and continue to perform) there are certain facts already emerging that will not require much formal research to ascertain.
One fact is that our systems to protect and care for vulnerable groups of older people, particularly in congregated settings, were and are not fit for purpose. Of all of the deaths so far in Ireland, circa 92% were people over the age of 65 years. Tragically, almost two thirds of deaths are of people aged 80+ years. It is particularly sad that more than 6 out of every 10 deaths occurred in settings of “care”, that is, of people who were dependent on some body of the State for their care, including Psychiatric Long-Term Care facilities.
The College of Psychiatrists of Ireland has consistently emphasized the need for parity of esteem for those with mental illness, the need to invest the same degree of importance into our mental health care systems as is already done as a matter of course into physical health care systems. This includes our older age population with serious pervasive mental health difficulties.
While there has been a recent effort on the part of the HSE to get back to “business as usual”, the facts regarding the challenges in mental health services for older people too are coming more and more into stark relief.
Many of the clinical spaces that we use for inpatients and for outpatients were already patently not fit for purpose. This is so much more starkly obvious, regarding physical space and design, in a pandemic.
Operating in an environment that has to be set up to prevent the spread of the virus means there is a huge increase in the time required to do a clinical assessment and a limit to the numbers of people who can be seen in clinics or on home visits in any one day.
Much of our new clinical work will need to be done remotely with appropriate technology so there is a requirement to invest in upgraded information and communication technologies and reliable networks, enabling for instance consultations using video technology. But even with this there are limitations when it comes to how effective such technologies can be to deliver the right care to our patients.
So, it is not time to go back to ‘business as usual”.
It is time to finally start getting mental healthcare right for this treasured and large cohort of our population who deserve better.
It is time to build our health and social care systems so that now, and in any future pandemic, we will be able to provide timely, comprehensive, efficient, effective and in particular, safe care to all of our older citizens.
It is time for clinical medical leadership to take its rightful place at the helm of health service design and provision where clinical need and scientific and clinical knowledge can dictate the direction of travel for this group so that the systems can be accurately designed to meet their needs.
It is not a time for a further reshuffle of the system we have, a further rearranging of the deck-chairs.
It will take significant new investment, considerable effort, hard decisions and radical re-thinking of many facets of our system.
We cannot allow a further neglect of our older citizens and their right to a quality of life like every other citizen that includes best practice and care for their mental as well as physical needs.
Three quarters of a million people (746,357) will be over 65 by 2021 (Census 2021 prediction). Every one of them – our parents, aunts, uncles, siblings, friends – deserve to know that their future life in those substantial later years will include a quality of care for their mental as well as physical health, when needed, that has been adequately planned, developed and, most importantly, is safely available.
It is time for more than ‘raising awareness of their special needs’ through policy and programmatic interventions but for implementing interventions and care that meets their needs.
They deserve no less.