Background and introduction

There is a great need for effective well-organized systems of service delivery to mentally ill elderly people. As the world population ages, the problem of delivering timely services to frail elders with psychiatric illness becomes a global one. Frequently, even in developed countries, opportunities for prevention are missed. Older people in community and nursing homes suffer from untreated depression, and premature institutionalization often ensues because of inadequate support and a lack of preventive services. Mental health services are very limited in the Third World, particularly for the elderly. By 1990, the absolute numbers of elderly people in underdeveloped countries had exceeded those in developed countries.(1) Even in developed countries the elderly have often been overlooked in the planning of mental health services, and where they do exist such services have often become available faster than social support systems, leaving families struggling to provide basic personal and domestic care to the mentally ill elderly.

Several special challenges are encountered in planning for the provision of mental health services to the elderly. These include the range and inter-relatedness of physical and psychiatric problems experienced by older people, the compartmentalization of medicine into distinct specialties, the separation of health and social welfare systems, and the often budget-related distinction between 'treatment' and 'care'.(2) Older people must compete for psychiatric services with other age groups but are often hesitant to seek psychiatric help, which increases the likelihood of crisis admission. People with dementia do not usually recognize the problem themselves, or they may try to mask the symptoms; family members may also overlook the dementia, attributing it to 'old age'. Some physicians are uncomfortable handling the complexity of geriatric care, and may avoid investigating problems they perceive to be inevitable and age-related. Also, physicians may fail to recognize dementia or incipient dementia, or the risk of delirium, and pay more attention to a less significant physical problem than to a coexisting mental disorder. Iatrogenic illness is a common problem, particularly in cognitively impaired individuals who may have difficulty understanding and following instructions regarding medications. Older inpatients risk further institutionalization. The increasing trend for short lengths of stay in hospital brings its own complications. For instance, the complex problems of the elderly patient can be regarded as exasperating by staff in acute-care settings who may be resistant to learning how to care for the elderly, perceiving the care of the older patient as being outside their range of responsibility. Since even initially enthusiastic staff can become burnt out, special attention needs to be paid to their support and education. In many countries, deinstitutionalization of the chronically mentally ill and the downsizing of large mental hospitals (where older adults with behavioural problems related to dementia were traditionally admitted) has led to a higher prevalence of mental illness, particularly dementia, in long-term care settings which are usually staffed with low paid workers who are not trained to recognize and manage mental illness.

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