Older People’s JSNA Factsheet : Mental Health Summary This factsheet covers mainly dementia and depression. Around 1800 people are estimated to have dementia in Southwark. Prevalence rises steeply with age. Under half of people with dementia over 65 appear to be recognised (on registers) with local GPs. Dementia may be a precipitating factor in admission, for example when the person forgets to take medication. The main reasons for admissions among people with dementia are preventable( falls and urinary and respiratory infections) and should be addressed. There is a local Dementia Strategy. A memory assessment service provides multi-disciplinary early intervention for people with suspected dementia. In 2009/10 service user and carers described confusing pathways, multiple assessments, delayed diagnosis and a general lack of awareness of dementia amongst involved professionals.
Figure 1: Number of people aged 65 and over predicted to have dementia by age and gender, projected to 2025, Southwark
2010 2015 2020 2025 2010 2015 2020 2025 Definitions
Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community ( WHO).
The local picture Some mental health problems, notably dementia, are most common among older people. Older people with mental health problems are likely to have increased needs for care, particularly as conditions such as dementia may accompany physically frailty. This section focuses on dementia and depression. Dementia Dementia is a syndrome (a group of related symptoms) associated with progressive decline of the brain affecting many of the functions needed to sustain everyday life and self-care: Emotions, motivation and the capacity to cope in social situations are also affected. Its onset may be quite slow and insidious and it is sometimes difficult to distinguish from depression. In many cases it is progressive and whilst it may be possible to manage at home in the early stages, it becomes more difficult as mental capacity diminishes. Dementia can impose enormous strain on carers. Many cases of dementia go undiagnosed, particularly in its earlier stages: in March 2011 there were 752 people aged 65 + recorded on GP Disease Registers as being diagnosed with dementia, this was 96% of those with dementia of all ages. People with learning disability and stroke are at increased risk of dementia. It is estimated that currently there are more than 1800 people aged 65 and over with some form of dementia rising to almost 2300.by 2082 by 2020. The majority of people with dementia are over 65 but a minority have early onset dementia ( see table) Under half of people with dementia over 65 appear to be recognised (on registers) with local GPs, slightly higher than the London figure of 37% of people with dementia are recorded on GP registers. Table 1: Estimated numbers over 65 years with dementia (Source: POPPI)
The following table shows the extent to which dementia is undetected in primary care by practice, using a range of prevalence estimates ( low and high). Some practices do no even achieve rates of detection based on the low estimate. Table 2: Expected versus actual numbers of overs with dementia, by practice in Southwark Name of Practice
Note: + The prevalence of dementia is highly age- specific and rises steeply with age. The low estimate assumes an average prevalence of 1.25% which is the population prevalence rate in 65-69
years olds. The high estimate assumes an average prevalence of 8.8% which is the population prevalence rate in all over 65 year olds ( range 65-90+). The low estimate is therefore a very conservative estimate.
Dementia may be a precipitating factor in admission, for example when the person forgets to take medication. In 2010/11 there were 774 admissions coded for dementia, and 98% of them were unplanned via A & E. Where the primary diagnosis was dementia the reason given for admission was falls, renal tract infections, respiratory infections. 30 patients were admitted on 3- 5 occasions . The estimated cost of this unplanned care was £2.5million.
Long term care is needed when remaining at home is no longer possible. The following table shows the breakdown of permanent placements by condition. Mental health conditions only result in a small number of placements. Often people with dementia first need social care in relation to physical ill- health or disability. Their dementia has a significant impact upon their need for further and ongoing support, and these figures do not show this. Older people with dementia appear to be significantly over represented within institutional care as opposed to community based provision. Social work staff and the care home providers estimate that the real proportion of those residents who may have some form of dementia is nearer to 70%.
Table3: Permanent placements of older people in Residential and Nursing Care for individual years, broken down by client group
Primary Client 65 + Total placements Residential permanent placement What we know works Dementia can be prevented in middle age by addressing risk factors such as smoking, excess alcohol use, diabetes and hypertension. It is important to assess and diagnose people early through assessment (memory)clinics. NICE has produced an evidence based quality standard for people with dementia. The opportunity to participate in group cognitive stimulation therapy should be available in order to
optimise independence. Donepezil, galantamine and rivastigmine are recommended by NICE as options for managing mild as well as moderate Alzheimer’s disease. Care should be coordinated between health and social care and the needs of the carers taken into account. The care plan should include support for activities of daily living through to joint decision making with the individual and carer and provision for end of life care when needed.
Local action South London and Maudsley's (SLaM) Mental Health of Older Adults and Dementia Clinical Academic Group is commissioned to provide community mental health services for older people in Southwark through sector-based multi-disciplinary teams, in the north and the south of the borough. There is a local Dementia Strategy.
A memory assessment service provides multi-disciplinary early intervention for people with suspected dementia. The service offers comprehensive assessment, diagnostic and treatment functions for individuals experiencing mild to moderate cognitive decline consistent with an underlying dementia, regardless of age and who do not have an existing diagnosis of dementia.
Currently 73% of people with dementia who are eligible for a review in primary care actually receive one ( QoF 2007/8 ).Fourteen percent ( 245) people over 65 were receiving social care for a mental health problem in 2007/8 ( DH RAP return).
What still needs to be done People may not receive a timely diagnosis, and when they do, the pathway to further support and advice was poor. When they did get help it was often too late. In the absence of more timely, planned support people seek help at times of crisis when the individual situation has deteriorated to the extent that residential, nursing home and in-patient admissions remain the only option. User/Carer Views During 2009-10 Southwark completed an exercise to obtain the views of a wide range of stakeholders on both the Older People’s and Carer’s Commissioning Strategies. Service user and carers described confusing pathways, multiple assessments, delayed diagnosis and a general lack of awareness of dementia amongst involved professionals. Other issues include:
• Lack of awareness of dementia • Early diagnosis and access to services • Support to remain at home and more information about available services • Support of carers
Depression Depression is less prevalent among older adults. Depression may however develop in later life as a result of a less active daily life and reduced social contacts, loss of job and family related roles and responsibilities, death of a partner, friends and family members; insomnia; having less money, ill-health or disability; anxiety about being able to cope or long term strain from being a carer for a disabled partner or family member. Depression may also be associated with long term conditions such as cardiovascular disease or diabetes. If depression develops and does not resolve or is not treated it may seriously affect the person’s ability to look after themselves. It may also be a gateway to other illnesses. It is estimated that there are currently more than 2,100 people aged 65 and over with depression. About a third of these people will suffer severe depression. This figure is expected to rise to 2,550 by 2025.
Table 4: Disease Registers in primary care for mental health problems among the over 65s by gender (March 2011).
Aged 65 years All over 65s as patients a % of total on registers
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