ProfJohnSnowdons OLD AGE PSYCHIATRY in VIETNAM

OLD AGE PSYCHIATRY IN VIETNAM Old age psychiatry services in different countries by John Snowdon Old age psychiatrist, Sydney October, 2012 Prevalence of mental disorders in old age • • • • • • • • Dementia Delirium + other brain syndromes Depression (melancholia 1%) Mania (bipolar) Schizophrenia & paranoid disorders Anxiety states Alcoholism Personality disorders to 10% – 2% 13% 0.5% 2% to 10% 3% lots! Do we need old age psychiatry services? • How good are our general adult mental health services at dealing with elderly? Are they willing & able to adapt services to needs of disabled? Ageist? • Is Vietnam different? Attitudes towards elderly? • Who advocates for special needs of elderly? • Links with other services for elderly, and the need for special knowledge concerning what’s available to help them, medication use, the ways disorders present • Special interest in the problems of old age has prompted research – vascular depression, dementia, BPSD, end-of-life care • Increasing number of older people, and growth in expectations Old age psychiatry services around the world • Old age psych services in the UK, Canada, Australia, N.Z., Norway, Germany, Switzerland, Hong Kong, Finland, Sweden, Japan, Denmark, Netherlands, USA, Israel are well developed (Reifler & Cohen, 1998) • In some countries the emphasis is mainly on dementia, and there are no mobile old age psychiatry teams • US services entrepreneurial, fee-for-service, uncoordinated (Reifler & Cohen, International Psychogeriatrics, 1998, 10, 351-368) • Some countries provide community care If hospitals are scarce or far away, the primary care doctors and teams are vital • In Thailand, 10 of the 350 psychiatrists were working at least parttime in old age psychiatry (Nivataphand, 1999) How many in Vietnam? There were million Thai people aged 65+, all inpatient and outpatient old age psych services being still under general psychiatry (Chiu et al, IJGP, 1997) Principles • • • • espoused by Arie & others: Good quality care for older people with mental health problems is provided by services that are COMPREHENSIVE, MULTIDISCIPLINARY, addressing patients’ physical, psychological, social needs and wishes, ensuring good collaboration between services, ACCESSIBLE, FLEXIBLE, user-friendly, no barriers, RESPONSIVE, AVAILABLE, acting promptly, INDIVIDUALISED, looking at needs of carers as well as patients, supporting in the home environment Aware of cultural aspects HEALTH SERVICES FOR OLDER PERSONS: Adaptations needed in order to best help those with physical or mental disability (E.g difficulty with stairs or public transport) Commonly both physical & mental problems, so need good geriatric/psychogeriatric liaison Primary care doctor is the lynchpin Multidisciplinary team, domiciliary assessments Give attention to carers Be aware of the special services/facilities that are available, e.g re day centres, Comprehensive old age psychiatric services • Catchment area geriatric and old age psychiatry services 20,000 elderly, psychogeriatrician • Acute inpatient beds: 10 (functional + organic) • Long-term beds: ? in nursing homes • Community team: nurses, social worker, access to psychologist, OT, music therapist • Day centres (socialisation, roles & self-esteem, respite) • Outpatient clinics; memory disorder clinics • Linkage with community services, e.g home care and meals-on-wheels, respite care • Liaison psychiatry for elderly in general hospitals Effectiveness of old age psychiatry services • Banerjee et al (1996) compared the efficacy of interventions by (1) a multidisciplinary psychogeriatric team that developed a management plan and individualised packages for depressed frail elderly living at home, with (2) usual GP care 58% versus 25% recovered • Blanchard et al (1995): a study nurse working closely with GPs tried to implement a depression management plan – hours’ face-to-face time over three months More improvement than in a group managed by usual GP care [Might a similar arrangement work in residential care facilities?] • Rabins et al (2000): nurse-based mobile outreach team in US more effective than usual care for seriously mentally ill aged Teaching and training in old age psychiatry • Camus et al (IJGP 2003, 18, 694-699) reported answers from • • • • 50 WPA member societies (48 countries) regarding education in old age psychiatry Included Korea and Thailand Specific old age psychiatry services were reported in 40, and 13 countries (27%), including Thailand, recognised old age psychiatry as a sub-specialty 32 countries (66%) had chairs of geriatric medicine, and 18 (38%) had chairs in old age psychiatry Median duration of formal undergraduate teaching included 50 hours (30 to 100) of adult psychiatry, 10 hours (4 to 12) of child and adolescent, and hours (2 to 7.5) in old age psychiatry In a majority of countries there was reported to be no requirement for trainees to rotate through old age psychiatry Concerns • Community care is absent in most countries • A shortage of trained person-power and inadequate budgetary allocations will seriously limit the development of specialised old age psychiatry services in developing countries “Instead the emphasis should be upon integration of psychogeriatric services into general health care by training primary care doctors to identify and manage common conditions like dementia and depression” (Dening & Shaji, chapter 21 in Draper, Melding & Brodaty, 2005) The future • National populations are ageing! The rate of change is higher in developing countries, with a daunting increase in the proportion of people with dementia How can existing old age psychiatry services cope with the added workload and expectations? • Preventative approaches – exercise etc Prevent vascular depression and late-onset paranoid disorders – maybe Prevent BPSD through person-oriented care • There will be developments in pharmacology, neuroimaging, molecular biology, diagnostics and other treatments, but most importantly there will be (there have to be) developments in the way services are financed, organised and delivered  ... ill aged Teaching and training in old age psychiatry • Camus et al (IJGP 2003, 18, 694-699) reported answers from • • • • 50 WPA member societies (48 countries) regarding education in old age psychiatry. .. vital • In Thailand, 10 of the 350 psychiatrists were working at least parttime in old age psychiatry (Nivataphand, 1999) How many in Vietnam? There were million Thai people aged 65+, all inpatient... in old age psychiatry Included Korea and Thailand Specific old age psychiatry services were reported in 40, and 13 countries (27%), including Thailand, recognised old age psychiatry as a sub-specialty