Psychiatry for older adults A foolish challenge? concept1 Ronald Schmidt, MD Director long term care Cordaan, Amsterdam

pagina 2 Care for the elderly in the Netherlands There is a growing elderly population in the Netherlands (with a maximum peak around 2020)

pagina 3 Care for the elderly in the Netherlands Historically strictly divided care models: nursing home care and psychiatry Psychiatric symptoms: contra-indication for nursing home admittance Ample capacity for crisis-intervention in psychiatric setting Important role for (ambulant) psychiatry in diagnosis and case management in dementia Difference in finance models Long term care in clinical setting only Outreaching approach only reserved for psychiatry

pagina 4 Because of the economic situation the rules of the game in psychiatry change drastically Huge decrease in clinical capacity Long term care slowly being banned from psychiatry Psychiatric involvement to patients still living at home is being reserved for complicated cases More co-operation between psychiatry and other care-professionals in outreaching dementia care: DOC teams, expert teams More important role for general practitioners and nurse practitioners

pagina 5 Also, the care facilities for the elderly, especially with dementia, are changing Traditional -Large scaled homes/wards -Focus on medication -Restraints and fixation common -All stages of dementia hospitalized -Psychiatric symptoms rare Developments -Small scaled, groups 6-8 -Focus on atmosphere and relational aspects -Fixation banned, medication minimalized -Only advanced stages of dementia, early stages stay at home much longer -Psychiatric symptoms common

pagina 6 This poses a new challenge for the elderly care in the Netherlands Nursing homes physicians specialise in psychogeriatric and gerontopsychiatric care Nurses are being trained in coping with severe behavioural symptoms Special wards are being formed, focussed on short term stay for crises intervention and “time out” for regular team Caring for patients with dementia in small scaled units decreases the amount of behavioural symptoms significantly Specialisation: “young demented patients”, Korsakoff, Huntington’s, acquired brain damage, elderly chronic psyciatric patients without severe psychiatric symptoms (i.e. elderly schizofrenic patients) Last but not least: we need to reach out!

pagina 7 Patients with dementia stay at home much longer…a necessary, wanted, but firm challenge Delaying clinical admittance for patients with dementia, with or without psychiatric symptoms and elderly psychiatric patients is a strong political driver… Home care (home nursing) needs to anticipate on these cases Geriatricians, nursing home physicians and psychiatrists need to join forces: case management, diagnosis and treatment close at home and as cost effective as possible: DOC teams, expert teams Day care facilities support living at home longer: different models, from completely being run by volunteers up to full-professional run settings. Focus on patient and focus on support system (partner, family) Much to be learned from the Greek: in an individualised, relatively rich society caring for one another is not common! Nevertheless…

pagina 8 Mental healthcare and care for the elderly: time to join forces! Mental healthcare provider GGZ Ingeest and Cordaan work together in several ways: -Education and training of Cordaan professionals by Ingeest -Consultation and advice in complicated cases: involvement in early stages reduces the need for clinical intervention in case of crises. Consultation consists of doctor-doctor advise but also (en maybe even more effective) nurse-nurse advise! -And of course, if needed, Ingeest takes over the treatment and sometimes even the patient. But: only for a short while…

pagina 9 Summary The care for the elderly is changing. Patients with psychiatric symptoms are becoming more and more common in the nursing homes and care facilities. Patients tend to stay at home longer, inspite of severe symptoms. -The know-how of the staff in chronic care facilities needs to be updated: training, education, consultation by mental healthcare -Outreaching care needs to be updated and forces between different specialties must be joined -Investment in psycho-education for non-professional care givers is needed (Greek model) -The dutch situation provides us with some perfect opportunities to effectuate the above: * Specialised nursing home physiancians care for the elderly in and out of the nursing homes * Psychologists are already available in the staff of facilities for the elderly * As are social workers, musical therapists and occupational therapists -Mental healthcare and elderly care need to join forces more frequently