Caring for people who enter old age with enduring or relapsing mental illness (‘graduates’)

This document has been produced jointly by the Faculty of General Psychiatry, the Section of Rehabilitation Psychiatry and the Faculty of Old Age Psychiatry.

Its purpose is to define and encourage good practice in the management of mental disorder in people who suffered from enduring or episodic severe mental disorder throughout adulthood and are now reaching old age. Such people are sometimes described as ‘graduating’ from services designed for the needs of adults of working age to those designed for older people. These patients are potentially at risk of neglect or sub-optimal care by services because of changes that have occurred in the organisation and responsibilities of services over the past 30-40 years. Their particular needs have never been addressed in policy documents. The principles of care for people with mental disorder, as outlined in the ‘National Service Framework for Mental Health’ remain applicable to them, although in many instances their care will fall to specialist services for older people working within the ‘National Service Framework for Older People’.

Previous generations of graduates lived out their lives in mental hospitals. Many are now housed in hostels, residential or nursing homes, or may be supported with complicated packages of care in private households. Estimates of the most severely affected range from 11 to 60 per 100 000 population. The majority suffer from chronic schizophrenia or relapsing mood disorder. Many continue to demonstrate evidence of florid symptomatology as well as defect states. Their physical health is often poor and they might have no social infrastructure other than that provided by statutory services. Some have been relocated out of their district of origin as part of a mental hospital closure programme, and might have lost contact with their original services. New graduates often encounter difficulties when general psychiatry or rehabilitation services feel that they should give way to services for older people.

Recommendations to services

1. • Each local health and social care economy should identify all graduates as characterised.

2. • A full reassessment should be made of each individual's current health and social care needs and a care plan should be agreed, designed to meet these needs within available resources. Progress towards improved care and improved health should be monitored by annual reviews.

3. • For people who are currently approaching the age of 65, their birthday should trigger a comprehensive review of health and social care needs. Following this review, a care plan should be agreed and be subject to annual review.

4. • Medical responsibility will rest with a principal in general practice or a consultant psychiatrist, and maintenance of continuous review should be the responsibility of the case manager.

It is intended, with the support of the National Institute for Mental Health for England, to monitor progress in the implementation of these recommendations and to publish the findings annually.