Editorials

Older people with schizophrenia: providing services for a neglected group

It's the quality of their environment that matters, not where it is 

Schizophrenia is a severe psychiatric disorder affecting about 1% of the elderly population.¹ Symptoms include delusions and hallucinations as well as apathy, blunting or incongruity of emotional responses, and social withdrawal. Most older people with schizophrenia will have developed the illness before the age of 45. In the past many of these patients have ended up in long stay psychiatric beds, but their exact number is unknown. In Britain the drive to close long stay psychiatric hospitals is continuing at a time when the elderly population is increasing.² It is important that older people suffering from schizophrenia are not neglected as community psychiatric services are planned.

One survey of five English psychiatric hospitals due for closure reported that about 20% of the long stay population was over the age of 65 years and had a diagnosis of schizophrenia.³ Few studies have specifically looked at elderly people with schizophrenia, but those who reside in long stay wards are known to suffer from significant disabilities, particularly in affect, motivation, and the ability to perform the basic functions necessary for independent living.⁴ In the community they represent at least as high an economic burden as younger patients,⁵ but public awareness about schizophrenia is often focused on younger sufferers who may present more floridly and are more likely to commit violent acts.⁶

Closures of psychiatric hospitals began in America far earlier than in Europe and information about how this process has worked has come largely from American studies. Many elderly sufferers of schizophrenia will end up in residential or nursing homes. What kind of life can they expect? In America Linn et al studied a group of older men, including 159 suffering from schizophrenia, who were long term psychiatric patients in Veterans Administration hospitals. ^{7 8} The patients were assigned to either a nursing home in the community, a Veterans Administration nursing home, or another long stay psychiatric ward or they remained on the same ward. At 12 months outcomes were best for the group transferred to another long stay ward and worst for the group transferred to community nursing homes. The important factors affecting outcome were found to be staff characteristics and the functional ability of the other residents in each unit.⁸ The community nursing homes had the lowest staff-patient ratios, the highest staff turnover, and also the least able residents.

A smaller retrospective study from Britain followed up a group of elderly long stay patients most of whom suffered from schizophrenia.⁹ Half the patients remained in hospital and half were relocated to community homes. Two to three years later the patients who had been transferred to the community had declined more slowly than those who remained in hospital.

Although at first sight the findings in the British and American studies appear contradictory, the quality of the environment rather than the type determined the outcome for patients in both countries. The average size of community nursing homes in the American studies was 120 beds, which is far larger than residential homes in Britain. In the British study staff-patient contacts were found to be more frequent in community facilities than on the long stay wards. Patients with schizophrenia can benefit from deinstitutionalisation,¹⁰ but community care has to be carefully planned and adequately resourced. Because a residential home is in the "community" does not mean the quality of the environment is automatically any better than that in a traditional psychiatric institution.

Those working for health or social services or for other agencies in contact with elderly people with schizophrenia need to be aware of the potential to improve their quality of life. The recently published Handbook on the Mental Health of Older People contains some guidelines for purchasers.² Four factors in particular should help in providing effective and seamless services for these patients.

Firstly, general practitioners have a central role in coordinating service provision,¹¹ and it is important that they assess the physical needs of these patients as well as their mental states.¹² Secondly, since many of these patients will be living in nursing and residential homes, the organisation of specialist mental health services should take this into account. Thirdly, purchasers need to be aware of the effect environmental factors have on the functioning of these patients when planning their residential care needs. Finally, many agencies (including psychiatric, social, and voluntary services) operate age related services. There should be clarity about which services have the responsibility for each individual's care at any one time. If patients move from one service to another this transfer should be planned in advance and coordinated. Resources should be allocated so that account is taken of this movement in and out of services.