Principles and Practice of Geriatric Psychiatry

By Cornelius L. E. Katona and Anand Kumar

The renowned Principles and Practice of Geriatric Psychiatry, now in its third edition, addresses the social and biological concepts of geriatric mental health from an international perspective. Featuring contributions by distinguished authors from around the world, the book offers a distinctive angle on issues in this continually developing discipline.

Principles and Practice of Geriatric Psychiatry provides a comprehensive review of:

• geriatric psychiatry spanning both psychiatric and non-psychiatric disorders
• scientific advances in service development
• specific clinical dilemmas

New chapters on:

• genetics of aging
• somatoform disorders
• epidemiology of substance abuse
• somatoform disorders
• care of the dying patient

Continuing the practice of earlier editions, the major sections of the book address aging, diagnosis and assessment and clinical conditions, incorporating an engaging discussion on substance abuse and schizophrenic disorders. Shorter sections include the presentation of mental illness in elderly people from different cultures—one of the most popular sections in previous editions. Learning and behavioural studies, as well as models of geriatric psychiatry practice, are covered extensively. This book provides a detailed overview of the entire range of mental illness in old age, presented within an accessible format.

Principles and Practice of Geriatric Psychiatry is an essential read for psychiatrists, geriatricians, neurologists and psychologists. It is of particular use for instructors of general psychiatry programs and their residents.

• Language: English
• Publisher: Wiley
• Release date: Jul 28, 2011
• ISBN: 9781119956662

Book preview

Preface

It has been eight years since the second edition of Principles and Practice of Geriatric Psychiatry was published. During this time there has been substantial progress in the science and practice of geriatric psychiatry. This third edition attempts to capture these advances and provide an up-to-date summary for trainees and practitioners.

Two of the Editors of the previous editions, John R M Copeland and Dan G Blazer, decided to withdraw and two new Editors (one from the UK and one from the US) have been recruited. We wish first of all to express our grateful thanks to John and Dan for their remarkable stewardship over the production of the two previous editions. We would also like to acknowledge the invaluable contribution of the six Associate Editors in bringing this third edition to completion.

The previous edition received good reviews as well as some helpful criticisms. We therefore decided to maintain the textbook's overall scope, structure, headings, list of contents and international authorship. The majority of the textbook's chapters have been updated by the original authors. We have, however, recruited several new authors who are internationally recognized experts in their fields and commissioned substantial completely new material.

We believe that the value and the strengths of this textbook rest in its comprehensive coverage of the basic and clinical sciences of normal and abnormal ageing, of the full range of psychiatric disorders in the elderly, and of the organization of psychogeriatric services in the UK and the US as well as chapters on prevention, training and education.

We hope that this third edition is well received by its readers and that it proves to be a useful and readable way for them to update their knowledge of the science and practice of geriatric psychiatry.

Mohammed T Abou-Saleh

Cornelius L E Katona

Anand Kumar

Preface to Second Edition

The editors were very gratified that the first edition of this textbook was generally well received and that a second edition has been called for. It is now seven years since the original book appeared, and there have been many more advances in the subject. In spite of new sections and some wholesale rewriting, it has been possible once again, to contain the information in one volume. Very sadly some of our original contributors have died. New authors have replaced them while others have been added in an endeavour to keep the text authoritative and up-to-date. The helpful criticisms of the first edition have been carefully considered in the preparation of this one. Having so many distinguished authors with such a breadth of interest, while greatly enhancing the book, has led to a long gestation period, but we believe that it has been worthwhile. Much of the original format has been retained in order to continue to stimulate lively debate and exchange of views. If the book contributes to the growing strength of Geriatric Psychiatry internationally, it will have done its work.

John R. M. Copeland

Mohammed T. Abou-Saleh

Dan G. Blazer

Preface to First Edition

The discipline of the psychiatry of old age has moved rapidly in recent years and the number of practitioners has expanded worldwide. An authoritative text is required which draws on the knowledge of these experts and which reflects both new scientific advances and innovations in service development.

In a comparatively new subject many of the issues are still contentious and on some of these we have tried to provide the opportunity for the expression of different points of view. Readers are asked to judge the issues for themselves from the evidence set out.

Here and there short, special articles have been commissioned which present research findings in more detail and describe new aspects of care.

They are intended to enliven the text and their choice has been dependent on timing and opportunity.

We have also tried to give a feel for what is happening in developing countries and the scope of the problems experienced by local practitioners.

Even a book of this size can never be complete and no doubt gaps in the coverage of subjects will be identified. We would be glad to have them pointed out. The more comprehensive a book aims to be the longer it takes to come to publication and in a fast-moving area of knowledge this can be a problem. Many of our authors have been kind enough to update their contributions at a late stage, which we hope has overcome this difficulty to some extent.

In the early stages of the development of a subject there is insufficient corpus of knowledge to assemble in book form. This situation has changed dramatically for geriatric psychiatry in recent years. We hope that the knowledge gathered here from our distinguished international panel of authors bears this out.

John R. M. Copeland

Mohammed T. Abou-Saleh

Dan G. Blazer

Part A

Historical Background

1

A Conceptual History in the Nineteenth Century

German E. Berrios

Department of Psychiatry, Addenbrooke’s Hospital, Cambridge, UK

The history of geriatric psychiatry can be written from two viewpoints. The ‘externalist’ approach focuses on the social and political variables that have controlled attitudes towards abnormal behaviour in old age, and on the professionalization of those charged with the care of the mentally infirm elderly. The ‘internalist’ approach – to be followed in this chapter – concentrates on the origin of the scientific language of psychogeriatrics. An adequate historical account should include information on theories of ageing, both physical and mental, brain sclerosis and the formation of a viable concept of mental illness. On the first rubric much research has been done¹-⁹; far less work exists on the other two. On psychogeriatric care before the nineteenth century¹⁰,¹¹ there is very little: this may simply reflect a historical reality.

VIEWS ON AGEING BEFORE THE NINETEENTH CENTURY

Like most other aspects of human life, ageing has also been portrayed in terms of metaphors. Classical views, following the nature-nurture controversy, conceived of ageing as resulting from either internal instructions or from the buffeting of foreign factors⁴,⁸.

The ‘wear and tear’ view happened to be popular during the early nineteenth century, the period on which this chapter will concentrate. It was based, as it had always been, on the ageless observation that all natural objects, whether animate or not, are subject to the ravages of time. Surprisingly enough, the ‘wear and tear’ view has not always generated an understanding attitude. In fact, across times and cultures great ambiguity has existed in regard to the treatment of old folk. Fortunately, a realistic acceptance seems to have predominated although there is plenty of evidence of hostility. The Hebrew tradition, and indeed its Christian offshoot, encouraged much reverence towards the wisdom and value of old age. But even in societies that have made great play of this view, veneration has been reserved for those in positions of power or influence¹². Little is known about attitudes towards elderly women or old men in humbler stations¹¹.

So, it can be concluded that, all in all, a view seems to have predominated that ageing was undesirable and that the identification of wear factors was important to devising ways of prolonging life⁵,¹³.

A second ambiguity can be detected in these earlier writings. It concerns the extent to which the ageing process necessarily involves the human mind. While it was a palpable fact that all human frames decayed, not everyone accepted that this had necessarily to affect the soul or mind. Extant descriptions of the psychological changes brought about by old age suggest that people were aware that the mind also underwent a decline. However, theory and religion encouraged the view that the spirit could or did escape wear and tear, and that human beings grew ever more wise and useful, thanks to the accumulation of experience and knowledge. This belief must have been available in all those societies that felt the need to create adequate spaces for all manner of intellectual and/or sociopolitical gerontocracies². Some seem even to have separated chronological age and functional age in order to justify such concessions. From the point of view of the history of psychogeriatrics, it would be useful to know to what extent this belief was undermined by the occasional case of dementia among those elderly in positions of power¹. Historical evidence seems to show that these situations were neither more nor less perturbing than mental illness occurring at other periods of life. Indeed, fail-safe devices seem to have been available in these societies to cope with the upheavals created by such occurrences.

Men like Buffon, Darwin and Goethe reshaped ideas on ageing during the eighteenth century. Buffon¹⁴ wrote: ‘All changes and dies in Nature. As soon as it reaches its point of perfection it begins to decay. At first this is subtle and it takes years for one to realise that major changes have in fact taken place’ (p. 106). Buffon put this down to an ‘ossification’ process similar to that affecting trees: ‘this cause of death is common to animals and vegetables. Oaks die as their core becomes so hard that they can no longer feed. They trap humidity, and this eventually makes them rot away’ (p. 111).

Erasmus Darwin’s views resulted from the application of yet another metaphor, namely that ageing results from a breakdown of ‘communication’ between man and his environment¹⁵. Darwin suggested that such breakdown followed a loss of irritability (a property of nerve fibres) and a decreased response to sensation:

It seems our bodies by long habit cease to obey the stimulus of the aliment, which support us … three causes may conspire to render our nerves less excitable: 1. If a stimulus be greater than natural, it produces too great an exertion of the stimulated organ, and in consequence exhausts the spirit of animation; and the moving organ ceases to act, even though the stimulus is continued. 2. If excitations weaker than natural be applied, so as not to excite the organ into action, they may be gradually increased, without exciting the organ into action, which will thus acquire a habit of disobedience to the stimulus. 3. When irritative motions continue to be produced in consequence of stimulus, but are not succeeded by sensation. (p. 365)

VIEWS ON AGEING DURING THE NINETEENTH CENTURY

In 1807 Sir John Sinclair¹⁶ published a major compendium on ageing and longevity, which included references to most pre-nineteenth century sources. It was, in a way, the last grand glance to the past. Soon afterwards work started by those who, like Leon Rostan (1791-1866), based their claims on empirical findings. Rostan, one of the most original members of the Paris school, published in 1819 his Recherches sur le Ramollissement du Cerveau¹⁷, where the view commenced that vascular disorders might be as important as parenchymal ones in brain ageing. Even more important was his uncompromising anti-vitalistic position enshrined in the claim that all diseases were related to pathological changes in specific organs¹⁸,¹⁹.

During the 1850s Reveille-Parise³ saw his task as writing on ‘the history of ageing, that is, mapping the imprint of time on the human body, whether on its organs or on its spiritual essence’ (p. v). In regard to ageing itself he wrote: ‘the cause of ageing is a gradual increase in the work of decomposition … but how does it happen? What are the laws that control the degradation that affects the organization and mind of man?’ (p. 13). Reveille-Parise dismissed the toxic view defended by the Italian writer Michel Levy²⁰ according to which there was a gradual accumulation of calcium phosphates that led to petrification, to an ‘anticipation of the grave’. This view, he stated, had no empirical foundation and was based on a generalization from localized findings. Reveille-Parise supported the view that ageing results from a negative balance between composition and elimination, which equally affected the cardiovascular, respiratory and reproductive organs.

Finally, the views should be mentioned of J. M. Charcot, who in 1868 offered a series of 24 lectures on the diseases affecting the elderly²¹. Charcot dedicated Lecture 1 to the ‘general characters of senile pathology’; he started by saying that all books on geriatrics up to his time had ‘a particularly literary or philosophical turn [and had been] more or less ingenious paraphrases of the famous treatise De Senectute’ (p. 25). He praised Rostan for his views on asthma and brain softening in the elderly, and predictably also mentioned Cruveilhier, Hourman and Dechambre, Durand-Fardel and Prus. He criticized Canstatt and other German physicians because in their work, ‘imagination holds an immense place at the expense of impartial and positive observation’ (p. 26). Charcot’s own contribution was based on the general principle that ‘changes of texture impressed on the organism by old age sometimes become so marked, that the physiological and pathological states seem to merge into one another by insensible transitions, and cannot be clearly distinguished’ (p. 27).

THE DEVELOPMENT OF THE NOTION OF BRAIN SCLEROSIS

When in 1833 Lobstein²² described the basic pathology of arteriosclerosis, he did not imagine that it would, during the second half of the century, become the mechanism of ‘senility’ par excellence¹⁴,²³,²⁴. Motor and sensory deficits, vertigo, delusions, hallucinations and volitional, cognitive and affective disorder were all attributed to the effect of arteriosclerosis²⁵,²⁶. They related to the brain via a two-stage speculative pathophysiology: parenchymal and/or vascular disorders could affect the brain, and the distribution of the lesions could be diffused or focal. Vascular changes included acute ischaemia (on which clinical observation was adequate)²⁷,²⁸ and chronic ischaemia, invented as a separate syndrome by extrapolating from the symptoms and signs observed during the acute states²⁴. The role of arteriosclerosis as a causal and prognostic factor in relation to the involutional psychoses was challenged early in the twentieth century²⁹ but this paper remained unnoticed. Hence, some of the old notions, such as that of ‘arteriosclerotic dementia’, remained active well into the 1960s³⁰.

Alienists during the same period, however, were already able to distinguish between states where a putative chronic and diffuse reduction in blood supply had taken place from focalized damage, i.e. what they called ‘multifocal arteriosclerotic dementia’ and was equivalent to what is currently called multi-infarct dementia²⁴,³¹,³².

NINETEENTH CENTURY VIEWS ON MENTAL DECAY IN THE ELDERLY

It is against this background that the history of the language and concepts dedicated to understanding mental disorders in the elderly must be understood. In addition to these neurobiological frameworks, a psychological theory that explained the manner of the decline was required. Such a psychopathology was provided by the heuristic combination of associationism, faculty psychology³³, and statistics³⁴ that characterized the early and middle parts of the nineteenth century.

Yet another perspective, originating in clinical observation, was added during the 1830s. It led to the realization that, in addition to the well-known forms of mental disorder, the elderly might exhibit specific forms of deterioration, and that these could be related to recognizable brain changes. There is only space in this chapter to deal with two examples: one typifying a ‘specific’ disorder of old age, namely the history of chronic cognitive failure or dementia; the other illustrating the effect of a general mental disorder (melancholia) on the elderly.

THE FORMATION OF THE CONCEPT OF SENILE DEMENTIA

The history of the word and concept of dementia before the nineteenth century has been touched upon elsewhere³⁵. Suffice it to say here that, at the beginning of the nineteenth century, ‘dementia’ had a ‘legal’ and a ‘medical’ meaning and referred to most acquired states of intellectual dysfunction that resulted in serious psychoso- cial incompetence. Neither age of acquisition nor reversibility was part of its definition. These two dimensions were only incorporated during the nineteenth century and completely changed the semantic territory of the dementia concept.

Anecdotal observation of cases of senile dementia abound both in the fictional literature and in historical documents³⁶, but the concept of ‘senile dementia’, as it is currently understood, only took shape during the latter part of the nineteenth century. Indeed, it could not have been otherwise, as the neurobiological and clinical language that made it possible only became available during this period³⁷,³⁸. But even after the nosological status of senile dementia had become clearer, there were many who, like Rauzier³⁹, felt able to state: ‘it may appear either as a primary state or follow most of the mental disorders affecting the elderly’ (p. 615). Following Rogues de Fursac⁴⁰, Adrien Pic – the author of one of the most influential geriatric manuals during this period⁴¹ – defined senile dementia as: ‘a state of intellectual decline, whether or not accompanied by delusions, that results from brain lesions associated with ageing’ (pp. 364-365). It was against this background that the concept of Alzheimer’s disease, which became the prototype for all senile dementias, was created during the first decade of the twentieth century³⁷. Recent work has shown that its ‘discovery’ was controlled by ideological forces well beyond what could be described as ‘scientific’³⁷,⁴². These forces also introduced unwarranted clinical strictures, such as the exclusion of non-cognitive symptoms⁴³,⁴⁴ and false age boundaries, which took many years to disappear.

THE FORMATION OF THE CONCEPT OF INVOLUTIONAL MELANCHOLIA

The concept of ‘senile or involutional psychoses’, which featured so prominently in Kraepelin’s early classification, included presenile delusional insanity, senile dementia, late catatonia and involutional melancholia⁴⁵,⁴⁶. The reasons that led Kraepelin to separate this group were mostly theoretical, to wit, that they appeared during a period of life when ‘sclerotic’ changes were beginning to occur; the same factor accounted for their bad prognosis⁴⁶.

The general history of melancholia and depression has been analysed elsewhere⁴⁷-⁴⁹. Suffice it to say here that by the 1860s depression was considered to be an independent syndrome resulting from a primary disorder of affect. This meant that hallucinations, delusions and cognitive impairment were secondary to the pathological feelings. This conviction was particularly strong towards the end of the century, when emotional mechanisms became popular in the explanation of most forms of mental disorder⁵⁰. By the end of the century the metaphor of depression as a form of ‘reduction’ or ‘loss’ had become firmly established. No better example can be found than the fact that up to 1893 (fourth edition) Kraepelin felt obliged to classify all forms of agitated depression as mania!⁵¹

KRAEPELIN AND INVOLUTIONAL MELANCHOLIA

Much of the current confusion on the meaning of involutional melancholia can be explained if attention is given to the circumstances of its historical development (for a full analysis of this process and list of references, see Berrios⁵²). The conventional story⁵³-⁵⁶ is that up to the seventh edition of his textbook Kraepelin considered involu- tional melancholia as a separate disease, and that when confronted by the evidence collected by Dreyfus⁵⁷, he decided to include it, in the eighth edition, under the general heading of manic depressive insanity. Indeed, this account was first offered by Kraepelin himself (see Dreyfus, p. 169).

The story is, however, more complex and it is unlikely that the findings of Dreyfus alone caused Kraepelin’s change of heart. For example, Thalbitzer⁵⁸ claimed that his own work had also been influential (p. 41). In the eighth edition Kraepelin abandoned not only involutional melancholia but the entire group of ‘senile psychoses’. A recent statistical analysis of Dreyfus’s old series has also shown that his conclusion that the natural history of involutional melancholia was no different from that of depression affecting younger subjects was wrong⁵¹.

CONCLUSIONS

This short chapter, providing a historical vignette on the origin of the language of old age psychiatry, suggests that it was born during the nineteenth century from three conceptual sources: theories of ageing, neurobiological hypotheses concerning brain sclerosis, and the realization that specific forms of mental disorder might affect the elderly. Two clinical illustrations were provided, one pertaining to the origins of the concept of senile dementia, and the other to the notion of involutional melancholia.

REFERENCES

1. Huber J-P, Gourin P. Le vieillard dément dans l’Antiquité classique. Psychiatr Fr 1987; 13: 12–18.

2. Minois G. Histoire de la Vieillesse. De l’Antiquité à la Renaissance. Paris: Fayard, 1987.

3. Reveillé-Parise JH. Traité de la Vieillesse. Paris: Baillière, 1853.

4. Grmek MD. On Ageing and Old Age. The Hague: W Junk, 1958.

5. Legrand MA. La Longévité à Travers les Âges. Paris: Flammarion, 1911.

6. Freeman JJ. Aging. Its History and Literature. New York: Human Sciences Press, 1979.

7. Kotsovsky D. Le problème de la vieillesse dans son developpement historique. Riv Biol 1931; 13: 99–111.

8. Grant RL. Concepts of aging: an historical review. Persp Biol Med 1963; 6: 443–78.

9. Bastai P, Dogliotti GC. Physiopathologie de la Vieillesse. Paris: Masson, 1938.

10. Robinson DR. The evolution of geriatric psychiatry. Med Hist 1972; 16: 184–93.

11. Kastenbaum R, Ross B. Historical perspectives on care. In How- ells J (ed.), Modern Perspectives in the Psychiatry of Old Age. Edinburgh: Churchill Livingstone, 1975, 421–49.

12. Cicero. De Senectute, De Amicitia, De Divinatione, trans. Falconer WA. London: Loeb, 1923.

13. Gruman GJ. A history of ideas about the prolongation of life. Trans Am Phil Soc 1966; 56: 1–97.

14. Buffon M le Comte, Georges-Louis Leclerc. Histoire Naturelle de l’Homme, de la Vieillesse et de la Mort, vol. 4: Histoire Naturelle de l’Homme. Paris: De L’imprimerie Royale, 1774.

15. Darwin E. Zoonomia; or, the Laws of Organic Life, 2 vols. London: Johnson, 1794–1796.

16. Sinclair Sir J. The Code of Health and Longevity. Edinburgh: Constable, 1807.

17. Rostan LL. Recherches sur le Ramollissement du Cerveau. Paris: Bechet, 1819 and 1823.

18. Rostan LL. Jusqu à quel point l’anatomie pathologique peut-elle éclairer la thé rapeutique des maladies. Thèse de concours. Paris: Moessard, 1833.

19. Chereau A. Rostan. In Dechambre A, Lereboullet L (eds), Dic- tionnaire Encyclopédique des Sciences Médicales, vol. 84. Paris: Masson, 1877, 238 -40.

20. Lévy M. Traité d’hygiéne Publique et Priveé. Paris: Baillière 1850.

21. Charcot JM. Clinical Lectures on Senile and Chronic Diseases, trans. Tuke WS. London: The New Sydenham Society, 1981.

22. Lobstein JG. Traité de Anatomie Pathologique, vol. 2. Paris: Baillière, 1838.

23. Demange E. Ètude Clinique et Anatomopathologique de la Vieillesse. Paris: Ducost, 1886.

24. Potain C. Cerveau (Pathologie). In Dechambre A, Lereboullet L (eds), Dictionnaire Encyclopédique des Sciences Médicales, vol. 14. Paris: Masson, 1873, 214–345.

25. Marie A. Démence. Paris: Doin, 1906.

26. Albrecht T. Manischdepressiven Irresein und Arteriosklerose. AllgZ Psychiatr 1906; 63: 402–47.

27. Schiller F. Concepts of stroke before and after Virchow. Med Hist 1970; 14: 115–31.

28. Fields WS, Lamak NA. A History of Stroke. New York: Oxford University Press, 1989.

29. Walton GL. Arteriosclerosis probably not an important factor in the etiology and prognosis of involution psychoses. Boston Med Surg J 1912; 167: 834–6.

30. Weitbrecht HJ. Psychiatrie im Crundriss. Berlin: Springer, 1968.

31. Ball B, Chambard E. Démence. In Dechambre A, Lereboullet L (eds), Dictionnaire Encyclopédique des Sciences Médicales, vol. 26. Paris: Masson, 1882, 559–635.

32. Spielmeyer W. Die Psychosen des RUckbildungs und Creisenalters. Leipzig: Deuticke, 1912.

33. Berrios GE. Historical background to abnormal psychology. In Miller E, Cooper PJ (eds), Adult Abnormal Psychology. Edinburgh: Churchill Livingstone, 1988, 26–51.

34. Birren JE. A brief history of the psychology of ageing. Geron- tologist 1961; 1: 69–77.

35. Berrios GE. Dementia during the seventeenth and eighteenth centuries: a conceptual history. Psychol Med 1987; 17: 829–37.

36. Torack RM. The early history of senile dementia. In Reisberg B (ed.), Alzheimer’s Disease. New York: Free Press, 1983, 23–8.

37. Berrios GE. Alzheimer’s disease: a conceptual history. Int J Geriatr Psych 1990; 5: 355–65.

38. Schwalbe J. Dementia senilis. In Lehrbuch der Greisenkrankheiten. Stuttgart: Enke, 1909, 479–89.

39. Rauzier G. Traité des Maladies des Vieillards. Paris: Baillière, 1909.

40. Rogues de Fursac J. Manual de Psiquiatri à, trans. of 5th French edn by Peset J. Valencia: Editorial Pubul, 1921.

41. Pic A. Précis des Maladies des Vieillards. Paris: Doin, 1912.

42. Dillman R. Alzheimer’s Disease. The Concept of Disease and the Construction of Medical Knowledge. Amsterdam: Thesis Publishers, 1990.

43. Berrios GE. Non-cognitive symptoms and the diagnosis of dementia. Historical and clinical aspects. Br J Psychiat 1989; 154(suppl 4): 11–16.

44. Berrios GE. Memory and the cognitive paradigm of dementia during the 19th century: a conceptual history. In Murray RM, Turner TH (eds), Lectures on the History of Psychiatry. London: Gaskell, 1990, 194–211.

45. Cabaleiro Goas M. Los sindromes psicóticos de la presenilidad. Actas Luso Esp Neurol Psiquiatr 1955; 14: 17–26.

46. Cabaleiro Goas M. Psicosis preseniles no orgànicocerebrales y su prevención. In Proceedings of I Congreso Nacional de Geronto-Psiquiatria preventiva. Xl Reunion de la Sociedad Espanola de Psiquiatria. Madrid: Liade, 1974, 117–42.

47. Berrios GE. Melancholia and depression during the 19th century: a conceptual history. Br J Psychiatry 1988; 153: 298–304.

48. Berrios GE. Depressive and manic states during the 19th century. In Georgotas A, Cancro R (eds), Depression and Mania. New York: Elsevier, 1988, 13–25.

49. Berrios GE. The history of the affective disorders. In Paykel ES (ed.), Handbook ofAffective Disorders, 2nd edn. Edinburgh: Churchill Livingstone, 1992, 43–56.

50. Berrios GE. The psychopathology of affectivity: conceptual and historical aspects. Psychol Med 1985; 15: 745–58.

51. Kraepelin E. Psychiatrie, 4th edn. Leipzig: Meixner, 1893.

52. Berrios GE. Affective symptoms in old age: a conceptual history. Int J Geriatr Psychiatry 1991; 6: 337–46.

53. Serieux P. Review of Dreyfus’s Melancholie. L’Encephale 1907; 2: 456–8.

54. Post F. The Clinical Psychiatry of Late Life. Oxford: Pergamon, 1965.

55. Kendell RE. The Classification of Depressive Illness. Oxford: Oxford University Press, 1968.

56. Jackson SW. Melancholia and Depression. From Hippocratic Times to Modern Times. New Haven, CT: Yale University Press, 1985.

57. Dreyfus GL. Die Melancholie. Ein Zustandsbild des manischdepressiven Irreseins. Jena: Gustav Fischer, 1907.

58. Thalbitzer S. Emotions and Insanity. London: Kegan Paul, Trench, Trubner, 1926.

2

The Development of Old Age Psychiatry in the UK

Claire Hilton¹ and Tom Arie²

¹ Central and North West London NHS Foundation Trust, Harrow, UK

² University of Nottingham, Ageing and Disability Research Unit, Nottingham, UK

Old age psychiatry in Britain was born in the 1960s and 1970s, and came of age at its recognition by the government as a distinct specialty in 1989.i Yet the need for it had been recognized as far back as the 1940s. Why was the gestation so long, and how has it developed in the last twenty years since its recognition? What can we learn from this history?

THE EARLIEST DAYS

The likelihood that older people would become major users of psychiatric services was identified during the Second World War. Increasing longevity meant there were more, and even older, old people. Falling birth rates increased the proportion of old people and since more women were in employment it was harder for them to take on traditional caring roles. Some of the more frail older people were cared for in ‘chronic sick’ and mental hospitals, which might be needed for war casualties.

Until the 1940s mental and physical ill health in old age had been considered largely irremediable. In the 1940s Marjory Warren, the pioneering geriatrician, demonstrated the scope for rehabilitating old people¹, psychiatrist Felix Post wrote on psychiatric differential diagnosis and multidisciplinary approaches to treatment², and Willi Mayer-Gross described how severely depressed old people could improve with electroconvulsive therapy (ECT)³ii. Despite the evidence of successful treatment, older people were not given priority in health policy. In 1942 the Beveridge Report laid the foundations of the ‘welfare state’ and a National Health Service (NHS). However, it stated, ‘It is dangerous to be in any way lavish to old age, until adequate provision has been assured for all other vital needs’³.

After the war, at the instigation of Professor Aubrey Lewis, a psychiatric ‘geriatric unit’ was opened at the Bethlem Hospital in South London, part of the Bethlem-Maudsley postgraduate psychiatric teaching hospital (see Chapter 03). This unit was for functionally ill patients regarded as treatable. Patients with dementia, especially those requiring long stay care, were excluded, in part because of opposition from academic psychiatrists who did not see their care as being worthy of study and investigation.

We shall touch on matters relating to these early influences, since all run throughout the development of the specialty. In addition, each generation rediscovers the demography of ageing as if it were a new phenomenon. Yet unlike, say, trends in fertility, or in transportation, which cannot be predicted with certainty, we always know the size of prospective populations of older people and the epidemiology of the crucial illnesses⁴. Repeatedly, the government has laid plans and failed adequately to implement or fund them, and then has ‘discovered’ afresh the scale of need. In 1950 we hear, ‘It is recognised that the present conditions of financial stringency limit opportunities for action at this time’⁵. In 2001, a national service ‘framework’ for older people had no allocated new funding for mental health⁷, whereas a parallel framework for mental health for younger people was substantially funded⁸.

Another initiative in 2007 to improve access to psychological therapies has followed an economic model and has been targeted towards getting unemployed younger people into work, although this may well be changing to become more inclusive across all ages⁹. A contrast exists even within Britain: since 2002, Scotland provides both free personal and nursing care, if deemed appropriate after assessment, while England and Wales do not.

WORKING WITH GERIATRICIANS

Working with geriatricians is crucial in view of the multiple and interlinked disorders of old people, yet at times this has been erratic. Although active treatment, both physical and mental, was being advocated by the 1940s, geriatrics developed much earlier than psychogeriatrics. This was in part because many early geriatricians saw themselves as holistic practitioners for older people, therefore requesting little psychiatric assistance. The advocacy of Lord Amulree, a civil servant and geriatrician, and the other founders of geriatrics drew the successes of rehabilitation, including emptying hospital beds, to the attention of the government¹⁰. Such a phenomenon did not occur in old age psychiatry until around 1970 when new local services, such as that established at Goodmayes Hospital in 1969¹¹, were drawn to the attention of the Department of Health and Social Security¹²: only then it was recognized that a modern approach could reduce bed occupancy, improve outcomes and save money. Until the 1970s old age psychiatry in the UK was characterized by research in clinical treatment, nosology, pathology and epidemiology, with only small pockets of local service innovation.

In 1970 there were 200 geriatric medicine consultants¹³ but only a handful of psychogeriatricians¹⁴,¹⁵. By 2006 there were 700 psychogeriatricians¹⁶. Where enthusiastic geriatricians and psychiatrists existed in a particular locality they collaborated. In addition, collaboration between the Royal College of Psychiatrists and the British Geriatrics Society¹⁷ since the 1970s has led to the development of guidelines for good practice and working collaboratively¹⁸. Moving services away from isolated mental and ‘chronic sick’ hospitals and their coming together in district general hospitals has given better access to each other’s services. Sometimes this facilitated joint working, but formal joint services were rare. In 1977, a department of Health Care of the Elderly, comprising both medicine and psychiatry working together, along with other relevant disciplines and professions was set up in Nottingham. There was an orthopaedic-geriatric unit, a stroke unit and a continence service, and joint research, along with extensive teaching of medical students and postgraduate trainees of relevant disciplines, and of overseas workers¹⁹-²¹.

‘Memory clinics’ are another development, now widespread, with their roots in both psychogeriatric and geriatric practice in the mid-1980s²². More recent developments include psychiatric liaison services for patients with acute physical illness in district general hospitals²³. Jointly run ‘intermediate care’ or ‘convalescent’ rehabilitation units for confused older people, especially those recovering from both delirium and physical illness, are also new. Geriatricians and psychiatrists still have much to learn from each other, and ‘seamless’ services remain the ideal. ‘Guidelines for collaboration’ have recently been updated²⁴.

WORKING WITH PSYCHIATRISTS CARING FOR YOUNGER PEOPLE

Before the establishment of the specialty, mentally ill old people requiring secondary care were the responsibility of general psychiatrists, but they rarely showed interest in actually working with them, especially those with dementia. However, some of the pioneering psychogeriatric services, such as Sam Robinson’s in Dumfries (195 8)²⁵, or Brice Pitt’s at Claybury, Essex (1966)²⁶, emerged in part due to the far sightedness and encouragement of general psychiatrists who were medical superintendents of mental hospitals. Despite such early developments, it took until 1989 for the Royal College of Psychiatrists and the government to agree officially to the creation of the new specialty of old age psychiatry. Until then, lack of recognition meant that it had often been impossible to extract from official statistics adequate data on older people’s use of services, and hence to establish the scale of need for services and for training.

Competition for resources is inevitable, so long as resources are limited. The low status of the aged, the perceived needs of people of working age, and the common misperception that young severely mentally ill people are frequently dangerous have generally resulted in funding for services for younger people disproportionately exceeding that for older people.

A CENTRAL BODY FOR COORDINATING DEVELOPMENT

A powerful national focus for securing improved recognition and better resources has been the flourishing Faculty of the Psychiatry of Old Age at the Royal College of Psychiatrists (since 1988), and its predecessor bodies (from 1973). It has, among other things, encouraged research, innovation, multidisciplinary working, and links with voluntary and statutory organizations and with the government, and has taken an interest in architecture and design for elderly confused people²⁷. A first series of newsletters in the 1980s served as a constructive means of communication among clinicians. A second series since 1996, available online since 2000 (www.rcpsych.ac.uk/college/faculties/oldage/newsletter.aspx), often expresses thoughtful comment related to current clinical and policy dilemmas. Faculty meetings have remained a source of debate, education, inspiration and problem solving. The Faculty’s website is a mine of information (www.rcpsych.ac.uk/college/faculties/oldage.aspx).

RESEARCH AND ACADEMIC DEVELOPMENT

Research on older people’s mental health has flourished and has helped the development of evidence-based practice. Sir Martin Roth in the 1950s defined the major diagnostic categories in older people²⁸, rather as Emil Kraepelin had done 50 years earlier for younger people. Felix Post undertook follow-up studies of treatment of depression and psychotic disorders. Nick Corsellis²⁹ followed by Bernard Tom- linson, Martin Roth³⁰ and Elaine and Robert Perry unpicked the neu- rochemical and neuropathological features of Alzheimer’s disease³¹. Early research by Raymond Levy into lecithin and later tacrine was a forerunner of today’s evidence-based antidementia drugs³².

Difficulty in obtaining funding for research has been characteristic¹⁵. But the growth of the neurosciences, along with the influence of bodies such as the Alzheimer’s Society, has enhanced the scale of funding for research into the dementias, and has attracted able workers.

Research has also grown through the development of academic departments of old age psychiatry. The first old age psychiatrist to be appointed professor became head of the joint department of Health Care of the Elderly in Nottingham in 1977. The first professor of old age psychiatry, at Guy’s Hospital, London, was appointed in 1983. The International Journal of Geriatric Psychiatry was started in 1986. In 1989 there were half a dozen professorial departments³³; now most medical schools have an academic presence for old age psychiatry, and many NHS consultants are involved in teaching medical students and postgraduates. Many other departments in universities are now conducting relevant research, and there are further thriving journals.

TEACHING AND TRAINING

Biographical information reveals that many colleagues did not envisage becoming old age psychiatrists, but were inspired by others to do so; they saw and experienced what could be done to help old people. Such effective teaching is crucial¹⁵.

Sharing our knowledge with other specialties and disciplines can change the way colleagues respond to elderly mentally ill people – in primary care, in management, in palliative care, social services, learning disability services, voluntary organizations, Citizens Advice Bureaux, and within the multidisciplinary teams within which we work. Other groups that have sought teaching include architects, designers, lawyers and the police.

Structured training for old age psychiatrists has also evolved over the years. The earliest psychogeriatricians in the 1960s and 1970s had little or no specific training. Six months’ experience in old age psychiatry is considered valuable for trainees in psychiatry and in general practice. Specialized training for career old age psychiatrists is during the last three years of a six-year psychiatry training scheme. There is a competency-based curriculum³⁴, and at least two years (full-time equivalent) old age psychiatry in recognized training posts are usually required.

CLINICAL INNOVATION

The demise of the vast Victorian mental hospitals, the coming of community care, more liberal mental health legislation and new effective psychopharmacology have all helped to shape the progress of psychiatry since the 1950s. The psychogeriatricians have consistently fought to prevent older people being left behind younger people in new developments. Important classic texts of innovation in old age psychiatry such as In the Service of Old Age by Tony Whitehead (1971)³⁵ deserve particular mention, as do the reports in the 1960s and 1970s of abuses in the unfashionable sectors of care. The Ely Hospital Report (1969)³⁶ was also instrumental in bringing about the Hospital (later Health) Advisory Service (HAS), which advised on the neglected areas of the health service. The HAS was a valuable ally of the early old age psychiatrists, encouraging and spreading good practice. Its first director became an old age psychiatrist upon demitting office³⁷.

Home assessment and support by consultants and other team members was the norm: in some services this is still the usual first point of contact. Initial assessment at home was introduced in the 1960s, in order to evaluate, in the light of knowledge of the home setting, who could be helped without hospital admission, or who might need a medical or a surgical bed rather than psychiatric help. Often the entire management of the patient could be undertaken in the patient’s home. Home assessment and treatment is valued by patients, carers and staff, and it helps to build a close working relationship with the local community, and is popular with medical students.

The importance of support for carers of people with dementia has long been recognized. Respite admissions³⁸, social services day care, help with personal care at home and the Admiral Nurse service established in 1994 (www.fordementia.org.uk/admiral.htm) are important in delivering such support.

Psychotherapy, including family therapy with old people and their adult children, dates from the 1960s³⁹ but is still not widespread, despite pockets of enthusiasm⁴⁰. In a very few places psychiatric intensive care units, in particular providing care for elderly men with dementia and disruptive behaviours, have evolved, such older people being excluded from similar services for younger people⁴¹. Elsewhere, intensive home treatment teams are appearing for even those with severe mental illness such as would traditionally require admission.

Old age psychiatry day hospitals date from the 1950s onwards. They were often a substitute for long stay care for people with chronic mental illness living at home or with their family. More recently they have developed to offer assessment, treatment, rehabilitation and support such as might be beyond the capacity of a social care day centre. They enable some with particularly disruptive behaviours unmanageable by a social care day centre to remain in the community⁴².

More recently as ‘ethnic minority’ populations have aged, understanding cultural and religious customs and attitudes to mental illness and ageing has become important in many local communities.

Other disciplines have developed in parallel to old age psychiatry. The British Psychological Society, for example, established a special interest group for psychologists working with older people in 1980 (www.psige.org/index.php).

Table 2.1 Core features of a service in 2009

Without evaluated creativity, we would not have the rich array of services that, despite constraints of limited funding, serve our patients, their relatives and carers. But by no means every service for older people yet has all the components described above (see Table 2.1).

LONG STAY CARE

Up to the 1980s, most long stay care for dementia, along with that of aged people with chronic psychosis, took place in hospitals. Local authority residential homes were intended to care for frail old people, but with the passage of time they too increasingly became facilities for demented people, but lacking nursing skills and facilities appropriate to their residents’ needs. During the Thatcher era of the 1980s, long stay care in hospitals was replaced by care in commercial, or, less often, charitable homes. Surveillance of standards in multiple dispersed units became very difficult. Third party inspection and definition of ‘minimum standards’ was instituted by the Blair government⁴³. Education and training of care home staff, long virtually absent, is now becoming more prevalent. But ‘scandals’ in the care of old people continue, and although they often achieve publicity, they generally evoke less indignation and less remedial action than similar scandals in child care. Fortunately, architects and designers often now devote special skills to the needs of old people.

THE FUTURE

Old age psychiatrists, like workers in other health specialties, practise within the context of the structure and culture of society. At the time of writing we enter a recession, with uncertainty about the future, but with ever more evidence of the effectiveness of our interventions.

There are more government initiatives. The National Dementia Strategy, emphasizes raising awareness, early diagnosis and intervention, and improving quality of care in dementia, and is welcome on that account. However, the government’s initial financial backing for the strategy amounts to less than 1% of the total annual cost of dementia care. It is hard to believe that this will make any significant impact. In addition it states, ‘Decisions on funding for subsequent years will only be made once we have had the opportunity to consider the results from the initial demonstrator sites and evaluation work. There is no expectation therefore that all areas will necessarily be able to implement the Strategy within five years’⁴⁴. This resonates with previous policies advocating good practice, which are neither mandatory nor adequately funded.

A new Mental Capacity Act seeks to provide a statutory framework to protect vulnerable people who are not able to make their own decisions⁴⁵. There is also new legislation relating to ‘deprivation of liberty’, significantly affecting people with dementia who lack capacity to decide on their place of care, to determine whether and how they can be confined to a care home or hospital in their best interests. The new Equality Bill should prevent discrimination in services on the basis of chronological age⁴⁶. However, it also carries the paradoxical risk that a separate service for old people may be regarded as discriminatory. Challenges to our special services have long arisen from this viewpoint, and we must continue to show that special services for an inherently low status and thus usually neglected group make for better care, and to point to the reasons why.

Legal and medical changes, and changes in society, will raise new questions, but the 1970s adage for an old age psychiatrist will continue to be ‘occasional militancy… to gain for the elderly a fair share of scant resources, to put them to best use, to make do with too little while wheeling, dealing, and fighting for more’⁴⁷.

REFERENCES

1. Warren M. Care of chronic sick. Br Med J 1943; ii: 822–3.

2. Post F. Some problems arising from a study of mental patients over the age of 60 years. J Ment Sci 1944; 90: 554–65.

3. Mayer-Gross W. Electric convulsion treatment in patients over 60. J Ment Sci 1945; 91: 101–3.

4. Beveridge W. Social Insurance and Allied Services (Cmnd 6404). London: HMSO, 1942.

5. Kay DWK, Beamish P, Roth M. Old age mental disorders in Newcastle upon Tyne, Part 1: A study of prevalence. Br J Psychiatry 1964; 110: 146–58.

6. Ministry of Health. Care of the Aged Suffering from Mental Infirmity, report HMC (50) 25. Typescript in King’s Fund Library, London, 1950.

7. Department of Health. National Service Framework for Older People, 2001. At www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/DH_4003066, accessed 9 Jan 2010.

8. Department of Health. National Service Framework for Mental Health, 2001. At www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4009598, accessed 9 Jan 2010.

9. Department of Health. Commissioning IAPT for the Whole Community: Improving Access to Psychological Therapies, 2008. At www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_0_90011, accessed 9 Jan 2010.

10. Exton-Smith AN. Obituary: Lord Amulree. Br Med J 1984; 288: 156.

11. Arie T. The first year of the Goodmayes psychiatric service for old people. Lancet 1970; ii: 1179–82.

12. Fry J. The Keppel Club (1952–74): lessons from the past for the future. Br Med J 1991; 303: 1596–8.

13. Brocklehurst JC. The Geriatric Day Hospital. London: King Edward’s Hospital Fund for London, 1970.

14. Arie T, Jolley D. Psychogeriatrics. In Freeman H. (ed.), A Century of Psychiatry . London: Mosby-Wolfe, 1999, 260–65.

15. Hilton C (ed.). The Development of Old Age Psychiatry from the 1960s until 1989, Guthrie Trust Witness Seminar, Centre for the History of Medicine, University of Glasgow, 9 May 2008. At www.gla.ac.uk/media/media_107314_en.pdf, accessed 9 Jan 2010.

16. Royal College of Psychiatrists. Workforce Figures for Psychiatrists. London: Royal College of Psychiatrists, 2006. At www.rcpsych.ac.uk/PDF/Results%20for%20the%202006%20Census%20(2).pdf, accessed 9 Jan 2010.

17. British Geriatrics Society Cerebral Ageing and Mental Health Special Interest Group. At www.bgs.org.uk/Special%20Interest/cerebral_ageing.htm, accessed 9 Jan 2010.

18. British Geriatrics Society and Royal College of Psychiatrists. Joint report on matters relating to the care of psycho-geriatric patients. Br J Psychiatry 1973; 123: News and Notes 2–3.

19. Arie T. Combined geriatrics and psychogeriatrics: a new model. GeriatrMed 1990; April: 24–7.

20. Arie T. Education in the care of the elderly. Bull N Y Acad Med 1985; 61(6): 492–500.

21. Bendall MJ. The interface between geriatrics and psychogeriatrics. Curr Med Lit Geriatr 1988; 1(1): 2–7.

22. Van der Cammen TJM, Simpson JM, Fraser RM, Preker AS, Exton-Smith AN. The memory clinic: a new approach to the detection of dementia. Br J Psychiatry 1987; 150: 359–64.

23. Working Group for Liaison Mental Health Services for Older People, Faculty of Old Age Psychiatry. Who Cares Wins. London: Royal College of Psychiatrists, 2005. At www.bgs.org.uk/PDF Downloads/WhoCaresWins.pdf, accessed 9 Jan 2010.

24. British Geriatrics Society. Guidelines for Collaboration between Physicians of Geriatric Medicine and Psychiatrists of Old Age, BGS Best Practice Guide 3.4, 2007. At www.bgs.org.uk/Publications/Compendium/compend_3–4.htm, accessed 9 Jan 2010.

25. Robinson RA. The organisation of a diagnostic and treatment unit for the aged in a mental hospital. In Psychiatric Disorders in the Aged, report on the World Psychiatric Association Symposium. Manchester: Geigy, 1965, 186–205.

26. Pitt B, interviewed for Oral History of Geriatrics as a Medical Specialty, National Sound Archive, 1991. At http://cadensa.bl.uk/uhtbin/cgisirsi/BLMW1dvUMJ/10190012/9 (summary), accessed 9 Jan 2010.

27. Kemp M. Accommodation for elderly patients with severe dementia, minutes, Group for the Psychiatry of Old Age, Royal College of Psychiatrists 28 Mar 1974 (13), 13 June 1974 (4).

28. Roth M. The natural history of mental disorders in old age. J Ment Sci 1955; 101: 281–301.

29. Corsellis JAN. Mental Illness and the Ageing Brain, Maudsley Monograph 9. London: Oxford University Press, 1962.

30. Roth M, Tomlinson BE, Blessed G. The relationship between qualitative measures of dementia and degenerative change in cerebral grey matter of elderly subjects. Proc R Soc Med 1967; 60: 254–60.

31. Perry EK, Perry RH, Blessed G, Tomlinson B. Necropsy evidence of central cholinergic deficits in senile dementia. Lancet 1977; i: 189.

32. Eagger SA, Levy R, Sahakian BJ. Tacrine in Alzheimer’s disease. Lancet 1991; 337: 989–92.

33. Arie T. Martin Roth and the ‘Psychogeriatricians’. In Davison K, Kerr A. (eds), Contemporary Themes in Psychiatry: A Tribute to Sir Martin Roth. London: Gaskell, 1989, 231–8.

34. Royal College of Psychiatrists. A Competency Based Curriculum for Specialist Training in Psychiatry: Specialist Module in Old Age Psychiatry, 2009. At www.rcpsych.ac.uk/PDF/01d_Age_Feb09.pdf, accessed 9 Jan 2010.

35. Whitehead T. In the Service of Old Age: The Welfare of Psy- chogeriatric Patients. Harmondsworth: Penguin, 1970.

36. DHSS. Report of the Committee of Inquiry into Allegations ofIll- treatment ofPatients and other Irregularities at the Ely Hospital, Cardiff (Cmnd 3975). London: HMSO, 1969.

37. Baker AA. Why psychogeriatrics? Lancet 1974; i: 795–6.

38. De Largy J. Six weeks in, 6 weeks out. A geriatric hospital scheme for rehabilitating the aged and relieving their relatives. Lancet 1957; i: 418–19.

39. Colwell C, Post F. The parent-child relationship in the treatment of elderly psychiatric patients. Ment Health (Lond) 1964; 23: 7–9.

40. Benbow SM, Marriott A. Family therapy with elderly people. Adv Psychiatr Treat 1997; 3: 138–45.

41. Department of Health. Mental Health Policy Implementation Guide: National Minimum Standards for General Adult Services in Psychiatric Intensive Care Units (PICU) and Low Secure Environments, 2002. At www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4010439, accessed 9 Jan 2010.

42. Arie T. Day care in geriatric psychiatry 1978. Age Ageing 1979; 8(suppl): 87–91.

43. Department of Health. Fit for the Future? National Required Standards for Residential and Nursing Homes for Older People (Consultation Document), 1999. At www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd-Guidance/DH_4009506, accessed 9 Jan 2010.

44. Department of Health. Living Well with Dementia: A National Dementia Strategy, 2009. At www.dh.gov.uk/en/socialcare/deliveringadultsocialcare/olderpeople/nationaldementiastrategy/index.htm, accessed 9 Jan 2010.

45. Office of Public Sector Information. Mental Capacity Act 2005, 2005. At www.opsi.gov.uk/ACTS/acts2005/ukpga_20050009_en_l, accessed 9 Jan 2010.

46. Office of Public Sector Information. Equality Act 2006, 2006. At www.opsi.gov.uk/acts/acts2006/pdf/ukpga_20060003_en.pdf, accessed 9 Jan 2010.

47. Anon. Group into section? Minutes, Group for the Psychiatry of Old Age, Royal College of Psychiatrists, 1977 (typescript).

iOriginally called ‘psychogeriatrics’, ‘old age psychiatry’ is now more commonly used. However, the former is retained in some contexts, e.g. journal titles such as International Psychogeriatrics. The Royal College of Psychiatrists has a Faculty of the Psychiatry of Old Age, while many clinical departments refer to themselves as ‘Mental Health Services’ for older people or older adults.

iiBefore antidepressants, ECT was the only effective physical treatment.

3

Commentary on ‘In the Beginning’ by Felix Post

Claire Hilton

Central and North West London NHS Foundation Trust, Harrow, UK

INTRODUCTION

Felix Post was probably the first dedicated old-age psychiatrist anywhere in the world. ‘In the Beginning’ is his autobiographical account of the earliest days of old-age psychiatry in Britain. Such accounts are valuable primary sources for understanding the development of the specialty. We are now reaching a point in time when our earliest pioneers like Felix Post (1913–2001) and Martin Roth (1917–2006) have died. It is important that we remember the contributions of our teachers from the past who have set the foundations for our specialty, just as Phillipe Pinel, Emil Kraepelin, Sigmund Freud and many others are celebrated for their contributions to the mental well-being of mainly younger people.

This short chapter by Felix Post has been described as ‘pure Felix’. It characteristically reveals his humility and modesty, and his praise of others, attributing little achievement to himself. A brief biographical note and commentary are therefore warranted to set it in context.

‘IN THE BEGINNING’ BY THE LATE FELIX POST

In 1943, after a year’s early training as one of the war-time refugees of the Maudsley Hospital, Professor Aubrey Lewis passed me on to Professor D.K. Henderson and the Royal Edinburgh Hospital for Nervous and Mental Diseases, where I initially worked in the private department. During one of his rounds, Henderson said to me: ‘Post, do you see all these old people here? Why don’t you write ‘em up?’ This I obediently did, and my article appeared in the Journal of Mental Sciencei. The article started by demonstrating that the admission rate of patients over 60 to the Royal Edinburgh Hospital had risen between 1901 and 1941 more steeply than the proportion of this age group in the Scottish population. Interestingly, at this early date, I had found no difficulties in the differential diagnosis of my colleagues’ and my own patients. There were 22 senile, arteriosclerotic and presenile dementia patients, 20 manic-depressive patients, 25 patients suffering from involutional or senile melancholia and 51 patients with schizophrenia. Assuming that the functional psychoses were the concern of general psychiatry, the rest of the paper dealt with the dementias and with an attempt to link the type associated with delusions and hallucinations to earlier personality characteristics. I noted that a high proportion of dementia admissions had been precipitated by terminal confusional states, and that of 111 patients admitted over the preceding four years with organic psychoses, only 23 were still occupying beds. I made the false prediction that in the future the main burden of the hospital services would be represented by the chronicity and survival of melancholic and paranoid patients. I did not anticipate that electroconvulsive therapy (ECT) and antidepressive drugs, while producing lasting recoveries in only 25% of cases, would make at least temporary discharge from inpatient care possible in most cases.

Aubrey Lewis was more farsighted. He had published, with a psychiatric social workerii a paper describing the psychiatric and social features of the patients in the Tooting Bec Hospital for Senile Dementia, London, UK, and in 1946 predicted, in the Journal of Mental Scienceiii that ageing and senility would become a major problem of psychiatry.

After army service, I consulted Lewis about possible positions and he recommended me for the post of assistant physician at the Maudsley Hospital. I flattered myself that in me Lewis had seen a future brilliant psychiatrist, but was soon to be disillusioned. Even before the Bethlem Royal and Maudsley Hospitals were united in 1948, Lewis had conceived the idea of using some of the Bethlem beds to establish a unit for patients over the age of 60. After a heated discussion with the Bethlem matron, Lewis obtained agreement for the admission of senile patients to a hospital which, like the Maudsley, had previously admitted only patients thought to be recoverable. Uncovering his batteries, he asked me to take on the development of this Geriatric Unit. Once again, I obeyed (to say without enthusiasm would be an understatement) and, right up to my retirement, I continued also to run a unit and outpatient clinic for younger adults.

A report in the Bethlem Maudsley Gazetteiv demonstrated that both the Bethlem staff and I had ‘caught fire’. The article started with a tribute to Professor Aubrey Lewis and his almost revolutionary idea of including experience in geriatric psychiatry within postgraduate training. The article went on to describe how patients over 60 had gradually infiltrated the Bethlem wards to emerge as a unit for 26 women and 20 men. The two wards were staffed by the same number of senior and junior nurses as the other adult wards, with two trainee psychiatrists changing every six months to other departments. There was one psychiatric social worker, later usually assisted by a trainee. The occupational therapy department had collaborated with the nursing staff to devise and carry out a daily occupational programme as well as socializing activities. The psychiatric social worker ran a weekly afternoon of handicrafts, tea and talk near the Maudsley, where throughout my tenure I conducted a weekly follow-up and supportive clinic. The first year during which the unit had been in full swing was 1952, and it was recorded that during that year there had been 3.00 admissions to each geriatric bed compared to 3.74 admissions to each general psychiatric place. Patients who had been dementing, but whose home care was no longer possible had been excluded from admission, though not rigidly, as well as patients with recurring illnesses that had been adequately treated at the Bethlem-Maudsley or other hospitals. Of 133 patients, nine died, only four had to be transferred to their regional mental hospitals, seven were resettled in homes for the elderly, while 113 could be returned to family care. One year after discharge, information was successfully obtained about 121 of 124 cases. Seven patients had died, including one suicide of a woman who had discharged herself. Thirty ex-patients had to be readmitted to our or other hospitals, 35 were still outside hospital but by no means symptom-free, but 45 patients would be classified as recovered. These relatively favourable results were due to 89 patients having suffered from affective illnesses: 24 had symptoms associated with brain damage, 10 were mainly paranoid and 10 were regarded as having psychoneurosis. In spite of 4–6 weeks of conservative management 52 patients had to be given ECT. I concluded the article by pointing to research needs and by opining that with 30–40% of patients admitted to British mental hospitals being over the age of 60, training in the special problems of this age group was essential for all entrants to general psychiatry.

The history of the beginning would be incomplete without a brief account of further developments. My little textbook (rightly out of print) and publications on the long-term outcome of affective, paraphrenic and schizo-affective illnesses were largely my own work, but many of the junior psychiatrists made contributions and they and clinical psychologists, as well as social workers, instigated their own researches. Many later made a name for themselves, and some became leading psychogeriatricians. Among them were Tom Arie, the late L.K. Hemsi, David Jolley, Robin Jacoby, David Kay, Kenneth Shulman and, last but certainly not least, Raymond Levy. After the Bethlem-Maudsley had accepted a district commitment and the admission of involuntary (sectioned) patients, Raymond Levy and my successor, Klaus Bergmann (not a Bethlem trainee), managed to move the Geriatric Unit to the Maudsley, so much closer to the patients’ family homes. Raymond Levy succeeded in establishing an Academic Department of Old Age Psychiatry, which has continued to conduct research into the dementias of late life, that most important subject, previously neglected on account of admission restrictions before the hospital abandoned its ivory tower to accept a district commitment. With similar developments elsewhere, psychogeriatrics became a world movement, and Sir Aubrey Lewis would be pleased.

REFERENCES

i. Post F. Some problems arising from a study of mental patients over the age of sixty years. J Ment Sci 1944; 90: 554–65.

ii. Lewis AJ, Goldschmidt H. Social causes of admission to a mental hospital for the aged. Sociol Rev 1943; 365: 86–98.

iii. Lewis AJ. Ageing and senility: a major problem of psychiatry. J Ment Sci 1946; 92: 150–70.

iv. Post F. Geriatric unit (a report on progress made, with special reference to 1952). Bethlem Maudsley Hosp Gaz 1955; 1: 270–71.

COMMENTARY

Felix was a refugee from Nazi Germany¹. He enrolled at St Bartholomew’s Hospital in 1934, qualifying in 1939. He entered medicine in an era when it was widely assumed that older mentally ill people were ‘senile’ and therefore nothing could be done for them.

Felix refers to his 1944 paper². He commented on his ‘false prediction’ for older people requiring long-stay care in hospital, that those with chronic functional illnesses would numerically exceed those with organic illnesses. However, he did not emphasize the real significance of his paper, his observations that ‘Old age alone does not produce mental illness’, that appropriate diagnoses can be made, and that a multidisciplinary approach is important in treating older people. The possibility of differential diagnosis from a hopeless mass of mental symptoms in old age was not widely recognized until Martin Roth’s classic paper in 1955³. Felix was a decade ahead. His conclusions were radical. Felix’s paper caught the attention of Professor Aubrey Lewis (1900–1975); he referred to it in his own landmark paper⁴; they shared a common, new and challenging belief that something could be done to treat elderly mentally ill people.

Lewis had three contemporaries writing constructively on mental illness in older people. Two were relatively senior refugee psychiatrists: Willi Mayer-Gross⁵ and Erwin Stengel⁶. The third, Felix, was earmarked by Lewis for a clinical role with older people. However, Felix had no intentions of becoming a psychiatrist, let alone one working with older people. But he was aware that refugee doctors were having difficulty in securing senior appointments, especially in traditional elitist teaching hospitals. Lewis offered him a post in 1947 at the Maudsley Hospital, London, a psychiatric teaching hospital. Henceforth, he regarded himself as owing Lewis a huge debt, and thus when Lewis asked him to