Journal of Geriatric Mental Health

SERVICE DEVELOPMENT
Year
: 2021  |  Volume : 8  |  Issue : 1  |  Page : 11--14

Establishment of a geriatric clinic in psychiatry outpatient setting of a tertiary care hospital: Impact on care of elderly and training


Sandeep Grover, Chandrima Naskar, Subho Chakrabarti, Aseem Mehra, Ritu Nehra 
 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Dr. Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India

Abstract

Although there is a rapid increase in the elderly population in India, there is a lack of geriatric mental health services across the country. In India, although the postgraduation psychiatry program is available across many centers, little attention is paid to the subspecialty of geriatric psychiatry during the postgraduation training. There are very few courses (in the form of doctorate of medicine and fellowship programs) available in the subspecialty of geriatric psychiatry in the country. In this background, this paper focuses on the experience of establishing a geriatric clinic in a postgraduation psychiatry department and the impact of the same on patient care, research, and training in the area of geriatric psychiatry. The patient care data suggest that with the establishment of the geriatric clinic, there is an increase in the number of elderly patients admitted to the inpatient setting and those receiving electroconvulsive therapy. Further, there is an increase in the research in the area of geriatric psychiatry.



How to cite this article:
Grover S, Naskar C, Chakrabarti S, Mehra A, Nehra R. Establishment of a geriatric clinic in psychiatry outpatient setting of a tertiary care hospital: Impact on care of elderly and training.J Geriatr Ment Health 2021;8:11-14


How to cite this URL:
Grover S, Naskar C, Chakrabarti S, Mehra A, Nehra R. Establishment of a geriatric clinic in psychiatry outpatient setting of a tertiary care hospital: Impact on care of elderly and training. J Geriatr Ment Health [serial online] 2021 [cited 2021 Dec 9 ];8:11-14
Available from: https://www.jgmh.org/text.asp?2021/8/1/11/323105


Full Text



 Introduction



According to United Nations, a country is considered to be “aging,” if the elderly population exceeds 7%.[1,2] If one goes by this definition, India is an “aging” nation, which according to the 2011 census had 8.6% of its population in the elderly age group.[3] It is projected by the United Nations Population Division,[4] that by 2050, in India the elderly population will amount to 19% of the total population. It is further suggested that compared to the 55% increase in the total population between the years 2000 and 2050, the elderly population is going to increase by 326% and those aged ≥80 years are going to increase by 700%.[4] If one looks at these figures, it can be safely concluded that, in India, there is a need to prepare health-care services to meet the needs of the elderly.

Mental health ailments are common among the elderly. Data emerging from India suggest that the prevalence of mental disorders in the elderly ranges from 8.9% to 61.2%, with a majority of studies reporting figures above 30%.[5],[6],[7],[8],[9] Data also suggest that compared to the nongeriatric population, the prevalence of mental disorders is higher among the elderly.[8] Hospital outpatient-based studies suggest that the elderly form 4.17%–5.14% of the total outpatients.[10] In general, across different settings, depression/mood disorders form the most common diagnosis among the elderly, and other commonly encountered disorders include dementia, anxiety disorders, substance use disorders, delirium, and psychosis.[10,11] All these findings further emphasize the need to gear up the mental health-care services for the care of the elderly.

India has a significantly lower number of mental health professionals than required.[12] Only a small proportion of them specifically focuses on the elderly. In terms of the mental health services for the elderly, at most places, there are no specific services for the elderly and the elderly patients have to compete with people of other age groups to receive the mental health services. A recent survey, which evaluated the psychiatry training in India, reported that only one-third of the participants considered their training in geriatric psychiatry to be “good or very good,” compared to >80% reporting their training for adult psychiatry to be “good or very good.” Further, compared to other subspecialties, i.e., child psychiatry, consultation-liaison psychiatry, addiction psychiatry, electroconvulsive therapy (ECT), women mental health, and psychosexual health, a lower proportion of the participants reported their training in geriatric psychiatry to be “good or very good.” The only areas of specialization, for which a lower proportion of the participants reported their training to be “good or very good” when compared to geriatric psychiatry, were forensic psychiatry, and brain stimulation techniques.[13]

In India, very few centers have geriatric clinics as part of the mental health services. During the postgraduate psychiatry training, exposure to geriatric psychiatry is limited,[13] and due to this mental health professionals do not feel confident in managing mental health issues among the elderly. There are only 2 centers (KGMU, Lucknow and NIMHANS, Bangaluru) in the country, which are offering the DM course in geriatric psychiatry and fellowship programs in geriatric mental health care.

Considering the rising elderly population, high prevalence of mental health disorders among the elderly, and limited exposure to geriatric psychiatry, there is a need to enhance the training in the area of geriatric psychiatry in the country.

At our institute, before 2017, there was no specific “clinic” for providing mental health services to the elderly patients visiting the psychiatry outpatient services. The elderly patients were provided with the mental health-care services along with the adult patients, except for the fact that the elderly were given some priority in registering for the outpatient services and were given some priority while being seen in the walk-in clinic and follow-up. Due to this, there was a high rate of dropout of the elderly from the services.[13] Further, the workups for the elderly were done in the same format as adult patients, making it difficult to note the elderly-specific issues. Due to this, issues specific to the elderly which require clinical attention would often be missed.

Keeping the needs of the elderly, a geriatric clinic was set up in March 2017. In this paper, we would discuss the impact of setting up the “Geriatric Clinic,” on providing health-care services, training, and research in the area of geriatric psychiatry.

 Methodology



Set-up

The Department of Psychiatry at our institute was started in the year 1963 and over the years, many services were started in the department. Before 2017, besides providing mental health-care services to adult patients, the department has been running a Drug Deaddiction and Treatment Centre, Child and Adolescent Psychiatry services, Consultation-liaison psychiatry services, ECT services, Marital and Psychosexual Clinic, Lithium Clinic, Mental Disability Clinic, Community Psychiatry Services, Psychotherapy Services, Brain Stimulation (rTMS) services, and Telepsychiatry services. Besides having a Doctor of Medicine (MD) program in MD Psychiatry, the department also runs DM courses in Addiction Psychiatry and Child and Adolescent Psychiatry. In addition, the department also has a Doctor of Philosophy program for Psychiatry and Clinical Psychology. In collaboration with the nursing institute, the department also offers training for Bachelor of Science Nursing and Masters of Science in Psychiatric Nursing. In the year 2019, a 1-year fellowship program in Consultation-Liaison Psychiatry was also started.

On average in recent times, about 13,000–15,000 new patients attend the adult psychiatry outpatient services annually.[14,15] In terms of the inpatient setting, the department has 29 beds for adult patients, 20 for deaddiction services, and 9 beds for the child and adolescent psychiatry services. On an average, 200–300 patients are admitted annually to the adult psychiatry ward in recent years.

Setting up the geriatric clinic

As mentioned earlier, before 2017, there were no specific services for elderly patients. In March 2017, the “Geriatric Clinic” was established, to focus especially on the geriatric population attending the outpatient services and to modify overall services for the elderly with a better understanding of the needs of this population. Four faculty members (3 psychiatrists and 1 clinical psychologist) were assigned the responsibility for providing the services and developing the geriatric services. It was decided that the clinic will provide services to the people aged 60 years or more coming to the psychiatry outpatient.

A specific proforma was designed for the geriatric clinic, which has provisions for recording the physical comorbidities, cognitive functions, neuropsychiatry inventory, clinical dementia rating scale, everyday ability scale for India, provision for recording the physical examination, and investigations. One specific day (Thursday) was fixed for detailed workup of the elderly, but if required, detailed workup could be done on other days too [Table 1].{Table 1}

Data extraction

For this paper, we reviewed the data of the outpatient services, inpatient services, training, and research output from the department to understand the impact of establishing the geriatric clinic. For the impact on the outpatient and the inpatient services, we evaluated the change in the pattern of the number of detailed workups done for the elderly at the outpatient level and the number of inpatient admission before starting the clinic and after starting the clinic. For the impact of the clinic on the training, we evaluated the data of the case conference and the thesis in the area of geriatric psychiatry. We evaluated the data for the years 2014–2019, and compared it with data of 2014–2016. We did not include the data for 2020, as the services were impacted by the ongoing COVID pandemic.

 Results



As is evident from [Table 2], the establishment of the geriatric clinic led to improvement in clinical care being provided to the elderly patients in the form of an increase in the number of workups for the elderly, and proportion of patients admitted to the psychiatry ward and proportion of those receiving ECT being elderly. In terms of research, the establishment of the clinic led to improvement in the number of research projects (nonfunded and collaborative), the number of research publications, and the number of thesis being done in the area of geriatric psychiatry. In terms of training, there was a marginal increase in the number of elderly cases being discussed in the departmental case conferences.{Table 2}

 Discussion



The elderly population is increasing in India, and there is an urgent need to re-organize the services to cater to the needs of the elderly. As mental health morbidity is common among the elderly, there is a need to establish geriatric clinics to address the needs of the elderly. These clinics can have different models, ranging from having separate staff and facilities for the elderly to those being integrated with the currently running adult psychiatry services. Further, geriatric psychiatry services can be embedded in multispecialty elderly services under one roof. Initiating these services can help in improving the services provided to the elderly. Our analysis suggests that a simple attempt such as starting a geriatric clinic as part of the adult psychiatry services can improve the focus on the geriatric services. Our findings though preliminary also suggest that this can help in mental health services being provided to the elderly, as reflected in our analysis in the form of an increase in the proportion of elderly patients being admitted to the inpatient facilities and those considered for ECT. Our findings also suggest that having specific services also provide an opportunity for carrying out research this area. In terms of training too, starting the geriatric clinic also possibly led to higher opportunity to carry out a detailed evaluation of the patients in the inpatient and the outpatient setting, administering ECT to the elderly, carrying out research in the form of a thesis, and discussion of elderly cases in the academics.

Our analysis has limitations that must be kept in mind while interpreting the findings. We did not evaluate the impact of establishing a geriatric clinic in terms of the satisfaction of the patients and the caregivers availing the services. Similarly, we did not evaluate the satisfaction of the trainees concerning geriatric services. We also did not carry out any quality assessment of the services being provided.

To conclude, our analysis suggests that starting a geriatric clinic as part of the ongoing adult psychiatry services in various general hospital psychiatry units and mental health institutions can help in improving the care for elderly seeking mental health care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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