How many psychologists that you know have provided a professional service in an aged care facility this year? How many people do you know with grandparents, parents, or other relatives living in a nursing home? Our crystal ball predicts that for the great majority of readers, the answer to the second question is a notably larger number than the response to the first one, to which the answer is likely to be zero. Snowdon, Ames, Chiu and Wattis (1995) reported that psychology had the lowest ratio of service delivery to older adults of the mental health disciplines, and things have not changed dramatically since then. Our arguments as to why ‘zero' should not continue as an answer to that question on the number of psychologists providing services in aged care are provided here, as well as those on why psychological services in aged care are important.
First, we need to consider who is ‘aged' and thereby eligible for ‘aged care'. If we accept the common definition of an older adult as someone over 65, then we adopt an arbitrary figure that is inconsistent with the numbers of people under that age in residential care. In practice, many people in their mid seventies or even early eighties quite reasonably do not regard themselves as ‘old', while the functionally old may experience conditions associated with old age much earlier. Therefore, being old is a fluid concept. Nevertheless, recent census figures show that the most rapidly growing section of the Australian population is people over 85. Consequently, that age group also comprises the highest proportion of people receiving home care services, and living in nursing homes and other residential aged care facilities (RACF; AIHW, 2007).
The Australian National Survey of Health and Wellbeing (ANSHW) found significantly lower prevalence of mental disorders in those over 65 than in younger cohorts (ABS, 1997), contributing to a debate over the actual prevalence of mental disorders in later life. For example, people with common conditions of later life (including dementia or physical/medical comorbidities) and common predictors of mental illness (especially depression) are frequently excluded from community surveys such as the ANSHW, as are those in residential care where many people experiencing these disorders live. Reviewing 34 studies, Beekman, Copeland and Prince (1999) found extremely rubbery figures: a prevalence of late-life depression of between 0.4 and 35 per cent. The ANSHW reported higher prevalence of anxiety over depression, suggesting that the rate of mental health disturbances across diagnoses is likely closer to the higher of those figures.
What is not debated is that mental disorders in older people have serious consequences. Depression in later life is a risk factor for impairments in mobility and functioning, physical ill health, dementia, and premature death (e.g., Bird & Parslow, 2002). Yet older people have severely limited access to psychological treatments (Koder & Helmes, 2006), and the challenging, interesting and often highly rewarding opportunities for work with older people have rarely been taken up by psychologists. Older people are thus deprived of the non-invasive psychological interventions that have been shown to be effective in randomised trials with people of all ages, specifically including older adults and older residents of aged care facilities (e.g., Powers, 2008).
Residents of aged care facilities are a group with particularly high levels of psychological distress. Loneliness, loss of privacy, fears, grief (loss of possessions, family and friends, status or capacities), physical illness, dementia, pain and other factors combine to result in high rates of psychological distress, in particular anxiety and depression (e.g., Snowdon & Fleming, 2008). Many have mental, cognitive, and medical comorbidities that complicate treatment plans. The sequelae of neurological disorders can lead to a variety of behaviours that distress both residents and care staff. In most cases, these behaviours are treated with psychotropic medication, often inappropriately and with minimal effect (e.g., Sink et al., 2005). Older people are much more subject to dangerous side effects from drugs such as anxiolytics and antipsychotics. This makes them ideal candidates for effective psychological treatments.
For older adults with mood and anxiety disorders, relatively minor modifications of standard psychological interventions are also effective in care facilities. The clinician, however, needs a wide range of additional skills and knowledge, including understanding basic medical issues such as delirium, common drug side effects, and working effectively with care staff who, as the most important people in the residents' day, must often be engaged as co-therapists. Such collaboration provides greater opportunities for effective work by psychologists to assist older adults.
The analytical and case-formulation skills of psychologists are also particularly pertinent for disturbed behaviour associated with dementia, which is nearly always case-specific and often due to multiple factors, including care staff behaviour. Significantly, all major psychosocial intervention trials have been led by clinical psychologists (e.g., Bird et al., 2007; Fossey et al., 2006).
There are many reasons few psychologists provide services in residential care. One of the main reasons, however, is that few psychologists have the interest, skills, or the applied experience to assist individuals directly or by providing clinical leadership and support (Koder & Helmes, 2006). Only two universities - the University of Queensland and James Cook University - offer specialist structured training in this area at the postgraduate level. Experience elsewhere has suggested that formal training alone is insufficient to promote substantial numbers of psychologists into work with older adults; positive experiences in actual practical work is needed as well.
Interest in work with older people can be aroused by many factors, from an inspirational experience with a centenarian to an aroused sense of social justice at learning of a case of elder abuse. Interest alone is not enough. In working in aged care, as in many areas, one must both know what to do and have had practice in doing it in order to work most effectively and efficiently. In order to provide more opportunities for the skills training and the applied practice necessary to counter the comparative absence of psychologists in aged care, both a stronger ageing component in traditional structured postgraduate clinical training together with appropriate supervised clinical placements are needed. This combination of both important elements would provide all psychologists with the skills to do effective work with older people, who will soon comprise 20 per cent of the population. If more psychologists provided pro bono services in local care facilities, consulting care staff on their concerns and addressing the distress of residents, the current small pool of experienced clinicians and supervisors would grow. Shadowing experienced clinicians, whether psychologists, aged care psychiatrists, or geriatricians, would provide psychologists with exposure to the varied clinical issues that older people experience and allow them to contribute psychological input to other disciplines when there may be no psychologists.
It is clear that demand far exceeds current supply and that experienced supervision for work in aged care facilities needs expansion. Mechanisms must be found if psychological services for older people are to be increased, especially in residential care where half the potential clientele resides. Accordingly, together with Associate Professor Nancy Pachana and David Stokes from the APS National Office, the authors have negotiated funding from the Eastern Australia Dementia Training and Study Centre, established by the Department of Health and Ageing to foster the development of the skills of graduates, for a pilot trial of funded supervision of postgraduate psychology students. One or two psychology students at clinical Masters or Doctorate level will be on placement in RACFs each semester at three separate sites - ACT/Southern NSW, Brisbane and Townsville/Cairns - with supervision provided by RACF-literate psychologists. The trial will be assessed after one year to evaluate the effects on facility staff and residents, and on the students. If successful, the trial will be expanded to other sites. Watch this space.
Australian Bureau of Statistics (1997). Mental Health and Wellbeing: Profile of Adults. Canberra: Australian Government.
Australian Institute of Health and Welfare (2007). Older Australians at a glance. Canberra: Australian Government, Department of Health and Ageing.
Beekman, A., Copeland, J., & Prince, J. (1999). Review of community prevalence of depression in later life. British Journal of Psychiatry, 174, 307-311.
Bird, M., Llewellyn-Jones, R., Korten, A., & Smithers, H. (2007). A controlled trial of a predominantly psychosocial approach to BPSD: treating causality. International Psychogeriatrics, 19(5), 874-891.
Bird, M., & Parslow, R. (2002). Potential for community programs to prevent depression in older people. Medical Journal of Australia, 177, S107-110.
Fossey, J., Ballard, C., Juszczak, E., James, I. A., Alder, N., Jacoby, R., & Howard, R. (2006). Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: Cluster randomised trial. British Medical Journal, 332, 756-758.
Koder, D., & Helmes, E. (2006). Clinical psychologists in aged care in Australia: A question of attitude or training? Australian Psychologist, 41, 179-185.
Powers, D. V. (2008). Psychotherapy in long-term care: II. Evidence-based psychological treatments and other outcome research. Professional Psychology: Research and Practice, 39, 257-263.
Sink, K.M., Holden F.H., & Yaffe, K. (2005). Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. Journal of the American Medical Association, 293, 596-608.
Snowdon, J., Ames, D., Chiu, E., & Wattis, J. (1995). A survey of psychiatric services for elderly people I Australia. Australian and New Zealand Journal of Psychiatry, 29 ,207-214.
Snowdon, J. & Fleming, R. (2008). Recognising depression in residential facilities: An Australian Challenge. International Journal of Geriatric Psychiatry, 23, 295-300.