New Relevant Information
BBC headline on 14 July 2014 states 'One in three Alzheimers cases preventable, says research'. The column goes on to say
'The One in three cases of Alzheimer's disease worldwide is preventable, according to research from the University of Cambridge. The main risk factors for the disease are a lack of exercise, smoking, depression and poor education, it says. Previous research from 2011 put the estimate at one in two cases, but this new study takes into account overlapping risk factors. Alzheimer's Research UK said age was still the biggest risk factor. Writing in The Lancet Neurology, the Cambridge team analysed population-based data to work out the main seven risk factors for Alzheimer's disease. These are: Diabetes, Mid-life hypertension, Mid-life obesity, Physical inactivity, Depression, Smoking, Low educational attainment'
This joint strategic needs assessment reviews the mental health needs of older people in Cambridgeshire, with a particular focus on dementia and depression. It is important to be clear about the differences between mental wellbeing (or general mental health), and mental illness. In the document we refer to both using the definitions below:
Mental wellbeing (or mental health): There are many different definitions of mental wellbeing but they generally include factors known to promote mental health such as: life satisfaction, optimism, self-esteem, mastery and feeling in control, having a purpose in life, and a sense of belonging and support. Good mental health is not simply the absence of diagnosable mental health problems, although good mental health is likely to help protect against the development of many such problems.
Mental illness or disorder: Mental illness or disorder refers to a diagnosable condition that significantly interferes with an individual’s cognitive, emotional or social abilities eg dementia, depression, anxiety, and schizophrenia.
Over a third of older people in the UK are likely to experience mental health problems. Depression and anxiety are the most common conditions, followed by dementia. Other less common conditions include delirium (acute confusion), schizophrenia, bipolar disorder, personality disorder and autism, alcohol and drug (including prescription drug) misuse; this needs assessment focuses primarily on depression and dementia.
Dementia is a group of related symptoms associated with an ongoing decline of the brain and its abilities. This includes problems with memory loss, thinking speed, mental agility, language, understanding and judgement. People with dementia can become apathetic or uninterested in their usual activities, and have problems controlling their emotions. They may also find social situations challenging, lose interest in socialising, and aspects of their personality may change. A person with dementia may lose empathy (understanding and compassion), they may see or hear things that other people do not (hallucinations), or they may make false claims or statements. As dementia affects a person's mental abilities, they may find planning and organising difficult. Maintaining their independence may also become a problem. A person with dementia will therefore usually need help from friends or relatives, including help with decision making.
Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. It affects how one feels, thinks and behaves. It may make it difficult to carry out normal day-to-day activities and make one feel that life is not worth living. Depression and dementia can co-exist and can be difficult to distinguish.
Both conditions, especially when moderate or severe, can reduce markedly the quality of life of those living with the condition. They also affect the family and friends who care for their loved ones. Depression is highly treatable, but the progressive nature of dementia can cause extensive physical, psychological, emotional and financial stresses to those with the condition, their family, carers and the wider community.
This report starts by describing the population of Cambridgeshire, with particular emphasis on the older population and the factors which contribute to mental health problems in that population. It goes on to estimate how many people in Cambridgeshire have depression and dementia, both now and in the future. The report then describes the present pattern of services available in Cambridgeshire for older people with mental health problems, and summarises relevant NICE guidance and reports findings from research about the interventions which, if used early in the course of illness, may reduce its severity. The report then summarises the results of engagement with service users, carers and providers, before setting out some conclusions and key findings.
The difficulties with securing data on NHS activity meant that the report has adopted a qualitative approach. There are also other sources of information which were not available or accessible during this project, and these mean there are limits to the conclusions we are able to draw. These include details of where people with mental health problems live, the exact nature of all clinical and social care services provided locally and the outcomes of service interventions. It has not been possible therefore to assess the degree of correlation between needs and access to services, and whether services are delivered to national standards.
- The population of Cambridgeshire will age substantially by 2026: the number of people aged over 90 years will more than double, and the number of people in their 80s rise by more than 50%. This will lead to steep rises in the number of older people with dementia and, to a lesser extent, depression.
- Cambridgeshire’s population is more affluent and less ethnically diverse than that of England, but social isolation is no less common. Most risk factors for poor mental health show similar patterns of prevalence across Cambridgeshire, though in some cases the Cambridgeshire population shows a lower risk profile. There are also areas within the county where risk factors are concentrated, such as Fenland.
- Assuming prevalence rates remain the same as current rates, between 2012 and 2026, the number of older people with depression in Cambridgeshire is expected to rise by 12%, from approx. 11,900 to 13,360. The number of people over 65 years with dementia is expected to rise from 7,400 to 12,100, an increase of 64%. There is forecast to be a 43% increase in the number of older people with learning disability. Increases of this size over a short period will put severe strain on existing services.
- In Cambridgeshire, many people with depression and most of those with dementia have not been diagnosed and recorded by their primary care teams, which reflects a national trend. This means they cannot receive the treatment and support they need. This suggests that there is unmet mental health need within the population.
- Cambridgeshire apparently devotes less health service spending per head to mental health than average for England. The Cambridgeshire and Peterborough Clinical Commissioning Group (CCG) is relatively under-funded and faces a challenging financial future.
- Increasing older population
- Due to an increasing population there is forecast to be an increase in the number of older people with dementia and, to a lesser extent, depression, within a few years.
- However, the resources available from statutory agencies, for health services given the current financial restraints, will at best remain the same, requiring the development of new service models to meet need. A holistic approach is vital.
- Risk factors for depression and dementia
- Older people’s mental health needs are complex. They cause substantial impact on wellbeing and the ability to lead a normal life. They have wider impacts on the family and other carers.
- Mental health needs interact in complex ways with long-term physical health problems. Adults with severe mental illness have a substantially reduced life expectancy due to both mental and physical ill health. There is often inequality of access to health services for physical illness for people who use mental health services. Physical health and mental health are inseparable and demand a holistic approach to the care of all patients with mental health problems.
- Evidence-based guidelines from NICE recommend reviewing and treating vascular and other risk factors for dementia in middle-aged and older people. These include smoking, excessive alcohol use, obesity, diabetes, hypertension and raised cholesterol levels.
- NICE are also currently developing two relevant pieces of public health guidance: the first, due to be published in February 2015, focuses on mid-life approaches to prevent or delay the onset of disability, dementia and frailty in later; the second, due for publication in November 2015, considers independence and mental wellbeing (including social and emotional wellbeing) for older people.
- Diagnosis and assessment
- There is apparent widespread under-diagnosis of depression in primary care. Rates of diagnosis also vary between practices for unexplained reasons. Depression is a distressing, but highly treatable condition, so improvement in rates of diagnosis is important.
- Dementia is also under-diagnosed in primary care, with unexplained variation in rates of diagnosis and prescribing. Early diagnosis means that patients and carers can receive appropriate information and support, so ensuring the condition is recognised promptly is beneficial.
- Improving diagnosis in primary care is a priority, as part of an integrated approach and partnership working, to improve awareness of mental health needs in the community.
- Current spending
- The NHS in Cambridgeshire apparently spends 18% less per head on mental health services than the average for England. It is, however, less well funded than average. This information is based on programme budgets, and differences in budgetary definitions and coding behaviour may underlie these findings. More analysis of the reasons for the differences would be of value.
- Current service provision
- The JSNA full report describes acute and community mental health services available for older people and details three local clinical pathways for ‘Functional mental illness’ (includes depression, anxiety, bipolar affective disorder, psychosis, personality disorder); ‘Memory assessment’; and ‘Complex dementia’. Training programmes to raise awareness of dementia are in place across primary care, community and acute settings. Local support services are also provided by the Alzheimer’s Society and Mind. These are jointly commissioned by the CCG and Cambridgeshire County Council (CCC) and are also described in more detail in the full report.
- There is substantial variation in the rate of referrals to the older people’s mental health service, with lower rates seen in South Cambridgeshire, and higher rates in Cambridge City, Fenland and East Cambridgeshire. The reasons for this variation are unclear, and may relate to data quality problems, but it would merit further investigation.
- No information on activity levels and expenditure patterns, by the main NHS mental health service provider in Cambridgeshire, was available within the timescale of this report. This impedes service planning and evaluation by commissioners and limits the extent to which patterns of service delivery can be reported and analysed. The routinely collected anonymised national minimum dataset should be available in a timely and accessible format to providers and commissioners of mental health services.
- There are other sources of information which were not available or accessible during this project, and these limited the conclusions we are able to draw. These include details of where people with mental health problems live, the exact nature of all clinical and social care services provided locally and the outcomes of service interventions. It has not been possible, therefore, to assess the degree of correlation between needs and access to services, and whether services are delivered to national standards.
- The current re-procurement of older people’s services is expected to lead to improvements in mental health services for older people. The re-procurement process will involve clarifying what mental health services for older people are available, where and to whom.
- National guidance and evidence on provision of services and standards
- National guidance in the form of Clinical Guidelines and Quality Standards published by NICE describe, in detail, what patients should receive from the NHS and social services.
- A review of the evidence did not find any reliably evaluated early interventions for mental health disorders in older people that were not included in existing NICE guidance.
- Existing service specifications from commissioners describe what should be available from NHS mental health services. The extent, to which national guidance and local service specifications are followed, in practice, was not reviewed as part of this JSNA. This could form part of a future work programme.
- Stakeholder feedback
- The main concerns of service users and carers reported to us were:
- Service delivery
- Organisational challenges
- Coordination of services
- Safeguarding of vulnerable people
- Access to services
- Transition between services
- Continuity of relationships
- Culture and equity
- Physical health and mental health
- Carers’ needs.
- Service improvement ideas from service users and carers, included more help with practical things, such as maintaining relationships, applying for benefits, and a focus on the positives rather than the diagnosis. Community support, and signposting for where to go for help, ideas or friendship were also considered important. Information and training for families and carers as well as those with mental health disorders, and seeing the same health professional consistently were also suggested.
- Further information
Building on the findings of this JSNA, further work may be useful to:
- Establish the activity and cost levels at the main NHS mental health provider;
- Review the validity of the apparent low levels of NHS spending on mental health in Cambridgeshire;
- Audit the extent to which NICE guidance is followed and understand gaps in mental health service provision for older people;
- Investigate the apparent variation in referral rates to the older people’s mental health service.