Spring 2011 21st Anniversary

brating
C e le
21 Years
Old Age
ld of
Age Psychiat
r Psychiatrist
y
O
as a
specialty Newsletter of the Faculty of Psychiatry of Old Age
ISSN 1463-6662 Spring 2011, Number 53
SPECIAL ISSUE: 21 YEARS OF OLD AGE PSYCHIATRY!

‘Those who do not learn from history are asm of those we approached visions of younger people involved
doomed to repeat it.’ directly meant that that was not with the specialty. We need to
George Santayana (1863–1952) possible for a single newsletter. pay heed to them as much as to
Indeed, we are aware of the gaps our experienced colleagues. Their
This extraordinary newsletter in our current edition – in suggestions and wishes for the
commemorates 21 years of particular from primary care and future at times call unsuspecting
old age psychiatry since it was National Health Service senior for the re-establishment of
accorded specialty status by the management. We are also most aspects of our services which
Department of Health in 1989. The grateful to our colleagues in the have been demolished during
idea for this celebration evolved localities where we both work for these 21 years under the rubric
from a determination that such a their enthusiasm in sharing their of ‘cost improvements’ and other
landmark should be remembered, ideas, although this does give managerial jargon.
rather than from an ambition a marginal bias of contributors If you would like to respond to
to declaim great historical from Manchester and north-west any of the issues raised, letters of up
or philosophical teachings. London. to 200 words would be welcome;
Nevertheless, learning from the On the important issue of style, the newsletter editor, Jonathan
past may help inform debates this newsletter was planned to be Hillam, will consider publishing
about future directions, especially informal, and we have deliberately them in a future edition.
at a time of major changes within not referenced every quoted text, Please enjoy this newsletter,
our health services. We believe that especially where they are easily and stretch your knowledge and
what follows includes reflections accessible on the internet (e.g. imagination, perhaps with your
and ideas that will enthuse and National Service Frameworks). team members, family or friends,
enrich the readership. Setting the past 21 years in with the party games!
We initially approached people context, we must not forget that
known to us personally to the roots of our specialty pre-date
contribute ‘Janus’ articles – looking the 1989 recognition by well over Claire Hilton
forwards and backwards – from 40 years, and some people have ([email protected])
their own specific perspectives. We alluded to these earlier periods Dave Jolley
in their writings. It is not just the ([email protected])
had intended to open the invita-
tion wider, but time constraints wisdom of the most experienced Guest Editors
and the overwhelming enthusi- that we have included, but also the
Honorary Editors Editorial Board Old Age Psychiatrist is produced four times a year. Articles should be submitted in a recognisable MS
Nori Graham, Brice Pitt Chris Fox, Henry O’Connell, Anad Word format by email and should not exceed 1500 words unless agreed with the Editor. Shorter typed
Ramakrishnan and Kallur Suresh contributions are acceptable. Letters should not exceed 200 words. The Editor reserves the right to edit
Editor contributions as deemed necessary. Opinions expressed in the newsletter are of the authors and not
Jonathan Hillam Address for correspondence of the College unless expressly stated. Each article remains the copyright of its author, but the College
Jonathan Hillam, The Julian reserves the right to reproduce the article on the Faculty website pages.
Website Editor Hospital, Bowthorpe Road, Norwich
James Warner NR2 3TD, email: jonathan.hillam@
International Editor nwmhp.nhs.uk
Carmelo Aquilina
Special Issue: 21 years of Old Age Psychiatry
CONTENTS
Mainly from the Clinical Old Age Perspective From the Academic Old Age Psychiatry
21 years as a consultant in old age psychiatry 3 Perspective
Dave Anderson Research and me 31
Sailing into the wind 4 Klaus Bergmann
Susan Benbow Of pioneers and progress, but prognosis guarded 32
Two fascinating decades 5 Robin Jacoby
Tom Dening An old age psychiatrist at work and play 33
A hallmark of a civilised society 7 Raymond Levy
Pearl Hettiaratchy Perspectives of a (not so) young clinical academic 35
We’re 21: recognition and discrimination 8 Nitin Bhalchandra Purandare
Claire Hilton
International Views
Memories from Goodmayes 10
Old age psychiatry Down Under 37
Hilary Kinsler
Edmond Chiu & David Ames
Goodmayes: home of old age psychiatry 11
A view from Hong Kong 38
Kate Maxmin
Helen Chiu
Relinquishing youth and encouraging maturity 12
Where will I be in 21 years? 39
Colm Owens
Shirlony Morgan
The memory clinic 13
Reflections from Canada 40
Michael Philpot
Kenneth Shulman
Reflections 14
John Wattis A Carer’s View of Frontotemporal Dementia
Multi-agency and multidisciplinary cooperation 42
From Scotland and Wales
Neville Hughes
21 years of old age psychiatry 16
Peter Connelly A Word About ...
Services for elderly people in Scotland 17 Collaborating with the Alzheimer’s Society 43
Sam (R. A.) Robinson Nori Graham
A view from Swansea 19 A Word From …
Don Williams
The President of the Royal College of Psychiatrists 44
From Geriatric Medicine Dinesh Bhugra
The future of old age psychiatry 20 The Tzar 45
Shuli Levy Alistair Burns
Old age physicians and psychiatrists 21 The National Director for Mental Health (2000–2010) 46
Jackie Morris Louis Appleby
The House of Lords 47
From the Multidisciplinary Team
Elaine Murphy
Older people’s community mental health nursing 23
A medical student 49
Eric Craig
Alasdair Scott
The essence of our care 24
Tom Arie: what’s happened and what’s changed? 50
Sue Hadden
Tom Arie
And what about occupational therapy? 26
Maggie Lee Reflections and Conclusions 52
A social worker’s perspective 28 Claire Hilton & Dave Jolley
Mary Marshall Party Games 53
To age or not to age 29 Compiled by Claire Hilton & Dave Jolley
Marie-Clare Mendham
Now I am 71 and you are 21 30
Norma Raynes
2
Mainly from the Clinical Old Age

Perspective
21 years as a consultant in old age psychiatry
Dave Anderson
Consultant Old Age Psychiatrist, Mossley Hill Hospital, Liverpool
I became a consultant old age Rose-tinted bespectacled Aneurin Bevan said that priority
psychiatrist in Liverpool in 1989, people who tell me it was better 21 is the language of politics. The
just as old age psychiatry became years ago are infuriating. Yes, we ageing priority is pretty clear. The
a National Health Service (NHS) have lost some things that were Centre for Workforce Intelligence
specialty. Catchment population worth retaining for longer but is advises the government; for
28 000, one community nurse, treatment for patients better now? psychiatry, until 2018, it identifies
one senior house officer (Carmello Of course it is. Is training better the greatest percentage increase
Aquilina, creator of the Newsletter), now? Of course it is. Is knowledge needed in training posts and
long-stay beds in a fire- greater now? Of course it is. Are consultant numbers to be in old
condemned wooden building in there better resources now? Of age, more than double any other
the grounds of a decaying mental course there are. psychiatric specialty.2
hospital 20 miles away, some But is it more bureaucratic,
decent acute beds, a 20-place day more risk averse and more The future
hospital in the basement room of administratively tedious now? How will it be in another 21
a gastroenterology unit, with one Unfortunately, yes it is, but change years? I have no idea because
toilet and me – and I loved it. So is never all good or all bad but unforeseen things happen and
much to change. All I could see a mixture of both and if more of it need not concern us. Will it be
was potential and I was part of the the former then it’s progress while different? I would be surprised
most complete biopsychosocial the bad bits trigger the process of and disappointed if it isn’t.
specialty in medicine. change to continue. Will it be better? Probably. Will
The private care sector had In the past 10 years the political treatments be better? Pretty likely.
exploded – long-stay beds were profiles of the specialty and older Will healthcare be fairer to older
closing, a few asylums were still people’s mental health have people? Probably.
going, NHS management just developed rapidly. We now have How will that healthcare be
introduced, battling for resources universal acceptance that there is delivered? I don’t know, but it
with general psychiatry and discrimination and neglect of older will, and more of the people
managers, imaginative new ways people and of the seriousness queuing up outside the door
to deliver services and some of the ageing population. Age- of the surgery, clinic, hospital
serious academics appearing. inclusive policies, the National and Social Services will be older
Although essentially a service Dementia Strategy and equality people and, unless we find more
specialty grown from necessity, legislation represent huge steps effective ways of preserving and
it was beginning to develop an forward and mean older people improving their health, then
evidence base. The next 10 years have a greater chance of a fairer health and Social Services will
was a period of significant service future. Old age psychiatry has be unsustainable as we know
expansion and better research been a key partner in these them today. We can be sure that
that would continue into the developments and I think that the we will need leaders, innovators
next century, and the specialty specialty’s own policy response and research that provide us
fought hard for better resources to the changing position is an with a better understanding of
and standards of practice – and important statement that was the conditions we treat and with
succeeded. It was a specialty that overdue.1 better treatments. That would
was innovative in response to Will these things stay high on change everything and I hope I’m
need. the political agenda? I think so. around to see it.
3
I think that what people and and prepare to adapt to change References
services are whatever you need because change is as inevitable as 1 Royal College of Psychiatrists. Age
them to be. The needs of the next the passage of time. Discrimination in Mental Health Services:
21 years will be different and so Old age psychiatry should be Making Equality a Reality. Royal College
people and services will need to be pleased with its progress after of Psychiatrists Position Statement
PS2/2009. Royal College of Psychiatrists,
different. But that is how old age 21 years. If I was starting as a 2009 (http://www.rcpsych.ac.uk/pdf/
psychiatry was born, responding consultant now, I would be as PS2_2009_for%20websitex.pdf ).
to need and in different ways. It excited as I was 21 years ago. What 2 Sharp P. Recommendation for Medical
must remain a specialty that is great opportunities there are to do Specialty Training 2011. Centre for
defined by the needs of its patient things better – just what I thought Workforce Intelligence, 2010 (http://
population: train people to 21 years ago. w w w. c f w i . o rg. u k / d o c u m e n t s /
recommendation-for-medical-
acquire the competencies to meet Happy birthday old age specialty-training-2011).
that need, understand the agenda psychiatry!
and drivers, seize opportunities
Sailing into the wind

Susan Benbow
Visiting Professor of Mental Health and Ageing, Staffordshire University, and Director, Older
Mind Matters
In 1989 I was a consultant for windsurfing helped me: I’m brought new opportunities
old age psychiatrist in central not very sporty so I can’t think (including Chasewater and canal
Manchester, based at Manchester of anything else when I’m on the boating). I cashed in an insurance
Royal Infirmary, and I remember water and the first time I fell in policy, bought a narrow-boat and
the feeling of elation when we I knew I was hooked. However, moored it near Wolverhampton.
achieved specialty status. I had eventually I decided I needed When an appointment with the
been appointed consultant in to bang my head on a different National Institute for Mental
1984 after training in the North wall for a change and moved to a Health in England as National
West, including a stint with Dave consultant post in Wolverhampton Fellow in Mental Health and
Jolley (having had to choose alongside Dave Jolley. This Ageing was advertised, I applied
between psychotherapy and and was successful. It felt, at the
old age psychiatry). There was time, as though the role might
an issue then about what we allow me to work with others to
called our specialty and the usual develop older people’s mental
disagreements with general health services nationally, and we
psychiatrists about whether their did our best. It also brought me
crazy ideas should influence our into contact with colleagues now
practice – curious how everything based at the Centre for Ageing
changes but somehow things and Mental Health at Staffordshire
stay the same. My employers University. This group has grown
generously supported my training and my colleagues continue to
in family therapy at the Family offer mutual stimulation, creativity,
Institute in Cardiff and I discovered comradeship and support.
that I enjoyed service-based I surprised myself in 2009 by tak-
research, writing and teaching. ing advantage of my mental health
officer status and redesigning
A change of job my life. I took ‘early retirement’
I soldiered on in central from my National Health Service
Manchester until 2001, surviving consultant post, set up Older Mind
a series of reorganisations. Matters (www.oldermindmatters.
Discovering an unlikely passion Making the wind work for you? com) and have been developing
4
a portfolio of work involving a appeared to care about the views tight, whatever the politicians
combination of education, training and experiences of the highly might say about equality and age
and research, while writing a PhD skilled professionals working in the discrimination, older people come
thesis on service user and carer service and bombarded us with a way down the agenda whether
participation in old age psychiatry. series of major changes resulting they have dementia, depression or
If ‘retirement’ taught me anything, from their biases and political a combination of chronic physical
it taught me that what matters are fashions rather than any attempt health problems. It may feel as
the patients and we lose our focus at evidence. I could no longer though we are sailing into the wind
on them at our peril. look the service users and their but we need old age psychiatrists
families in the face and justify the to continue to speak up for those
Old age psychiatry and the changes that were being imposed who use our services and to stand
current NHS or tell them that they would get a by them when they speak up for
One of the current difficulties service that I feared would not be themselves. As professionals we
for old age psychiatrists and our delivered. When Dave Jolley and I need to be proud that we are
colleagues from other professions worked on stress and burnout in medical practitioners and that we
working with us is to look after old age psychiatry I wrote about apply our expertise in medical,
ourselves and each other. I fear what constitutes a balanced job psychiatric, psychological and
the NHS is becoming a toxic in an article that, I think, remains social treatments in the interests
environment. In the past, one as relevant now as when it was of our patients and their families.
could take an idea to a manager written.1
and work with them and other We still need old age psychiatry. Reference
colleagues to develop a service In fact, I think we need it more 1 Benbow SM. Jam on the outside.
improvement. By the time I left than ever. When services are Association of Clinical Pathologists 2003;
the NHS the managers no longer under threat, when money is Summer: 35–6.
Two fascinating decades

Tom Dening
Consultant Old Age Psychiatrist and Medical Director, Cambridgeshire and Peterborough
NHS Foundation Trust
I’ve been a consultant in old age onset dementia are now younger. has increased and is now probably
psychiatry in Cambridge since When I started, several people well over 80. Referrals of patients
1991. The most obvious change thought I looked too young to aged over 90 were unusual in
is that a whole generation of be an old age psychiatrist (they 1991, not so now. We still don’t get
patients has moved on. When I expected someone more august!). asked to see many centenarians
took up my post, there were still Sadly, this hasn’t happened for but in 20 years’ time, this will have
some people alive who had been several years now. The average age changed too. The children of our
born in the 19th century. First of patients referred to our service patients are often retired and their
World War veterans were grandchildren are often well
not uncommon. Many rural into adulthood themselves.
patients had grown up in The biggest changes in
primitive conditions, with the services we provide
no sanitation, hardly leaving are that we have far fewer
the parish they were born in. beds, in newer and more
Nowadays, men and women pleasant accommodation,
who served in the Second and that there are far more
World War are becoming personnel. When I was a
scarcer. Relentlessly, the registrar in 1985, there was
dates of birth of my patients one consultant and two
have converged on my own community psychiatric
– indeed, some with young- Ward at Fulbourn Hospital, Cambridge, c. 1990. nurses. There were nine
5
grim wards, all in the old community teams with

19th-century hospital. Social Services. Over the
Even when I started as years these have been
a consultant, I had half a separated and then
colleague to cover 50 000 slowly and painfully put
people over the age of back together again but
65. We have closed long- still do not work as well
stay wards and invested as originally. In dementia,
money in community we have concentrated on
mental health teams, diagnostic assessment
consultants and other and the management
skilled staff. There of behaviour problems.
are now 6 of us in Thus we offer less
Cambridge and 12 in The new building at Fulbourn Hospital, Cambridge, c. 2008 continuity to patients
the trust covering the and families than was
whole county, yet we all the case, even though
seem to be busy! We will appoint few years, I reached a point where the National Dementia Strategy
a professor shortly, something my one either should become a civil shows that continuity is highly
predecessor dreamed of. servant or else relinquish the role, valued.
so I left for the roller coaster ride
At the Department of Health of being a medical director. The future: a paradox
Between 1999 and 2002 I had the Although we should be
privilege of being a professional Moving forward extraordinarily confident about
advisor at the Department of Compared with 20 years ago, the future of our specialty, we
Health. This was exciting as it some things work better but other actually feel threatened about its
was the period of developing aspects are actually less satisfac- existence. We still are faced with
the National Service Framework tory. For example, the standard of the stupid argument that old age
(NSF) for Older People. There care in care homes is better and psychiatry is ageist, and there are
has been disappointment that more consistent, with more at- moves to subsume functional
older people’s mental health was tention paid to dementia care. We disorders into an all-ages service.
separated from the rest of mental have cholinesterase inhibitors and My mantra is ‘Make yourself
health, since the NSF for Mental their modest benefits. Through indispensable and they can’t get
Health appeared earlier and carried DeNDRoN (Dementias and Neu- rid of you.’ In other words, there
resources which the NSF for Older rodegenerative Diseases Research are irrefutable arguments about
People did not. The latter therefore Network), we have more support the epidemiology of the ageing
contained a lot of good sense but for research and drug trials. We as- population. Beyond a certain
did not oblige commissioners to sess nearly all our new referrals at point, the distinction between
do much. Investments in services home without a waiting list and we functional and organic is pointless.
for those under 65 years were not have an intermediate care team to It requires specialist skills to
matched for older people. On the offer intensive support at times of assess whether something is early
other hand, old age psychiatry crisis. The standard of our service dementia or not, or whether there
seems to have missed most of the is high and old age psychiatry has is depression that needs treatment
mayhem that followed New Ways the highest level of general prac- as well as cognitive impairment.
of Working. titioner satisfaction among the The people who can make these
I also worked on other issues, services offered by our trust. distinctions and manage older
such as the revision of the Mental On the downside, resources patients without killing them
Health Act 1983 and the drafting are tight. Despite the increasing with overtreatment are old age
of the Mental Capacity Act 2005. older population, almost all our psychiatrists. So even if we may
Personally, I don’t think these developments have required re- need to redefine our boundaries,
items of legislation are entirely investments of our own money, so there is plenty of work to be
satisfactory and the interface we are probably less well resourced done.
between the two (e.g. giving now than before. Local Authority
electroconvulsive therapy to an cuts will affect social care and
informal but incapacitous patient) seriously deplete day services. In
is difficult for clinicians. After a 1991, we already had integrated
6
A hallmark of a civilised society

Pearl Hettiaratchy
Former Consultant in Old Age Psychiatry, Portsmouth, then Winchester
It is a real delight to contribute to Social Services and voluntary appropriate long-term care for
this special 21st-birthday edition organisations, starting from those who can no longer live on
of the Faculty newsletter. nothing. their own due to advanced age
Looking back in nostalgia, I and end-stage dementia.
worked in old age psychiatry as Challenges of long-term care We are the fourth richest
a trainee in 1972, going on to since the 1990s country in the world. Providing
serve as consultant from 1975 good homely care for this most
Working as a consultant in
until retirement in 2002. Having vulnerable group of our society is
Winchester from 1994 was a
taken to psychiatry, not out of a hallmark of a civilised society. I
demanding and challenging task.
choice but out of necessity, I can very much hope that this will be
It was also a time when I had to
look back and say it has been a achieved in this decade.
stand up to management and
most exciting, exhilarating and
be my patients’ advocate. This
challenging career, especially my Reference
stand, to protect my patients
work with the elderly mentally ill.
with end-stage dementia and 1 Select Committee on Public
If I had to make a career choice Administration. Second Special Report.
close to death being discharged
again I would choose psychiatry North and Mid Hampshire Health
into community resources, which Authority, Loddon Community NHS Trust
and especially old age psychiatry.
had no experience in caring for – Hospital Discharge Policy. HSMO, 1997
There were uncertainties when
this patient group, led to several (http://www.publications.parliament.
I first walked onto the old age uk/pa/cm199798/cmselect/
inquiries. Most importantly there
psychiatry unit run by the late cmpubadm/396s2/pas205.htm).
was the Ombudsman inquiry and
Pearl Goddard in the early 1970s
Parliamentary Select Committee
as to what it had to offer me.
scrutinising the decisions made
Within 24 h I realised this was
by managers.1
my future. The fulfilment and
The Parliamentary Select
satisfaction a lifetime’s service in
Committee roundly condemned
old age psychiatry has given me is
the action of managers who acted
unimaginable and immeasurable.
against my advice leading to the
highest mortality of any group of
The 1970s and 1980s discharged elderly patients in the
In those early years, innovation UK. A third died within 2 months
in care, running educational and of discharge and the deaths were
training programmes, working painful and distressing. Following
collaboratively with voluntary this, clear guidelines were issued
organisations locally, regionally by the Department of Health
and nationally was the norm. At that each trust should have clear
Portsmouth, the development of continuing care criteria and should
the UK’s first travelling day hospital provide some long-stay provision.
for the elderly mentally ill and Looking back over four decades
the Wessex regional day-release of clinical practice, old age
course in old age psychiatry, psychiatry has progressed and in
which I ran single-handedly for every district specialist services are
5 years, were improvements that meeting the needs of the elderly
I can look back on with pride. mentally ill. Research is marching
Having established a nationally ahead, increasing our knowledge
recognised service in Portsmouth of and widening treatments for
I moved to Winchester to set up those with dementia. However,
a community-based, innovative we still have a long way to go in
service in collaboration with providing humane, sensitive and
7
We’re 21: recognition and discrimination

Claire Hilton
Consultant Old Age Psychiatrist, Central and North West London NHS Foundation Trust
The year 1989 was an eventful old people, they would lose out are still relegated to second
year. The Berlin wall came down, on payments for those visits. Our place in mental health policy.
the Tiananmen Square massacre closest colleagues were not always Old age services have never
took place, Margaret Thatcher our supporters.1,5 reached the priority of those for
celebrated 10 years as Prime The position of old age psychiatry younger people. Historically, old
Minister, and old age psychiatry as a distinct discipline or not re- people were last to leave the
was finally recognised as a echoes today, as we are told to mental hospitals and last to be
specialty in its own right by the abolish age cut-offs for referrals established in the community
Department of Health. to our services, as that would and in units in general hospitals.
be discriminatory. Age cut-offs Often they are last for research on
Recognition and equality of for child and adolescent mental new medications (except for the
health are not regarded as anti-dementia drugs), and have
our specialty
discriminatory. Driving, marriage, been consistently last in other
Recognition meant that official voting, retiring, watching films, innovations, especially those
data would finally be collected bus passes and railcards (even for requiring financial investment.
on older mentally ill people to students) and other aspects of
enable planning and resourcing society are all similarly regulated. Clinical responsibilities and
of services, and that training pro- Equality must promote the
grammes for the specialty would
discrimination
interests of different groups,
be formally established. Before not destroy previously positive We have made progress during the
then, despite many specialist old achievements. An entirely past 21 years. There are new drugs,
age teams emerging, data were needs and ability base for every especially for Alzheimer’s disease,
inadequate and individual train- permissible role would be access to various brain scans, more
ing placements often needed to virtually unworkable, even if ideal. people in the multidisciplinary
be fought for.1 The Section for the My 13-year-old son would like an team, and some extremely
Psychiatry of Old Age, the fore- exam for those under 18 years of patchy input into psychological
runner of the Faculty, conducted age who want to vote; if they know interventions, liaison psychiatry
surveys and collected data itself, enough they should have the vote and intermediate care.6 Every
often under the watchful eye of too. It is a sensible idea, avoiding locality now has some sort of old
John Wattis.2 age discrimination, but it would age mental health service. Some
The period of gestation had probably prove unworkable. are gold star, well-resourced
been long, since the 1940s. Despite the Equality Act 2010 services and a paragon of good
Amidst debates about whether and ample evidence for the practice. Others are not.
old age psychiatry was part of benefits of interventions in old An age cut-off for referrals to
general psychiatry or a specialty age, attitudes to older mentally old age mental health services is
in its own right,3 its birth was ill people have tended to remain appropriate as organic conditions
not straightforward. The midwife negative. Many of us have become more frequent, mood-
was just as much a part of the experienced other professionals related symptoms co-exist and
Royal College of Physicians as the rejecting our patients or under- confound, and age-related
Royal College of Psychiatrists.4 A estimating the potential benefits medical, social and physiological
specialist service for older people of adequate treatment. I recently factors overlap. Psychiatrists
was often opposed by general asked a medical student what working with younger people
psychiatrists; such specialist could be done to assist a very often have neither the desire nor
services would risk removing forgetful elderly woman to experience to make these clinical
resources from their departments, maintain her quality of life. formulations. ‘Dual diagnosis’ has
and since old people required ‘Nothing’ he replied. On the come to mean substance misuse
more domiciliary assessments, if contrary, I said, there is always and functional disorders mainly
that responsibility was handed something to make life easier. affecting younger people for
to psychiatrists specialising in Old people and our services whom services such as assertive
8
outreach are resourced.7 Our old inclusion of old age had been a theme. Perhaps ageing baby
age versions of dual diagnosis, mistake, but such spontaneously boomers and equality legislation
organic plus functional or arising slips underlie common can improve services for mentally
dementia plus delirium, are not beliefs and stereotypes. ill older people, but I suspect that
recognised, but are also complex, In the past, old age psychiatrists such change will have to come
costly and life threatening developed services and evaluated from us persisting with our long-
when detection and treatment them. Today we do not have free learned skills.
are inadequate. The widely rein to do this. Large provider
implemented multidisciplinary trusts, the commissioner–provider References
New Ways of Working approach divide, plus the dominance of 1 Pitt B. Audio-recorded interview, 2006.
to assessment does not do justice managers, all tend to favour their
2 Wattis J, Wattis L, Arie T. Psychogeriatrics:
to those with complex diagnostic model of what should be done, a national survey of a new branch of
conundrums. often lip service being paid to the psychiatry. BMJ 1981; 282: 1529–33.
Treatment, however, may need experience of clinicians. If summed 3 Old age psychiatry specialty recogni-
a different age paradigm. Some up, the total old age psychiatric tion 1987–8. Royal College of
people well over 65 need services experience of consultants in our Psychiatrists Archives.
generally restricted to younger trust would be in the region of 200 4 Royal College of Physicians, Royal
College of Psychiatrists. The Care
people, and some younger people years. Managers cannot match
of Older People with Mental Illness:
may be better served by services that. Specialist Services and Medical Training.
for older people. The treatment Gaskell, 1989.
part of our services should be Future old age mental health 5 Wattis J. Manpower problems in
needs- rather than age-based. equality psychiatry of old age. BMJ 1985; 291:
For younger people, there has Equality legislation may help 1281.
been a burgeoning of specialist change negative attitudes 6 Royal College of Psychiatrists. Age
Discrimination in Mental Health Services:
services such as assertive towards older people. However, Making Equality a Reality. Royal College
outreach, intensive care, crisis ‘prohibition on age discrimination of Psychiatrists’ Position Statement
response, and greater access to in services and public functions’ PS2/2009. Royal College of Psychiatrists,
psychological therapies, all of is one area of the Equality Act 2009.
which could benefit some older which the government remains 7 Department of Health. Mental
people. Abandoning age cut-offs undecided about how best to Health Policy Implementation
Guide: Dual Diagnosis Good Practice
for older people is in part related implement. There is a risk of Guide. TSO (The Stationery Office),
to concerns about access to these inappropriate implementation of 2002 (http://www.dh.gov.uk/en/
developments. But why not let the Act by sticking to the letter of Publicationsandstatistics/Publications/
old people access them if clinical the law rather than interpreting its PublicationsPolic yAndGuidance/
DH_4009058).
needs demand? We are at risk of message to avoid disadvantaging
8 Age Concern, Help the Aged. Ending
returning to the days when old older people.8
Age Discrimination in Services and Public
people were not offered parity On our 21st birthday we cele- Functions. Age Concern, Help the Aged,
of care with younger people brate our past and look forward 2009.
precisely because they had to our future. Unfortunately we 9 Group into section? Minutes, Group for
the same ‘all-age’ consultants; continue in our predecessors’ the Psychiatry of Old Age. Royal College
pessimistic attitudes to old footsteps using of Psychiatrists Archives, 1977.
people and misunderstanding ‘occasional militancy … to gain for the
of their needs were, and remain, elderly a fair share of scant resources, to
commonplace. For example, a put them to best use, to make do with
National Health Service mental too little while wheeling, dealing, and
fighting for more’.9
health newsletter (August 2010)
cautioned using antipsychotics Although much has been
‘where patients also have achieved and we continue to work
physical health conditions, e.g. to the best of our ability, sadly we
cardiovascular disease, renal still have to justify our existence
impairment, epilepsy, old age and and fight for resources probably
diabetes’. Old age may be a risk more than other specialties,
factor for illness, but it is no more recession or not. Underestimating
a ‘physical health condition’ than the value of old age services is a
childhood. I was informed that the past, current and probably future
9
Memories from Goodmayes

Hilary Kinsler
Consultant Old Age Psychiatrist, Goodmayes Hospital, Essex
Goodmayes has often been a Personally, I may be up for some lottery-funded palliative care
place of innovation, but many of sort of long service record. I first project and we have two young
these have been somewhat quiet. worked at Grovelands as a senior bright new ‘Goodmayes’ girls’, Kate
Everyone seems to know about house officer in 1991 and when Maxmin and Viv Gould, to bring
Tom Arie and the early days and I pouring a glass of water (whiskey some new innovations.
am often asked if I am one of his may be more appropriate!) after
‘Goodmayes’ girls’. a long memory clinic I noticed a Reference
Some people still in the service plaque saying that Grovelands 1 Ong YL. Country Madness: An English
remember Rae Smith, whom was opened in 1991 by Professor Country Diary of a Singaporean
everyone adored. She set up Elaine Murphy. I remember that Psychiatrist. Monsoon Books, 2011.
an integrated, multidisciplinary day, in part because the pizzas I
community mental health team had agreed to make were so soggy
in the 1980s. This was well before they dripped tomato sauce over
anyone had thought of New Ways everyone’s smart clothes. I am so
of Working or even integrated much better at making pizza now.
mental health teams. She also I returned as a locum staff grade
set up Grovelands Day Hospital, about 3 years later, and made it
when day hospitals were heralded clear to Zenub Kahn, who was
as a way of reducing in-patient holding the fort as usual acting
admissions. up as locum consultant, that I
Yong Lock Ong was a pioneer would very much like her job. She
in transcultural psychiatry and was always quite clear it wasn’t
found Redbridge to be fertile available. I then returned after
territory for research. His new senior registrar training in 1999,
book1 promises to be fascinating, job-sharing with Mark Jones. It
as was his gentleman’s club; many was fairly innovative to job-share
of us were lucky enough to be in those days.
invited to his rather grand club in Consultant numbers have since
central London, which had areas expanded. A new, whole-time
that were for men only. post was created (Professor Martin
Mark Jones introduced a memory Orrell’s business plans often did
clinic in 1999. He managed to the trick) and Steve O’Connor
get permission from the health was appointed, only to be rapidly
authority to treat 50 patients promoted to an assistant medical
with brand new anti-dementia director in Havering when his
drugs. It is a good job that that potential was spotted. I still have
health authority is no longer another 10 years to go before
around to count how many retiring. Not that I am counting of
patients we have now. The course! It would be rather unusual
community mental health team to retire while still working at
and the memory service are still Goodmayes.
thriving. Other innovations have We still have areas of innovation
been more brief such as an in- which promise much for the
reach service to Black and minority future. The Redbridge Dementia
ethnic community groups many Partnership, a collaboration of
years ago, and more recently a health services, Social Services
home treatment team, both lost and voluntary organisations is
in various rounds of cuts. blossoming. We have a small,
10
Goodmayes: home of old age psychiatry

Kate Maxmin
Consultant Old Age Psychiatrist, Goodmayes Hospital, Essex
In my career as an old age specialty highlighted that older that we do not automatically
psychiatrist, Goodmayes Hospital people deserve and warrant have this wisdom to hand as new
has often been quoted as ‘the specialist care. Tom Arie’s consultants today, with the added
home of old age psychiatry’, so psychiatric service for the elderly pressures of this harsh economic
now to be a consultant here with began at Goodmayes in 1969. I climate. Remembering how the
all the history that goes before find it fascinating to read about unit started here and the aims of
and hopefully after I have joined his team’s strong views on the the service 40 years ago is a very
feels quite special. importance of domiciliary visits, good place to start and keep in
joint working across services mind.
Goodmayes’ girls and the need to see old age
psychiatry covering the spectrum References
Tom Arie, Goodmayes and old
of psychiatric presentations in
age psychiatry in general have 1 Arie T. The first year of the Goodmayes
the older person, functional and psychiatric service for old people.
also been pioneers and keen
organic, acute and chronic.1 How Lancet 1970; 296: 1179–82.
supporters of women doctors and
relevant these issues are today; the 2 Arie T. Morale and the planning of
flexible working. Our predecessors
split within our specialty between psychogeriatric services. BMJ 1971; 3:
at Goodmayes include Nori 166–70.
in-patient and community, and
Graham (who Viv Gould and I were
the worries about potentially
fortunate enough to work with as
losing our functional patients
senior house officers (SHOs) at the
to our general adult colleagues
Royal Free) and Baroness Elaine
and becoming a ‘dementia only’
Murphy. Currently, our department
service permeate all our meetings
consists of three substantive
about service development.
part-time consultants: Hilary
The focus on maintaining morale
Kinsler, who first worked here
within the team2 is also pertinent
as an SHO in 1991 and returned
when thinking about old age
as a consultant in 1999, and me
psychiatry services today. It was
and my job-share colleague Viv
recognised in the early days that
Gould, who started in September
inspiring medical students to enter
2009. We would apparently have
psychiatry in general and, more
been affectionately known as
specifically the old age specialty,
‘Goodmayes’ girls’ in those early
was the key to maintaining quality
days.
within the service. It is again high
on the agenda of consultants in
Learning from our 2011.
predecessors Last week our community
We owe a great deal to the mental health team manager was
enthusiasm and determination of recounting how she had been
those who have gone before us as clearing out piles of dusty files from
we do our best to keep alive the a retired colleague’s office. She
values and uniqueness of old age was astounded to see volumes of
psychiatry in Goodmayes as we abandoned paperwork concerned
undergo service reorganisation with service reorganisation,
over the next few months. epidemiology of the borough and
Old age psychiatry developed the effort put into past attempts
here with Tom Arie as the clinical to change the service to meet the
leader. He described how the evolving needs of the population.
ageing population and the We had little idea about what
development of geriatrics as a had gone before. It is a shame
11
Relinquishing youth and encouraging maturity

Colm Owens
Consultant Old Age Psychiatrist, Central and North West London NHS Foundation Trust
As a recently appointed consult- over 21 years ago for equality being no matter what advertisements
ant, I suppose it is inevitable that better served by acknowledging for cosmetic surgery tell us. Until
it seems to me to be a particu- differences rather than imagining we face up to this, it will remain
larly daunting and exciting time that the expertise needed to deal commonplace to ignore and
in old age psychiatry. Notwith- with pathology in patients of 20 disdain the elderly and to project
standing this, there do seem to and 80 was the same. The counter our fears of ageing onto them.
be a number of challenges in our argument to this is that services Such willful ignorance results in
specialty at the moment. We face should be needs-based rather the woefully inadequate standard
something of a perfect storm of than age-based. I would agree. of home care and residential
financial stringency, service rede- There is, however, a real danger homes in this country. We know
sign and significant sociodemo- that this kind of assessment could that over two-thirds of general
graphic change. However, these pay too much heed to cognition hospital in-patients are elderly,1
challenges do provide us with and ignore other differences and and according to the National
an opportunity to think carefully vulnerabilities. It is difficult to Confidential Enquiry into Patient
about why our specialty should imagine a septuagenerian with Outcome and Death, only a third
exist and whom it should serve. depression being prioritised in a of those who require surgery
I have been fortunate enough service more used to dealing with receive an acceptable level of
to have completed most of younger people with impulsive post-operative care.2
my training during an era of and more (noticeably) harmful
continuous growth in healthcare behaviour.
Successful ageing
spending. Now this has come to
an end, we will inevitably face What we also know from our
Reality check patients is that many of them
difficult choices regarding the
allocation of resources. Despite Over the last two decades, the most can recover in the face of great
assurances about ‘ring fenced’ marked demographic change has adversity and lead rewarding
budgets, additional pressures been the steady ageing of the lives despite impairment. This
will arise as our partners in social population. We have yet to truly is the message that we need to
care face very real cuts in their acknowledge this as a society. The send out; we will almost all get
financing. cult of youth is becoming ever old, we will have greater needs
Our specialty was established more visible as our society ages. and vulnerabilities, but despite
by colleagues who had a vision of A significant proportion of us will this it is still possible to have
improving the quality of life for a face a period of relative frailty for a good quality of life. Old age
particularly ignored group in our a number of years before the end psychiatrists are uniquely placed
society. In certain quarters, it now of our lives, during which time to get this message across.
appears to be having its raison mental and physical illness will We have regular contact with
d’être questioned. In numerous be likely. This may be seen as a older patients, their life stories,
National Health Service trusts, pessimistic portrayal but I think their families, their neighbours
reorganisations are taking place that it is a realistic one. as well as our colleagues in
which will split off ‘organic’ or Such a stark view may elicit a social work, general practice,
dementia services and place the number of reactions. We may be old age medicine, emergency
care of cognitively intact older tempted to bury our head in the departments and a broad sweep
patients in the same services as sand and imagine that it may of other medical specialties.
younger adults with potentially never happen to us – the forlorn There is casual discrimination
very different needs. The thought hope that we will be in the peak against the elderly despite their
processes leading to such changes of health one day and suddenly increasing numbers and we can
are not necessarily malevolent dead the next. However, advances do something about this. We need
but often stem from a lack of in modern medicine are making to redefine our specialty and we
understanding of the needs of the that increasingly unlikely. There need to work much more closely
older population. A case was made is no panacea or cure for ageing, with providers of residential
12
care as well as our colleagues care staff deal increasingly with 2005 (http://www.rcpsych.ac.uk/PDF/
in general hospitals. Huge the elderly and the complex issues WhoCaresWins.pdf ).
amounts of psychopathology are of capacity and risk assessment 2 National Confidential Enquiry into
Patient Outcome and Death. Elective
concentrated in these settings1,3 that can arise from mental illness and Emergency Surgery in the Elderly: an
and yet psychiatric input is patchy. and physical frailty. Yet it is more Age Old Problem. NCEPOD, 2010 (http://
This means that these patients common than not for physicians, www.ncepod.org.uk/2010eese.htm).
are cared for by staff that have psychiatrists and social workers 3 Seitz D, Purandare N, Conn D. Prevalence
very little relevant mental health to work in different organisations. of psychiatric disorders among older
training. This is astonishingly myopic. Truly, adults in long-term care homes: a
systematic review. Int Psychoger 2010;
there is no health without mental 22: 1025–39.
health.4,5 This phrase is particularly 4 Prince M, Patel V, Saxena S, et al. No
Mature services resonant as we age. Old age health without mental health. Lancet
There is a real case to be made for psychiatry has an important job 2007; 370: 859–77
joint elderly care services. It seems to do over the next 21 years but 5 Royal College of Psychiatrists. No
increasingly artificial to draw we need to look outside of the Health without Mental Health.
boundaries between physical Royal College of Psychiatrists,
traditional areas occupied by
2010 (http://www.rcpsych.ac.uk/
and mental healthcare in this age mental healthcare. quality/quality,accreditationaudit/
group. Many of the older patients nohealthwithout.aspx).
in general hospitals will have References
a diagnosable mental illness.1
1 Royal College of Psychiatrists. Who
The overwhelming majority Cares Wins. Improving the Outcome for
of our patients have physical Older People Admitted to the General
comorbidity. Social workers and Hospital. Royal College of Psychiatrists,
The memory clinic

Michael Philpot
Consultant in Old Age Psychiatry, Mental Health of Older Adults and Dementia Clinical
Academic Group, Maudsley Hospital, London
‘While detection of a dementing illness and the idea was exported to the referrer. Barbara conducted
may not be of direct benefit to the the UK in the early 1980s. Clinics the detailed neuropsychological
sufferer, it may assist patients or their
families and carers to come to terms were founded by geriatricians assessments and, in those early
with the diagnosis and plan future in London and Cardiff but the days, pioneered the use of
management, particularly if counselled first with an old age psychiatry problem-solving and memory re-
sympathetically.’ 1 focus was set up at the Maudsley training techniques. The interview
Apart from hoping that that was Hospital in 1984. Raymond Levy with Professor Levy rounded off
the last time I ever used the word had just been appointed professor what was a busy day for the patient
‘dementing’ in any sense, I think of old age psychiatry at the and their family, and concluded
the basic sentiments expressed Institute of Psychiatry and a few with him giving his honest view
are certainly valid today and are months later, Barbara Sahakian of the likely diagnosis. At follow-
indeed enshrined in the National and I were appointed his lecturers. up visits, patients were helped
Dementia Strategy (2009). It took a few weeks to organise to come to terms with this and
However, it is easy to forget how the clinic routine so that much of then usually recruited to one of
unusual those practices were 30 the clinical assessment and brain the trials. After a few months the
years ago. The drive to make an computed tomography scanning clinic was joined by a succession
early diagnosis has gone hand were carried out on the same day. of research workers including
in hand with the growth of the We saw our first patient on 15 Nigel Hymas, Eileen Joyce, Alistair
‘consumer’ culture in healthcare, May 1984, ironically a man with Burns, Gemma Jones, Melanie
and perhaps accounts for the very severe dementia. My role Abas, Sarah Eagger, Osvaldo
memory clinics’ success. was to clerk the patients, book the Almeida and many others. For
Memory clinics originally investigations, present the case to us juniors the clinic was an ideal
appeared in the USA in the 1970s Professor Levy and write back to and inspiring setting for training,
13
and frequent visitors from home

and abroad helped make its
reputation.
Of course, one of the main
purposes of the clinic was to
involve all the patients in research.
Margaret Reith was employed
as a nurse to coordinate a series
of drug trials (lecithin, 2-methyl-
alpha-ergokryptine, and later
tacrine) and other studies, and
many patients also took part in
the studies of computer-based
cognitive testing, neuroimaging
and neurophysiology. The
dedication required in some of Professor Raymond Levy and some of the Maudsley memory clinic baking team, April
this effort might surprise today’s 1986.
trainees. For example, before the
days of cholinesterase inhibitors, survey in 2001,3 the number had have called this model something
acetylcholine precursor-loading grown to over 100 but the focus sexy and distinctive. However,
with choline and lecithin was had shifted away from research to we have recently implemented
attempted. Choline left patients the provision of basic clinical and a major objective of the National
smelling of fish and in the first psychosocial care, as well as to the Dementia Strategy and set up a
lecithin trial at the Maudsley the prescription of drugs for dementia new memory service, serving all
drug was delivered in liquid form, that were by then available on the adults in two boroughs, and based
like a greasy milkshake. For the National Health Service; and the on the service pioneered by Sube
second trial, we sourced lecithin newer clinics were more likely to Banerjee and David Matthews in
flour which could be transformed be run by old age psychiatrists. Croydon.
into delicious cookies that we Now Wikipedia tells us that in 2009 It’s comforting to be almost back
had to bake ourselves. The photo there were 246 memory clinics to where I started.
above was taken after one such in the UK! Some have extended
baking session, late one evening in into the community in a variety References
the Institute’s kitchen. Raymond’s of imaginative ways, some have 1 Philpot M, Levy R. A memory clinic for
white coat is not a lab coat but his become highly specialised and the early diagnosis of dementia. Int J
chef’s uniform … some are in the private sector. Geriatr Psychiatry 1987; 2: 195–200.
When James Lindesay conduct- At the Maudsley, the Memory 2 Wright N, Lindesay J. A survey of
Clinic ceased to operate in 1997 memory clinics in the British Isles. Int J
ed the first national survey of
Geriatr Psychiatry 1995; 10: 379–85.
memory clinics in 19932 there but its functions were incorporated
3 Lindesay J, Marudkar M, van Diepen E,
were 20 such clinics, mostly into the local community mental et al. The second Leicester survey of
research-based and in university health teams with out-patients as memory clinics in the British Isles. Int J
centres. By the time of his second an option for follow-up. We should Geriatr Psychiatry 2002; 17: 41–7.
Reflections
John Wattis
Professor of Old Age Psychiatry, University of Huddersfield
Before I became a consultant, I of old age psychiatry in a series reflections. First, the post-war
was lucky enough to be the first of surveys.1,2 This work was culture in which old age psychiatry
lecturer in psychiatry of old age in instrumental in getting recogni- services had their roots was very
Tom Arie’s then new Department tion for the specialty. different from the present culture
of Health Care of the Elderly at Instead of reciting detailed in which ‘the market’ is regarded
Nottingham Medical School. We history, I want to use the space I as some kind of deity. In the 1960s
chronicled the early development have been given for a few personal and 1970s there was a political
14
consensus about public services turned out to be equally abusive. Concern, to be strong advocates
and a recognition that health To some extent, all experts, but for the needs of old people with
services were better provided on psychiatrists more than most mental disorders. Happy 21st!
a national basis, with equality of doctors, were marginalised as a
access and treatment. In many new managerialism took over. References
areas the asylums were still around More recently the Mental Capacity
1 Wattis J, Wattis L, Arie T. Psychogeriatrics:
and provided free National Health Act 2005 has brought a whole new a national survey of a new branch of
Service (NHS) accommodation for layer of bureaucracy, and some psychiatry. BMJ 1981; 282: 1529–33.
old people with severe dementia increased protection for those 2 Wattis J. Geographical variations in the
and behavioural problems (so- lacking capacity. provision of psychiatric services for old
called elderly severely mentally Alongside these social and people. Age Ageing 1988; 17: 171–80.
infirm). Geriatric medicine still political changes there were
provided free NHS accommodation significant technological advanc- Professor Wattis is former Public
for those with severe dementia es in the treatment of psychiatric Education Officer, Secretary and
and immobility. Most of the non- disorders in old age, including: Chair of the Section/Faculty of
hospital residential care was new techniques for imaging the Psychiatry of Old Age. From
provided by local authorities in the living brain; the emergence 1981 he was a consultant old age
‘Part 3’ homes (some specialising of cholinesterase inhibitors for psychiatrist in Leeds and then
in the elderly mentally infirm) and some forms of dementia; a better from 2000 in Huddersfield. He
nursing homes were generally understanding of genetics and retired from clinical work in 2005,
run privately for the well off. It the preventive measures that but retains an academic interest
was all very different! The early could reduce the incidence of in old age psychiatry and medical
‘psychogeriatricians’ developed vascular and possibly Alzheimer’s management.
community services by closing dementia; the emergence of
some (but not all) long-stay beds diffuse Lewy body dementia as
and using the money to develop a significant diagnostic cate-
day hospitals, better acute in- gory; and the application of
patient facilities and, most psychological therapies still all
importantly, to pay staff to work too rarely available to old people
in multidisciplinary community in many areas.
mental health teams for the Looking to the future is always
elderly. dangerous. Social and political
Old age psychiatrists were changes are always with us and
in the vanguard of setting up some of us hope (probably in
decent services for people with vain) that the banking crisis of
dementia and in setting up 2008/9 will lead to a reappraisal
effective treatment and care of the position of market forces
for those with other conditions, as the chief deity in the modern
principally depressive disorder. pantheon, followed by a return
Other disciplines tended to follow to a more equal society. We
the medical lead, and managers shall see. Technological changes
thought that psychiatrists knew seem very likely to have a big
how to design and deliver services impact, particularly in the area
for old people! After Thatcher it of prevention and treatment of
all changed; the market ruled. dementia, and psychiatrists will
Residential/nursing care was probably find their place more as
effectively privatised through the ‘advanced diagnosticians’ of
changes in the social security the many mental disorders found
rules and the gradual withdrawal in old age, with routine treatment
of free NHS long-term care. The schedules (care pathways) largely
care and undoubted abuses in managed by others. I hope that
some of the old asylums and old age psychiatrists will also
some ‘Part 3’ homes were replaced continue, with the assistance
by care in private nursing and of voluntary bodies such as the
residential homes, some of which Alzheimer’s Society and Age
15
From Scotland and Wales

21 years of old age psychiatry: then, now and the
future
Peter Connelly
Consultant Old Age Psychiatrist, Murray Royal Hospital, and Chair of the Faculty of the
Psychiatry of Old Age
A Scottish perspective and colleagues there anticipated The fact that the answer to
In 1989 I was a fresh-faced removal of people who were the latter question is positive
consultant having been appointed troublesome. makes the answer to the first
on 1 October 1987 to Murray Royal In the intervening years there resoundingly so. In 1989 most
Hospital in Perth. I may have been has been a huge national expan- patients tended to be in their mid-
the first person in Scotland to sion of consultants, nurses and 70s, with a sprinkling over 80 and
complete a specifically designed other professionals working with the over-90s only rarely seen. Now
3-year training programme in old older people with mental illness. we inevitably deal with people in
age psychiatry and certainly at Most of the pioneers are now their mid-80s, and, over the next
that time I was the youngest old enjoying retirement, hopefully 21 years, we can expect to focus
age psychiatrist around. I am still in without the need to access our even more on people in their
the same place but, like a favourite services. A whole new cohort of late 80s and 90s, who will have
axe, there have been three new academics has helped improve very different causes underlying
handles and two new heads, but research, although the academic their illnesses and very different
the axe is still the same! profile of old age psychiatry is expectations of the recovery
Fifteen months into the post, less evident in the devolved na- process than someone aged 40.
the Scottish Health Authorities tions. Cholinesterase inhibitors, Old age psychiatrists have become
Review of Priorities for the Eighties although having modest effects, uniquely skilled at identifying and
and Nineties1 was beginning to brought a new population into managing all of the complexity of
recognise the growing number contact with us and changed the diagnosing and all the interplay
of older people. The number way we managed dementia. We of multiple comorbidity that
of care homes seemed to be can now find examples of state-of- increased age brings. It would be
mushrooming in an unplanned the-art services in early recogni- madness to give it all up now.
way, with a new population of tion, post-diagnostic counselling, The Faculty has become more
dementia in their midst. The noise innovative forms of community political and must prepare itself
of their doors locking as a patient service, care home or general hos- to be in a strongly influential
entered only just drowned out pital liaison services and end-of- position once the current
the more important sound of case life care. Perhaps it is a pity that financial crisis begins to resolve.
files closing. Older people with we would struggle to find a serv- We must also recognise that
functional mental illness were in ice which was doing all of these we cannot manage every part
the same ward as younger people, particularly well. of old age psychiatry equally
which was an absolute disaster. well. Although not advocating
Community nurses had huge
A Faculty perspective multiple subspecialisations, as
case-loads, usually a mixed bag Two questions I was asked with younger adults, we need
of diagnoses. We did have a social recently. to have a way of improving
worker as part of our team (now 1. Is there any point in being an conjoint working so that we can
lost through ‘improvement’), even old age psychiatrist? access skills in substance misuse,
though she had a huge rural area 2. Is there any difference mentally disordered offending,
to cover. In the general hospitals, between a 40-year-old with liaison services and so forth, while
people with delirium and depression and a 75-year-old still maintaining a high level of
dementia were managed poorly with depression? specialisation in the problems of
16
older people. We need to make with are the result of devastating same thing. Oh well, maybe that
the most of research networks, neuropathological changes and was me!
not simply to promote the we must resist wholesale
importance of academic old age socialisation of the mental illness, Reference
psychiatry, but also to inhibit silo something which does a disservice 1 Scottish Home and Health Department.
thinking and, most importantly, to to older people. We need to Scottish Health Authorities Review of
increase recruitment into studies ensure that the UK remains at Priorities for the Eighties and Nineties
to ensure that research findings the forefront of plans to increase (SHARPEN). HMSO, 1988.
shape clinical practice much more recognition of old age psychiatry
rapidly than at present. We need internationally, and does not
to improve the sharing of best return to the dark ages where the
practice, but value in doing so will needs of older people are always
be limited if service commissioners second best.
do not rise to the challenge of I wonder whether, if I went back
developing innovative services. 21 years, there wouldn’t have
Many of the illnesses we deal been someone saying exactly the
Services for elderly people in Scotland: from the

inside
Sam (R. A.) Robinson
Formerly Consultant Psychiatrist, Crichton Royal Hospital and Edinburgh
In my opening remarks at the confirmed. The doctor told me anorexia and insomnia. I had
Witness Seminar in 20081 I said that it was an indication that my continuous ‘white nights’, a sort of
that the infirmities of old age took immune system was impaired and coma vigil. I suppose I must have
even geriatricians by surprise. that I should keep clear of people slept a bit but it didn’t seem so.
Little did I realise how soon I was with coughs, colds and flu. He My doctor got his community
to test this statement. expressed surprise that I seemed nurse to apply absorbent
so well with such a severe rash – dressings to my discharging rash
Shingles! prophetic words! He gave me a and later lidocaine patches. As I
What an innocuous sounding term supply of acyclovir and painkillers was getting no better, a relative
for such a diabolical condition! and wished me well. All this within agreed to take me in. Then I had
Looking back, it began with 5 h of the appearance of the rash. an attack of Ménière’s syndrome;
shooting pains in my left wrist and Daniel Hannan2 please roll over!! my last one had been 35 years
elbow. I thought at first of coronary In fairness I should add that a earlier and I had thought I was
insufficiency but the episodes subsequent enquiry was dealt free of it. There were four attacks
seemed to be too transient for with somewhat less briskly. in a month. Again I had to call
that. Two days later the cause was I was still feeling quite well and on NHS 24 – after some delay a
revealed. A wild-looking purple/ on the way home stocked up at male nurse came and injected
red rash extending from left axilla a local supermarket for what I me with prochlorperazine. He
to midline, front and back (C5/6). thought might be a week or two of assured me that it would be
It was a Sunday morning invalidism. Aged 86, I live alone. effective within 30 min – and so
so I decided to ring NHS 24 – During the next few days I it was. He also gave me a supply
without revealing my medical was well enough to browse the of Buccastem, which proved
background – more as a test than internet for recent news about effective in subsequent attacks. I
in expectation of results. However, shingles. Most of the articles was relatively comfortable only in
the response was immediate dealt with the painful rash and its bed, reading.
and surprising. I was offered a treatment. There was little about Eventually my family decided
medical consultation at the Royal the systemic symptoms which that I was well enough to try living
Infirmary, Edinburgh, within the were now beginning to afflict at home. My daughter came from
hour. There, my diagnosis was me. Increasing anergia, nausea, Leeds to help look after me; soon
17
I was able to manage everything Infirmary. The pain was much long shoehorn were prescribed.
except showering. She arranged diminished. Then, subsequently, A ‘package of care’ was arranged
for a social work assessment, as analgesics were liberally with Social Services. I was to have
a result of which an occupational prescribed. The following day I ‘carers’ morning and evening, and
therapist provided a toilet chair was mobilised and to my surprise visits from a community psychiatric
and a cushion to help me rise from was able to walk a few steps. nurse and physiotherapist. All this
my chair. My daughter suggested Numerous appliances, a stand- is free in Scotland.
(sensibly) that I should move to a upper and several others which I It came to pass without any
sheltered flat. This had been my had never seen or even imagined, effort on my part; and all worked
long-term intention. But none was helped in the process. perfectly. I have two regular
available in the desired location. At first my depressed mood was helps – Janice and Jacqui – in
Unusually and providentially regarded as reactive and ascribed the morning, rotating every 4
(it seemed) one was offered on to the numerous physical and days. They help me shower, dress,
a short-term let. So I moved, lifestyle setbacks which I had apply various creams, put on my
dependent on family assistance. experienced in the preceding 9 support stockings, make my bed,
Numerous problems developed; months. It was felt that I would prepare sandwiches for lunch
moth infestation, faulty applianc- gradually improve, but I was not and attend to any other personal
es and plumbing, and so on. I never so sure. Eventually, mirtazapine care that I require. Their constant
felt at ease there. I was kept awake 30 mg was prescribed, with cheerfulness and encouragement
one night by persistent vomiting. disastrous results. The following is a great morale booster. In the
My new doctor came, found that I morning I was so sedated that I meantime I have moved to a
had a slight pyrexia and said that could hardly open my eyes and new flat which I like. This would
his ‘best guess’ was that I had a required help with feeding and not have been possible without
urinary infection. He started me dressing. I refused further doses the organisation and help of my
on trimethoprim – later it was until I had seen a doctor. Eventually, daughter, son and family.
found that the organism Klebsiella citalopram 10 mg was substituted. Just when I thought that all was
was insensitive. He also set up a I have to say that in spite of its going well I fell heavily as a result
Crisis Care package – although adverse effects I felt that there of an overenthusiastic knees-
after a day or two I was able to had been a lightening of my mood bend. My legs collapsed beneath
cope alone. My vomiting ceased after the mirtazapine episode. My me with considerable pain. With
but was replaced by renewed urinary infection responded to 3 difficulty I got to my feet only to
nausea. days of ciprofloxacin. fall again in the same way. This
time I couldn’t get up and had
Depression Recovery to summon help. I had pulled
Meanwhile my spirits declined Thereafter my progress was all the muscles of my ankles and
sharply. I was neither eating encouraging. I could soon walk knees. Fortunately my hip was
nor sleeping properly, even fairly well with a Zimmer frame spared. This episode, in terms of
with hypnotics. One evening, and later with two walking sticks. disability, has been worse than
due to a faulty fridge door, I fell I began to sleep better, although my fracture. I can only get about
heavily. The pain in my right leg the early morning arousing, for with the support of my trolley or
was excruciating if I attempted the blood pressure round, was a three-wheeler. Otherwise I am
to move. I could not reach the constant trial. My appetite return- improving, still on citalopram,
Careline alarm cord. Fortunately ed and the meals were quite good. now 20 mg.
my daughter was in the building I had numerous assessments, in
and found me within a few minutes. addition to walking and climbing What of the future?
The subsequent ambulance ride a few stairs, dressing, showering, Personally, I feel that I am almost
to hospital was prolonged torture bathing and kitchen tests were within reach of shops and facilities
in spite of a shot of morphine. all passed successfully, if slowly. in the locality and will have to
There the diagnosis of ‘displaced I began to enjoy my stay; the be content with that. Carers will
intracapsular NOF [neck of femur] supported life in Ward 108 seemed still be required for an indefinite
fracture right hip’ was confirmed almost preferable to the probable period.
and an operation was arranged trials which I faced at home. Can the munificence of Social
for the following day. Three weeks passed and Services be maintained in the
The bipolar hemiarthroplasty preparations began for my future economic climate? I
went well and I woke in an discharge. A bath seat, magnetised estimate that without their help I
orthopaedic ward in the Royal ‘pick up’, walking sticks and a would be in a care home costing
18
me maybe £1250 weekly. It seems References nhs-attack-1772164.html).

possible that means-testing 1 Claire Hilton (ed). The Development of
3 Anon. Happy death day. BMJ 1975; 4:
or limitation of services will be 423.
Old Age Psychiatry from the 1960s until
necessary. 1989. Guthrie Trust Witness Seminar,
Centre for the History of Medicine, Dr Robinson, formerly a consultant
In the longer term, economics
University of Glasgow, 2008 (http:// psychiatrist, Crichton Royal
may determine future develop- www.gla.ac.uk/media/media_107314_ Hospital, then Royal Victoria
ments. Faced with the ever- en.pdf ). Hospital, Edinburgh; senior lecturer,
increasing elderly population, who 2 Anon. David Cameron slaps down Tory University of Edinburgh; and
knows what will happen. Maybe MEP Daniel Hannan over NHS attack.
The Independent 14 August, 2009
chairman of the Section for the
in another 21 years voluntary
(http://www.independent.co.uk/news/ Psychiatry of Old Age 1978–81.
termination of life at age 85 will
uk/politics/david-cameron-slaps-
be an acceptable option. Happy down-tory-mep-daniel-hannan-over-
Death Day!3
A view from Swansea

Don Williams
Honorary Consultant, Cefn Coed Hospital, Swansea
September 1974 was the The afternoon meetings were an independent discipline had
beginning of my only consultant lively; one paper then tea followed gathered momentum. There were
post at a traditional psychiatric by an open meeting focusing lively meetings, when the majority
hospital in Swansea. My training mainly on developing services. of colleagues were enthusiastic
was in general psychiatry with During these meetings the idea for change. By 1989 this was
an interest in psychotherapy. emerged that old age psychiatry achieved. Now 21 years on, it is
In 1976 the hospital needed a should become an independent timely to consider its significance
dementia service. I had attended specialty. Two colleagues were and benefits. Certainly it improved
the Maudsley Bequest lectures really inspirational, Tom Arie and our image and status, which
when Tom Arie had convinced me Brice Pitt; they reinforced the hitherto had been considered a
that this work was a rewarding challenging nature of our work, Cinderella specialty. We felt on
challenge. I responded to the which was also enjoyable and a par with general psychiatry.
need. I enjoyed the work and was rewarding. Working in a clinical The esprit de corps of the new
rehabilitated as a proper doctor field, which was evolving and discipline was palpable but as
diagnosing medical conditions developing, was also stimulating. it became established, and with
including constipation-with- One had a mission which could be more consultant posts created,
overflow. delivered. this evaporated. After separation
Soon I attended meetings of the The first task was to establish a from general psychiatry we had
Section for Old Age Psychiatry. dementia service; once achieved, more clout in determining our
the next phase was creating a training needs and during the
comprehensive old age psychiatry early years a number of important
service. Age was not a criterion, reports were produced.
it was a service for patients who
were ageing or it was considered
that their care would be better met Further developments
in an old age service. In time we Our hopes of having better
had separate facilities for patients relationships with geriatricians
with dementia and functional were not realised. And it was
impairment. disappointing that Tom Arie’s
vision of a unified hospital service
for the elderly could not be
Achieving recognition replicated. Geriatric physicians had
Siarad mewn cyfarfod yn Llanymddyfri.
(Caught on camera while speaking at a By the mid-1980s the idea that their own problems of maintaining
meeting at Llandovery.) the specialty should become professional parity with their
19
medical colleagues, particularly new practices emerged; the Since being a separate specialty
when general medicine changed indiscriminate use of flu jabs, we have allowed almost all the
into a grouping of organ specialists. PEG (percutaneous endoscopic long-term care for dementia to be
It was difficult to maintain the gastrostomy) feeding and provided by the private sector. This
core values of geriatric medicine. memantine, and as a result, non- is to be regretted, adequate beds
At this point old age psychiatry intrusive caring and acceptance for this purpose should have been
should have incorporated of the timely end of a distressing retained in the National Health
more general medicine into its illness was replaced by measures Service as a vital component of a
training programme to ensure which prolonged suffering. modern comprehensive old age
comprehensive care for its Our specialty has been psychiatry service.
vulnerable clientele. preoccupied with treating During these 21 years much has
The momentum generated dementia and has expended much been achieved. We must celebrate
to create a new specialty was time and energy insisting on the and congratulate ourselves for
not maintained. As secretary of wide availability of drugs, which creating a much needed modern
the Section, Nigel Tyre created are only of marginal benefit. In popular specialty. However, as
the Seize the Initiative agenda. view of the prolonged uncertainty this is being done, we should be
Although adopted, instead of which existed about the efficacy redefining our strategic vision for
establishing the bold big picture of these drugs, we should have the new century.
of the way forward, it became a campaigned vigorously for a large
‘to do’ list. We failed to maintain multicentred Medical Research Reference
a progressive strategic vision Council trial to establish the facts. 1 Thiery M. Clinical trial of the treatment
and there are areas where this This would have been similar to the of depressive illness. Report to the
new specialty should have done landmark study by Thiery,1 which Medical Research Council by its Clinical
better. created the modern foundation Psychiatry Committee. BMJ 1965; 1:
As comprehensive services for the treatment of depression 881–6.
became the norm, a key element and would have reflected well on
should have been palliative care an emerging specialty.
for terminal dementia. Instead,
From Geriatric Medicine

The future of old age psychiatry: a geriatric
trainee’s perspective
Shuli Levy
ST4, Northwick Park Hospital, Harrow
As I write this from my geriatric – the man speaks! After 2 weeks disease and an apparent conver-
ward, out of the corner of my of silence and somnolence, of sion disorder woke in the night to
eye I see a nurse gently offering titrating analgesics, reducing find she could not move her legs
painkillers and water to a man with sedatives (too quickly as it at all. Clinically this was purely
dementia, admitted with a hip turned out), removing catheters, voluntary and the consultant
fracture and a subsequent acute meticulous pressure care, treating physician on post-take wasted
delirium. He gives her his usual infection and rehydrating – he no time in pointing this out to
blank stare, then out of nowhere finally speaks! her, after which it spontaneously
he roars ‘b****r off ’ in a rather What was last week’s old age resolved. Meanwhile, on the
pleasing Irish lilt and hurls the cup psychiatry highlight? It’s one of ward, a man with cerebrovascular
of water into the unsuspecting two, possibly three. On call, a disease, alcohol dependence and
hoist next to him. We are delighted 70-year-old lady with Parkinson’s possible depression developed
20
paranoid ideas about some of This high proportion reflects are managed correctly and
the staff and other patients, not just the rising prevalence of referred on appropriately.
then demanded his release from dementia, but also the physical Next, I wish for shared care wards
‘this prison’, stating he knew his frailty and reduced survival rates to manage patients with multiple
rights. A flurry of activity ensued that the disease engenders. complex needs, with regular old
– discussion with his wife, with These patients are vulnerable age psychiatry and geriatric input,
the multidisciplinary team (MDT), and have complex needs, and a coordinated MDT and a fully
with his general practitioner, require detailed assessments by patient-centred approach to care
assessment of capacity with a trained and caring professionals (this last point may be obvious
speech therapist, a call to the who can create individualised to some, but in an acute setting,
social worker ... and then, does management plans and monitor the MDT is discharge- rather
anyone know how to fill out a their implementation. We do our than patient-oriented). The icing
Deprivation of Liberty Safeguards best to do all those things but we on the cake would be ongoing
application in this hospital? recognise that some patients – community follow-up by the
The man, who took to his bed often those with no meaningful same geriatrician and psychiatrist,
(after the consultant decided he communication and no relatives enabling admission avoidance,
did have capacity and discharged – get short-changed due to lack advance care planning and, where
him), is also on course for a brush of both expertise and limited necessary, timely terminal care.
with a dementia screen and a resources. Finally, perhaps there should
computed tomography scanner. be more geriatrics in old age
‘Are those your cats by the Three wishes … psychiatry so that the interface
window?’ he asked me yesterday Without being too clichéd, I between us isn’t quite so rigid
between mouthfuls of Ensure. I am have three wishes for your 21st and impenetrable. It sometimes
preparing to ignore this question birthday. From my perspective as feels like we gingerly dip our toes
as I walk away, then stop in my a hospital trainee, an expanding in each other’s specialty pools
tracks as I remember he is on a role for liaison old age psychiatry, when in fact we need to take
trial of carbidopa–levodopa from in greater numbers and with much long, regular swims and gradually
another geriatrician for possible more time, would considerably absorb knowledge and skills. I
Parkinson’s disease. A mini Eureka improve the level of care we are gained a huge amount from a
moment! Dementia with Lewy delivering. It would also allow (mandatory) 2-week attachment
bodies perhaps? for more training for all relevant in old age psychiatry, and I hope
A brief survey of my current in- hospital specialties so that day- to do more at a later stage in my
patient list reveals that a stagger- to-day problems such as newly training. Wouldn’t it benefit old
ing 14 out of 24 have one or more recognised cognitive impairment, age psychiatry trainees to spend
psychiatric problems – mostly delirium, consent and capacity, time with us and experience
dementia but also bipolar affective alcohol withdrawal, prescribing things from our perspective?
disorder, depression and delirium. sedatives and discharge planning
Old age physicians and psychiatrists: past, present

and future collaborations
Jackie Morris
Honorary Research Associate, Research Department of Primary Care and Population
Health, Faculty of Biomedical Sciences, University College London Medical School
Past as well as being very clever and to their physical ones. As a

It was 1976, the hottest summer great fun. I used to ask her to see psychiatrist she seemed to have
for years and my first experience them in order to read her very a much broader understanding of
of geriatric medicine as a senior entertaining and useful notes their needs than I had as a mere
registrar.The flame-haired registrar about these vulnerable older physician. I spent many months
in psychiatry was extremely kind people. They often had major trying to persuade her to do old
and helpful to my elderly patients psychiatric problems in addition age psychiatry as she seemed
21
made for it. She went off to do psychiatry unit on the top of health problems. He works in
an MD and later to become a Hampstead Heath. It was called partnership as dementia lead with
distinguished professor of old age Queen Mary’s House. Nori is a psychiatrist Dr Richard Prettyman.
psychiatry and then a working wonderful clinician and always For the past 3 years Gill
peer. Her name is Elaine Murphy. dispensed extremely wise advice Livingstone and I have been
In September 1976 I spent a about my complex and often collaborating on end-of-life
wonderfully informative few weeks challenging patients. While I care in advanced dementia in a
with Dr Tom Arie at Goodmayes worked with her, despite chairing 120-bedded Jewish Care nursing
Hospital in east London. He later the Alzheimer’s Society, she was home. Her logic, intelligence and
became professor at Nottingham. always there for our patients wisdom are very useful attributes.
His incredible enthusiasm to the and us. I first met Professor Gill The project, funded by the King’s
importance of shared approaches Livingston when she was a senior Fund, is in the last 18 months of a
to the care of older people was registrar with Nori. She used to 3-year grant.
extremely infectious. His clinical attend my medical ward rounds
and academic approach was at the Royal Free. I have very
so successful that he was then fond memories of enjoyable The message
able to set up a Department challenging afternoons spent I think that the essential
of Health Care of the Elderly at with her. Dr Amanda Thomspell components of all these
Nottingham combining both worked with me and then saw the relationships and partnerships are
medicine and psychiatry for older light and started her training as an a shared approach to the care of
people. Later on when I became a old age psychiatrist with Nori. older people. For the healthcare
consultant physician at St Mary’s of older people to continue to
and St Charles, London, I took my improve and be delivered with
colleagues to visit the department Present compassion and humanity there
to demonstrate the advantages of Amanda went on to develop an is a need for physicians and
this form of care. outstanding liaison service for psychiatrists to work together.
In 1983 the Department of Health care homes in Southwark. Queen While 40% of people occupying
awarded us, at St Charles, £250 000 Mary’s no longer has rehabilitation acute beds and 70% of older
to pump prime a department beds but is a thriving department people in care homes have
of old age psychiatry based in a of old age psychiatry, which is led dementia, we can no longer work
purpose-built unit. Dr Mark Arden by Dr Suzanne Joels in her role as in silos. The National Dementia
was appointed as the consultant associate clinical director. Suzanne Strategy should help this to
to lead the psychiatry team and to and Ruth Allen share what was become a reality.
work with us in the Department of Nori’s post. They now offer much
Medicine for the Elderly. Mark was more intensive liaison support to Jackie Morris, consultant physician,
a wonderful colleague and for the older patients who so often St Mary’s Hospital and Royal Free
quite a few years a very successful present with delirium when NHS Trust London, 1979–2006.
joint department of medicine and acutely unwell. Dr Tony Katz, who
mental health for the elderly was is supported by two liaison nurses,
run – in some ways similar to the mans this with additional help
Nottingham model. from a dementia nurse provided
Sadly, the benefits of by the Royal Free acute trust. He
collaboration were seen to be also provides a wonderful liaison
secondary to the development service at University College
of larger separate departments of Hospital. His sense of humour
medicine and mental health. and fun does so much to relieve
On taking up an appointment at stressful situations.
the Royal Free Hospital in London Nottingham’s Queen’s Medical
in 1985, I was very fortunate to Centre has taken this one stage
work with Dr Nori Graham, who further. Professor Rowan Harwood,
had previously worked with Tom a physician, has set up a medical
Arie. Together with Professor and mental health unit to improve
Archie Young and Professor Shah the care of patients by providing
Ebrahim, we commissioned a a more relaxed environment and
new rehabilitation and old age training nurses to deal with mental
22
From the Multidisciplinary Team

Older people’s community mental health nursing
Eric Craig
Service Manager, Older Adult Mental Health Services, Westminster
‘The simplest remedies were perhaps the maternity, even for mental health at caring for people outside the
best.’ nurses – then back to the hospital hospital. Now, students expect
Mary Seacole for more learning. and demand experience in all
At the start of my career, nurses areas of mental healthcare,
The history of community mental were mainly trained in hospital, including the community, that is
health nursing goes back many an environment where both widely available to them.
years before the Department patients and staff could live There are some who argue that
of Health recognised old age without setting foot outside. I, the profession has lost the skill
psychiatry as a specialty. for one, spent a week in the main in caring and has become more
In 1961, Enoch Powell in his hospital building, going from academic. In some ways I agree.
Water Tower speech envisaged the nurses’ home to the college, I would also argue that if the right
the closure of large institutional to the ward and to the canteen person is selected and is trained to
hospitals. The Hospital Plan for without setting foot outside the a high academic standard then the
England and Wales was published Crichton Hall. In the large rural profession will improve and the
the following year. However, it community we covered (about person being cared for will have
was not until the 1980s–90s that 65 x 45 miles), student placements better care; you go to a specialist
these hospitals were closing in were available, but with only two because of their specialist
greater numbers. This signalled a general psychiatry community knowledge and skills, and that is
significant increase in community- health nurses for the entire area. what we should provide.
based nursing services. However, This significantly limited any Community nursing then was
older people’s community services experience a student could have as broad and complex as it is
lagged behind. now but without the support of
community mental health teams
Training in Scotland and comprehensive social care.
When I was a student nurse in On the whole, older people were
Scotland in the early 1980s, the offered support in day centres
curriculum had just been reviewed. and day hospitals but, owing to
Nurses trained on a common the lack of community support,
foundation course, similar to the admission to residential homes
much maligned Project 2000. and long-stay hospital was
The course involved all students arranged far earlier than would
initially working in older adults’ even be considered now. It is
services, with mental health noteworthy that people were
nurses working in the mental ‘coped with’ in the communities
hospital and general nurses in which they lived because of the
working in physical care. We then network they had, but there was
progressed together as one group little support available to carers.
to medical, surgical and mental
health placements in a hospital Since the National Service
setting before specialising. Once Frameworks
we specialised there was a new Over the next few years there was a
world open to us but only for a significant increase in community-
short period – working in the Revisiting Crichton Royal Hospital 2010: the based services. The National
community, health visiting and hospital kirk. Service Framework (NSF) for
23
Mental Health in 1999 prescribed presented to us and take control of patients to meet their physical,
the need for both health and what we will do. One of the most psychological and social care
social care staff to work together exciting documents for nursing in needs. Nurse consultants run and
in community mental heath the last few years is New Ways of manage clinics independently.
teams (CMHTs). This was closely Working. This is a real opportunity One of the most striking changes
followed by the NSF for Older for nurses to take on roles that for me is the recognition of
People in 2001. Unfortunately, the they are best placed to do, being diagnostic skills which nurses
NSF for Older People came with at the centre of people’s care. have always had but have never
guidance, rather than prescription Although other professions try to embraced. It is only in the last few
of what was to be provided, and maintain their ‘specialist’ skills, I years that we have been confident
little funding. By this stage many would argue that nurses are the enough to recognise we don’t
areas had functioning CMHTs and best skilled generic workers. need a doctor using information
crisis teams for people under 65 I believe that nursing is the we have collected to formulate
years of age but there was still profession people want to see a diagnosis and plan care. I have
poor provision for those over 65 being developed, as they trust always known we have been able
years. Undaunted, some older us and we can become the key to do this but it is only now we are
adult mental health services people in healthcare. The Readers recognised and, more importantly,
developed home nursing and Digest report in 2009 polled 1700 believe we can do it. This is not to
home treatment teams providing people and found that 95% of detract from the specialist skills of
extended domiciliary assessment people trust nurses ‘a great deal’ other professions but to recognise
and treatment. There was or ‘quite a lot’, whereas only 87% the skills we have.
recognition by the voluntary of respondents placed the same In essence I believe that nurses
and statutory services of the level of trust in doctors. The figure need to embrace their generic
need to work better together to was increasing for nurses but working role and are best skilled,
support older people. Other key decreasing for doctors. best placed and most trusted to
initiatives to capture this energy We are taking on roles from work on building care packages
were set up, such as the Dementia which others may shy away such around people’s needs by using
Liaison Group, a networking and as care coordinating complex the simplest of remedies.
campaigning group in Kensington cases where there is high risk and
& Chelsea and Westminster. The out-of-hours work. Nursing has Eric Craig qualified as a mental
role and scope for community already taken on skills from doctors health nurse at Crichton Royal
nursing of older people changed such as prescribing, building on Hospital, Dumfries, Scotland, in
beyond belief. our skills of monitoring effects 1983. He has held various clinical
and side-effects of medication. and management posts in mental
There are opportunities now to health.
Where will nursing go to over become approved mental health
the next 21 years? professionals. Most nurses can
The profession needs to continue and should be commissioning
to take on the challenges social care packages alongside
The essence of our care: a nursing perspective

Sue Hadden
Ward Manager, Cavendish Ward, Manchester Mental Health and Social Care Trust
In 1985 I chose to work as a Cinderella service, unsurprising discover what needs someone has
new registered mental nurse with such a derogatory label. Yet it through talking, offering physical
on a ward that had inspired was clear to me that on the ward care and observing interactions
me during my training. Senior we had the chance to truly assess and behaviour in a safe,
staff were perplexed that I all aspects of a person, observing supportive environment was the
wanted ‘psychogerries’ – an area holistic care in action rather key to successful treatment and
traditionally seen as an unpopular than in a textbook. To be able to recovery. Twenty-five years later,
24
my confidence in that principle emotional intensity of care that with new ideas. We have waiting
remains, despite innumerable was needed and how we devised lists of staff wanting to work on
changes along the way. innovative care plans to meet the ward and students requesting
What I remember fondly is the those needs. older age as a specialty. The
pride we took in maintaining Through the 1990s we had the multidisciplinary team has grown
a homely environment and a development of specialist old age vastly from the early days, offering
flexible routine that has matched services such as memory clinics wider options for specialist input
as near to a person’s lifestyle as we and trials of new drug treatments for individuals on the ward and
could. Colourful knitted blankets, for dementia. My ward grew a range of follow-up care when
chip-shop treats on a Friday and bigger and we saw early-onset someone leaves hospital.
a range of clothing for those dementia admissions and the As I have reflected on the
who had nothing were all part of increase in the care of ‘challenging evolution of our service, it has
the informality and were much behaviour’ (a term I don’t recall been heartening to realise that
appreciated. Health and Safety until then). We continued to offer the standards that mattered so
and Infection Control rules have reminiscence – but Max Bygraves much in the earliest days are still
gradually eliminated all of those was superseded by Elvis and The embedded and thriving. I hope
touches, but the aim of a calm Beatles. We recently had a lady those standards will continue to
and welcoming atmosphere is still complain that we had no Westlife be shared more widely, passing on
preserved and vital to building or Madonna records, a lesson that our positive messages to general
confidence for patients and sometimes staff have to catch up hospital teams and nursing homes.
families. with changing times! This will enable old age psychiatry
In 1989, old age psychiatry was to be fully appreciated in the
given specialist recognition and it Today wider health service – Cinderella
did begin to feel different. We still What are the differences between no longer!
had limited resources. I remember now and then? Fondness for the
the medicine trolley having just a simplicity of the early days is Sue Hadden started her career as
handful of psychiatric medicines understandable but not always a general nurse gaining her SRN
– promazine, thioridazine, accurate. High-quality care (RGN) in 1982. Quickly becoming
orphenadrine to combat side- was and remains paramount, disillusioned with the ‘conveyor
effects, a couple of tricyclics and but our care then was at times belt’ care of older people, Sue did
a large bottle of lactulose! Today paternalistic and we presumed a post-registration RMN course
our bulging trolley contains so compliance. Today we work much and qualified in 1984. Her first post
many more options, with slow- more collaboratively, taking time was on the ward where she still
release or patch options that to reflect on plans and ensuring works, although it has expanded
would have been unimaginable the patient and their family remain and moved location twice.
then. But in each comparison I central to and part of all decision- Cavendish Ward is now a 24-bed
also see similarities. The careful making. We stress the importance acute assessment ward for older
teaching to student nurses about of active listening and careful adults and Sue has been the ward
vigilant observation of effects and assessment. Noticing subtle manager since 1985. Her current
side-effects remains the same changes in mood or behaviour role is barely recognisable from the
however extensive the range of is a skill often undervalued, but early years, but despite the politics
prescriptions. Also, the advance crucial to getting a clear diagnosis and paperwork, she is proud to lead
in physical treatment options or amending a treatment plan. the nursing team as they continue
encourages ongoing learning for These qualities are timeless; staff to find innovative ways to improve
staff, so we can continue to nurse still need the same understanding care.
people with a range of physical and confidence to share their
health needs. observations as they did 21 years
I remember the first couple of ago.
people I nursed with Lewy body The days of three staff per shift
dementia, although it didn’t have have happily gone – our staffing
a name in the early days. We saw levels are matched to daily need.
a collection of symptoms and Safety and quality issues are
distressing behaviour patterns embedded in treatment and
in these people that were clearly documentation, and there is more
connected. Staff still recall the opportunity to question or lead
25
And what about occupational therapy?

Maggie Lee
Occupational Therapist, Central and North West London NHS Foundation Trust
A long-stay unit in the 1980s occupational therapists in older clearly demonstrates our efficacy
My first ever role as an occupational adults’ mental health and the lack and cost-effectiveness. National
therapy assistant was in a long- of therapists apparently wanting Institute for Health and Clinical
stay unit. It was well staffed, with to work with the elderly. A lecturer Excellence guidelines in 2008
three members of the occupational on a recent course stated that if you called for our services,3 and we
therapy team, psychologists, wanted a career as an occupational must deliver.
music therapists, speech therapist in the 1980s, you didn’t
therapists, physiotherapists, work with older people. For the
first 10 years of my career I was Core beliefs: lost and found
volunteer coordinator, police
cadets on placement from often the only candidate applying I believe occupational therapists
Hendon, as well as doctors and for the post. Although thrilled to in mental health lost their way
nurses. It set a standard I have yet have no competition at interview, around the 1990s, with many
to see replicated. It was before the apparent general lack of wanting to be involved in talking
person-centred care but we knew interest was disappointing as I therapy rather than in ‘doing’. This
everyone’s life stories, individual strongly believed we had much to trend has shifted as we rediscover
preferences and what engaged offer this client group. our roots and better value and
them. It was before social inclusion Occupational therapists believe articulate our role. We deal with
but we had access to a wealth of that occupation, ‘doing, being, all those taken for granted aspects
opportunities around London. becoming,’1 is fundamental to of daily life – self-care, meaningful
One abiding memory is a man health and well-being. What we do routines, leisure pursuits; there is
who could no longer verbally influences how we feel, how others more to focus on in a person than
communicate holding up his perceive us and how we perceive just their ability to take medication
hands and gasping in awe at an ourselves and the possibilities or dress themselves and our
original Renoir painting during open to us. The environment has services should acknowledge this.
a visit to an exhibition. Infection a major impact on this – both in So what helped this return
Control would probably now terms of physical resources and to occupational therapy’s core
frown upon the guinea pigs and social support or constraints. beliefs? Models of practice have
cats we kept and I doubt the Irrespective of the medical developed significantly since the
weekly pub session would now be condition, the occupational 1980s, providing an evidence base
allowed, but we reasoned these therapist’s role is to help people for assessment and intervention,
things were part of people’s lives engage in those activities which offering a more client-centred
and that residents should have are meaningful and important to approach than the old Activities
access to them. It wasn’t perfect them and to build confidence and of Daily Living (ADL) tick-box
(the toileting regimes were rigid skills or change the environment lists, and looking not just at what
and the hairdresser only seemed to enable this. Mental health someone can or can’t do but what
to have one style) but it was services for older adults is a supports or inhibits them from
enough to inspire me to want to perfect environment in which to doing so.
train as an occupational therapist put this into practice and our dual Therapists have benefited from
and was what I expected other training makes us able to address developments such as the person-
places to be like when I qualified. both physical and mental health centred approach and validation
(They weren’t!) needs. What is sad is that so often therapy, which released us from
referrals acknowledge only a uncomfortable reality-orientation
small part of our skills – a bath- methods, instilled hope that we
Occupational therapy and board, a tea-making assessment, could make a difference, and
older adults with mental ‘boredom’. Occupational thera- allowed us to see the person
health issues pists need to market themselves behind the dementia and the
One of the things that initially better and make others aware of impact of our own behaviour on an
struck me was the lack of the evidence available,2 which individual’s well-being. Although
26
cognitive stimulation therapy has therapists’. There was a feeling that with dementia and their care givers:
reintroduced an aspect of reality resources for older adults’ services cost effectiveness study. BMJ 2008;
336: 134–8.
orientation, it feels far gentler than were limited in comparison with
3 National Institute for Health and
the old methods and is a small other services, with one person Clinical Excellence. Occupational
part of the overall programme. commenting they felt ‘like a Therapy Interventions and Physical
It grieves me that I still see large Cinderella service with no prince in Activity Interventions to Promote the
groups being run as the norm. It sight’. One person asked for ‘more Mental Wellbeing of Older People in
Primary Care and Residential Care. NICE,
was once said that lots of people respect from colleagues who
2008.
sitting together doing the same work in other fields – they do not
4 Lee M. Job satisfaction in occupational
activity does not mean that it appreciate what skills are required therapists working in mental
is therapeutic. One size does to work with older people with health services for older people – a
not fit all and services require mental health needs’. Olshanksky5 comparative study. MSc in Ageing
adequate staffing and training to described ‘stigma by association’ and Mental Health, University College
London, 2002.
allow clients to receive needs-led in which not only family but
5 Olshansky S. Stigma: its meaning and
interventions, not crowd control. therapists associated with
some of its problems for vocational
stigmatised members of society rehabilitation agencies. Rehabil Lit
What the patient wants themselves become victims of 1965; 26: 71–4.
Another challenge now is that we prejudice and devalued simply
are involved much earlier with because of their interactions with
people with dementia, particularly that person. Could this apply to
through memory clinics. Tele-care our services?
has been a major development,
although each borough appears Challenges for the future
to provide this differently. It is Challenging times are upon us.
interesting that, although I often Payment by results looms and
get the ‘Are they safe with the gas although I strongly believe that
cooker?’ referrals, when I visit the occupational therapists can
individual, the cooker is not their demonstrate outcomes, I hope
priority – they want to know how we are afforded the time and
to put their affairs in order, how opportunity to do so. Occupa-
to tell their friends and how to tional therapy interventions
remain engaged in activities that generally take longer because
are important to them. Do our they involve the client actually
services adequately address this? doing something not just talking
Where our services sit has been about it – those developing the
much debated over the years systems recording ‘face-to-face’
– with psychiatry or care of the interventions need to understand
elderly? I have experienced both and respect this.
and have sometimes felt a poor Overall, although challenging,
relation either way. I found myself working with this client group
with three mantras – ‘And older has been enormously satisfying
adults!’ with psychiatry colleagues, and rewarding. There are
‘And mental health!’ with care opportunities for occupational
of the elderly, ‘And occupational therapists to make a significant
therapy!’ with everybody. contribution to services but we
A survey of occupational need to promote ourselves. There
therapists working in mental is some mileage yet in the mantra
health services for older adults4 ‘And occupational therapy!’
indicated good job satisfaction.
Several comments had resonance. References
Some referred to enjoying the
challenge of ‘working with a 1 Wilcock AA. Reflections on doing, being
and becoming. Austr Occupation Ther J
marginalised group’, whereas 1999; 46: 1–11.
others felt that older people 2 Graff MJL, Adang EMM, Vernooij-
were ‘not viewed in a positive Dassen MJM, et al. Community
light even by other occupational occupational therapy for older patients
27
A social worker’s perspective

Mary Marshall
Professor Emeritus, University of Stirling
As a lecturer in social work in the could not produce any evidence. In the future I would like to see
1970s, I learned about working Evidence remains an issue with old age psychiatrists working with
with people with dementia and old age psychiatrists drilled in only others to ensure that a range of
their families from David Jolley believing randomised controlled interventions, not least those that
and his colleague, social worker trials (RCTs) and us social scientists are as effective as cholinesterase
Pat Smith, when I placed students trying to take account of a range inhibitors (so far activities and
in their unit. They were by no of interacting factors which are psychosocial interventions with
means typical in their approach not appropriate for RCTs. Our kind carers have the RCT evidence
of seeing the world from the of research accumulates to give a behind them), being available to
point of view of the person with sense of direction. all people with dementia. I am
dementia. Generally, dementia It is very hard to generalise about concerned at the preoccupation
was seen as a hopeless condition old age psychiatrists since you are with medication rather than the
and the only help offered was such a varied bunch. I do detect full range of interventions. I know
support for relatives. Tom Arie a most welcome trend (on the there are increasing numbers
provided a shaft of light with basis of very little evidence!) that of active and energetic social
his energetic insistence on you are increasingly interested in scientists, as well as social workers,
teamwork. Six months as a social the way services are delivered. At with a passion for dementia, who
worker in Victoria, Australia, in your international conference in will make strong partners in both
1982 convinced me of the value Newcastle I was one of the only care and research. An emerging
of the social model of dementia non-scientific speakers, whereas concern for rights and ethics is
care; they were developing small at your conference in Leeds in linking us increasingly closely. I
housing units and community 2010 there were a great many also think that we will be hearing
day-care centres in contrast to papers on how best to provide a more of the voices of people
their medical model which was service to people with dementia with dementia, which will help
deeply pessimistic, like ours at the in a whole range of settings, us all to remain outraged at the
time. including the acute sector. poor standards that are so often
I was subsequently able to This does not mean that I think tolerated.
maintain my interest in dementia you should not take medical
as the director, first of Age science very seriously indeed. It
Concern Scotland and then the means that you are beginning
Dementia Services Development to be seriously interested in
Centre at the University of Stirling. the interaction of people with
I also helped to edit the British dementia and their social and built
Association of Social Workers’ environment, which potentially
book on working with people causes a great deal of extra and
with dementia, which helped unnecessary disability. What I
me to see a social model of hope is happening is an increasing
intervention more clearly. As a respect for the social model of
social worker, you are interested in care. Psychiatrists do not have
the interaction of the person with to be experts in it; you have your
the impairments, with a range of own area of expertise, but you do
factors including personal history, need to accord a proper regard for
health, social circumstances and those of us who do know about
the built environment. I was it. I see the medical model and
especially interested in the impact the social model as two equally
of the last of these and I vividly relevant ways of approaching
recall being ridiculed at an old dementia and they need to stand
age psychiatry meeting because I side by side.
28
To age or not to age: that is the conundrum

Marie-Clare Mendham
Consultant Psychologist, Head of Older Adult Psychology, Central and North West London
NHS Foundation Trust
To age or not to age is not so much minds – we are all perpetually 22 disproportionately low referral
a question these days as a rite of in our mind’s eye. Have advances rates.
passage. Although medicine has in psychological knowledge
allowed us to live longer, are we all managed to counter, in any way, So where are we 10 years on?
living psychologically healthier? the most personal and general of There has been some progress:
For many years, clinicians treat- fears? the emergence of the older adult
ed geriatric mental health (as it psychologist, understanding
was) with cavalier condescension, The 1970s until 2000 psychological theories of
regarding anyone over 50 as ‘past If we look back to the early 1970s, ageing, providing psychological
it and no longer a valuable mem- psychologists’ work with older treatment, and a plethora of
ber of society worthy of treatment. people was almost totally confin- research. We are able to move
Himself a sprightly 49, Freud con- ed to assessment, in particular on from assessment, sifting the
sidered that ‘Near or above the neuropsychological assessment, stream of evidence pertaining
age of 50 the elasticity of mental with the sole aim of assisting the to change, including rich data
process, on which the treatment old age psychiatrist with diagnosis. fields from interventions such as
depends is, as a rule, lacking – old Little intervention and even cognitive–behavioural therapy,
people are no longer educable’.1 less involvement with the wider cognitive analytical therapy,
Such therapeutic nihilism has population and organisations was interpersonal therapy, systemic
had a profoundly negative effect forthcoming. By the late 1970s therapy, and even Freud has got
on psychotherapy/psychological we saw an increasing interest in in on the act with psychodynamic
theory and mental health serv- intervention models but with little therapy proving it has its place.
ices, a corrosively dismissive view thought or funding given to their All these interventions and more
that has seeped into wider soci- application, although there was have advanced our understanding
ety. How many times do we hear a slow emergence of specialty for people with functional as well
our clients mutter the mantra ‘I psychologists. as organic disorders. We in older
am too old to change’? How of- The 1980s saw the development adult psychology have become
ten do colleagues in adult mental of a bespoke, specific component quite good at understanding the
health services suggest that all we in the training related to older true meaning of biopsychosocial.
do is ‘have a chat with a sweet old adults. In 1980, a proactive and However, poor referral rates
dear’? In Western society we are passionate group of psychologists persist and discrimination and
increasingly attuned to combat- formed the UK-wide Psychologists abandonment permeate the
ing sexism and racism; however, Specialist Interest Group in the mindset of both professionals and
ageism has lagged in their wake, Elderly (PSIGE), which was later to society as a whole.
as a youth-obsessed culture tries become a Faculty of the Division The development of IAPT
to forget that we will (almost) all of Clinical Psychology of the British (Improving Access to Psychologi-
be old one day. In this respect, it Psychological Society. Its regional cal Therapies) brings along as its
is older people who are by far the groups have been an important handmaiden another question, ‘to
most discriminated against group, influence in developing, teaching, merge or not to merge’. Access is
not to mention older people and research and practice in this a pertinent subject for inquiry, for
mental health – two taboos that hitherto neglected area. data suggest that older adults are
we would rather just ignore. Murphy2 surveyed the not accessing these services as
Although the media is bringing prevalence of availability of they are not seen as age-friendly
this very fact into our conscious psychological therapy services and have a focus on getting
awareness, there is a tendency for older people in the UK; 87% people back to work. Are we only
to avoid that which provokes felt that their services failed to valuable to society if we work?
anxiety for us all, namely, getting deliver to older people, with low However, once you allow people
old and potentially ‘losing’ our expectations of treatment and to self-refer, then providers see
29
an increase in access; so who is it a weapon against specialist special attention, for as Michel
that is currently blocking access services, services we have fought de Montaigne once noted: ‘Age
and perpetuating discrimination? hard to develop. Although all imprints more wrinkles in the
General practitioners perhaps? are regarded as equal, some are mind than it does on the face.’
Is there a widely held view that far more equal than others, with
being forgetful and grumpy really Western society turning a deaf ear References
are a natural part of ageing, as to its rapidly ageing population. 1 Freud S. On psychotherapy (1905) In
opposed to being a treatable We have not moved on far enough The Standard Edition of the Complete
Psychological Works of Sigmund Freud,
mental illness? Sadly, I suspect yet to merge; we must champion
Vol VII (trans and ed J Strachey).
that this is frequently the case. the rights of the older adult with Hogarth Press, 1953–1974.
There is also strong pressure their distinct requirements, rather 2 Murphy S. Provision of psychotherapy
to dissolve older adult services, than allow them to become a services for older people. Psychiatr Bull
incorporating them within ‘adult’ bolt-on to generalised services 2000; 24: 181–4.
services. Anti-discrimination whose needs and priorities are so
legislation is being used as very different. Older adults need
Now I am 71 and you are 21

Norma Raynes
Executive Director, Intergen Community Interest Company
When I wrote this I was in institutional care. Some of the of research-based practice and
Hamburg at a symposium institutions were designed for improved care.
organised by the Koerber older people, some for people I hope now that you are part
Foundation on initiatives in old with intellectual difficulties, some of the solution and the service,
age. What could you have learnt for deprived children and some for that if I were to go back to that
dear psychogeriatricians if you children with physical disabilities. institution where my 82-year-old
had been there? Many things I They had, as we all now know, lived, I would not discover the
think, not least about the layers, many things in common. If I were distortions of research findings
the resilience and the learning to go back to the home where and poor practice which the
that comes with age. I met the 82-year-old lady who Department of Health paid me to
But you know about these things, described her day to me, what see.
I hope, for I think that you have would I find? I know that little love is lost
been learning something too in The Department of Health asked between psychiatrists and
the past 21 years, and sharing your me to revisit, after a period of years psychologists, but perhaps unlike
knowledge with non-medical as and a lot of research, a hospital your colleagues with other clinical
well as other medical colleagues. for people with intellectual populations to serve, you have
I remember when you did difficulties. What happened? Did learnt the value of partnership
not exist and I could write the I find nothing had changed? No, and respect. For if the old people
following small story told to me by it was worse than that. Research, you treat will have taught you
a woman aged 82 in a residential which had underpinned new anything, it must be both respect
care home. I asked her to describe developments at policy level, for others and the need to do
her day for me. had been transformed at ward things together such as cognitive–
‘I get up, I get dressed, I get breakfast, I level to fit the new system and behavioural therapy and drugs,
get up and I sit. I get up and I go to the the value that was placed on intergenerational activities and
toilet and I come back to the day room personalised care in the form laughter therapy, gardening and
and I sit. I get up and eat lunch and I
come back and I sit. I get up and I go to
of own clothing and places to walking, and running and jumping
the toilet and I come back. I sit, and I sit. put it in such a way that new and standing still.
I get up and eat supper and I come back deprivations, humiliations and Happy birthday all of you,
and I sit. I get up and go the toilet. I go depersonalisations for the and may there be many happy
to bed.’ residents were now visibly in place. returns.
I’ve spent 30 years of my Meanwhile, the clothing and the
life undertaking research into new lockers shone as beacons
30
From the Academic Old Age Psychiatry

Perspective
Research and me
Klaus Bergmann
Retired Consultant, Bethlem Royal and Maudsley hospitals
Unlike many other people who from them and who socialised also established the sampling
have entered the old age field energetically in a variety of base in Newcastle upon Tyne,
with the intention of looking after settings. This aroused my interest with stratifications across the
and caring for people in later life, in looking at old age as a coping social spectrum in order to obtain
my entry took a different route. period successfully undertaken a representative sample.
After the period during which by the majority of people in the During my time in Newcastle,
I was a psychiatric registrar I absence of disabling ill health or Bernard Tomlinson and Garry
felt the need to obtain some psychiatric disturbance. Blessed produced standardised
research experience to broaden My interest in the care of the assessments of memory and
my education and improve my elderly was aroused and my behaviour and quantifiable
prospects of a good consultant awareness of what they could neurological measures such as the
post. achieve made the understanding mean plaque count and volumes
In the mid-1960s I had two of physical and psychiatric of infarction, and demonstrated
and a half children and could disorder seem both important significant correlations between
not wait around for some ideal and therapeutically optimistic. such measures and the clinical
opportunity. However, Martin Coming from a psychodynami- picture.
Roth in Newcastle upon Tyne cally oriented department under
had advertised a post offering Erwin Stengel, I looked to see
research experience, carrying out what was known about neurotic Other research in the 1960s
a survey of the psychiatric, medical disorder in the elderly. I found Further away from Newcastle, the
and social needs of the elderly little to help me understand clinical research published by Felix
living in their own homes. The either the prognosis of long- Post at the Bethlem Royal and
sample population had already standing neurotic disorders in Maudsley hospitals shed light on
been developed and had yielded later life (where do the flies go in many clinical aspects of paranoid
epidemiological data under the wintertime?) or about the advent disorders and depressions. Sam
supervision of David Kay. of emotional problems in old age. Robinson at the Crichton Royal
Like many doctors brought up The focus of my own research Hospital published many clinical
in the ambience of the teaching went in that direction. papers and descriptions of the
hospitals I had been imbued My interest in other old age organisation of care. In Edinburgh,
with a fairly negative view of research was also aroused Jimmy Williamson carried out a
elderly patients suffering from from my contacts in Newcastle. general practice-based survey
generalised decrepitude and Martin Roth had in many ways of the physical, psychiatric and
being labelled as ‘bed blockers’. established clear and reliable social problems of the elderly. In
My contact with the community diagnostic criteria and in my Chichester, Peter Sainsbury and
resident elderly yielded by view could be regarded as the his fellow workers investigated
random sampling came as a great Kraepelin of the old age field. His the comparison between
surprise and I realised I had a lot to definitions were employed in the hospital- and community-based
learn. The picture I obtained of the majority of early epidemiological programmes of care for the
majority of my respondents was of studies. David Kay had produced elderly, taking particular note of
energetic, busy, motivated people a number of publications based the problems and wishes of their
who help their younger relatives on his Scandinavian work on a carers. In Essex, Nick Corsellis
more often than receiving aid longitudinal hospital sample. He collected a large sample of brains
31
from elderly patients and assessed the old age field. The diagnostic The development of brain
the relationship between the differentiation of various psychia- imaging, of biological and
extent of brain damage and the tric conditions in later life has biochemical research has
severity of cognitive impairment. led to a more therapeutically attracted many gifted and talented
optimistic view of the care of scientists into the area of old age
The value of research older people. Developments in research. This gives us some hope
I have often been asked ‘Has the field of epidemiology and for the development of rational
research in old age psychiatry the introduction of standardised treatment for the dementias.
been worthwhile?’The suggestion computer-compatible diagnostic Our knowledge is certainly not
behind this question appeared questionnaires by John Copeland sufficiently advanced to relegate
to be that the organisation of and his co-workers have allowed the priority of research in this
services and development of care cross-national comparisons of the field.
should be the major concern of prevalence of psychiatric disorders
old age psychiatry and indeed to take place. The planning Klaus Bergmann, consultant old
much worthwhile work has been of services has also benefited age psychiatrist, Brighton, then
published covering these topics. from being able to estimate the Newcastle upon Tyne, then the
My answer has always been a size of the problem and to give Bethlem Royal and Maudsley
strong affirmative to clinical prognostic information to service hospitals.
and experimental research in planners.
Of pioneers and progress, but prognosis guarded

Robin Jacoby
Professor Emeritus of Old Age Psychiatry, University of Oxford
At the Maudsley your hands he was relaxed and There is no doubt that budgetary
My formal training in old age kind. I found this no problem, and restraints have worsened services
psychiatry consisted of 6 months he soon emerged from his rather that reached a peak of high
as Felix Post’s registrar. Other than prickly cocoon as a kind and quality in the mid- to late 1990s,
that it was learning on the job. humorous albeit reserved person. although my perspective has not
I never dreamt of going into this He was not rigidly medical, but he been exclusively service-oriented,
specialty but it happened thus. I had read Jaspers and understood but also research-focused. In an
had spent 18 months as a trainee the difference between causal and ideal world, of course, all clinicians
at the Maudsley before which I had meaningful connections. should be engaged in research,
been a medical registrar. I was a At the Maudsley, old age but that is not going to happen.
little disillusioned with psychiatry psychiatry was almost exclusively So inevitably the two streams are
and thinking of going back into an in-patient and out-patient more or less separate.
general medicine. Given the affair then. After Klaus Bergmann
nature of the career pyramid at the was appointed when Felix retired, Research
time, I believed that I had no hope and later I myself joined him, the Before I became a psychiatrist
of getting back into mainstream number of our own home visits there were two major players
medicine but only geriatrics. So increased. Of course, this was also a undertaking essentially clinical
I thought that I had better do 6 time (the 1980s) when community research in the UK: Felix Post and
months of psychogeriatrics as it psychiatric nurses were appearing Martin Roth. The great change in
was then called. I was assigned in greater numbers. By the time my lifetime was the proliferation
to Felix Post and never looked at I moved to Oxford in 1994, the of their heirs. In the north in New-
general medicine again. service there had become highly castle, Martin Roth, Gary Blessed
Felix had a reputation of ferocity community-based with no out- and Klaus Bergmann, starting
towards registrars, but this was patient clinics but only home from Roth’s epidemiological
only because he was anxious visits. Since my retirement and work in Chichester, produced
about the care of his patients. extreme cost-cutting, out-patient landmark studies in the
Once he felt they were safe in clinics have returned. community and equally important
32
neuropathological investigations while making major contributions some outstanding local services,
with Bernard Tomlinson. In the himself, was especially good at possibly beyond repair. In this
south at the Maudsley, Felix Post encouraging younger talent. It can short piece I have not mentioned
had published clinical descriptive be invidious to mention names, the great service innovators of
studies that still form the basis of but I have to point out that Simon the 1970s and 1980s such as Tom
our understanding of affective Lovestone and Rob Howard, two Arie and David Jolley because I am
and schizophrenia-like disorders current major players in our field, sure that they will be given due
in old age. Into this north/south were both Raymond’s protégés. credit elsewhere in this collection.
mix we must add the biochemical However, considering the dire
discoveries of cholinergic deficits The future state of service deterioration,
in dementia by David Bowen I am confident about the future if they were dead, which thank
in London and Elaine Perry in of research in old age psychiatry goodness they are not (!), they
Newcastle. Not only were these because the dementia tide will would be spinning with distress in
vital discoveries in themselves, sweep it along, and I predict their graves.
but almost more importantly they disease-modifying treatments for
made dementia a sexy subject Alzheimer’s disease within the next From 1984 to 1994, Professor Jacoby
for young scientists, which has 25 years. I am much less confident was a consultant at the Bethlem
completely transformed our about the state of clinical services. Royal and Maudsley hospitals,
specialty. The drive in Western countries latterly exclusively an old age
My own research career was to cut costs has already caused psychiatrist.
nurtured by Raymond Levy who, serious damage to many good and
An old age psychiatrist at work and play:

a research perspective
Raymond Levy
Emeritus Professor of Old Age Psychiatry, Institute of Psychiatry, University of London
I was born in Cairo and went to PhD in neurophysiology before geriatric unit, which was then at
school at Victoria College, where embarking on psychiatric training the Bethlem Royal Hospital. This
I was a close contemporary of at the Maudsley in 1961. Starting set the seal on my future career.
Omar Sharif, with whom I acted at the same time was Loic Hemsi,
in Le Malade Imaginaire. From who had been at school with me Early research
Cairo, I went to study medicine in and was a neighbour in a hospital I immediately applied my
Edinburgh – a cultural and climatic house opposite the Bethlem, neurophysiological expertise to
shock from which I took long to Philip Graham, Trevor Silverstone the study of peripheral nerve
recover. In psychiatry, Professor and John Brothwood, who later conduction velocity in Alzheimer’s
Henderson had been replaced by made a mark at the Department disease as a possible marker for
the charismatic and flamboyant of Health and Social Security. the condition. This became the
Alexander Kennedy, who regaled I soon fell under the influence subject of my dissertation for
us with large public sessions of of Sir Aubrey Lewis and Felix Post, the Maudsley DPM (Diploma in
hypnosis, which led many from both of whom had fearsome Psychological Medicine). I found
my year to become interested in reputations but whom I found to some changes but not sufficient
psychiatry. be delightful and civilised men, to act as a diagnostic marker.
I exercised my hypnotic skills who appreciated students who After a period as senior registrar
in carrying out the 12 normal stood their ground in discussion to Michael Shepherd, I moved to
deliveries we had to complete as and refused to be intimidated. the Middlesex Hospital Medical
undergraduates. After graduation My first post was in Felix Post’s School as a senior lecturer. While
and house jobs in neurology general psychiatry unit and I so there, I established a liaison with
and neurosurgery, I completed much appreciated his teaching John Wedgwood in the geriatric
an MRCP in neurology and a that I asked to be attached to his unit and Michael Kremer in
33
neurology and continued my and in Alzheimer’s disease and joined by Clive Holmes and
neurophysiological work on affective disorders in the elderly. Declan McLaughlan. These were
cortical-evoked potentials in the I was also fortunate to have the marvellous years when we all
dementias and affective disorders help of the late Mohsen Naguib in seemed to laugh all the time and
in old age, and also on conversion studies of imaging and cognitive vicious practical jokes were the
symptoms in younger individuals. function in late-onset psychosis, order of the day.
I also became acquainted with now termed ‘very late-onset On the clinical side, Michael
the work of John Gedye, who schizophrenia’. We demonstrated Philpot and I set up the first
was attempting to develop that this was seldom a harbinger memory clinic in a psychiatric
computerised psychological of dementia. setting. Later, when Klaus
tests for elderly patients. This was In 1984 the Institute of Bergmann took over from Felix
something I later used to test the Psychiatry established a chair Post, we had a long struggle to
possible effects of cyclandelate in old age psychiatry and I move the in-patient unit from the
in a collaborative study with Felix applied successfully for this. I Bethlem to the Maudsley (i.e. in the
Post. did not, however, take up my locality where the patients lived)
In addition, with Vic Meyer, we appointment until I was able to and to set up day hospital and
introduced behaviour therapy negotiate an allocation of suitable community facilities. At various
for the treatment of obsessional space, something which was then stages both before and after
disorders. This was received with at a premium, and the minimal Felix’s retirement we were joined
great scepticism as obsessions support of two lecturers. In the for varying periods of time by
were considered as defences meantime, Elaine Murphy was Ken Shulman from Toronto, John
against psychosis. I have never appointed to a new chair at Guy’s, Breitner from Duke University,
had so much difficulty in getting so although my chair was the first David Ames from Melbourne,
a paper published than one in the subject, Elaine was in fact Engin Ekker and Turan Ertan from
describing the treatment in a the first professor. Istanbul, and Andrea Spano from
few early cases. A version of this I started with the help of Michael Modena.
treatment became a standard Philpot and Barbara Sahakian as Following the termination of my
procedure when later written up lectuters and as funds became period as secretary and then presi-
by Isaac Marks and Jack Rachman. available I was able to recruit a dent of the Geriatric Section of the
cohort of bright young men and World Psychiatric Association, I be-
Consultant and research at women who included Alistair came president of the Internation-
the Maudsley Burns, Simon Lovestone, Robert al Psychogeriatric Association and
Howard, Melanie Abas, Barbara developed extensive international
In 1971, I returned to the Maudsley
Beats, Sarah Eagger, John O’Brien, collaboration.
as a consultant in old age and
Adrian Owen, Osvaldo Almeida Funding became easier but
general psychiatry and a colleague
and Hans Förstl. We were later clinical and academic work
of Felix Post. As there were then
no academic posts in old age
psychiatry, I tried to combine my
research activities with my clinical
duties. This was not easy as funds
for research in this field were very
limited. However, with Elaine
Hendrickson I was able to show
that in late-onset depression there
were cerebral changes similar to
but less severe than in Alzheimer’s
disease and that these changes
were not reversed after clinical
recovery.
When I was able to raise funds
for the Maudsley to get one of
the first computed tomography
scanners, Robin Jacoby joined
me to carry out the first imaging From left to right: Professor Raymond Levy, Professor Robin Jacoby, Dr Aykan Pulular and
studies in healthy old people Professor Ken Shulman, April 2008.
34
became more bureaucratic and I BMJ over the future of biological Until this is done, the UK will
retired in 1996. I had by this time treatment of Alzheimer’s disease. increasingly lose its previous pre-
attracted a respectable cadre of eminence in the field and see it
clinicians and research workers increasingly dominated by other
and established links with Reflections European countries, by the USA,
neuroscience, neuropatholgy, Looking back, I cannot help Canada and Australia.
neuropsychology and epide- but be greatly satisfied by the Since my retirement, I have
miology and set up a number establisnment of our subject stopped working in the field
of clinical trials in dementia and as one of the major specialties and, with the exception of an
depression. Unfortunately, we of psychiatry but somewhat invited contribution to the 25th
were not taken very seriously by disappointed by the failure to Anniversary of the International
the predecessors of the Faculty establish a major academic Psychogeriatric Association in
of Old Age Psychiatry or by the base in more than a few centres. Osaka, I have not presented any
Royal College of Psychiatrists Although funding has become papers.
itself. Understandably, but I think more generous, it has become This has allowed me to
wrongly, preoccupation lay almost more difficult to attract new talent. concentrate on tennis and scuba-
entirely with the development of In order to do this we will have to diving, on polishing my Italian
unevaluated new services. David get young people early, preferably and on trying to write a book on
Jolley, half jokingly, told me that as medical students, and to make my native city of Cairo. The book
he considered research as a form it easier for them to be jointly is half written and I hope to return
of occupational therapy. Tom trained in old age psychiatry and to Cairo this winter to complete it.
Arie and I crossed swords in the in associated academic disciplines.
Perspectives of a (not so) young clinical academic

Nitin Bhalchandra Purandare
Senior Lecturer and Honorary Consultant in Old Age Psychiatry, University of Manchester
and Manchester Mental Health and Social Care Trust
I have worked in academic old Academic old age psychiatry need to develop local youths or
age psychiatry at the University today long-term succession planning.
of Manchester since 1999, initially Third, one should value and use
as a lecturer and since 2002 as a Some of the giants have retired the wisdom of senior players,
senior lecturer. When I look back and others are slowing down, even if they cannot score as many
at the past 21 years of academic while some of the younger ones goals as they used to. Sometimes
old age psychiatry, I see an era are succeeding in making their senior scholars struggle to change
of giants (whom I wouldn’t like mark. The change in the ethos with the fluid expectations of
to name in case the one I miss across universities, with even universities and this is reflected
comes after me) who developed greater emphasis on grants and in the lack of academic growth in
the research in this neglected field impact factors of journals, means some units.
against all odds, especially against that to be successful one needs Intentionally or unintentionally,
the stigma that psychiatry was not only an academic ability and we seem to be moving towards
not really a science. The academic drive but also other qualities fewer but more heavily research-
and clinical seeds were sewn such as a business mind and active departments, which may
together, not just at the Institute networking abilities, to name just limit the fertile ground for future
of Psychiatry in London but two. The universities often think, academic trainees. The annual
throughout the country, and it’s and behave, like football clubs meeting of the Academic Old Age
not surprising that both flourished but forget three things. First, one Psychiatry Association, which was
so well. However, the times and needs to focus on the whole team an opportunity for young and old
the pace of academic (and clinical) and not just the forwards who are academics to meet and reflect on
life are changing. in the limelight. Second, there is the research in old age psychiatry,
35
Should and will tomorrow’s

trainees choose the academic
path?
Of course they should and
hopefully they will. It adds variety
to a daily job, keeps you thinking
and learning, allows you to
travel and meet researchers from
different disciplines and countries,
and if you maintain your clinical
links you can earn the respect and
satisfaction that is worthy of the
stress of managing three bosses,
including family. It is unfortunate
that there is less opportunity to
do research for specialist trainees.
Some of the CALM-AD1 investigators. From left to right: Martin Knapp (health economist),
Tony Johnson (MRC statistician), Richard Brown (psychologist), Ed Juczszak (project
However, academic clinical
statistician), Alistair Burns, Peter Bentham, Rob Howard, Clive Holmes, Clive Ballard, Roger fellowships and National Institute
Bullock, Robin Jacoby, John O’Brien. With kind premission from Robin Jacoby’s collection. for Health Research and Medical
Research Council fellowships do
has become just a distant memory. subject rather than scientific value offer new opportunities. I hope
The academic Faculty of the Royal alone. that our inquisitiveness as human
College of Psychiatrists offered Future academics are likely to beings and the rising importance
an alternative forum but the need much supportive mentoring of old age psychiatry, in keeping
participation of old age psychiatry to ensure that the pressure to with the projected growth of
academics in annual meetings has become focused to succeed in an the older population, will ensure
so far been limited. academic career doesn’t lead to that academic old age psychiatry
Nowadays, academics spend focus on the self and losing sight continues to flourish in the right
much time chasing or at least of the primary goal to improve direction.
thinking about, and many a times clinical care of our patients
worrying about, the shrinking pot through research. Our clinical Reference
of research funds. This inefficient expertise identifies us as distinct 1 Howard RJ, Juszczak E, Ballard CG,
use of academic effort has led to from other non-medical and non- et al. Donepezil for the treatment of
a new initiative by the Wellcome clinical academics. However, the agitation in Alzheimer’s disease. N Engl
J Med 2007; 357: 1382–92.
Trust. The Trust will select boundaries are getting blurred;
academics and fund their research disease-focused groups could be a
for the next 5 years. The academic threat to us as an entity, but also an
will have a greater flexibility and opportunity to reinvent our roles.
can plan a series of projects rather Other major threats are increasing
than be at the mercy of funding pressure on National Health
bodies for individual projects. Service (NHS) budgets and cuts
However, only a few, if any, to the research and development
academic old age psychiatrists levy that leads to tussles between
are likely to benefit from such the NHS and universities over the
a scheme. The focus on impact contributions to the salaries of
factors means that psychosocial academics, and contributions of
or health service research may academics to clinical services and
get neglected if all academics are undergraduate and junior doctor
tempted to do more biological training. If this is not resolved at
(e.g. genetics) research. The shift an organisational level it could
to citation index may help but leave an individual academic in a
has a disadvantage of assessing vulnerable and awkward position
research on popularity of the with clinical colleagues.
36
International Views
Old age psychiatry Down Under
Edmond Chiu† & David Ames‡
†
Professorial Fellow of Old Age Psychiatry, University of Melbourne; ‡Professor of Ageing
and Health, and Director, National Ageing Research Institute, University of Melbourne
In celebrating 21 years of old age The initial meeting of the Special the equal of any country in the
psychiatry in the UK, it should be Interest Group was hosted by world. Our Faculty is the only part
acknowledged that the specialty Henry Brodaty at the Prince of of the RANZCP which is totally self-
in Australia has its roots in the UK Wales Hospital, Sydney, in the funded, not needing any financial
and we owe our flourishing Faculty presence of Tom Arie (photo). We support from the College coffers!
to the early influential days of UK became a Section of the RANZCP in
old age psychiatry. 1989. In 1999, the transition from The work of the specialty
The British Council courses at the Section to Faculty was approved Our international footprint is a
University of Nottingham, which by the RANZCP, to become the proud tradition of our Faculty.
commenced in 1980, with Tom second of the only two faculties Henry succeeded Nori as the
Arie as director, gave Australian within the College. chair of Alzheimer’s Disease
old age psychiatry its start when From the start the old age International. The International
there was no specific training faculty has had a most enviable, Psychogeriatric Association (IPA)
programme Down Under. The late vigorous training programme. positions of secretary (Ed and
Arthur Harrison was the first to The constant production of newly Daniel), president (Ed), board
attend, followed by Ed Chiu, John qualified old age psychiatrists has members (Ed, Henry, David, John,
Snowdon, Henry Brodaty, Manjula seen membership of the faculty Brian, Nancy Pachana, Gerard
O’Connor and Brian Draper, all swell to over 200 individuals in Byrne), editor of the IPA Bulletin
of whom became leaders in the Australia and New Zealand, while (David), and editor of International
development of both services and both countries now possess Psychogeriatrics (David and soon
the discipline in Australia. To add publicly funded, clinician-led old Nicola) have all been occupied by
to this group, David Ames had age psychiatry services, which are Australians.
his old age psychiatry training at
the Royal Free Hospital, London,
with Anthony Mann and Nori
Graham; and Daniel O’Connor
was in Cambridge with Sir Martin
Roth and Osvaldo Almeida at the
Maudsley with Raymond Levy. It
is to be noted that all the senior
academics in old age psychiatry in
Australia, with the sole exception
of Nicola Lautenschlager (who
trained with Alexander Kurz in
Munich) had their training in the
UK.
Old age psychiatry and the

RANZCP
In 1987, a core group of old age
Founding meeting of the Old Age Psychiatry Special Interest Group in Australia, 1987. From
psychiatrists met within the Royal right to left: Henry Brodaty, Sid Williams, Ute Rosenbilds, Fred Stamp, Ed Chiu, sponsoring
Australian and New Zealand pharma representative, Manjula O’Connor, Tom Arie, Arthur Harrison, Steve Rosenman
College of Psychiatrists (RANZCP). and John Snowden.
37
In addition to these contribu- and psychopharmacological What of the future?

tions, faculty members have research we are more than We will continue to be a force in
provided leadership in clinical competitive in the field. Our the development of best practice
services, policy advice to academic performance has seen in old age psychiatry and plan to
governments, advocacy on very important papers published remain proud contributors to the
behalf of our patients and in refereed journals and the field, while working to give our
carers, education to other health production of many books. patients and the community the
professionals, and regional Our relationship with the UK best quality of service and support
education and training – many Faculty of the Psychiatry of Old to add life to their years.
pioneers of old age psychiatry Age is strong, as can be seen from
in Asia have had training in the joint activities such as statements
discipline in Australia. In clinical of importance.
A view from Hong Kong

Helen Chiu
Chair and Professor, Department of Psychiatry, The Chinese University of Hong Kong
Old age psychiatry in the psychogeriatric service model. the field. The past two decades
UK has always been highly Essential components included have seen exciting developments.
influential in the development of the multidisciplinary team, full The Faculty has been actively
psychogeriatric services in other range of services from hospital involved in the formulation of
parts of the world. The UK is the to the community, collaboration policies on psychiatric services
country where psychiatry of late with other agencies, support to older people. It also emerges
life was pioneered. Since the for carers and advocacy. Apart as one of the key stakeholders in
early days of old age psychiatry, from the high quality of service, I advising the government, non-
Professor Tom Arie, Professor was very impressed by the great governmental organisations and
Raymond Levy, Professor Elaine respect for the patient’s dignity, the general public on matters
Murphy and many other renown- autonomy and choice by the pertaining to the mental health
ed British psychogeriatricians professional staff. Professor Tom of older people. These policies
have inspired overseas colleagues Arie was extremely patient and and reports not only guide
with their visions, wisdom and kind to me. I was really very lucky psychogeriatric practice in the
experience. The well known ‘Tom and privileged to have such a UK but also have implications for
Arie’s model’, which has taken charismatic and inspiring teacher old age psychiatry worldwide.
root in both Australia and Asia, and mentor. After I returned to For example, the Faculty has
is undoubtedly one of the most Hong Kong, I adapted the UK campaigned tirelessly, with
prominent examples of such an model to the local setting and people with dementia, their
impact. psychogeriatric services in Hong caregivers and other professional
Kong developed steadily in the organisations, to the National
Nottingham 1992 subsequent years. I know many Institute for Health and Clinical
On a lovely summer day in colleagues in Asia and Australia Excellence (NICE) for better access
1992, I arrived in Nottingham. have a similar story, and so the to anti-dementia drug treatments.
We had decided to establish UK model has a far-reaching Its submissions to NICE provided
psychogeriatric services in Hong effect on the development of sound evidence supporting less
Kong and I had come to England psychogeriatric services in the restricted use of anti-dementia
for a period of clinical attachment Asia Pacific region. medications and appropriate
to Professor Tom Arie’s unit. ways of monitoring, which offered
Looking back, my experiences The Faculty valuable reference to professionals
in Nottingham changed not The establishment of the Faculty by in other countries.
only my career but my life too. I the Royal College of Psychiatrists The other important channel
learned about the principles of further fosters the role of British of communication between the
a comprehensive and holistic psychogeriatricians as leaders in Faculty and psychogeriatricians
38
practising outside the UK is the development of old age psychiatry meeting in Dublin 2 years ago
regular publication of the Old Age in their countries. As Professor when I was the IPA president. The
Psychiatrist. Since its inaugural John Wattis hoped in 1995, Old cooperation between the two
issue in September 1995, Old Age Age Psychiatrist has been able to organisations has been further
Psychiatrist has proved to be a serve as a good source of help and enhanced since then. The Faculty
popular newsletter widely read inspiration for the psychogeriatric is now affiliated with the IPA. With
by colleagues from around the community. our conjoint effort and expertise, I
world. I very much enjoy reading I cannot conclude this short believe that we are able to promote
this publication. Its informative piece without mentioning the mental health of older people and
articles cover a broad array of Faculty’s collaboration with the guide the future development
topics, which range from in- International Psychogeriatric of old age psychiatry around the
depth clinical discussion to Association (IPA), the other globe.
interviews, service development premier professional organisation
and training issues. Together they dedicated to promoting geriatric Helen Chiu is a psychogeriatrician in
give overseas members a detailed mental health. As early as Hong Kong, an overseas member of
and updated account of mental April 2000, the IPA and Faculty the Faculty of the Psychiatry of Old
health services for older people in organised the first joint meeting Age, and immediate past president
the UK. Overseas colleagues also in Newcastle upon Tyne, and I of the International Psychogeriatric
make use of this avenue to inform am most delighted that the two Association.
their British counterparts of the organisations had another joint
Where will I be in 21 years?

Shirlony Morgan
Older Adult Psychiatry Specialty Trainee, St Mary’s Rotation, London Deanery
As a higher specialist trainee, I am hospital located in Durban. by the College of Psychiatrists of

a relative newcomer to old age I expected that my clinical South Africa. There are differences
psychiatry. In 1989, the extent experience would be valued and in the age demographics (South
of my medical repertoire was was prepared to work with the Africa: 5% >65 years; UK: 20%
limited to administering first aid limited resources of the South >65 years) and disease profiles
at school and I was unaware of the African national health service. compared with the UK. There
transformations in the specialty. Closer to my departure date, I is definitely a need for old age
I completed my undergraduate started feeling anxious about psychiatrists in South Africa.
training in South Africa and was the specialised nature of my In Durban I worked at newly
aware of the differences that exist training and wondered how my developed memory and older
between the urban and rural areas new colleagues would view my adult specialist clinics. However,
across the country and between skills as an old age psychiatrist. working with the Red Cross
the health services in South Africa I am usually immune to feelings highlighted the need for these
and in the UK. Until quite recently of self-doubt but I couldn’t help services to extend to rural
I did not appreciate what it would recalling a medical school friend communities as well. Twice a
have been like to work with elderly once remarking that my choice of week I flew to district hospitals as
psychiatric patients in a health specialty would be less beneficial if part of the psychiatric outreach
service that does not specifically I intended to work in South Africa programme. Historically, these
address their needs. That changed again. Fortunately, my colleague communities comprise the very
after I spent 6 months working in was wrong and my anxieties were young and old, with working-age
Kwa-Zulu Natal, a province on the unfounded. adults migrating to the cities. I was
east coast of South Africa. Most surprised, not by the number of
of my time was divided between older adults I was asked to review,
working as a ‘flying doctor’with the Old age psychiatry in South but rather by the number of non-
Air Mercy Service (South African Africa HIV dementia cases I diagnosed.
Red Cross) and working at King Our discipline has only recently As a medical student, I often
George V, a psychiatric teaching been recognised as a specialty included dementia as a differential,
39
Africa and the UK are due to

many factors, including resource
availability, the AIDS epidemic,
the previous political regime
and geographical challenges.
Currently, there are consultations
to model the South African
health service on a national
insurance scheme, similar to the
UK National Health Service (NHS).
With an increase in spending,
introduction of older adult clinical
High-flying old age psychiatrist: community clinics South African style. posts and publication of research
there should be further pressure
to improve old age psychiatric
but I had seldom seen a patient neurologist, psychologists and services. The next few years are
diagnosed with it. The increase of occupational therapists. However, expected to be challenging as the
dementia has been anecdotally this is a diagnostic-only service. health service evolves, and for an
observed by local doctors and Cholinesterase inhibitors are old age psychiatrist it will be an
has driven a number of research unavailable in state hospitals and interesting period.
studies as well as the introduction there is no national agenda for old During my 6 months in South
of specialist services at larger age psychiatry. Africa, I tried not to focus on the
teaching centres. Prevalence In the past 17 years, since the difficulties of working without
data collection is underway and end of apartheid, a number of the benefits of NHS resources
I worked on an epidemiological changes in healthcare provi- and instead thought of ways to
study that sampled a population sion have been implemented, improve the existing service. I am
based in Durban and validated including mental health policy sure that the success of UK services
cognitive assessment tools. Less guidelines, mental health legisla- is in part due to the clinicians, past
is known about dementia in the tion and decentralisation of serv- and present, who championed
rural communities and future ices. These initiatives have been their patients’ needs and produced
studies will pose a number of patient-centred and have positive- quality research. In the future,
scientific and logistic challenges ly transformed psychiatric servic- I would like the opportunity to
for researchers. es. The collaboration between the work in South Africa as an old age
The memory clinic in Durban Department of Health and the Red psychiatrist and contribute my
is an important first step but it Cross to deliver outreach services experience and enthusiasm to the
has to serve an area the size of to patients who were previously field as it develops there.
Portugal, with a population of unable to access specialist care is
9.9 million. Up to five patients a testament of this success.
a month are assessed jointly The differences between
by geriatricians, psychiatrists, a healthcare provision in South
Reflections from Canada

Kenneth I. Shulman
Professor, Department of Psychiatry, Sunnybrook Health Sciences Centre, University
of Toronto, Canada
I spent 2 years training in London, The 1970s services, led by clinicians such
England, from 1976 to 1978, first During the mid to late 1970s, as Tom Arie, Brice Pitt and Colin
with Tom Arie at Goodmayes the psychiatry of old age was Godber. The field in the UK was
Hospital in east London and then beginning to flourish. The Group, led by charismatic and capable
with Felix Post at the Bethlem then Section, for the psychiatry pioneers who were fuelled by
Royal Hospital and the Institute of of old age was mainly focused on a collective sense of purpose
Psychiatry. the provision of innovative health and challenge to advocate for
40
a vulnerable, stigmatised and especially about the future’. I prefer needs of our patient population
underserviced population. There Peter Drucker’s famous quote: will be determined ultimately on
was a sense that we were all part ‘The best way to predict the future a local basis. Whether we persist
of a movement/cause espousing is to invent it’. So what should we with an age-based discipline or
principles and guidelines to invent? The nature of psychiatric a disease-based one is a mug’s
inform health policy. Papers on disorders in old age suggests game, as we will likely require
the principles for service delivery that an integrative approach a mixed approach in order to
emerged, with particular note with cognate disciplines such as meet the needs of old persons
of Tom Arie’s description of the geriatric medicine and cognitive with psychiatric, behavioural and
Goodmayes’ psychogeriatric neurology is the best way to cognitive disorders. Can we create
service in the late 1960s and early meet the needs of our patient a brain scientist with a social
1970s.1,2 population and to understand the conscience?
The 1970s also saw the mental disorders from which they
burgeoning of a new clinical suffer. In the UK, the focus has been References
knowledge base related to the on the collaboration between 1 Arie T. The first year of the Goodmayes
psychiatry of old age. Seminal geriatric psychiatry and geriatric psychiatric service for old people.
papers by Martin Roth3 in 1955 medicine. However, in a review of Lancet 1970; ii: 1179–82.
and Felix Post’s monographs ten psychogeriatric services in the 2 Arie T, Dunn T. A ‘do-it-yourself’
on depression4 and paranoia in UK that I conducted in the 1980s, psychiatric-geriatric joint patient unit.
the 1960s5 as well as Marshall I found little evidence of true Lancet 1973; ii: 1313–6.
Folstein’s publication of the Mini- collaboration. A notable exception 3 Roth M. The natural history of mental
disorders in old age. J Ment Sci 1955;
Mental State Examination in was the successful experiment 101: 281–301.
1975,6 all had a profound impact at the University of Nottingham
4 Post F. The Significance of Affective
on the clinical specialty. For the where Tom Arie created the Symptoms in Old Age. Oxford University
first time the psychiatry of old Department of Health Care of Press, 1962.
age was provided with a scientific the Elderly that included both 5 Post F. Persistent Persecutory States of
base which brought credibility divisions of old age psychiatry the Elderly. Pergamon Press, 1966.
to the field, encouraging young and geriatric medicine that were 6 Folstein MF, Folstein SE, McHugh PR.
academically oriented registrars collegial, complementary and ‘Mini-mental state’. A practical method
for grading the cognitive state of
to enter it. Clinical research integrative. Unfortunately, the patients for the clinician. J Psychiatric
developments were centered experiment was not sustained Res 1975; 12: 189–98.
at the Maudsley and Bethlem following Tom’s retirement.
Royal hospitals with Felix Post, My perspective on the future
Raymond Levy and Robin Jacoby, relates to the creation of an
and in Newcastle with Sir Martin umbrella organisational structure
Roth, Klaus Bergmann and Garry called ‘Brain Sciences’ or ‘Clinical
Blessed. Neurosciences’. This moniker
The appointment of Felix reflects the reality that the major
Post as the first chairman of psychiatric disorders of late life
the Group for the psychiatry have a neurobiological basis
of old age in 1973 highlighted and are intimately connected
the importance of academic with neurodegenerative and
credibility. Felix mainly focused cerebrovascular changes in
on clinical phenomenology the brain. For example, we are
and clinical research. None- increasingly aware of the troubling
theless, he supported those relationship between late-life
psychogeriatricians who were at mood disorders and dementia.
the forefront of service delivery Thus, knowledge of neurology,
innovation. neuroimaging, neuropathology
as well as geriatric medicine is
The future? critical to the understanding and
Speculation about the future management of old people with
should always arouse skepticism psychiatric disorders. Just how we
as suggested by the luminary Niels integrate the various traditional
Bohr: ‘Prediction is very difficult, medical disciplines to meet the
41
A Carer’s View of Frontotemporal

Dementia
Multi-agency and multidisciplinary cooperation:
where to in the future?
Neville Hughes
Harrow, Middlesex
I welcome the opportunity to Service (NHS) quickly. A private favourite food. All very simple but
contribute to the special issue of scan showed frontotemporal logical. And it worked. While still
the Old Age Psychiatrist, but I enter lobar degeneration. This physically fit enough, we did 15–
your academic world with some knowledge made a massive 20 min foot cycling, good exercise
trepidation. However, having difference to my understanding and good for concentration. I
looked after my wife, Nina, who and contributed significantly obtained a 6-inch babies ball with
had dementia for several years, I to my ability to cope over a noise inside it and I would throw
would like to pass on some of my subsequent years. I happened to it to Nina. By then she couldn’t
experiences and views. I hope it meet my local MP, a then junior speak but the pleasure when she
encourages you to continue your government minister. He still caught it was tremendous.
efforts for the future. remembers my vitriolic attack on Early in Nina’s dementia, I
Very briefly, Nina started his government’s policies! developed a serious health
showing unusual behaviour mid- I was very fortunate that about condition and had to be ready
2004 when we had been married this time the first Admiral Nurse to enter hospital within 2 h. It
47 years. I suspected some form was appointed in Harrow, Kate focused my thinking. Potential
of mental health problem. I had Lim. We worked very closely respite care homes were found
spent 40 years in a technical role together and I pay tribute to their and I started writing Nina’s care
in industry, solving production work. I see this service as being at needs covering everything from
problems. Nina and I had had least comparable with Macmillan food preferences to clothes to
a wide involvement in local Nurses and hope that every effort medication. I updated it regularly.
activities – mine included 8 years will be made to expand them When Nina had to enter a nursing
as an independent councillor on across the UK. home, it was suggested I had
the Social Services Committee Nina deteriorated quite quickly, time to write Nina’s life story, an
and various other health-related particularly physically. There were excellent idea mainly based on
groups. All that experience was many challenges and with support photographs. It was a great help
invaluable. from my Admiral Nurse I worked to the carers as Nina could not
Nina had an assessment and I out how to cope. Eating was communicate in any way and I
immediately challenged the result consistently a problem and I use also used it regularly. I strongly
– I had no confidence that Nina that as an example. Getting Nina’s recommend it; I should have done
was ‘depressed’. Fortunately, a maximum attention was key – no it earlier.
further assessment was made by a television, instead her favourite I have had many challenges
second doctor. I was advised that music, usually Mozart. Food quality but a major reason for writing
it appeared to be one of the less was paramount – perfect puree, this article is the reaction I have
common forms of dementia but with persuasion, persistence and had at times from the NHS and
it required a magnetic resonance patience (the four P’s of feeding). local government. It is typified by
imaging scan. A request to the One detail is perhaps interesting. the frequency that professional
local hospital was rejected – it was I filled each spoonful and then staff seem to think dementia is
not life threatening and did not gave two taps on the plate. That synonymous with Alzheimer’s
meet government targets! I was focused Nina and I found it very disease. I strongly support
learning about the National Health successful. I always started with a the idea that in every general
42
practice there should be at least approved. When Nina passed so often interwoven with nursing,
one practitioner with a specialist away some months later, it was they surely need some form of
knowledge of dementia. I fought due to the dementia, not the professional recognition.
battles over continuing-care cancer. It is totally unacceptable Throughout my caring period
funding and despite Nina being that dementia often does not get I had some tremendous support
absolutely disabled and needing the attention and support it needs and Nina’s care home was fantastic,
24-hour nursing care, she did not and deserves. It also highlights but I believe there is much more
‘meet the criteria’. Nina developed the total lack of recognition of to be done.
breast cancer, no real change the skill and value of professional,
in care needs, but it was then experienced carers. Their role is
A Word About ...

Collaborating with the Alzheimer’s Society
Nori Graham
Emeritus Consultant in Old Age Psychiatry, Royal Free Hospital, London
In 1987, as a consultant in old age people experienced in the Society and encouraging people
psychiatry (late-onset), I had set voluntary sector (which I was not), to get involved in their branches.
up a community-based service in as well as a number of dedicated Very gradually interest started to
north London that seemed to be carers, during the 7 years of my develop, with colleagues wanting
functioning well and was keen chairmanship the Society really did to get more closely connected
to consider another challenge. become much better established. on an individual basis. I always
Involvement in a research project, By 1994, with an income that had felt that, as professionals, doctors
perhaps? risen from £300 000 to £3 million can give status to an organisation,
But then the telephone rang. (now £60 million!), we were able to with the result that advocacy for
It was Christine Kirk, an old age offer support to a really significant better services is more likely to be
psychiatrist in York, asking whether number of people with dementia effective. Further, as I could testify
I would consider putting my name and their carers. This involved from my own experience, doctors
up for the position of chairman of setting up a computerised central can learn a great deal from a
the Alzheimer’s Disease Society office able to communicate different type of contact with
(as it was then called), which effectively with its branches; they carers and people with dementia
she was about to relinquish. too needed to be computerised. and this improves the clinical
Jonathan Miller, then president We had to appoint a team of service they provide. Gradually
of the Society, had suggested my staff and volunteers, prepare an too the Section was persuaded to
name. After some heart-searching authoritative list of publications, become involved with the Society.
I allowed my name to go forward a regular newsletter and training Both CEOs were invited to speak at
and was elected. I should add materials, devise a fund-raising Section meetings. An Alzheimer’s
that there had not been much of strategy, initiate parliamentary Society Lecture was established
a rush from my colleagues for this lobbying and decide on a research at the Section’s annual residential
position. This did really change plan. meeting. The Society and Section
my life. During this period, old age (then Faculty) developed a close
Those early days with the psychiatry had been recognised liaison on policy matters relating
Alzheimer’s Disease Society as a specialty by the Department to dementia.
(founded in 1979) were very of Health. Right from the
hard work. Led successively by beginning, I used to drive my
two wonderful chief executive colleagues crazy by finding Alzheimer’s Disease
officers (CEOs), Noreen Miller and every possible opportunity at International
Harry Cayton, supported by a the Section meetings to update After my term of chairman came
small team of experts in finance, everyone with the progress at the to an end in 1994 I became
43
involved in Alzheimer’s Disease part in diagnosis and support of course in every home not only
International and was chairman and the close collaboration in this country but everywhere in
from 1996 until 2002. Alzheimer’s between old age psychiatry and the world. If an equal amount of
Disease International developed the Alzheimer’s Society in our money, time and energy were put
a wide range of activities, but the country. It was clear then, and it is into information and care as we
one of which I am perhaps most still the case, that this represents have recently seen go into getting
proud was the support provided a unique collaboration between anti-dementia drugs accepted,
to Martin Prince and his 10/66 equal partners supportive to one the UK would lead the world and
network of researchers across low- another. the world would be a better place.
and middle-income countries. My In the world in which we live, most
international interest resulted in countries have no specialists in
the introduction of workshops at Future collaboration old age psychiatry and precious
our annual residential meetings Looking into the future, and few in general psychiatry; there
to discuss how the Faculty and its specifically into collaboration is certainly no money for pills. But
members could facilitate support between the voluntary sector and there are wonderful families and
overseas. the Faculty, I should like to see joint carers who, if given information,
During my travels there campaigns on particular issues. understanding and support, can
was always great interest in Everyone touched by dementia ensure a much better quality of life
hearing about the role old age should have easy access to advice for all those affected by dementia.
psychiatry plays in the UK to raise and information. Decent, kindly
awareness about dementia, its care should be available as a matter
A Word From ...

The President of the Royal College of Psychiatrists
Dinesh Bhugra
Professor of Mental Health and Cultural Diversity, Institute of Psychiatry, King’s College
London
The development of old age special interest sessions in old dementia services. The challenges
psychiatry parallels my own age psychiatry and the services over the next few decades are
journey through my career, initially were in the centre of the town. going to be the numbers of
as a trainee and now as a trainer. What I remember most, apart people with dementia around
As I arrived in Leicester in 1981 to from the actual learning and the the globe. From a personal,
start my psychiatric training, my clinical experience, is the fierce clinical and academic experience,
third placement after academic commitment of the members another key challenge is going
psychiatry and general adult of the multidisciplinary team. At to be the relationship between
psychiatry was in a dementia- least the latter has not changed. culture and old age. In several
only service. It was indeed a Domiciliary visits in a town where cultures, the elders are venerated
formative experience in more a quarter of the population and honoured. Filial piety and
ways than one. Subsequently, was over 65 was an interesting social expectations mean that
I did another placement in old experience. children are expected to look after
age psychiatry as a senior house We know that the number of the elderly. Under those circum-
officer, and then I arrived at the older adults will continue to rise, stances, the burden of disease will
Bethlem and Maudsley rotation as will the rates of dementia. have major implications for carers.
in 1986 as a senior registrar. I was It is heartening to see that the With changes resulting from
posted to Eastbourne working government is committed to globalisation, industrialisation
in adult psychiatry. I chose to do developing and maintaining and urbanisation, traditional
44
patterns of collectivist cultures are lead on delivering this. Another medication according to genetic
giving way to more individualistic exciting development is that of the make-up will become the norm.
ones. With increased movement newer anti-dementia drugs, which However, the profession needs to
of people, younger individuals to my mind will transform the care start addressing ethical issues.
are migrating; this means leaving of the elderly. In association with As I go around Westminster
behind their older relatives, who the Royal College of Physicians meeting new MPs, it is clear that
are often lonely and feel neglected. of London and the Royal College many of them have a family
The change resulting from of Practitioners, our College was member with dementia and are
cultures-in-transition will have given funding from the Health interested in the subject. It is really
a ripple effect on other cultures. Foundation to look at prescribing reassuring to see a significant
Other challenges include early in old age care homes. The report number of parliamentarians
diagnosis and early interventions. is nearly complete and will be committed both to mental health
The College’s commitment to ready before too long. We hope to (again, from a personal and
public mental health does include launch it formally in due course. constituency experience) and
strategies for early interventions The third area of development to the care of the elderly. I feel
in psychiatric disorders of the that may well transform the optimistic that the College and
elderly, especially dementia. It is healthcare of the elderly is psycho- the Faculty will continue to make
thus imperative that the training pharmacogenomics. It is likely that a mark, and that the future of the
incorporates public mental health with psychopharmacogenomics specialty is secure.
and that clinicians take a strong more individually targeted
The Tzar
Alistair Burns
Professor of Old Age Psychiatry, University of Manchester and the Manchester Academic
Health Science Centre; Honorary Consultant, Manchester Mental Health and Social Care
Trust; and National Clinical Director for dementia in England
Then … to long-stay National Health bit like the M25. Although this
Service care at Cane Hill Hospital design undoubtedly solved many
I was enthused to old age (at Coulsdon, Surrey), when we problems, there were a number
psychiatry by Klaus Bergmann, enquired a few weeks afterwards of occasions when I had to ask a
my consultant when I started at how people were, there rarely confused resident where the exit
Bethlem Royal Hospital, where seemed to be a problem. It was was.
all the new trainees started. This only when I visited Cane Hill that The second thing which struck
was a kind of sheltered workshop I realised that the space was such me was that many people with
where we had ample time to that people were able to wander dementia were on the ward for
delve into the patients’ histories and walk around and pace for so long that they developed
and behaviour in great detail. a long distance without being deficiencies of some vitamins and
For me, this experience was even blocked – it was that availability several lost weight. This led me to
more intense because there was of space which seemed to an interest in nutrition which was
a social work strike and very reduce the number of abnormal the basis for my MPhil and sowed
few people with dementia were behaviours. the seed of what was probably
being transferred to nursing or I recall a similar situation when the least blinded randomised
residential homes. I remember visiting ‘Part 3’ homes (named controlled trial.
there were two things that from the 1948 National Assistance I decided to give vitamin
intrigued me. First, we used to Act, to look after the elderly and supplements to a group of people
look after a number of patients infirm in Local Authority areas) with dementia at Cane Hill to
who were very agitated and where, because of the 1960s see whether it improved their
wandersome. Sometimes we had and 1970s design, there was a well-being and increased their
great difficulty managing them kind of track where people could weight. I managed to persuade
but when they were discharged walk and never have to stop – a a company who made a vitamin
45
supplement called Orovite. These were published only a year after dealing with the special needs
were more innocent times and the official codification of old age of older people with functional
the company were very good at psychiatry as a specialty. illness and being the mainstay of
providing a placebo but because liaison psychiatry in the general
of the aromatic effect of the B12 Now … hospital) will, if anything, increase.
vitamins it was easy to smell which The past few months I have had The five current priorities of the
bottle held the active medication the privilege of being the National National Dementia Strategy –
and which was placebo. I made Clinical Director for Dementia early diagnosis and intervention,
the fatal mistake of not being in England. There is no doubt support for carers, care for people
present when the trial started that interest in dementia and its with dementia in the general
and the consultant at Cane Hill, ramifications has increased in a big hospital, care for people in care
Tony Isaacs, telephoned me to way in the last few years and it is homes with the reduction in the
say that the nurses were opening appropriate to pay true testament use of antipsychotics – will all
all the bottles smelling them and to the work of Sube Banerjee, involve old age psychiatrists to a
saying ‘that’s active medication’ who (with Jenny Owen) wrote the greater or lesser extent.
or ‘that’s placebo’! I dashed down National Dementia Strategy and Old age psychiatry is the most
having bought some proprietary who singly wrote the report on exciting discipline in which to
foodstuffs to see if we could hide the reduction of antipsychotics work and we must continue to
the smell and we did this quite in people with dementia. It is the enthuse our trainees into what is
successfully. implementation of these reports a very special and satisfying area
Through the guidance of iconic which is now the work at hand. of work. Sometimes, by looking
figures in addition to Klaus Although highlighting issues back and reminding ourselves
Bergmann, such as Raymond of dementia and cognitive how our discipline began, we
Levy, Robin Jacoby, Felix Post impairment, the National can look forward. To paraphrase
and Alwyn Lishman, my career Dementia Strategy in and of itself Winston Churchill, the further we
stumbled on and I was fortunate should not be taken as a marker for look back, the further we can look
enough to be employed by the future of our discipline. There forward.
Raymond and Robin on a Medical is a wider debate which has been
Research Council grant looking at voiced by people more eloquent Professor Burns qualified in medi-
the natural history of people with than myself (notably Peter cine, Glasgow, in 1980. He spent 3
dementia. It was as the result of Connelly and Dave Anderson) years in medicine in Glasgow, then
that that we produced our papers about the unique status of old practised psychiatry at the Mauds-
describing non-cognitive features age psychiatry. It is clear that the ley Hospital in London.
and I like to think that they were nature of probably the main bulk
quite important in terms of the of the work we do (i.e. managing
development of our subject. They people with organic problems,
The National Director for Mental Health

(2000–2010)
Louis Appleby
Professor of Psychiatry, University of Manchester
I can hardly bear to admit what I most convincing signs that our transformed. In modern health
am about to describe, given that reforms were proving successful and social care the mental health
this is intended for an audience was when old age psychiatrists of older people is at the top of
of specialists in older people’s came to meetings complaining the list of priorities. We have a
mental health. However, when bitterly about being left behind. national strategy for dementia, we
I was responsible for changing I feel able to mention this now, have age equality legislation, and
mental health services for several years later, because this it is no exaggeration to say that
‘working age’ adults, one of the indefensible situation has been a major discovery in the field of
46
preventing or treating dementia has simultaneously become far in people’s lives, their efforts, their
would be seen as so important as more respectful towards the traumas and their achievements. I
to be one of the great advances qualities that accompany older think that this richness of later life
of the century. That is a very age. We no longer see the comic is much more widely recognised in
optimistic position for older caricatures of older people in the how we offer care to individuals.
people’s mental health to be in. media that were common a couple But what of older people’s mental
Now, before anyone points out of decades ago. We debate the health and the psychiatrists and
that dementia and older people’s retirement age in recognition of others who practise it? I once
mental health are not the same, I what older people can contribute. tried to track the origin of the fall
should say that I am well aware of And far more often we reflect in suicide in older people that
this. However, in setting policies on the rich and complex lives occurred from the mid-1950s in
and in changing something as that supposedly ordinary people England. It turned out to have
huge as the health and social care have led, leaving them older but begun at roughly the time when
system, one of the key tasks is to genuinely wiser. the very first appointments of
get the spearhead issue right. If In my national director role, ‘psychogeriatricians’ occurred. I
you can do this, then the benefits while promoting the expansion mentioned this to some old age
are much broader than that single of psychological therapies in the psychiatrists who, because of their
issue. So, dementia is a spearhead National Health Service (NHS), I was natural modesty, thought that the
issue that no one would challenge asked to meet a few patients who two could not be related. However,
and the benefit is likely to be in were taking advantage of the new I prefer to think that the growing
the mental health of older people services. One of these was a man importance of good mental health
more broadly, and indeed in the in his late 80s who was introduced in later life, which those early
welfare and dignity of people in to me as a person who suffered appointments were perhaps the
later life overall. from anxiety. In fact, in private first sign of in the NHS, has also
The issue of dignity is a crucial conversation he talked of a series been responsible for improved
one because, if you place it of traumas during his war service safety in older people who are
alongside the intense scientific and his great frustration that the vulnerable and depressed. In any
interest in ageing and its diseases, individual experiences that he case, it is a positive reflection on
then that is an unbeatable had had might not be understood a relatively young profession
combination. Strangely enough, by those who offered him therapy. and an exciting sign of what the
a society that has acquired a This was a good illustration of how combination of science and social
reputation for placing an excessive terms like anxiety are too small to values will achieve in the future.
emphasis on the virtues of youth describe the extent of the events
The House of Lords

Baroness Elaine Murphy of Aldgate
I remember 1989 very well indeed. tested out and argued over in our also in terms of the Department’s
I was working 17 hours a day, district at Guy’s Hospital. It was all understanding of the likely social
trying, not very successfully, to a bit of a nightmare. I have never and economic impact of the
combine academic work, clinical worked harder before or since. dementias. I remember Sir Donald
and managerial commitments, I remember well the sense Acheson, the Chief Medical
with days at that less-than-perfect of triumph and achievement Officer in 1989, telling me how
organisation, the Mental Health when the Department of Health worried he was that the future
Act Commission. The government granted our specialty recognition impact of dementia on health and
White Paper Working for Patients1 after so many years of pressure social care services was poorly
was separating purchasers from and negotiation by the executive understood by leaders of the
providers, and about to create members of the old age psychiatry NHS and local government Social
National Health Service (NHS) group in the Royal College of Services. He wanted me to join
trusts. A lot of the donkey work Psychiatrists. It meant so much the Registrar General’s Medical
for the forthcoming bill was being in terms of training posts, but Advisory Group, ‘And keep saying
47
and dementia by general medical But my goodness, don’t my

and surgical services in hospitals, colleague peers in the Lords
and many general practitioners all sit up and listen when I talk
are still only so-so at diagnosis about dementia? With a mean
and arranging care. The problem age of 68, a third of them will die
of depression in old age and with dementia. You can be sure
late-onset psychosis remains a the specialty is well recognised
key concern of psychiatrists, but down our end of the Palace of
is barely talked about outside Westminster and we have a
specialist circles. It seems special All Party Parliamentary
even more difficult to provide Group on Dementia which is now
appropriate care for these patients 3 years old and flourishing. I am
Elaine Murphy, 1975. in many districts now than when optimistic that if the specialty
we all had long-stay NHS beds. I adapts to the new environment of
“dementia”, which for a time I did, don’t advocate a return to those the NHS marketplace in healthcare
fighting to find a small voice for days but there are problems it will flourish; adaptability and
our patients simply to have the which have never been resolved. responsiveness will be key. I would
right to be counted. Our specialty has in some ways like to see old age psychiatry once
Lots of things have got better; slipped back a bit from being more pushing and shoving its way
dementia is better recognised in the pushy forefront of policy- to the front of the policy debates;
as a serious problem by the making; over the years too many the demographics are on our
general public; the coalition of us were preoccupied with side.
government has even declared fighting for NHS services and beds
dementia research as one of its and too little concerned with the Reference
key priorities; specialist services social care aspects of our patients’ 1 Department of Health. Working for
are available in every area; access lives. Many NHS changes have Patients. HMSO, 1989.
to independent sector domestic seen us on the back foot rather
and personal care services is more than grasping the opportunities Elaine Murphy trained in psychiatry
readily available. Some things, and, perhaps saddest of all, we in London, became a consultant in
however, have got worse; social never persuaded the powers that old age psychiatry at Goodmayes
care services are in meltdown in be in parliament to invest in older Hospital in Ilford, then from 1983
some local authorities, there does mental health patients when the to 1996 held the first UK chair in old
not yet seem much improvement money was being thrown about age psychiatry at the United Medical
in the understanding of confusion in general psychiatric services. Schools at Guy’s Hospital (now
part of King’s College London). She
then moved to NHS non-executive
management roles as chair of a
trust, then of a Strategic Health
Authority until 2006. She became a
cross-bench member of the House
of Lords in 2004 and is now secretary
to the All Party Parliamentary Group
on Mental Health.
Consultant old age psychiatrists who worked at Goodmayes at various times, at a

symposium, probably in Tewkesbury, 1980s. From left to right: Yong Lock Ong, Zoe Slattery,
Elaine Murphy, Tom Arie, Elizabeth Taws.
48
A medical student
Alasdair Scott
Undergraduate, Imperial College School of Medicine
I must begin by admitting that My colleagues and I ‘cut our teeth’ approach that perhaps medical
I’m not in the best position to on elderly patients and will be schools could improve. Although
comment on the 21-year history forever indebted to them for it. So we recognise the necessity to work
of old age psychiatry – I was although on the one hand many with colleagues from a variety of
celebrating my fourth birthday of us will only get formal exposure disciplines, we do not currently
when the specialty gained official to geriatrics in specialty modules embrace learning with them.
recognition by the Department and even fewer will gain significant It would be interesting to have
of Health. However, as a medical experience of psychogeriatrics, on opportunities to liaise with trainee
student finishing my psychiatry the other hand, elderly patients occupational therapists, nurses,
rotation I am well placed to are perhaps the population with physiotherapists and social workers
share my experiences of old age which we are most familiar. during our education to gain better
psychiatry in undergraduate insight into our respective roles
medical training. Multidisciplinary learning and to develop the professional
I’m currently in my penultimate I’ve had five and a half weeks skills required to work as part of
(fourth) year of study but I have of general psychiatry, with one a multidisciplinary team. A very
to go right back to the beginning afternoon/morning a week recent randomised controlled trial1
for my first encounter with devoted to seeing old age demonstrated that medical stu-
psychiatric problems in the old age patients either in a community- dents learning in multidisciplinary
population. The integrated nature based day assessment centre or groups with pharmacy and nursing
of my medical degree promoted as hospital liaison referrals. What trainees performed significantly
early patient contact, which for I found most interesting was the better at problem-based learning
me involved a home visit to an complex nature of the cases: the than groups of medical students
elderly lady with osteoarthritis and interplay between physical and alone. Given its nature, old
comorbid depression. Similarly, mental health is at its most potent, age psychiatry could offer the
my early general medical and whereas the distinction between perfect forum for this kind of
surgical experiences were largely the organic and the functional learning, improving professional
dominated by geriatric patients is at its most subtle. Every case development and enhancing
whose physical complaints is made challenging by the exposure to the specialty.
were frequently complicated by backdrop of overlapping factors In conclusion, I’ve enjoyed my
psychosocial issues. such as housing, finances, family, experience of psychogeriatrics
Although the age demographic carers, nutrition, loneliness and and have gained an appreciation
of these clinical encounters can autonomy. Does any specialty more for its complexities and the roles
certainly be explained by the large fully embody the biopsychosocial that psychiatrists and other
(and rapidly increasing) proportion model of disease? professionals play. Since my
of hospital in-patients aged 65 These complexities can only be fourth birthday the field has
and over, there is another factor solved by the multidisciplinary grown rapidly and I’m sure it
that cannot be overstated – time. approach that is at the core of old will continue to do so until my
I found (and still find now) that age psychiatry. In fact, to think fortieth and beyond. But today
elderly patients are much more of psychogeriatrics as a solely we recognise the 21st birthday of
willing to spend time chatting ‘medical’ discipline is to do it a old age psychiatry as an official
with medical students than great disservice; in the absence specialty, applaud its successes
younger patients. Unfortunately, of a social context the medical and wish it many happy returns.
I have no evidence base to wield interventions become rather lost. Hip-hip-hoorray, Hip-hip …
(an interesting audit perhaps) It seems to me that the role
but my subjective feeling is that of the old age psychiatrist is Reference
the old age population derive to weave social, occupational, 1 Nango E, Tanaka Y. Problem-based
greater enjoyment from talking pharmacological and psycholo- learning in a multidisciplinary group
enhances clinical decision making
to us, are more approachable and gical therapy together to create by medical students: a randomized
are significantly more forgiving of long-term, dynamic support for controlled trial. J Med Dent Sci 2010; 57:
our initial bumbling attempts to patients and their families. 109–18.
formulate a differential diagnosis. It is in this multidisciplinary
49
Tom Arie: what’s changed and what’s still the

same?
Tom Arie
Professor Emeritus of Health Care of the Elderly, University of Nottingham
My first unit for old age psychiatry

was at Goodmayes Hospital, from
January 1969. Specialty status
came 20 years later. We early
‘district psychogeriatricians’ were
chiefly developers of services,
teachers and advocates (and
agitators). Some of us went on to
set up academic departments, in
my case at Nottingham University
in 1977.
Old people’s hardships and
illnesses are little changed, but
there are very many more very Long ago! Some of the team at Goodmayes Hospital, c. 1973.
old people. In the work itself,
frustrations continue, differing telephoning ahead. Who could old eyes are not disadvantaged).
only in details and mostly owing he be referring to? People give I am learning about ageing in
to a shortage of resources. The up their seats for me on buses ways beyond what I ever learnt
satisfactions are still the same. and tubes. I used to think that the professionally, from myself and
And many more good people ‘Do you need help with packing?’ from the lives of contemporaries.
have joined us. at the supermarket checkout ‘Old age is a new country.’
Personally, what’s changed? was personal to me, but they ask
One feels still the same person everyone, and that is an example We are ‘part of the furniture’
as one grows old, but to others of a good ‘universal’ practice of now
one is clearly often different. ‘I which there should be many more
Old age psychiatry is publicly
have an elderly gentleman here’ (like clear print, which is good for
familiar now. Alzheimer was
said a receptionist the other day, everyone, while ensuring that
already a household name in
1989. ‘Geriatric psychiatrist’ first
appeared in an English novel (Nina
Bawden’s Family Money) in 1991.
We were already international
then – our Nottingham courses
in psychogeriatrics for the British
Council started in 1980, and the
International Psychogeriatric
Association began soon after that.
The media are good on issues
concerning our patients (who have
often become ‘clients’), and never
better than in Sir Gerry Robinson’s
recent television programme on
dementia care homes.
Science
We were already a world movement in 1989. This is a gathering in Vancouver, Canada, in I no longer do clinical work, so
1999. I don’t see the changes there at
50
Now.
first hand. But I see the science ment to old people. ‘Dementia
leaping ahead, full of promise. services’ don’t appeal to me, for all
The academic stream is bigger old people deserve a psychiatric
and different now: research in our service attuned to their special
field is now a many-sided activity, needs; and a prime task with
involving the basic sciences and our patients is to establish the
a host of other disciplines and diagnoses. (This is a quite separate
departments, not only medical. question from that of the settings
But I hope old age psychiatrists, in which different patients should
indeed all psychiatrists, along be cared for.)
with their research and the giving
of advice to other professions, will Ageing
continue to lead their services, to Being old has itself changed. Life
teach and to work ‘hands on’. expectation and healthy active
Our professors have changed, as life expectation have increased
in our sister specialty, geriatrics. dramatically in our time, even in
The prime quality valued in the those past 21 years. I am, I like to
first professors, who were few think, different in my personal
for a long time, was necessarily style from the generation that
leadership and innovation. were my own elders. (At any rate,
Evidence of scientific excellence, I dress differently!)
and of grants is what is now Age discrimination is outlawed
most sought. There are many in law, if often not in practice (just
more professors, and often they now the news is of flexi-scope
too are fine leaders, and our top screening for colon cancer – ‘for
academics hold their own with those up to 65’). New effective
scientists of any discipline. treatments will come, but will the
National Health Service provide
Dementia them? The coming austerity will
I worry that dementia often be cruel for the old. So the need
replaces old age psychiatry as the for professionals who devote
metier ascribed to us. We early themselves especially to the aged
psychogeriatricians saw our work will be greater than ever. We must
as bringing good ‘across-the- continue to be advocates, even
board’ psychiatry, with careful agitators – which, after all, is how
diagnosis and skilled manage- we began.
51
Reflections and Conclusions

Claire Hilton† & Dave Jolley‡
†
Consultant Old Age Psychiatrist, Central and North West London NHS Foundation Trust;
‡
Consultant Psychiatrist and Honorary Reader, University of Manchester
Various themes shine through Experience tells of the disaster of need to think laterally and share
much of this collection of having old people in the same ideas, and somehow influence
writings, with implications for wards as younger mentally ill commissioners.
future practice. Perhaps the patients; will such a situation Our overseas colleagues reflect
most frequent and consistent return under cover of non- highly on past contributions
reflections are on the teachers discrimination? from the UK to old age psychiatry
who have inspired us to work Our services have been internationally. One wonders
within the specialty. underfunded. Future funding by whether they would say the
Most themes, however, have a reinvesting from previous services same about our innovations and
double edge of opinion attached. is a meaningless and impossible services today.
They tell us that so much has objective for a population group We can’t put the world – or the
been achieved to date, but increasing in size and complexity. specialty – to right in one fell
unflinching optimism is muted If we are still a Cinderella specialty, swoop. We have laid spectacular
by heavily counteracted concern where is the glass slipper? Will a foundations both before and
for the future. Too many of our prince (or a tzar) help us escape during the past 21 years and
contributors have taken the from the grip of the three ugly need to build on this. Institutional
stance of ‘progress good, but sisters, Polly Tick, Penny Pinch, memory in the National Health
prognosis uncertain’, and some and Pru Judice?a We fear not. Service is not good; we need
services may have been damaged Research, too, has its difficulties – to keep in mind experiences,
‘beyond repair’. There is a heartfelt too few trainees and too few places changes, successes and failures
distress in the reports of services with academic departments. of the past to avoid throwing the
found to be effective in any Quantitative and qualitative baby out with the bath water.
locality being cut, and at times approaches to research both Or, as a tzar paraphrased a prime
recreated under a different guise. have their place. Undoubtedly minister, the further we look back,
Of our two geriatricians, the more research is vital, and the value of the further we can look forward.
experienced mourns the passing good research and technological
of joined up psychiatric–geriatric advance is emphasised in this
services, and the trainee wishes for collection. However, applying it
their creation. Parallel comments to clinical practice needs caution.
appear in the contributions of Perhaps, it is suggested, there is
the old age psychiatrists. Other currently too much reliance on
aspects of our services still cause the marginal benefits of anti-
concern, especially long-stay dementia drugs; for some they
care. No service claims to have may prolong suffering when
reached goals of excellence in all perhaps we need a more palliative
its dimensions, for which we still paradigm of care. Also, to achieve
strive. true dignity and respect for our
Some contributors envisage patients, we need to focus on
that supposedly well-meaning the individuals rather than on
anti-discrimination legislation the mere implementation of new
perversely looks set to undermine practice. Two of our contributors
much of the good so far achieved. refer to narrow ‘silo’ thinking; we
a. Don’t ask how they all got different surnames; was it foul play or hanky-panky on the part of Miss Trust or Hans Offourservices, or
others? Not that such things would go on in the National Health Service.
52
Party Games
Compiled by Claire Hilton and Dave Jolley, with more than a little
help from their friends
This is a birthday party, so we have included some party games, with a prize. The prize is £25, either vouchers
or a donation to a charity of your choice, or perhaps into the coffers of your trust or primary care trust or GP
commissioners in the hope that they might ring-fence something for your service.
Peter Connelly, Chair of the Faculty, will help us judge the answers, which need qualitative rather than
quantitative evaluation.
Your answers please (even if you do not manage all the questions) to [email protected] by 30 April 2011.
Individual, family, friends and team entries will all be welcome.
The name of the winner and the answers will be published in the next Faculty newsletter.
Good luck and we hope you have fun!
1. In 1989, who or what was: 3. Our cousin: providing services for old people
a. Prime Minister 1950s style . Who is it?a
b. First Division Football League Champions
c. Nobel Peace Prize winner
d. most popular name for a baby boy
e. most popular name for a baby girl
f. top of the pop charts January
g. top of the pop charts December.
2. Which of these were first seen in 1989:

a. EastEnders
b. Game Boy
4. Psychiatrist in the chair. Who is it?
c. Satanic Verses
d. World Wide Web
e. karaoke
f. Barbie doll
g. Global Positioning System (GPS)
h. Human Genome Project.
a. Permission to reproduce material in questions 3, 4, 5, 7, 9, 11 and 13 has been obtained. Full acknowledgements for all images and
quotations will be given with the quiz answers in the next edition of the newsletter.
53
5. A geriatrician ally. Who is it? 7. A serious matter: old age psychiatry conferences
1980s style!
Who are they? What might they be thinking?
Please add speech bubbles!
Artist: Geoff Campbell.
6. Who said what, when and where? 8. How many years before the National Dementia
a. ‘Psychogeriatrics … has developed ever more Strategy was the following written about
rapidly … and those few of my colleagues who medicine for old people?
argue that it should not exist are in no stronger a
‘This subject is one of the highest importance, and
position than Canute holding back the waves.’
yet has been strangely overlooked during the last
b. ‘In an attempt to “convert” the local psychiatrists I half century.’
was insufficiently charismatic, and got a very frosty
response. Fortunately, they couldn’t find the cross,
so I survived to write this article.’ 9. Which influential organisation, and when, would
c. ‘Perhaps to some of us [psychogeriatricians] stereotype its data like this:
the attraction in the work resembles the lives of
Norsemen – there is a thrill in sailing up some
administrative backwater and creating mayhem.
If so, then once a new service becomes accepted
and semi-respectable (I doubt if we can ever be
totally respectable for our colleagues) life begins
to get dull; accordingly one day we return to our
longboats – to the heartfelt relief of the locals –
and head for new places to conquer. The metaphor
is not wholly accurate – life would be easier could
we burn down the occasional administrative HQ
and out its occupants to the sword!’
d. ‘The care of old people can not wait on Utopias, for
many of them will be dead long before even the
earliest Utopias arrive, and unless social policy and
the training and professional aspirations of health
personnel undergo fundamental changes … the
elderly and the chronic sick, even in Utopia, are still
somehow to be at the end of the queue.’
54
10. Explain the differences between these paired n. The Health of the Nation
words: please chose five pairs. o. First Admiral Nurse service
a. Psychogeriatrics – Adult psychiatry p. Faculty residential meeting in Jersey
b. Brain failure – Confusional state q. Faculty residential meeting in Belfast
c. Care management – Case management r. Faculty residential meeting in Liverpool
d. SAP – QCF s. Donepezil licensed in England
e. SCIE – DeNDRoN t. Criteria for dementia with Lewy bodies, Newcastle
f. Benign senescence – Mild cognitive impairment u. Cornelius Katona appointed Professor at UCL
g. Personalisation – Depersonalisation v. Revised Code of Practice: Mental Health Act 1983
h. Palliative care – Supportive care
i. Cluster analysis – Delphi group
j. Personal budget – Individual budget 12. A map of a psychogeriatric service
k. The unfittest – Best fit In which newsletter and in what year did this
l. Nested estimates – Multicollinearity appear?
m. 10/66 – 36-hour day Is this a hope impossible for the future? Yes/no –
please state your reasons.
n. Intermediate care – Long-stay care
o. Graduates – Lifelong learning
p. Melancholia – Mega-colon
11. Each of the following appeared in a different

year from 1989 to 2010. Please match each to its
date.
a. Seminars in Old Age Psychiatry
b. Second NICE guidance on the use of anti-
dementia drugs
c. Social Care Institute for Excellence Guide 3:
Assessing the Mental Health Needs of Older People
d. Report of the Inquiry into the Care and Treatment of
Christopher Clunis
e. Promoting Mental Health: Strategy and Action Plan
(Northern Ireland)
f. Principles and Practice of Geriatric Psychiatry (First
Edition)
g. Old age psychiatry recognised as a specialty
h. NSF Older People (Wales)
i. NSF Older People (Scotland)
j. NSF Older People (England)
k. NSF Mental Health
l. National Dementia Tsar
m. National Dementia Strategy
55
13. The Tzar’s cars Driving it was a nightmare – the end of the bonnet
seemed to be in a world removed from my control
One is the real thing (Bentley), the other a cheaper and the windscreen confirmed this feeling of
look-alike (Chrysler), and the number plate gives watching a changing scene, which might be from
the date of Alzheimer’s paper. a penny arcade rather than the real (mean) streets.
There was the time when a neighbour’s wooden
gates fell before that bonnet, as I underestimated
my swing when attempting a turn.
Big’s registration number was GOC 449, which I took
to relate to Granddad (George Cooke) and the A449
which is a major road we used on journeys to the
seaside. I am sure it was just one of those things.
So, to the owner of the big black cars, I love them
because they say so much.
– Not afraid in any company.
– Out of the shadows.
– Proud of what he is about and pleased to share
• From where does the number plate originate? knowledge of it.
• Is this an automotive Capgras syndrome? – Humble in giving credit to the history (everyone
• What is the psychopathology which inspires this will remember that date now).
scenario? Please explain the psychodynamics.
– Dedicated to dementia and all its aspects.
• The picture was taken on private land; which car
would be contravening the Road Traffic Act if it – Respectful and cautious, ‘a workday suit and
was driven on a public road? one for Sunday best’ maintaining the image but
• Many of us remember having suits for Sunday taking very good care of the real thing between
best and others for the working week. Is this times.
the auto-equivalent? What is the name of this
And I know that the owner handles these big cars
phenomenon?
brilliantly. Driving to a meeting in Bristol in an earlier
• Who else is renowned for conducting home visits version Bentley, he parked with no qualms and no
in a real Bentley? Where was this? What was the problems in a multistorey car park which would
explanation? have worried me in my Morris Minor.
In safe hands here.
To help you, a sample answer is given below. My thesis is, I believe, validated by the whimsy on
the other Bentley driver I have known who knew she
I just love the picture and this is because it says so was safe in such a car even in a scary part of London
much to me. Town.
I know about big black cars: I learned to drive in
Big Bodied 1946 Austin 12. The car came in two Dave Jolley
versions, with the same engine: Big and Not so big.
Our Big belonged to my granddad Cooke. He was
smaller than I was and am, lived to be ninety-eight
and a half and insisted on climbing the pear tree in
his orchard into his nineties. Big was the only car in
the family and was driven by my uncle and dad as
well as granddad. Weekends were spent cleaning
it, painting over the rusty edges and rehearsing
journeys I hardly remembered.
56

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brating

ISSN 1463-6662 Spring 2011, Number 53

SPECIAL ISSUE: 21 YEARS OF OLD AGE PSYCHIATRY!

Mainly from the Clinical Old Age

Sailing into the wind

Two fascinating decades

grim wards, all in the old community teams with

A hallmark of a civilised society

We’re 21: recognition and discrimination

Memories from Goodmayes

Goodmayes: home of old age psychiatry

Relinquishing youth and encouraging maturity

The memory clinic

and frequent visitors from home

From Scotland and Wales

Services for elderly people in Scotland: from the

me maybe £1250 weekly. It seems References nhs-attack-1772164.html).

A view from Swansea

From Geriatric Medicine

Old age physicians and psychiatrists: past, present

Past as well as being very clever and to their physical ones. As a

From the Multidisciplinary Team

The essence of our care: a nursing perspective

And what about occupational therapy?

A social worker’s perspective

To age or not to age: that is the conundrum

Now I am 71 and you are 21

From the Academic Old Age Psychiatry

Of pioneers and progress, but prognosis guarded

An old age psychiatrist at work and play:

Perspectives of a (not so) young clinical academic

Should and will tomorrow’s

Old age psychiatry and the

In addition to these contribu- and psychopharmacological What of the future?

A view from Hong Kong

Where will I be in 21 years?

As a higher specialist trainee, I am hospital located in Durban. by the College of Psychiatrists of

Africa and the UK are due to

Reflections from Canada

A Carer’s View of Frontotemporal

A Word About ...

A Word From ...

The National Director for Mental Health

The House of Lords

and dementia by general medical But my goodness, don’t my

Consultant old age psychiatrists who worked at Goodmayes at various times, at a

Tom Arie: what’s changed and what’s still the

My first unit for old age psychiatry

Reflections and Conclusions

Good luck and we hope you have fun!

2. Which of these were first seen in 1989:

Artist: Geoff Campbell.

11. Each of the following appeared in a different

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