The legacy of GP attitudes to mentally ill older people
Claire Hilton |
Historical evidence dating back over 60 years reveals common negative attitudes and expectations of GPs towards their mentally ill older patients. This negativity can affect the treatment of illnesses such as depression and the group of disorders collectively called ‘dementia’. Too often, doctors fail to diagnose these illnesses. This underpins NHS England’s recent offer to GPs of £55 per diagnosis of dementia made between October 2014 and April 2015. Understanding the history of GP attitudes to older patients with mental illness might give insights into why this initiative has come about, possible outcomes, and alternatives.
In 1946, GP Dr Mungo Park criticised the complacency of the medical profession and civil servants about the lack of facilities for the ‘aged and infirm.’ He noted that ‘restless senile cases’ placed huge stress on relatives caring for them at home. GPs were aware that, ‘The noisy, restless, agitated old person will often die’ if moved to hospital. The British Medical Association (BMA) emphasised the need for GPs’ involvement in the treatment of older people. Despite these good intentions, there was little improvement during the post-war era.
In the 1950s, Stephen Taylor (Baron Taylor of Harlow) investigated 30 ‘outstanding’ general practices and found diverse views about older people. Some GPs thought that, with time and patience, working with them could be rewarding; others viewed them as 'difficult, and even unpleasant…often inarticulate, hard to get to know, and slow to respond.'
GPs Cuthbert and Beatrice Watts wrote:
Nothing can be done for these unfortunate people. The aged can be most difficult and trying.
Although some GPs were aware of the need to support families providing care for people with dementia, others advised the families that providing it 'can only have an adverse effect on their own lives, without benefiting the patient's in the slightest.' Since ‘no additional help can be sufficient to make it bearable’, admission to long-stay hospitals was preferable.
Geriatrician Professor James Williamson surveyed older people registered with GPs in Edinburgh, 1962-3. He found that GPs were often unaware of depression and dementia in their patients. Williamson attributed this to several causes: medical education focussed on acute illnesses; a person with dementia might have little insight into his plight and fail to recognise the need to see his doctor; older people tended not to seek medical help possibly because they were stoical, had grown up without a NHS, or they attributed symptoms to irreversible old age rather than treatable illness. Fear and stigma of mental illness, or its treatment, could also influence help-seeking. However, Williamson concluded, almost prophetically:
I am convinced that dementia is possibly the greatest single factor we have to worry about in dealing with problems of old people in our society.
In the 1980s, mental illness was omitted from the Royal College of General Practitioners’ Preventive Care of the Elderly and research in the British Journal of General Practice gave clues about GPs’ attitudes towards older people’s health. One study about how often older people consulted their GPs mentioned mental illness only in the context of excluding prospective research participants who were too confused or too depressed to be interviewed, without further explanation or definition. Such exclusions could lead to inaccuracies in determining patients’ needs. For example, depressed people might consult more if worried about their health, or less if they believed they had little hope of recovery. Older people were at particularly high risk of suicide, thus it was disquieting when one community study revealed that only 14% of older people diagnosed with depression received antidepressant treatment and relatively few were referred for specialist psychiatric advice.
Other research indicated that physical illnesses of older people were also under-diagnosed and that GPs did ‘less investigative work with elderly patients and the level of referral to consultants is the same for patients of all ages.’ Since more illnesses occur in old age, less investigation and no increase in referrals to specialists suggest GPs and patients saw impairment in old age as inevitable, despite evidence of the benefits of treatment. Some GPs mentioned the advantages of having specialist, consultant-led mental health services for older people closely allied to primary care. Where those services existed, GPs’ referral rates increased. Elsewhere, lack of easily accessible advice, treatment or clinical support could have affected GPs’ motivation for identifying disorders. There was little point in making diagnoses or referring patients to specialist mental health services if GPs believed that nothing could, or would, be achieved.
The 2014 financial incentives to diagnose dementia are controversial. For disorders such as cancer or diabetes where early diagnosis might mean a higher chance of a cure or successful treatment, such incentives might be acceptable. For disorders such as dementia where treatment is supportive and palliative, the reasoning is less robust. The scheme might increase the number of diagnoses, but many GPs lack training in this area, which risks inaccurate diagnoses, creating unnecessary distress for patients. Also, if GPs feel pressurised to make diagnoses, this might be harmful to those patients who are not ready to hear that they have incurable dementia. The emphasis needs to be towards timely diagnosis for the patient, rather than early diagnosis.
The government has successfully raised public awareness of dementia and many specialist memory clinic services are at breaking point due to increased referrals, without additional funding. The £55 incentive might reduce referrals to these services, or increase them if people diagnosed by their GP request a specialist opinion. Rather than financial incentives to GPs to make more diagnoses, it would be more constructive to bolster the existing specialist services and hold consultant-led memory clinics in GPs’ surgeries. The latter could also provide training to improve GPs’ clinical skills for working with mentally ill older people. This should help improve attitudes about what can be done to maintain quality of life for people with dementia, and their families, despite the degenerative nature of the disorder. If attitudes and expectations are more positive, incentives should not be necessary.
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