Delirium is a common condition in the elderly, affecting up to 30% of all older patients admitted to hospital. There is a particularly high risk of delirium in surgical inpatients, especially following operations for hip fracture or vascular surgery, but also for patients in the intensive care unit. Patients with delirium have higher morbidity and mortality rates, higher re-admission rates, and a greater risk of long term institutionalisation care, thereby having a significant impact on both health and social care expenditure. Delirium frequently goes unrecognised by clinicians and is often inadequately managed. Recent evidence suggests that a better understanding and knowledge of delirium among health care professionals can lead to early detection, the reduction of modifiable risk factors, and better management of the condition in the acute phase. Many cases of delirium are potentially preventable, and primary and secondary care services should be taking active steps in order to do prevent this condition.

Aims and MethodTo examine the standards of lithium monitoring in eastern Hull following the introduction of a local prescribing framework, we investigated the biochemistry records of patients currently prescribed lithium, identified from primary care computerised records. A survey of patients' knowledge about lithium therapy was also conducted.ResultsInadequate standards of lithium monitoring were demonstrated, with only 50% of patients having a level recorded during the preceding 3 months. Monitoring of thyroid and renal function was better, with two-thirds of patients tested in the past year. Patients' knowledge of the side-effects and risks of lithium was minimal; only 7 out of 27 patients questioned felt able to identify the signs of lithium toxicity; three-quarters of those surveyed felt they had not been given enough information about their medication.Clinical ImplicationsThe introduction of prescribing frameworks or other guidelines does not ensure good practice. Further actions may be needed to ensure lithium is prescribed safely, such as patient registers, monitoring cards and automatic recall systems. Education of patients and primary care staff about the safe use of psychotropic drugs needs to be an ongoing process.

SUMMARYA clinical and psychometric survey of depression and dementia in acute geriatric admissions (n = 50) found clinical evidence of depression and dementia in 25% and 35% of patients respectively, consistent with the results of prevalence surveys of geriatric hospital inpatients. There was a significant correlation between clinical assessment of dementia by geriatricians, and psychiatrists, and cognitive impairment using the Middlesex Elderly Assessment Memory Schedule (p < 0.01). Although an intercorrelation between clinical diagnosis of depression by geriatricians, psychiatrists and scores on the Geriatric Depression Scale (GDS) just reached significance (p < 0.05), there was no association between diagnosis of depression by geriatricians and GDS at a cutoff score of I 1/30. The relationship was significant at a cutoff score of 16/30 (p < 0.02). In contrast, the associations between diagnosis of depression by psychiatrists and GDS were highly significant at both cutoff points (p < 0.002 andp < 0.001 respectively). No significant differences were found between geriatricians and psychiatrists on indications for (1) antidepressant medication, (2) referral to liaison psychiatry, or (3) referral to a community mental health team. None of the inpatients assessed were receiving antidepressant medication at the time of their discharge from hospital although depression was diagnosed in a quarter of all inpatients and geriatricians supported the use of antidepressant treatment in 40?/0 of those cases identified. Factor analysis suggested that geriatricians were identifying a subgroup of patients as depressed who were not recognized either by psychiatrists or by psychometric testing. Patients with abnormal scores on psychometric testing were followed up after discharge and retested. There was evidence of a significant fall in GDS scores and a non-significant trend to increased fail scores on the MEAMS test suggesting an improvement in depressive symptoms with physical recovery and further cognitive decline following discharge. The results of the present study underline the need for active liaison between geriatricians and psychiatrists to improve the recognition and treatment of concurrent psychological problems during inpatient episodes.

There is increased recognition that the role and function of a consultant psychiatrist is ill-defined and associated with excessive workloads, low job satisfaction, high levels of stress and high rates of premature retirement (Kennedy & Griffiths, 2001). This has led to an examination and debate about how consultants in general psychiatry could adapt models of working to address these difficulties, and also face the agenda of change facing the NHS as a whole and the mental health services in particular (Kennedy & Griffiths, 2001; De Silva & Sutcliffe, 2003). These challenges are not, of course, unique to general psychiatry, but as yet, there has been little debate about how consultants in other specialities, including old age psychiatry, could begin to try and address these difficulties. This article aims to stimulate debate, by describing an adapted model of working adopted by two consultants in old age psychiatry within the Hull and East Riding Community Health NHS Trust.

Aims and MethodTo review the quality of information and advice contained in correspondence from old age psychiatrists to general practitioners (GPs) regarding the prescription of antipsychotic drugs for the management of behavioural and psychological symptoms of dementia. Discharge summaries (n=22) and subsequent out-patient review letters were examined and compared with evidence-based guidelines in two phases of an audit cycle; first in 2002 and latterly in 2005.ResultsPractice was below acceptable standards during both phases of the audit cycle, with an actual drop in the quality of explicit advice given to GPs in 2005, despite national publicity about the issues and guidance from the Royal College of Psychiatrists.Clinical ImplicationsThe prescription of antipsychotic drugs is associated with an adverse prognosis for people with dementia. As such, it is imperative that such treatment is regularly reviewed and time limited. Old age psychiatrists need to ensure that this message is communicated to their primary care colleagues.