Addressing inequalities between mental and physical healthcare in older adult healthcare is imperative for safe patient care. This evaluation of services at The Harbour mental health hospital, Blackpool, UK gives insight into parity of esteem and prompts investigation into the clinical decisions of doctors working in older adult mental healthcare.

With the launch of the Fair Deal for Mental Health campaign in 2008 the Royal College of Psychiatrists made a commitment to ensuring that ‘training for psychiatrists promotes the recovery approach’. National guidance emphasises the universal applicability of the recovery values for anyone of any age who has a significant mental health problem. Yet there has been little thinking as to whether the recovery approach is applicable to old age psychiatry and particularly to dementia care. This article explores the striking similarities between a recovery-oriented approach and person-centred care, the particular challenge posed in dementia care and the benefits of a collaborative approach in pursuit of common purposes.

The role that carers play in supporting older people with mental health needs in the community is well recognised by professionals and in current government policy. This article promotes the view that a systematic planned approach that engages the carer as an integral part of the system of care has potential benefits for patients, carers and services. Ways of working in partnership are outlined and evidence that psychosocial interventions with carers are effective is briefly reviewed. Examples of individual and group interventions for dementia carers are given, drawing on clinical experience and research literature. Areas for further development are highlighted, including greater partnerships with carers in primary and continuing care, as well as at the level of planning and service development.

Depressive disorder in those over the age of 60 has many clinical similarities to depression in younger adults, but biological changes related to ageing may necessitate a different approach to treatment. We present an evidence-based review of treatment for late-life depression, focusing on pharmacological approaches, including monotherapy, combination and augmentation strategies. Selective serotonin reuptake inhibitors such as sertraline and citalopram are well tolerated, have the advantage of a favourable side-effect profile, and are good options for first-line treatment. Second-line treatment options include combination therapy with a second antidepressant, or treatment augmentation with an antipsychotic or lithium. We also consider evidence for nonpharmacological treatment strategies, including psychological therapy and neurostimulation. Finally, we summarise evidence for treatment of depression in patients in dementia.

The relationship between alcohol use and cognitive impairment has been notoriously difficult to disentangle. We present what is known about cognitive impairment associated with alcohol use/misuse, covering the spectrum from mild and subtle cognitive change through to severe alcohol-related brain damage, including Wernicke-Korsakoff syndrome. We highlight aids to the diagnosis and management of these conditions, and emphasise the benefits of prompt treatment on outcome. We also review progress in understanding their neurobiology. Suggestions for possible service configuration based on both our clinical practice and national guidelines are given.

This article discusses the importance of residence capacity – an individual's mental capacity to decide where they should live – and suggests how it should be assessed. People with dementia or intellectual disabilities, as well as those with other mental disorders, are sometimes required to make this decision. Assessments of capacity must be conducted with considerable care, given the implications for the individual and for their human rights. The assessment must be objective and functional: the assessor must be able specifically to demonstrate a lack of decision-making ability. Yet assessments of capacity still require evaluative decisions to be made. We suggest some basic information that should be conveyed to the person faced by the prospect of a change of residence where there is a doubt about capacity.

Assessment of mental capacity is, or should be, a regular part of daily clinical practice in general hospitals. It is both particularly important and potentially complex in relation to an older person with dementia wishing to return home despite concern over perceived risk. Case law provides some guidance, but an ethical duty remains for clinicians to develop and hone their professional judgement in this increasingly important area of practice.

Psychiatrists may be daunted by the prospect of undertaking a neurological examination. In this article we briefly review the neurological signs that may be seen in the context of some common neurological disorders of cognition and movement which may present with neurobehavioural symptoms and therefore may be seen initially by psychiatrists. This approach emphasises that neurological examination is not simply an operationalised procedure but an interpretative process. We propose a minimum neurological examination suitable for use by psychiatrists. Many of the signs included are relatively simple to observe or elicit, require no special equipment, and the examination techniques involved are easy to master.

This article describes the establishment of a clinician as a referral coordinator to manage referrals into a typical mental health service for older adults. The referral coordinator model, which include risk assessment at the point of referral and accurate comprehensive collection of referrer data, is compared with other traditional and more recent models of referral management. The importance of thorough collation of clinical information to produce a preliminary risk assessment and the stages of development of an algorithm as a core requirement to guide the coordinator and ensure consistency over time are described. An initial analysis of local referrer data and trends over a period of 3 years is presented to emphasise the educational opportunities offered by taking control of referral management.

This overview considers causes of disordered eating, including eating disorders, in older people. Eating disorders are becoming more common in older adults and research has shown a related mortality of 21%. The wide range of medical and pharmacological causes of weight loss in older people means that eating disorders may go undetected, occurring insidiously and surreptitiously.

Historically, Parkinson's disease was viewed as a motor disorder and it is only in recent years that the spectrum of non-motor disorders associated with the condition has been fully recognised. There is a broad scope of neuropsychiatric manifestations, including depression, anxiety, apathy, psychosis and cognitive impairment. Patients are more predisposed to delirium, and Parkinson's disease treatments give rise to specific syndromes, including impulse control disorders, dopamine agonist withdrawal syndrome and dopamine dysregulation syndrome. This article gives a broad overview of the spectrum of these conditions, describes the association with severity of Parkinson's disease and the degree to which dopaminergic degeneration and/or treatment influence symptoms. We highlight useful assessment scales that inform diagnosis and current treatment strategies to ameliorate these troublesome symptoms, which frequently negatively affect quality of life.

This article reviews what we should tell patients and carers about dementia. The attitudes and views of patients, carers and peer groups are examined, as is the practice of doctors and other professionals working in dementia care. Factors influencing the decision to disclose the diagnosis of dementia, including the degree of certainty of the diagnosis, the degree of insight of the patient and the severity of the dementia are considered. Advantages, disadvantages and ethical issues of disclosure are discussed, as well as when or whether and how to disclose the diagnosis. Flexible guidelines regarding the process of disclosure are introduced.

We review the various functional cognitive disorders (FCDs) – complaints about memory function or another cognitive process in the absence of relevant neuropathology. These are increasingly coming to the attention of psychiatrists and neurologists and FCD encompasses some newly recognised conditions in addition to classic types such as pseudodementia and psychogenic amnesia. The clinical features, neuropsychological findings and treatment are presented and discussed.

Mania in late life is a serious disorder that demands specialist assessment and management. However, it is greatly under-researched, with only a paucity of studies specifically analysing older populations. The mainstay of the old age psychiatry workload will inevitably be concerned with assessing and managing dementia and depression, but the steady rise in the aging population with longer survival means that there will be an increase in absolute numbers of older people presenting with mania. There are no specific treatment algorithms available for mania in late life. This article reviews mania and hypomania in late life and concentrates on diagnosis, assessment and treatment, as well as on the management considerations associated with this important age group.

Neuropsychological assessment, in the broader sense, is common clinical practice with older adults because of the widespread use of mental status examinations and dementia rating scales. In the more narrow sense, a neuropsychological assessment conducted by a clinical psychologist or clinical neuropsychologist is used less frequently and for more specific purposes. This paper outlines these uses and provides a brief overview of the different types of test that might be used, with a clinical example to illustrate the type of information gained. This review is designed not to be comprehensive, but to provide a pointer towards the latest trends in test development.

Over 95% of cases of dementia are attributable to Alzheimer's disease, vascular, Lewy body and frontotemporal dementia, and a few other common causes. In this article we consider some of the rare and unusual causes that account for the remaining 5%. Categorising them according to aetiological group (degenerative, vascular and infectious causes, and human prion diseases), we discuss the presentation of these forms and reasons for variations in estimated prevalence rates in the general population.

Psychotherapies with older people have been slow to develop, both theoretically and operationally, in the UK. This is due to ageism and the predominance of models of psychological development relevant to children and younger adults. Despite this, many have applied their practice and skills to psychological work in old age psychiatry, countering the dominance of the ‘organic’ model. An evidence and practice base exists to suggest that cognitive–behavioural therapy, interpersonal therapy, cognitive analytic therapy, psychodynamic and systemic approaches can help in a range of psychiatric problems in older people, including affective disorders, personality disorders and dementia. The inclusion of older people in existing psychotherapy services and the development of networks of practitioners whose support and supervision are encouraged are likely to be positive ways forward.

An initial psychiatric assessment of elderly people at home is an important component of many old age psychiatry services. This article explores the clinical aspects of conducting such assessments and the skills required in addition to those brought to a standard psychiatric interview. Safety considerations and risk management when conducting home assessments are also discussed.

Balancing risk and safety in long-term care settings can be challenging while providing and respecting patients’/residents’ needs and rights in terms of sexual expression. We look at factors affecting the expression of sexuality, including staff attitudes and reactions, and the lack of policies governing sexuality. We review the various statute and case law, other legislative and quasi-legal provisions governing sexuality and sexual expression. Finally, we consider the need for clear policies and training for both staff and family members.

Very little attention has been paid to the invisible epidemic of substance misuse among older people in the UK. This article looks at the prevalence of substance misuse in the people over the age of 60. The reasons for difficulty in diagnosing substance misuse are explored and ways to improve diagnostic ability are discussed. Substance misuse leads to severe physical and psychiatric morbidity that is being managed by meagre resources. The article provides recommendations on specific issues related to interventions, biological and psychosocial, and training of psychiatrists.