The Royal College of Psychiatrists defines the 'graduates' as people who have had enduring or episodic severe mental disorder in adulthood and have reached the age of 65 years. Estimates of the most severely affected range from 11 to 60 per 100 000.1 This group of people seems to be uniquely disabled by a combination of social, mental health and physical disadvantages and there is a risk of falling between general adult, rehabilitation services and old age psychiatry.2

There has been an ongoing debate about identifying the best practice in the management of this group of patients who often have spent most of their lives in the old psychiatric asylums. The recommendations include identifying all graduates within the service followed by a full assessment of the patients' health and social care needs and the implementation of a care plan to meet these needs, to be reviewed at least annually. According to the report, the medical responsibility will rest with a principal in general practice or a consultant psychiatrist, and maintenance of continuous review should be the responsibility of the case manager.1

The Recovery and Rehabilitation Team (RRT) in Newham was founded in 1988 to facilitate the discharge of groups of patients from Goodmayes hospital (Essex). Patients discharged to residential care units and other supported schemes usually had spent many years in the institution and the team's remit after relocation into the community was mainly monitoring of mental health by conducting multiprofessional reviews in the care homes, crisis intervention, and the promotion of social networks and leisure activities. Over the following years, the team also received many referrals from Community Mental Health Teams (CMHT) for continuing care of people suffering from long term and severe mental illness. Today, a considerable proportion of these patients have 'graduated' into old age and the current percentage of the total caseload is now nearly 25%.

Our survey was carried out following an independent review by the Health and Social Care Advisory Service (HASCAS) in January 2005 for the rehabilitation services provided in the London Borough of Newham. The recommendations included an assessment of needs for all patients 65 years of age or over, using the Camberwell Assessment of Needs for the Elderly (CANE) .3This is a comprehensive needs assessment tool suitable for use in a variety of settings. It has been successfully used for older people in primary care, sheltered accommodation, residential homes, nursing homes, and mental health services for older people. However, it has not been used before to specifically assess the needs of older people who have graduated within the general adult mental health or rehabilitation services. CANE was found to be a valid and reliable tool and easy to use by different professions.4

The RRT database was searched for all patients aged 65 years or over. This yielded 52 names, who were then approached between June and September 2005 for a comprehensive assessment after an explanation about the survey. CMHTs were asked for numbers of graduates in their services, obtained from the respective databases.

The CANE is a structured, 24-item questionnaire covering different areas (see table 2), including social, psychological, mental health and physical needs. It is easily applicable by different professions and requires on average about one hour of assessment time. It measures met and unmet needs and obtains views from patients, carers, staff and the rater. Assessments were carried out by members of the multi-disciplinary team that consists of a consultant psychiatrist, the team manager, two senior clinical medical officers, two clinical psychologists, two occupational therapists, two social workers, five community psychiatric nurses and four community support workers. All raters had received a one day training provided by Juanita Hoe, one of the contributors in producing the CANE.

The collected data were analysed using Microsoft Excel

The total number of patients aged 65 years and above under the care of the rehabilitation services was 52 (24.5% of the total caseload of 212 patients). There were a further ten patients under the care of the adult CMHTs in Newham. Attempts were also made to determine the number of the graduates under the care of mental health services for older people, but these were unsuccessful.

Out of the 52 patients, 50 could be assessed using the CANE, two patients declined the assessment and the assessment sheet of one patient could not be traced, giving a total of 49 patients and a response rate of 79% of all known 'graduate' patients under the care of adult mental health services.

Results describing patient characteristics including mean age, gender, type of accommodation and diagnosis, are summarized in Table 1.

Table: 1 Demographic Details

Nearly two-thirds of patients were female, three-quarters of this population were living in supported living or residential care and 90% were suffering from a severe mental illness (two-thirds from schizophrenia).

The met and unmet needs of this population are described in table 2.

Regarding unmet needs, the highest value (nearly 37%) was on daytime activities, which 18/49 people scored. This is followed by company (22.5%), which was a problem for 11 people. Eyesight or hearing also scored strongly (20.5%), followed by money (18.4%) and different problems in areas such as food and self-care, physical health and psychological distress (each 12%). Problems with suicidal behaviour and drug or alcohol abuse were not evident in terms of unmet needs.

Our results show that the majority of needs identified by the CANE were adequately met by the current service provision or were only identified as unmet needs by a tiny minority (table 2). Since the vast majority of the patients were living in either residential or supported accommodation (25.51% and 26.53% respectively), items associated with domestic needs and activities appeared to be met to a great extent, e.g. accommodation (44.90% no need, 44.90% met need).

In terms of items related to mental state, the majority of patients seemed to be satisfactorily managed and receiving appropriate treatment. The raised number of patients who suffered from psychological distress could be explained by other psychosocial factors such as lack of daytime activities and lack of company which have been identified as the major unmet needs in our population.

A recent article,5 named risk of harm, unpredictability of behaviour, poor motivation, lack of insight and low public acceptability as the major reasons for social disability. However, in our review, over one-third of people clearly expressed the wish for more daytime activities, where the named disabilities might prevent a more active and satisfied lifestyle. In the interviews, it transpired that people mostly wished for an outreach service providing social contact, befriending and activities. The majority of people in our population seemed to be rather reluctant to access general facilities, like day centres for the elderly.

As we have assessed most of the patients under the care of adult mental health services, this survey should be able to inform service planning about the needs of this population. The development of an outreach service offering day time activities including a befriending component could be a challenge for the responsible service providers, e.g. social services, adult community mental health services and old age psychiatry.

Table 2: Levels of needs as rated by the rater (n=49)

The specific physical needs (especially eyesight and hearing) make it necessary for services to monitor these closely and implement this in the care plan in liaison with General Practitioners. specific group of patients, as the respective unmet needs might be dependent upon the level of service provision.

Similar reviews should be undertaken by community mental health services in other boroughs to highlight the needs of this

Acknowledgements: We would like to thank all members of the community rehabilitation team in Newham and all service users for their help and contribution.

Competing Interests: None Declared

1. Royal College Of Psychiatrists, Caring for people who enter old age with enduring relapsing mental illness (‘graduates`) (Council Report CR110). 2002, London: Royal College of Psychiatrists.
2. Jolley, D., Kosky, N. & Holloway, F. , Older people with long-standing mental illness: the graduates, Advances in Psychiatric Treatment, 2004; 10: 29-34
3. Orrell, M., & Hancock, G. , CANE: Camberwell Assessment of Needs for the Elderly, London: Gaskell 2004
4. Reynolds, T., Thornicroft, G., Abas, M., et al, Camberwell Assessment of Need for the Elderly (CANE) Development, validity and reliability. British Journal of Psychiatry 2000; 176: 444-452
5. Karim, S. & Burns, A. Invited commentary on: Older people with long- standing mental illness: the graduates. Advances in Psychiatric Treatment 2004; 10: 34-36