in contrast to liaison psychiatric services for adults , liaison services for older adults are still in their infancy . a recent review in the uk outlined that despite an increasing number of specialist teams , most of the services ( 73% ) are provided by a generic , sector - based psychiatry model . one of recent college documents who cares wins ( 2005 )   provides a comprehensive outlook on the mental health care for older people in general hospital settings , including liaison mental health teams . this document is in line with the national service framework for older people   that calls for a skill - mix able to meet complex needs of older people . the liaison old age psychiatry ( lpoa ) services meet at least several of the nsf standards . similar policy has now been accepted by the recent nice guidelines for depression   that incorporate screening for depression in general medical hospitals . the role of psychiatric input in the medical care of elderly individuals in general medical settings has been further stressed in the document everybody 's business ( http://www.everybodysbusiness.org.uk/ , 2005 ) . this is a service development guide that sets out the key components of a modern older people 's mental health service , aiming towards improving people 's quality of life , meeting complex needs in a coordinated way , providing person - centred approach and promoting age equality . similarly , the most recent national dementia strategy   also aims of achieving better awareness of dementia , early diagnosis and high quality treatment at whatever stage of the illness and in whatever setting . all these policy documents support the need for further development and implication of loap in providing mental health care in medical setting for the elderly population , in the light of the high admission rates of elderly to medical wards who also have high comorbidity with mental health problems . since very little work has been done on the composition of liaison services for older adults , their role , and professional input in clinical settings , we have undertaken a 5-year prospective study to address the clinical activity of the newcastle liaison service for older adults . a newly integrated liaison old age psychiatry ( loap ) service was established in the newcastle area ( estimated population 41,000 over 65 years of age ) in mid july 2005 following a service review . the service covers four hospital sites in the city and takes referrals from all wards providing medical / surgical care to elderly medically ill patients ( currently 63 wards ) and 2 care of the elderly day hospitals . the team consists of three full - time registered mental health nurses ( rmns ; ah / mh , gc , and mc ) , one of whom is also a registered general nurse ( gc ) , 0.8 administrator ( yaa ) and an equivalent of one consultant old age psychiatrist ( ebm - l and as , who are also specialists in neuropsychiatry and general medicine , resp . ) . we have ad - hoc consultations from the psychology service for older adults , but no input from occupational therapy or social work for our service . data regarding loap activity has been continuously collected over the last 5 years , with an aim to monitor the team activity ( figure 1 ) . during the last 2 years ( since 2007/2008 to now ) , the acute medical and primary care trusts have undergone organisational changes , with various medical wards being reorganised , and reduction of bed capacity . in particular , medical wards on two hospital sites , newcastle general hospital ( now campus for ageing and vitality ) and walkergate hospital , were closed , and some of them were either transferred or amalgamated within existing medical wards on the other 2 hospital sites ( the royal victoria infirmary and the freeman hospital ) . in this paper , we report on the prospectively collected and analysed referrals over a period of 5 years , providing more detailed analysis regarding the nature of referrals and outcomes for 1 year period only ( 18 july 2005 to 17 july 2006 ) . please note data for 2007/2008 are not included in analysis , as a result of not fully completed audit for this period , due to loap service redevelopment in this period . the information about the number of admissions on all 4-hospital sites during the same period was obtained from the information services department , the newcastle upon tyne hospitals nhs foundation trust . parameters collected for analysis include : gender , age , reason for referral , source of referral , urgency of referral , number of follow - ups , diagnosis , response time , previous contact with psychiatric services , and current involvement with psychiatric services . clinical diagnoses were based on dsm - iv criteria ( 1994 ) . for statistical analysis , nonparametric analysis was used ( chi - square test ) to test the differences between sample proportions . we have also used percentage analysis to present data ( a part in 100% ) for better understanding of the collected data . during five - year period , a total of 4637 referrals were made to loap ( average of 927 referrals annually ; 60% females and 40% males ; figure 1 ) which represent an average of 4.3% of all nonelective admissions in the newcastle hospitals . the average age of patients referred to the service is 81 years old , the oldest being 104 and the youngest 60 years . only a smaller portion of the referred patients were below the age of 65 years ( average of n = 19 annually ; 2.05% ) . the majority of these patients were referred from stroke or rehabilitation wards where there is currently no services provided by adult services . the referrals were predominantly generated from acute medical ( 25.86% ) , care of the elderly ( 25.3% ) , rehabilitation ( 15.9% ) wards , with only 2.35.5% ( 17/73155/1005 for 2005/2006 and 2009/2010 year , resp . ) from the two geriatric day hospitals . these figures remain largely unchanged over the 5 year period service activity , with only marginal increase ( 19.9% ; 157/789 ) in referrals from rehabilitation wards in 2010 year . referrals to loap came from various sources : nursing staff ( 42.5% ) , medical staff ( 48.5% , mainly junior medical doctors , whereas the referral rate from consultants was 3.5% ) . 6% of the referrals to loap came from old age psychiatry services in the newcastle area , with only 3% from social services and medical occupational therapists . in the first year of the loap service activity , out of the 731 referrals to the service ( 2005 - 2006 period ) , the majority ( 85.3% ) were seen within the first 2 working days ( table 1 ) : 287 ( 39.3% ) within the same day of referral , 209 ( 28.6% ) the following day and 127 ( 17.4% ) the second day . the remaining 108 patients were seen within the 35 working days ( 7.8% on the 3rd day , 4.2% on the 4th day , and 0.9% on the 5th day ) . thus , 98.2% of the referrals were seen within 25 working days , and this response time has remained unchanged over the 5 years ( 20052010 ) ( table 1 ) . however , over the last 2 years , 87%93% of all referred patients were seen within one day in comparison to 68% for the first year ( table 1 ) . on average 2% of patients tend to be seen after 5 days waiting period , and this is largely due to them being either too physically unwell or attending a geriatric day hospital , in which case , the day of the following attendance of the day hospital was chosen for the patient to be assessed by a member of the loap . the workload between doctors and nurses is rather evenly distributed within the team ( table 2 ) . however , we have observed some variability in the distribution of the workload over the analysed 5-year period , and this reflects both the temporal changes in the team composition ( e.g. , prolonged sick leave , having a full time clinical trainee ) and the flexibility of the team members to accommodate these changes so that the team continues to provide undisturbed quality of clinical care . the majority of the referred patients ( up to 86% in 2009/2010 year ) had the first assessment with the liaison nursing team . however , over the last 2 years of service activity , there was an increase in joint ( doctor / nurse ) first clinical assessments ( 18%-19% for the 4th and 5th year ) . this is largely due to the complexity of the referrals , requiring multiple immediate decisions regarding diagnosis , urgent medical treatment , and behavioural management , as well as providing support and further education about the management of acutely mentally disturbed medically ill individuals . although at the beginning of the loap service , there was a substantial clinical activity regarding the need for telephone triage of referrals ( 25.2% ; 22% done by nursing versus 3.2% by medical staff ; table 2 ) , the telephone triage was substantially reduced to 7.4% in 2008 - 2009 and even further in the last year to 2.3% ( table 2 ) . similarly , the number of referred patients who were not seen dropped down significantly in 2010 [ from 16.5% ( 37/731 ) in 2005 to 2.4% ( n = 19 ) in 2010 ] . this may largely be due to improving of the response time ( as discussed above ) , and the service users becoming more familiar with the clinical activities of the loap service over time .   in the first year of the establishment of the loap service , 16% of all referred patients were not seen ( discharged before being seen , mental problems resolved before being seen , advice given over the telephone , or inappropriate referrals needing involvement of other service , etc . ) . using the telephone triage , we identified additional 66 patients that did not need assessment ( total number of 184 , 25.2% ) . however , when patients who have been seen only once ( e.g. , for capacity , level of care and/or transfer ) , were not included in the analysis , the remaining 306 patients were seen on average 2.4 times .   over the following 4 years , this figure remained largely unchanged , with the latest analysis showing that the majority of referred subjects ( up to 59% ; 442/789 ) requiring 3 or more followups , after the initial assessment . this suggests that the loap provides intensive followup of medically ill patients referred to the service whilst they are inpatients . over the 5 years loap activity the reasons for referrals did not change substantially , with some patients requiring two or more assessments ( average 1.3 requests per patient ; 1.11.6/patient ) ( table 3 ) . the most frequent reasons for referral were mood , level of care , assessment of cognition , medication advice , and behavioural changes . over the 5-year analysed period , there were no major changes with respect to the observed reasons for referral for mood and anxiety , level of care , medication advice , and behavioural problems . however , the biggest change in the loap activity was the increased number of referrals for cognitive impairment , from 19% in the first year to 49% ( table 3 ) . usually the assessment outcome reflected the reason for referral . in a more detailed analysis for the first year of the loap activity , our assessments detected twofold higher social issues and needs than those noted in the referral notes ( table 3 ) . the outcome measures of level of care and capacity assessments were somewhat lower than the reason for referral , but did not reach significant level . this study outlines several important clinical activities undertaken by the loap : ( i ) most referred patients ( up to 8692% ) are seen and assessed for their mental health needs within one day of contacting the loap team ; ( ii ) majority of first clinical assessments are done by the nursing liaison team ; ( iii ) the loap team facilitates in identifying a high rate of social problems in the medically ill elderly . high referral rates for mood disorder ( 28% ) , similar to previous studies which reported a higher rate of referrals to both liaison services in general ( 25.9% ; ) and liaison psychogeriatric services ( 18.4%30% ; [ 9 , 10 ] ) . significant increase in referrals for cognitive assessments ( from 19% to 49% ) , supporting the implementation of the national dementia strategy , enabling a rapid access to specialised mental health services , and facilitating early diagnosis and treatment for the newly diagnosed dementia subjects . underrepresentation of delirium ( 1.63.3% referral rates ) , due to delirium being treated actively by physicians , with only complicated cases with prolonged delirium referred to the service . however , we can not exclude the possibility that some forms of delirium ( particularly subsyndromal and hypoactive states ) can go undetected .   lowering referral rates for mental capacity assessments ( from 11% to 6% ) . these rates are similar to a previous report that included also younger medically ill ( age range 1791 years of age ; ) . the introduction of the mental capacity act 2005   resulted in lower referral rates , since many of medical / surgical wards conduct mental capacity assessments , and make referrals to the loap service only for complex mental capacity issues , or when second opinion is needed . this highlights the need for specific social services input to the loap team . in the clinical setting , this is further complicated by a lack of social workers with sufficient knowledge and experience in dealing with medical and mental health problems . this warrants the development of educational programmes to address these issues and integrate them into field practice . in the first year of the establishment of the loap service , the telephone triage screening played an important role in identifying 25% referrals that can be dealt this way . however , with reducing response time , and the loap service getting known within the medical milieu , unnecessary referrals appear to have been substantially reduced . the educational activities undertaken regularly by all members of the loap team , and targeted towards various service users ( nurses , social workers , occupational and physiotherapists , trainee doctors , medical and nursing students ) may have also contributed to changing the culture dealing with the elderly with mental health problems in medical environment . similarly to a previous study conducted with adults , our findings confirm both a greater turnover and intensity of followup over a short period of time by loap . most importantly , the data also provides further evidence that newcastle loap has accepted a liaison ( proactive ) model rather than a consultation ( reactive ) model of service delivery , as demonstrated by the intensity of followup per person ( up to 3 times / patient ) , and the increase of assessments in relation to requests ( 14.1% , as based on the 2005/2006 audit ) . however , this figure represents an underestimation of our activity , since in a recent audit , undertaken by our team , we have confirmed a high compliance with the nice guidelines for dementia   and depression , with 80100% and 70100% of referred subjects being routinely screened for cognitive impairment , and depression , respectively ( mukaetova - ladinska et al . , unpublished data ) .   in this study , two - thirds of all initial loap assessments were done by the liaison nursing team . liaison nurses ' role is not only in the routine clinical assessment , but also being actively involved in triage of medically ill patients , that requires at times telephone prescreening of referrals . we found the latter useful for clarifying the appropriateness of referral to loap , the degree of urgency of the referral , as well as obtaining more detailed clinical information . our liaison nurses , similar to the medical members , also liaise with other services involved in patients ' care , and also obtain additional relevant collateral information . surprisingly , a recent uk survey found that dedicated liaison psychiatry nurses for older people were engaged in only 14% of the services . based on our analysis , the liaison psychiatric nursing team provides valuable support to loap services , enabling prompt delivery of clinical care on 4 hospital sites and 63 inpatient wards . only limited data is available to assess the value of liaison psychiatric nursing input into the medical care of elderly individuals . a randomised control trial on a nurse - led mental health liaison service for older people failed to find a reduction in general psychiatric morbidity , but reported a modest effect on depression . the main contributions of a liaison nursing team seem to be facilitating effective discharge planning and continuity of care , and improving staff nurse care for older patients , as documented by the intensive followup provided by the liaison loap team over a short period of time ( majority of patients being seen 3 or more times ) . another study demonstrated that the nursing component to the liaison team , besides facilitating access of general hospital patients to specialist mental health care services , is particularly helpful for its focus on practical and care - oriented interventions . this is also the case for our service , where up to 40% of the clinical case load was due to level of care and management of behavioural problems , in which instances the liaison nursing rather than the medical team are involved . further studies are now needed to evaluate the liaison nursing staff contribution to effective loap service in other areas of nursing activity , including counselling , liaison with families , psychological support to patients , their relatives and medical staff , as well as educational support . in contrast to general adult liaison services , loap did not have a major portion of urgent referrals . this can only be explained by the loap team 's rapid response ( 8692% of all referred patients seen within one day ) . our report , similar to a previous study conducted on liaison adult services , confirms greater turnover of patients , as well as more intense clinical involvement over a brief period of time having an average workload of 3046 patients at any one time for the loap service . a recent metareview on liaison psychiatric services outlined the need for more evidence - based research to guide liaison service development and planning . the findings of our study need to be taken into account in further old age psychiatry ( oap ) service development , which should acknowledge loap clinical activity in the context of the full clinical service when making provision for the further development of oap services and care pathways . development of good collection data tool will be useful as a guide to service developments . casemix has been reported to be such tool , which can also provide information about costs associated with the case of medically ill patients with mental health problems . however , this tool has also its limitations ( e.g. , can not provide information about change of diagnosis and treatment , recording of follow - ups and outpatient assessments , etc . ) . although already accepted in australia , it remains to be seen whether this or similar tools can be used successfully in monitoring the loap activity in the uk .
liaison old age psychiatry services ( loap ) have begun to emerge in the uk and further development of the service is supported by the latest health policies . since qualitative and quantitative studies in this area are lacking , we have undertaken a detailed quantitative prospective review of referrals to the newcastle loap to evaluate the clinical activity of the service . 
 we report high referral rates and turnover for the loap service . 
 reasons for referral are diverse , ranging from requests for level of care and capacity assessments and transfer to other clinical services to management of behaviour , diagnosis , and treatment . 
 we outline the value of a multidisciplinary model of loap activity , including the important role of the liaison nursing team , in providing a rapid response , screening , and followup of high number of clinical referrals to the service .