Elder abuse is a serious problem-each year hundreds of thousands of seniors are abused. Although the problem is described, defined and legislatures exist in many countries elder abuse is not still recognized as public health problem. Red Cross of Serbia has organized education of volunteers in Elder Abuse and Discrimination topic which is very important in sensibilisation among community-dwelling. Volunteers (N=226) were informed with generally accepted definitions, research in the field and legislature in Serbia concerning this issue and proposed network for prevention of elder abuse. Interactive workshops gave us data: distribution and types of elder abuse in their local communities and obstacles in referring and positive examples from practice as problem solving models.

In Turkey, in the families who moved from rural settlements into city, the young peoples go to work and the grand parents take care of the little children at home. When the grand parents become old, there will be no one who can take care of them. This situation shows two solutions: to move back to their native environment or to be settled in a nursing home. If they have no where to go, these nursing homes are their only chance.

The private nursing and caring homes, from the point of quality, are not in the same equality. The low-quality institutions are more familiar to the abuse. The residents of these institutions expect kindness, affection and warmth, but they never receive these expectations.

A new kind of elderly abuse in Turkey is the Automatic Transfer Machines thefts. On the paydays the thief comes next to the machine, offers help to the elderly who came to take his retirement salary from the machine; the thief takes the ATM card, put in the hole, ask the password, enter it and take the money and run with a high speed. The poor old person looks after.

There are no criminal codes yet which cover the elderly abuse in Turkey. Those kinds of incidents are taken as ordinary police incidents. The administration is now in preparation of a new program and a new regulation.

Aging of the world population risks to be accompanied by an increase of chronic health problems, and most particularly of mental health problems. To face to these problems the organization of care and education in old age psychiatry is still quite insufficient worldwide. Like in all countries in this part of the world, the geriatric psychiatry is still not enough represented. Only in some countries in Europe old age psychiatry is a recognized specialty (18% of European region countries responded at a WPA survey of teaching and training in OAP). The number of professionals working in the field is still very low to satisfy the needs of care of elderly with mental disorders. There is inadequate training for formal caregivers and lack of support for informal ones. This is the reason to support the development of postgraduate education on old age psychiatry as a priority in Europe. We discuss about teaching and training in old age psychiatry, psychiatric and psychological expertise exams and the assessment of competence in dementia and ethical aspect of care and research in elderly demented people.

We also present some aspects of elderly sexuality and abuse and about mental health from strategy to reality and dementia care in different Europe countries.

Chairs: Horacio Firmino-Portugal, Nicoleta Tataru-Romania.

Speakers:

1. 1. Alexandra Milicevic-Kalasic, Serbia: ‘Mental Health in Serbia-from Strategy to Reality’.

2. 2. Horacio Firmino, Portugal: ‘Education on Old Age Psychiatry at Europe: facts and proposals’.

3. 3. Ilkin Icelly, Turkey: ‘Elderly abuse in Turkey’.

4. 4. Jerzy Leszek, Poland: ‘Dementia care in Poland’.

Poland one of the central European countries has a population of about 40 milion, 7,4% of whom aged 60 and over.

The number of elderly in Poland is expected to rise dramatically to 16% by 2020. The health status of Poland’s middle aged and elderly population is not satisfactory; there is high mortality from cardiovascular diseases and malignancies. Poor health status results in higher consumption of health care especially by the elderly. For all mentally ill people there are about 2000 psychiatrists in university psychiatric clinic, psychiatrics departments and in ambulatory practice. A very small number of of psychiatrics(from general number 2000) are qualified in gerontopsychiatry in Poland. Among growing number of elderly patients are persons with dementia, incl. dementia Alzheimer’s type (about 250 000 patients). For their disposal are 4 psychogeriatry wards with small number of beds (average 15 for one ward). Memory clinic, aimed at elderly diagnosis, therapy and rehabilitation for patients with dementia are planned. First centre of this kind(with programme of training in psychogeriatry) for Alzheimer patients was opened in 2007 yr in Scinawa, near Wroclaw (Lower Silesia Province). Important role in caring of dementia patients is playing by families and self-service organization of families. The first organization of this kind was founded in Lower Silesia in 1991 (Wroclaw) as The Lower Silesia Alzheimer Association Family Support.

Dementia care in Poland as not satisfactory up to know, is currently under discussion and a new concept of caring will be prepared.

Old Age Psychiatry is a branch of psychiatry and forms part of the multidisciplinary delivery of mental health care to older people.

The specialty of psychiatry of the elderly requires a grounding in general psychiatry and in general medicine as well as training in the specific aspects of both psychiatric and medical conditions as they occur in older people. Psychiatry of the elderly should be taught in the variety of settings in which it is practised.

Training in mental health care of older people should be offered at both undergraduate and postgraduate level and also during continuing professional development.

It is important to recognise that in some countries, resources, especially in terms of mental health professionals, are very limited. In these countries it will be necessary to establish sensible priorities for mental health problems of the elderly.

In this presentation we goes to consider some ideas to develop educational training at European Countries.

The nature and frequency of sexual activity among the elderly are unknown. The elderly often view sexuality as an expression of passion, affection, admiration and loyalty; a renewall of romance. Sexual activity is a means for the elderly to affirm physical functioning, to maintain a strong sense of identity and to establish self-confidence.

However, not all elderly persons have positive attitudes towards sexuality. Even healthy elderly persons may internalize the stereotypes towards aging. The elderly will be viewed as:

• • Asexual invalids;

• • Dirty old men;

• • Lecherous old women.

National Mental Health Policy and Action Plan was adopted in January 2007 by Government of Republic Serbia. Elderly persons were brought in focus as growing population with growing number of elderly with mental disorders and services incapable to face this challenge. Last October, Institute of Gerontology promoted Geriatric Manual, published and distributed in Primary Care Facilities in Belgrade as it was supported by Municipal Secretariat of Health. Psychogeriatric issues took a part in Geriatric Manual with recognition of early detection of psychological disorders in elderly and importance of diagnose acute confusion state in everyday practice. It was just the beginning of education of primary care physicians in Belgrade. There were many meetings in Ministry of Health with aim of spreading this knowledge all around Serbia. Mental Health Department of Institute of Gerontology has ran education in psychogeriatric issues for primary care within Project supported by Municipal Secretariat of Health, Belgrade with main aim of developing network for caring of elderly mentally disturbed people. Very important part of network is within social institutions and in a private sector. On other hand in the same time round table within project was a part of antistigma campaign in primary care facilities and in community. A baseline report on health and social institutions accommodating with special focus on elderly with mental disorders were launched under WHO support.

During the twentieth century, many behavioural and biological theories of aging have been advanced that ageing is a multidimensional phenomenon. Ageing is a progressive decline in function and performance, which accompanies advancing years. Cicero noticed that the old people preserved their intellects if they maintained their interests.

To the social, economical and medical problems that old age arises to the society, one may add the continue increase of old people proportion in the general population. The ageing of population is becoming a reality in developed and in less developed countries too. We talk about a conceptual definition of normal ageing and also about successful and morbid ageing. Normal ageing is an ageing process without any clinical somatic or mental disorder and a morbid ageing is characterized by a process presenting clinical disorders which affects the somatic and mental health, the successful ageing being an ageing process in a favourable environmental conditions to promote individual development. We can consider not only the presence/absence of a disorder but also its impact in someone's life. The functioning capacity loss could be considered as a marker of the presence of a clinical disorder.

Stigma remains a major obstacle to ensuring access to good care for elderly with mental disorders, these patients suffers of a double jeopardy (old age and mental disorders). Both stigma and discrimination against these old persons depend on the type of mental disorder and we have to protect them against discrimination and improve their quality of life.

So far, successful ageing is usually a dream or presumed as an unreachable goal for those people with major psychotic disorders, especially the schizophrenia and bipolar I disorder. Thanks to the improvement of general health, better treatment, and decreased discriminations, there are more and more people with major psychotic disorders live into later age. Due to the persistent and active psychotic symptoms, the impaired cognitive performance and malfunctioned supportive system, most of our patients appeared less prepared for their later life. Unfortunately, how and what will they live through the jeopardy has been neglected and under discussed as there are few literatures in this topic.

The author will search the articles and theses relevant to this issue from the literature through evidence-based approaches and discuss it in three major parts. The first part of the presentation will be the review of the past condition and the facts of current situation of the people with major psychotic disorder in later life. Epidemiological study profiles with the frame of traditional biopsycho-social construct will be reported. The second part will be the possible ways these people may adopt to achieve successful aging with their efforts in a self-management model. In the third part, the author will propose possible and feasible programs that promote active living for the people with major psychotic disorders, aiming at the goal of successful ageing.

In conclusion, the author hopes that this presentation could become the morning bells and arouse the attention in this field.

Even though bipolar disorder is suggested to have a benign course with episodes and remissions, it has been shown that interepisode functioning of bipolar disorder is not so good. Subclinical residual mood symptoms are found to be in 24% of bipolar patients during remission. Furthermore, it appears that 30-60% of individuals with bipolar disorder fail to regain full functioning in occupational and social domains. In cognitive domain, euthymic bipolar patients demonstrate relatively marked impairment in aspects of executive function such as processing speed and verbal fluency, sustained attention, and verbal memory.

It is estimated that 30-50% of largely remitted patients fail to attain premorbid levels of psychosocial functioning due to their cognitive impairment. It is also suggested that the subsyndromal residual depressive symptoms have substantial effect on the persistence of cognitive and psychosocial impairment after remission. Thus, residual symptoms play an important role in the inter-episode functioning of the bipolar patients.

In the assessment of interepisode functioning, subjective QOL in bipolar patients may not accurately reflect objective functional outcome status. Especially, in the subjective assessment of cognitive functions, bipolar patients tend to over-estimate themselves. There is only weak to moderate correlation between subjective cognitive complains and objective cognitive tests. Therefore, it would be more accurate to assess the inter-episode functioning of the bipolar patients via objective tests and ratings.

The concept of disability has changed enormously, from a notion of handicap (ICIDM,1980) to the idea of person with disability (ICF,2001). The ICF considers three different levels of disability: body, person and environment, offering a possibility to address it in a universal, integrative and interactive perspective. The utility of the ICF in shifting the attention from a medical to a biopsychosocial perspective is therefore accepted. Having 1464 categories, it is hardly applicable to clinical practice and research. Mood disorders are characterized by a variety of psychiatric and somatic symptoms, associated with a significant loss of quality of life and functioning. Practical tools, such as Core Sets, that cover the spectrum of problems are needed. ICF Core Sets have been developed for depression and are currently being developed by our group for bipolar disorder. The ICF Comprehensive Core Sets for depression is the second larger among 12 Comprehensive ICF Core Sets for chronic disorders. This fact reflects the complex limitations in functioning and the numerous interactions with environmental factors. From the first version of the ICF Core Sets for depression as well as the preliminary studies for the bipolar disorder's core sets mental functions are mostly represented among the body functions domain. Few aspects important to mood disorders, as suicide, have been found to be relevant from both a systematic literature review and an expert survey in BD and in the consensus conference were the Core Sets for depression were establish but are not covered in the ICF.

Social psychiatry has always suffered from an inappropriate diagnostic classification system. Social psychiatry is directed toward the integration of disabled persons into their family, profession and society in general. As such the exclusive assessment of symptoms is only of minor value for the objectives of social psychiatric approaches. It lies in the core of social psychiatry to assess patients’ problems with functioning. This has already been possible by using the International Classification of Impairment Disability and Handicap (ICIDH) which primarily focused on the deficits of affected persons. The International Classification of Functioning, Disability and Health now allows to classify not only deficits of affected persons but also their resources. Disability is always defined as an interaction of deficits in functioning on one side and the environment on the other side. This is a much more dynamic approach to rehabilitation than previously conceptualized.

A good example for a modern view on the deficits and resources of affected persons is their occupational functioning. Only lately professionals almost without exception agreed on the fact that it is impossible to reintegrate or rehabilitate affected persons in the first labour market. For that reasons disabled persons were excluded from the labour market and trained and employed mainly in sheltered workshops. Today using a more interactive approach to occupational rehabilitation, professionals are much more optimistic to integrate disabled persons in the first labour market. This development in occupational rehabilitation will be described shortly and related to the International Classification of Functioning Disability and Health.

Modern psychiatry must take into account more and more the so called cultural differences in its practice. These differences are not merely the evident cultural aspects of diverse ethnic origin, but also the differences determined by economic, social and cultural reasons.

The main paradox of our times is that we try to believe on the ilusion of people homogenicity consequent to the globalization process, when we see that everyone access to the same markets, products, services and news or when we see that everyone can communicate with everyone all over the world. This ilusion is reinforced by the higher cosmopolitism levels of our towns, where we can see people from different ethnic or cultural backgrounds sharing the same space in a reasonable harmonic way.

However, this ilusion is covering the intimate aspiration of any person or group to preserve his identity and afirm his own values. In fact we are living in a society that expresses multiethnic, multiculture and multisocial differences in an interdepedent diversity.

Hospitals are in a way microsocieties where this paradox emerge or in purely sociologic terms described above, but also by the clinical expression of this diversity.

CL-Psychiatry is the field where this subject must be known and researched. This presentation will reviewed the situation.