Origins and Purpose of the HoNOS 65+
The Health of the Nation Outcome Scales for Elderly People (HoNOS 65+) emerged from the broader Health of the Nation Outcome Scales (HoNOS) developed in the UK. While the standard HoNOS is used for working-age adults, clinicians recognised the need for an adapted version that more accurately captured the unique physical and cognitive issues impacting older individuals accessing mental health services. The HoNOS 65+ was specifically designed to be used by mental health professionals to assess psychiatric symptoms and psychosocial functioning. Its primary use was to measure outcomes, allowing clinicians to evaluate a patient's condition before and after interventions to determine the effectiveness of treatment.
The Evolution to HoNOS Older Adults (HoNOS OA)
Following two decades of widespread use in the UK, Australia, and New Zealand, the HoNOS 65+ underwent a review to improve its reliability, validity, and clinical utility. This review aimed to remove ambiguities and inconsistencies from the scoring glossaries and align wording where needs were similar across different age groups. The updated version, published in 2018, was renamed the HoNOS Older Adults (HoNOS OA) to better reflect the changing demographics of the aging population and the variation in age cut-offs for specialist services. While the fundamental purpose remains the same, understanding this update is crucial for contemporary clinical practice.
The Twelve Domains of the HoNOS 65+
The HoNOS 65+ is composed of 12 distinct scales, or items, that cover four key areas of functioning: behavioural, symptom, impairment, and social. Each scale is rated individually based on the most severe problems observed, typically over the preceding two weeks. The 12 scales are as follows:
- Behavioural Disturbance: Covers aggressive, overactive, or disruptive behaviour.
- Non-accidental Self-Injury: Assesses any self-harming behaviours or threats.
- Problem Drinking or Drug Use: Looks for substance misuse issues.
- Cognitive Problems: Evaluates issues related to memory, concentration, and orientation.
- Physical Illness or Disability Problems: Considers the impact of physical health on mental well-being.
- Problems with Hallucinations and Delusions: Rates the severity of psychotic symptoms.
- Problems with Depressive Symptoms: Focuses on mood disturbances like sadness, anhedonia, and low energy.
- Other Mental and Behavioural Problems: A catch-all for other significant issues not covered by items 1–7.
- Problems with Relationships: Assesses difficulties with social or supportive relationships.
- Problems with Activities of Daily Living: Rates the impact of problems on routine tasks like hygiene and dressing.
- Overall Problems with Living Conditions: Considers the effect of the living environment.
- Problems with Work and Leisure Activities: Assesses the quality of daytime activities and work.
Understanding the HoNOS 65+ Scoring System
Each of the 12 scales is rated on a five-point scale from 0 to 4, where a higher score indicates a more severe problem.
- 0: No problem
- 1: Minor problem requiring no formal action
- 2: Mild problem but definitely present
- 3: Moderately severe problem
- 4: Severe to very severe problem
Supplementary values like '9' are used for 'Not known or not applicable'. The total score is the sum of the individual scale scores, which can range from 0 to 48. This total score provides a summary of the overall severity of a patient's psychiatric symptoms and functional impairments, allowing clinicians and service providers to track progress over time.
HoNOS 65+ vs. General Mental Health Assessment
To understand the specific value of the HoNOS 65+, it is helpful to compare it with general mental health assessment approaches. Its structured, multi-domain format is particularly suited for older adults, who often present with complex and overlapping physical and mental health issues.
| Feature | HoNOS 65+ (and HoNOS OA) | General Mental Health Assessment | Comparison |
|---|---|---|---|
| Target Population | Exclusively older adults (age 65+) with mental health issues. | Broadly applicable to all adults, or targeted by specific diagnostic criteria. | HoNOS 65+ is specifically tailored to the unique needs of older patients, including cognitive and physical problems. |
| Structure | 12 specific scales covering behaviour, symptoms, impairments, and social functioning. | Varies widely, from unstructured clinical interviews to symptom checklists like the PHQ-9 (depression) or GAD-7 (anxiety). | More comprehensive and systematic across a range of relevant geriatric issues. |
| Focus Areas | Includes domains specific to older adults like cognitive problems, physical illness impact, and activities of daily living. | Focuses primarily on psychiatric symptomatology and general functioning. | Offers a more holistic view of an older person's health, linking physical and cognitive status to mental health. |
| Primary Use | Routine outcome measurement in mental health services for older adults. | Diagnostic formulation, treatment planning, and monitoring response to treatment. | Functions as both an assessment and a measurable outcome metric over time. |
Validity, Reliability, and Limitations
Early studies found the HoNOS 65+ to have satisfactory reliability and reasonable validity when compared to other established measures for older people. It was also shown to be capable of discriminating between people with different types of illnesses, such as dementia versus functional psychiatric disorders. Inter-rater reliability, which measures the consistency between different clinicians' ratings, was generally good to very good for most items, though some scales, like 'cognitive problems' and 'problems with relationships,' showed more variability.
However, like any clinical tool, it has limitations. The HoNOS 65+ was primarily intended for routine outcome measurement, not as a diagnostic tool. The quality of the scoring relies heavily on the clinician's training and interpretation of the provided glossary. Furthermore, some experts have noted that the instrument can benefit from further refinement, particularly in areas like relationships and activities of daily living. The subsequent development of the HoNOS Older Adults (HoNOS OA) addresses many of these issues, improving clarity and updating the glossary to reflect modern clinical practice.
Conclusion: The Impact of the HoNOS 65+ on Senior Care
The HoNOS 65+ score has provided a crucial framework for evaluating and tracking the progress of older adults in mental health services for over two decades. By standardising the measurement of symptoms and functional impairments, it has enabled better clinical care, service monitoring, and research. The evolution to the HoNOS Older Adults reflects a continuous effort to refine and improve clinical tools to best meet the complex and specific needs of the aging population. For those involved in geriatric mental health, understanding how this scoring system works is foundational to providing effective and measurable care. Further detailed information on the updated tool can be found through resources provided by the Royal College of Psychiatrists, which has overseen its revision and management. For more information, please visit the Royal College of Psychiatrists.
