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Alcohol and old age
53
Book Reviews Family Care of the Elderly: Public Initiatives and Private Obligations, by DWIGHT L. FRANKFATHEK. MICHAEL J. SMITH and FRANCIS G. CAKO. Lexington Books. Lexington. MA. 1981. 123 pp. $18.95 As the greying of America has moved from demographic projection to everyday reality. concern about who will provide and pay for health care for the elderly has become commonplace but more issues have been raised than solved. Long term inattention to the health needs of old people plus fear that expansion of home health services to this segment of the population would atrophy withering familial support and encourage wholesale swindling of the system have paved the tortuous path to the present system of inadequate home health care in the United States. For those concerned with “how, what, to whom, and with what effect” aspects of the provision of home health care. this book by Frankfather, Smith and Caro with an excellent introduction by Robert Morris will provide useful information. The authors report on the results of a family support program conducted between 1976 and 1979 by the Community Service Society, one of the oldest and largest non-sectarian welfare agencies in the United States. A research and demonstration project, the Family Support Program wa,s designed to encourage family persistence in providing care and to sustain independent living arrangements for disabled elderly relatives whenever possible. During its years of operation. the Family Support Program provided service to 96 families for at least 6 months, 84 families for at least 1 year. and 48 families for at least 2 years. Only families that could assume primary responsibility were included in the project. although the criteria for determining “primary responsibility” were sometimes problematic. as the authors point out. A “series of chronic level of impairment” of the older relative was also required; initially. project staff did not use a standardized screening for measuring impairment but measured this in research interviews. The average age of those serviced was 77 years; 77”, were women. and 55”” were white. Most, as one would deduce from these demographic characteristics, were poor. One third lived alone, one third with a spouse. one third with other relatives. In almost tivo thirds of the cases. the responsible family member was an adult child, most often a daughter. The project, run on a “professional model” of consensus whereby professionals and family. rather than the older person. determined what services would actually be received and offered. whether homemaker. case management. entitlement advocacy services. or financial assistance for the basic amenities. The authors report that provision and utilization of services offered by the project were strong incentives to avoid or delay institutionalization of the elderly relative, although it was unclear whether “service incentives caused persistence or enabled already-persistent families to persevere” (p, 29). At the end of the project’s second year, 10 of the 25 terminations of service were due to entry into a nursing home. 9 to death. and the remaining six to moving from the geographic area or withdrawal fro-m the project. It is difficult to assess the cost-effectiveness of the services provided or the extent to which rates of institutionalization among the program participants differs from a comparable group of old unserved people. No control group was employed and this is a serious lack. At full capacity. however. according to the authors. the annualized program budget was almost S300.000. slightly over 50”” of which was for admmistrative costs. According to my calculations, this figure is considerably less than nursing home care was likel! to be: at S758 per month (based on the U.S. 1979 average cost for proprietar! nursing home care) it would cost approx. S873.216 yearI! to provide nursing home care for the 96 people served by the project at its peak capacity. Why do people seek home care services for an impaired relative rather than choosing a nursing home? The results
of this study indicate that the major motivations are indebtedness and affection. As one respondent said. “I’m obligated to do these things since I’m her daughter. but 1 really love her” (p. 39). Contrary lo the popular belief that families are disinterested in their impaired elderly relatives, Frankfather and his associates found that family members often maintained a relative at considerable sacrifices to themselves, including financial burdens, restricted freedom and increased regimentation of social activities, while facing their own anxiety about the future and stress-related physical ailments. That every family caretaker has her breaking point, not necessarily related to the level of impairment of her relative. is clearly brought out. With respect to services offered by the project, the results highlight the often forgotten point. that what professionals or family members think an older person should receive is not always what he or she wants. Homemakers, for example. were a mixed blessing: not only were turnover rates high (unless a family member was employed in this capacity). but often homemakers provided services that were not what the recipient wanted or was accustomed to. Not unexpectedly, occasional personality conflicts occurred between the service provider and the recipient. Nor was the social worker’s role as counselor clearly understood, as many older people preferred to view the social worker as a. personal friend rather than a professional counselor. While the Family Support Project clearly had its problems, the results of the study are encouraging. Only three of the 48 study families. for whom a 2 year follow up was possible. reduced their level of support to a family member when assistance in home care was provided. This finding contradicts conventional wisdom that provision of formal supports will weaken or atrophy informal s;pport networks. Perhaps informal supports remained strong because the formal supports received were relatively modest. supplementing rather than supplanting what the family had always done. In what was. in my view. the best developed chapter in the book. the authors argue that modest benefits for home care both reduce disincentives for withdrawing family support and promote the maintenance of the elderly relative. They suggest a two-tiered structure of home care entitlements, whereby those without family support receive extensive services and those with families receive modest benefits. A maintenance model that emphasizes user rather than professional control of benefits and a standardized determination of benefits is advocated. This model is elaborated to take account of recruitment and eligibility standards. actual numbers of beneficiaries, benefit levels and reductions, covered services, and method of benefit payments. A voucher system for eligible recipients, analogous to the Food Stamp program, and a case accountant (note: nor a case manager. but a case accountant). to monitor quality of services. offer service information and referral. and review claims are detailed. For those interested in the delivery of supportive health services in the community or in planning health care policy. this book is worth reading. One can learn much from the experience of the Family Support Project. as the authors have used the results of this demonstration to highlight the fallacies and futures for home care. Geror~rolog~. Cerltel Boston D‘niuersitj, Boston. MA. C.S.A.
ELIZABETH W. MARKSON
Alcohol and Old Age, by BRIAN L. MISHARA and ROBERT KASTENBAUM. Grune & Stratton. New York, 1980. 220 on. E22.00 This is an interdisciplinary review of the interface two well established scientific-medical disciplines
between (alcohol
54
Book Reviews
studies and geriatrics). Alcohol studies are emphasized more than geriatrics. but the book contains much useful information on both topics. The book begins with a brief survey of ancient and European cultural traditions pertaining to the topic. followed by a good summary of physiological effects of alcohol. Surveys of drinking behavior in the United States. conducted by Don Cahalan and his colleagues. provide the principal material for a chapter on extent of alcohol use. Other statistical surveys provide the material for a chapter on health problems. This chapter includes evidence, strengthened by subsequent reports. that alcohol use decreases the risk of coronary heart disease. Clinical studies constitute the principal source of information for chapters on problem drinking and on treatment of problem drinking. The longest chapter (36 pages) summarizes experimental studies showing beneficial effects for elderly people of alcoholic beverages. drunk in a social setting. Some of these studies are by the authors of this book. including an article in Social Science & Medicine (Mishara et al. 9. 535-547. 1975). Another chapter reports an unpublished experiment by one of the authors of the book (Kastenbaum) showing improvements in sleep and various other measures when elderly people individually drink one or two glasses of wine each evening. The methods of this study are described in the Appendix. This book provides a broad, well written, intelligently interpreted, and adequately documented summary. It is easily readable, concise, with simple. consistent conclusions, rather than comprehensive and scholarly. Some of the topics are reviewed sketchily. The chapter on extent of alcohol use gives only a small proportion of the available information. Studies of therapy are identified, and the authors make the interesting conclusion that the prognosis is good in elderly patients, buf without detailed information or evaluation of the studies. The book lacks descriptive or clinical case histories of drinking problems in the elderly. The surveys of drinking behavior show much lower percentages of heavy drinking and drinking problems above the age of 59 years. Nevertheless. millions of elderly people drink excessively. Their suffering is usually aggravated by diminished physical adaptability, other health problems. and poverty. ElTective treatment is usually blocked by isolation and neglect. This book deals with an important social problem. which is becoming more conspicuous with the increase in proportion of elderly people in the population. The authors adequately summarize the pathological effects of excessive drinking, but their principal interest is in demonstrating beneficial effects of regular. moderate drinking. This is expressed in a brief chapter of Summary and Recommendations. The experiments on drinking in social settings show preponderantly beneficial effects. Some of them include control groups or stages with nonalcoholic beverages. but they do not prove that the effective agent was the pharmacological action of alcohol rather than the social expectations, such as pleasure and conviviality, engendered by their awareness that their drinking of alcoholic beverages is being studied. The study of individual drinking in the evenings is interpreted in terms of soporific gamma-amino-butyric acid (GABA) in wine. but its contribution is meager and inconclusive. The nightly exposure to wine was rather brief. there was no adequate control condition. and no detailed. quantitative report of the data was given. This book is generally successful in creating a useful reference source in the interface between alcohol studies and geriatrics. It is recommended to teachers. lecturers. and writers on either of the two scientific-medical disciplines. and as supplemental reading for courses in either topic.
The book suffers from the general disadvantage of interdisciplinary work. that it is not likely to be accepted as an important contribution to either discipline. It is too detailed and techmcal to become popular reading for the general public. This book constitutes a good start. however. for future development of its interdisciplinary topic. It summarizes an early stage of a rapidly developing field of research. For example. a collection of articles on Neurobiological Interactions between Agmg and Alcohol Abuse has subsequently been published in .~lcoliolisni: Clit)icrrl and Euperimejltal Research (6, l-63. 1982). Future. more comprehensive reviews of the topic will benefit from the well selected and clearly written material of this initial book by Mishara and Kastenbaum. Department of‘ Pharmacology and HERBERT BARRY III 7-osicolog_i C’nirersity of Pittsburgh School of Phcwrnccc~~ Pittsburgh. P.4. U.S.A.
Entering Medicine: The Dynamics of Transition. A Seven Year Study of Medical Education in Israel, by JUDITH T. SHUVAL. Pergamon Press, Oxford. 1980. 274 pp. $25.00 Entering Medicine addresses the important question of how medical students develop their professional attitudes. The book reports on a seven year longitudinal study of the formation and evolution of attitudes about professional role and career preferences among Israeli medical students. The author examines student views on the importance of people, science and status. In addition she looks at the developmegt of professional role and career preferences. especially choice of specialty and place of practice, trying to identify curricular, social and cultural factors that may influence these choices. Dr Shuval relies on the questionnaire method to obtain data. surveying each student on entry to medical school. during each year of medical school training, and upon graduation. Several patterns emerge from this study. First. although students report that the people aspect of medicine is the most important of the three (people. science. status). its absolute score falls steadily throughout the course of training. Science occupies a middle position and also decreases in absolute score over time, whereas status has the lowest score, but this does not change over time. and thus occupies an increasingly important position by the end of training. Another interesting finding is that attitudes about community medicine remain rather negative throughout the seven years of medical school. with the hospital being viewed as the only place where “real medicine” is practiced. Family practice is a very unpopular career choice. although most students report that they recognize its importance. Also of interest is the fact that there is increasing heterogeneity of opinion as the entering class progresses through its medical education; there is no clustering of opinion along the lines of sex. age or socio-economic background. Moreover, attitudes manifested at the start of the training are only weakly related to such attitudes at the end. What emerges from this study is that medical education is characterized by a panopoly of influences and crosspressures. Students pick and choose among these mixed and often inconsistent inputs; it remains unclear from the study whether there are any predictors of how they will choose. Nevertheless, it is encouraging to know that the people, science and status components of the professional role do seem to maintain their relative degrees of importance throughout medical school. As a piece of quantitative sociologic research on attitudes. this is a fine work. However. as a book that will be useful to medical educators. it is a bit too overburdened with jargon and methodologic consrderations: in fact. it is
Book Reviews Family Care of the Elderly: Public Initiatives and Private Obligations, by DWIGHT L. FRANKFATHEK. MICHAEL J. SMITH and FRANCIS G. CAKO. Lexington Books. Lexington. MA. 1981. 123 pp. $18.95 As the greying of America has moved from demographic projection to everyday reality. concern about who will provide and pay for health care for the elderly has become commonplace but more issues have been raised than solved. Long term inattention to the health needs of old people plus fear that expansion of home health services to this segment of the population would atrophy withering familial support and encourage wholesale swindling of the system have paved the tortuous path to the present system of inadequate home health care in the United States. For those concerned with “how, what, to whom, and with what effect” aspects of the provision of home health care. this book by Frankfather, Smith and Caro with an excellent introduction by Robert Morris will provide useful information. The authors report on the results of a family support program conducted between 1976 and 1979 by the Community Service Society, one of the oldest and largest non-sectarian welfare agencies in the United States. A research and demonstration project, the Family Support Program wa,s designed to encourage family persistence in providing care and to sustain independent living arrangements for disabled elderly relatives whenever possible. During its years of operation. the Family Support Program provided service to 96 families for at least 6 months, 84 families for at least 1 year. and 48 families for at least 2 years. Only families that could assume primary responsibility were included in the project. although the criteria for determining “primary responsibility” were sometimes problematic. as the authors point out. A “series of chronic level of impairment” of the older relative was also required; initially. project staff did not use a standardized screening for measuring impairment but measured this in research interviews. The average age of those serviced was 77 years; 77”, were women. and 55”” were white. Most, as one would deduce from these demographic characteristics, were poor. One third lived alone, one third with a spouse. one third with other relatives. In almost tivo thirds of the cases. the responsible family member was an adult child, most often a daughter. The project, run on a “professional model” of consensus whereby professionals and family. rather than the older person. determined what services would actually be received and offered. whether homemaker. case management. entitlement advocacy services. or financial assistance for the basic amenities. The authors report that provision and utilization of services offered by the project were strong incentives to avoid or delay institutionalization of the elderly relative, although it was unclear whether “service incentives caused persistence or enabled already-persistent families to persevere” (p, 29). At the end of the project’s second year, 10 of the 25 terminations of service were due to entry into a nursing home. 9 to death. and the remaining six to moving from the geographic area or withdrawal fro-m the project. It is difficult to assess the cost-effectiveness of the services provided or the extent to which rates of institutionalization among the program participants differs from a comparable group of old unserved people. No control group was employed and this is a serious lack. At full capacity. however. according to the authors. the annualized program budget was almost S300.000. slightly over 50”” of which was for admmistrative costs. According to my calculations, this figure is considerably less than nursing home care was likel! to be: at S758 per month (based on the U.S. 1979 average cost for proprietar! nursing home care) it would cost approx. S873.216 yearI! to provide nursing home care for the 96 people served by the project at its peak capacity. Why do people seek home care services for an impaired relative rather than choosing a nursing home? The results
of this study indicate that the major motivations are indebtedness and affection. As one respondent said. “I’m obligated to do these things since I’m her daughter. but 1 really love her” (p. 39). Contrary lo the popular belief that families are disinterested in their impaired elderly relatives, Frankfather and his associates found that family members often maintained a relative at considerable sacrifices to themselves, including financial burdens, restricted freedom and increased regimentation of social activities, while facing their own anxiety about the future and stress-related physical ailments. That every family caretaker has her breaking point, not necessarily related to the level of impairment of her relative. is clearly brought out. With respect to services offered by the project, the results highlight the often forgotten point. that what professionals or family members think an older person should receive is not always what he or she wants. Homemakers, for example. were a mixed blessing: not only were turnover rates high (unless a family member was employed in this capacity). but often homemakers provided services that were not what the recipient wanted or was accustomed to. Not unexpectedly, occasional personality conflicts occurred between the service provider and the recipient. Nor was the social worker’s role as counselor clearly understood, as many older people preferred to view the social worker as a. personal friend rather than a professional counselor. While the Family Support Project clearly had its problems, the results of the study are encouraging. Only three of the 48 study families. for whom a 2 year follow up was possible. reduced their level of support to a family member when assistance in home care was provided. This finding contradicts conventional wisdom that provision of formal supports will weaken or atrophy informal s;pport networks. Perhaps informal supports remained strong because the formal supports received were relatively modest. supplementing rather than supplanting what the family had always done. In what was. in my view. the best developed chapter in the book. the authors argue that modest benefits for home care both reduce disincentives for withdrawing family support and promote the maintenance of the elderly relative. They suggest a two-tiered structure of home care entitlements, whereby those without family support receive extensive services and those with families receive modest benefits. A maintenance model that emphasizes user rather than professional control of benefits and a standardized determination of benefits is advocated. This model is elaborated to take account of recruitment and eligibility standards. actual numbers of beneficiaries, benefit levels and reductions, covered services, and method of benefit payments. A voucher system for eligible recipients, analogous to the Food Stamp program, and a case accountant (note: nor a case manager. but a case accountant). to monitor quality of services. offer service information and referral. and review claims are detailed. For those interested in the delivery of supportive health services in the community or in planning health care policy. this book is worth reading. One can learn much from the experience of the Family Support Project. as the authors have used the results of this demonstration to highlight the fallacies and futures for home care. Geror~rolog~. Cerltel Boston D‘niuersitj, Boston. MA. C.S.A.
ELIZABETH W. MARKSON
Alcohol and Old Age, by BRIAN L. MISHARA and ROBERT KASTENBAUM. Grune & Stratton. New York, 1980. 220 on. E22.00 This is an interdisciplinary review of the interface two well established scientific-medical disciplines
between (alcohol
54
Book Reviews
studies and geriatrics). Alcohol studies are emphasized more than geriatrics. but the book contains much useful information on both topics. The book begins with a brief survey of ancient and European cultural traditions pertaining to the topic. followed by a good summary of physiological effects of alcohol. Surveys of drinking behavior in the United States. conducted by Don Cahalan and his colleagues. provide the principal material for a chapter on extent of alcohol use. Other statistical surveys provide the material for a chapter on health problems. This chapter includes evidence, strengthened by subsequent reports. that alcohol use decreases the risk of coronary heart disease. Clinical studies constitute the principal source of information for chapters on problem drinking and on treatment of problem drinking. The longest chapter (36 pages) summarizes experimental studies showing beneficial effects for elderly people of alcoholic beverages. drunk in a social setting. Some of these studies are by the authors of this book. including an article in Social Science & Medicine (Mishara et al. 9. 535-547. 1975). Another chapter reports an unpublished experiment by one of the authors of the book (Kastenbaum) showing improvements in sleep and various other measures when elderly people individually drink one or two glasses of wine each evening. The methods of this study are described in the Appendix. This book provides a broad, well written, intelligently interpreted, and adequately documented summary. It is easily readable, concise, with simple. consistent conclusions, rather than comprehensive and scholarly. Some of the topics are reviewed sketchily. The chapter on extent of alcohol use gives only a small proportion of the available information. Studies of therapy are identified, and the authors make the interesting conclusion that the prognosis is good in elderly patients, buf without detailed information or evaluation of the studies. The book lacks descriptive or clinical case histories of drinking problems in the elderly. The surveys of drinking behavior show much lower percentages of heavy drinking and drinking problems above the age of 59 years. Nevertheless. millions of elderly people drink excessively. Their suffering is usually aggravated by diminished physical adaptability, other health problems. and poverty. ElTective treatment is usually blocked by isolation and neglect. This book deals with an important social problem. which is becoming more conspicuous with the increase in proportion of elderly people in the population. The authors adequately summarize the pathological effects of excessive drinking, but their principal interest is in demonstrating beneficial effects of regular. moderate drinking. This is expressed in a brief chapter of Summary and Recommendations. The experiments on drinking in social settings show preponderantly beneficial effects. Some of them include control groups or stages with nonalcoholic beverages. but they do not prove that the effective agent was the pharmacological action of alcohol rather than the social expectations, such as pleasure and conviviality, engendered by their awareness that their drinking of alcoholic beverages is being studied. The study of individual drinking in the evenings is interpreted in terms of soporific gamma-amino-butyric acid (GABA) in wine. but its contribution is meager and inconclusive. The nightly exposure to wine was rather brief. there was no adequate control condition. and no detailed. quantitative report of the data was given. This book is generally successful in creating a useful reference source in the interface between alcohol studies and geriatrics. It is recommended to teachers. lecturers. and writers on either of the two scientific-medical disciplines. and as supplemental reading for courses in either topic.
The book suffers from the general disadvantage of interdisciplinary work. that it is not likely to be accepted as an important contribution to either discipline. It is too detailed and techmcal to become popular reading for the general public. This book constitutes a good start. however. for future development of its interdisciplinary topic. It summarizes an early stage of a rapidly developing field of research. For example. a collection of articles on Neurobiological Interactions between Agmg and Alcohol Abuse has subsequently been published in .~lcoliolisni: Clit)icrrl and Euperimejltal Research (6, l-63. 1982). Future. more comprehensive reviews of the topic will benefit from the well selected and clearly written material of this initial book by Mishara and Kastenbaum. Department of‘ Pharmacology and HERBERT BARRY III 7-osicolog_i C’nirersity of Pittsburgh School of Phcwrnccc~~ Pittsburgh. P.4. U.S.A.
Entering Medicine: The Dynamics of Transition. A Seven Year Study of Medical Education in Israel, by JUDITH T. SHUVAL. Pergamon Press, Oxford. 1980. 274 pp. $25.00 Entering Medicine addresses the important question of how medical students develop their professional attitudes. The book reports on a seven year longitudinal study of the formation and evolution of attitudes about professional role and career preferences among Israeli medical students. The author examines student views on the importance of people, science and status. In addition she looks at the developmegt of professional role and career preferences. especially choice of specialty and place of practice, trying to identify curricular, social and cultural factors that may influence these choices. Dr Shuval relies on the questionnaire method to obtain data. surveying each student on entry to medical school. during each year of medical school training, and upon graduation. Several patterns emerge from this study. First. although students report that the people aspect of medicine is the most important of the three (people. science. status). its absolute score falls steadily throughout the course of training. Science occupies a middle position and also decreases in absolute score over time, whereas status has the lowest score, but this does not change over time. and thus occupies an increasingly important position by the end of training. Another interesting finding is that attitudes about community medicine remain rather negative throughout the seven years of medical school. with the hospital being viewed as the only place where “real medicine” is practiced. Family practice is a very unpopular career choice. although most students report that they recognize its importance. Also of interest is the fact that there is increasing heterogeneity of opinion as the entering class progresses through its medical education; there is no clustering of opinion along the lines of sex. age or socio-economic background. Moreover, attitudes manifested at the start of the training are only weakly related to such attitudes at the end. What emerges from this study is that medical education is characterized by a panopoly of influences and crosspressures. Students pick and choose among these mixed and often inconsistent inputs; it remains unclear from the study whether there are any predictors of how they will choose. Nevertheless, it is encouraging to know that the people, science and status components of the professional role do seem to maintain their relative degrees of importance throughout medical school. As a piece of quantitative sociologic research on attitudes. this is a fine work. However. as a book that will be useful to medical educators. it is a bit too overburdened with jargon and methodologic consrderations: in fact. it is