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The geriatric patient: Common problems and approaches to rehabilitation management
Book Reviews Old, Ahme and Negked,
221
by JWN~Em
KAYSER-JONES take an intemst in the care of the elderly, who continue to find themselves all too readily consigned to depressing and The book is the reissue of a report compiled in the late 1970s poorly run nursing homes. Even more worrying, however, is evidence that Britain is moving towards the American comparing the institutional care of old people in long stay hospital in Scotland, and a nursing home on the West Coast model, by encouraging the development of private nursing homes and fostering a market kd approach to the organisof America. This is no dry academic study but a subject ation of hospital care. close to the author’s heart, and stimulated by distress over My first reaction to the book was that it bore witness to the nursing home care of her own grandfather. the outstanding success of the National Health Service, and Praise is heaned unon the Scottish unit. Scottsdale. The was a damning indictment of attempts currently being made nurses are prof&ot&ly trained and hiby motivated, the to change its concepts and structures. Further reflection patients are contented and have a high level of selfdetermiraises certain reservations, however. nation, and the unit is under the supervision of an energetic One is that although I am impressed by the lucidity and and imaginative geriatrician. In contrast the staff of the detail of the report, I am concerned that the concern of the American counterpart, Pacific Manor, are poorly trained, author for her subject may have had some effect on objechave little motivation and see patients as objects rather than tivity. The study confines itself to two institutions. There individuals. Patients retain their own physicians who only may be some extremely good nursing homes in the United perform the statutory minimum and have no involvement in States, and I know of some appalling long stay wards in this the overall organisation of the unit. It is not surprising, country. therefore, that the physical and mental state of many of the Again it is not clear which of the many factors dispatients is wretched, and that, far from receiving adquate tinguishing the Scottish long stay hospital from the Americare, they are subject to verbal and physical abuse. Even can nursing home account for the disparity in care. Lack of theft of their personal possessions is endemic. medical leadership may be important. but recent reports Why should there be such a contrast? The evolution of the suggest that nurse led NHS nursing homes provide as high speciahty of geriatric medicine is a major factor. Aspects a standard of care as long stay units under the control of a include adequate medical evaluation of elderly patients, doctor. Again the lack of empathy of staff for patients may identification and treatment of disability, a multidisciplinary have as much to do with them having a different social and team approach to rehabilitation, and emphasis on preventethnic background from their patients. Such an issue does ing institutionalisation and returning patients to their own not arise in the homogeneous population of North-East homes. This philosophy has thrived in the environment Scotland. of the National Health Service where the geriatrician has I also detected flaws behind the rose-tinted report of life had responsibility for providing an area service, where in Scottsdale. The institution appeared doctor dominated nursing care of chronic disability has the same status as with an air of benign patemalism pervading the system. that of acute illness and where general practice, district Lack of complaints from patients might indicate acceptance nursing and local authority services provide effective home and institutionalisation rather than a high quality of life. It care. was also disturbing to note the high proportion of young In contrast, doctors in the United States earn their income disabled adults mixed with the elderly. We may have come by providing items of service for individual patients, and a long way in British Geriatric medicine. but it is important receive little incentive or encouragement to develop care that we do not rest on our laurels. programmes. Private nursing homes are run by proprietors In conclusion, this is a lucid and well written account of whose primary imperative is to make a profit for themselves an area of vitai importance to the future care of the elderly. and their shareholders. There is strong pressure, therefore, It would be all too easy, however. to dismiss it as a to minimixe costs. This can be achieved by recruiting staff straightforward indictment of the American system of care with minimal qualifications, by Ejecting any recreational for the elderly. What is required is a critical evaluation of project likely to cost money, and employing a director with which particulars of the system create the problem. Armed skills in cost cutting rather than patient care. Federal with this we shall be in a much stronger position to influence intervention has done little to improve the situation in that the major changes which we wig almost certainly experience payment is made to nursing homes for individual patients, in both the United States and Britain over the next few and inspection of homes concentrates on quipment, accomyears. modation and processes rather than outcomes. The report engendered within me a feeiing of pride and complacency about the care of the elderly in Britain. There Department GerirrlricMedicine W. J. MACLENNAN is a sting in the tail, however. This takes the form of an City Hospital epilogue updating the situation to 1990. The first depressing Greenbank Drive news is that despite the introduction of undergraduate courses and training programmes in the care of the elderly, Edinburgh EHIO SSB very little has changed in the United States. Few doctors Scotland
The Geriatric Patkntr Common Rohkms and Approaeha to Rehabilitation Management, edited by M. SINGLETON and E. BRANCH.The Haworth Press, New York, 1989. 105 pp., ISBN O-86656-875-1, hb. This is a collection of seven American articles on selected health problems of elderly people. Two are written by physical therapists, the others by: a nutritionist, a neuropathologist, a social worker, two orthopaedic speciahsts. and a geriatrician. There is no editorial comment or attempt at a synthesis. A short Foreword explains that from among the broad range of disabilities affecting ‘the geriatric
population’ the editors ‘have chosen to address some of the conditions more commonly encountered in clinical practice’. The 6rst article is addressed to physiotherapists and suggests that the profession is biased against elderly patients; it warns them, and other whose work spans a wide age range, to guard against ageist attitudes. One other article is concerned with understanding the patient’s social or emotional needs; after a basic description of some of the major physical and behavioural problems of Alxheimer’s disease it exhorts health professionals to be sensitive to the problems and anxieties of family caregivers and to support them in their tasls; it provides sensible advice for anyone new to the care
222
Rook Reviews
of dimentia sufferers and their families. Two articles review what is known about the determinants of conditions: one on bone loss in ageing women and the other again on Alzheimer’s disease. Roth are basic summaries of the extent of knowledge to date about the determinants of the conditions and would be useful to anyone (such as medical students) requiring an introduction of this kind. Moving from causation to patient assessment one short article describes the difficulties of assessing for malnutrition in older people and reviews assessment techniques and standards. Finally, two articles are particularly concerned with treatment; one on herpes zoster (shingles) and the other on balance deficits following a stroke. The former provides a useful summary of the ditferent types of drug and physiotherapy treatment for postherapetic neuralgia; the latter suggests that balance problems in stroke patients can be more fully understood and treated when the ‘neurological deficit is put into a biomechanical perspective’. The book is, therefore, a very selective collection, addressed to a variety
of audiences. It is hard to perceive any general themes which might justify or explain the bringing together of these articles apart from the fact that they all concern health problems of later life; for example, where the patient as an emotional and social being emerges it is interesting that one chapter exhorts us to treat elderly people as individuals whilst another contains an illustration of a semi-clad patient standing on a piece of foam rubber and wearing a lamp shade on his head. Some chapters appear to be addressed to physiotherapists but others to different kinds of professional; some are more suitable for people with little professional experience, others for the more specialised and experienced reader. It should be read selectively.
Preventing Alcohol and Tobacca Problems: Vol. I: The Addiction Market: Consumption, Production and Policy Development, Vol. II: Manipulating Consumption: Information, Law and Voluntary Controls. Avebury, Aldershot, 1990. Vol. I, 252 pp., Vol. II, 212pp.. f30 each.
clout. The alcoholic beverage industry has itself changed enormously over the years with a marked increase in the concentration of ownership. The largest five brewers gained control of 50% of the market and the top five tobacco firms controlled over 99% of the market between 1963 and 1985. Companies in both industries are set on integrating vertically and horizontally and are in addition frequently part of large multi-national companies whose economic power takes on a diverse and international dimension. A case study of particular clarity and fascination is devoted to the Scotch Whisky Industry. This considers amongst other things the consequences of reduced whisky consumption for employment in areas of rural Scotland. Many of these industries are no longer labour intensive and in fact the majority of the individuals likely to be. effected by a drop in production seem likely to be amongst workers in distribution of sales of these substances. Those who recommend measures designed for reduced level of alcohol consumption understandably stress the benefits which would follow such as improvement in personal health, the decline in the number of working days lost through alcohol related problems and increased safety on the roads. The attainment of these benefits is, however, not without cost because a reduction in alcohol consumption inevitably involves a reduced reaction demand for the products of the alcohol beverage industry and a consequent loss of employment and income for those involved. The consequences can be particularly dramatic for small Highland villages in Scotland which have been traditionally devoted to a single industry. Their needs require to be acknowledged in any policy formulation. The second volume concerns strategies for preventing or minim&g problems arising from alcohol and tobacco use. It examines voluntary controls and education and contrasts this with controls imposed by legislation using strategies such as liquor licencing or drink driving laws. Those of us concerned with public health often see voluntary regulation as a ‘soft option’ but if examined it has many merits. There is little point in introducing laws which are unenforceable, and do not enjoy wide public support. Legislation is cumbersome and the cost of law enforcement often high. Voluntary agreements can however be misused. Negotiations between the industry and the Government may become too intimate, even collusive. The Government becomes dependent on the industry for cooperation, for information and indeed in some situations for political support. Self regulation can also have the additional advantage of providing industries with a means of legitimating
These two volumes are the products of The Economic & Social Research Council Programme of the Addiction Research centre at the Universities of Hull and York in the U.K. It summarises their programme of research conducted between 1983 and 1988. The first volume contains an analysis of the alcohol and tobacco markets and examines economic and political factors which influences consumption. These most popular drugs have had rather different fortunes in the last quarter of this century, ‘consumption of alcohol waxed whilst tobacco consumption has waned’. They point out that the tobacco market has receded because the health message has been effectively sold to the public, despite contrary economic influences such as reduced real prices and increased purchasing power which might be expected to increase sales. At the same time the alcohol industry has increased its sales which they relate to the increased purchasing power of consumers and the reduced real price of wine and spirits. The real price of beer however has increased over the similar period. The first chapter describes the changes in the market for alcohol and tobacco against a background of changing prices, income and taxation. Alcohol taxes and their percentage of central government current account receipts have declined somewhat over the past 25 years while tobacco’s contribution to these receipts has slumped from 11.9% to 4%. The complexities of the relationship between price and demand are examined in subsequent chapters. The authors regularly stress the complexities of the issues involved and warn the reader against simplistic assumptions which may have unforeseen policy consequences. There are several fascinating and informative sections devoted to the role of administrators within government departments who tinker with economic factors, exclusively from the point of view of their own department often without regard to the consequences for other sectors of the community. The understandable self-interest of the alcohol and tobacco lobby also has a powerful effect on policy formation. To the authors’ credit they avoid painting a one-sided picture of the potential conflict between marketing and health promotion though it is clear where the ‘big battalions’ are massed in terms of influence and economic
Age Concern, Institute of Gerontology King’s College Cornwall House Annexe Waterloo Road Lmdon, England
JANET ASKHAM
221
by JWN~Em
KAYSER-JONES take an intemst in the care of the elderly, who continue to find themselves all too readily consigned to depressing and The book is the reissue of a report compiled in the late 1970s poorly run nursing homes. Even more worrying, however, is evidence that Britain is moving towards the American comparing the institutional care of old people in long stay hospital in Scotland, and a nursing home on the West Coast model, by encouraging the development of private nursing homes and fostering a market kd approach to the organisof America. This is no dry academic study but a subject ation of hospital care. close to the author’s heart, and stimulated by distress over My first reaction to the book was that it bore witness to the nursing home care of her own grandfather. the outstanding success of the National Health Service, and Praise is heaned unon the Scottish unit. Scottsdale. The was a damning indictment of attempts currently being made nurses are prof&ot&ly trained and hiby motivated, the to change its concepts and structures. Further reflection patients are contented and have a high level of selfdetermiraises certain reservations, however. nation, and the unit is under the supervision of an energetic One is that although I am impressed by the lucidity and and imaginative geriatrician. In contrast the staff of the detail of the report, I am concerned that the concern of the American counterpart, Pacific Manor, are poorly trained, author for her subject may have had some effect on objechave little motivation and see patients as objects rather than tivity. The study confines itself to two institutions. There individuals. Patients retain their own physicians who only may be some extremely good nursing homes in the United perform the statutory minimum and have no involvement in States, and I know of some appalling long stay wards in this the overall organisation of the unit. It is not surprising, country. therefore, that the physical and mental state of many of the Again it is not clear which of the many factors dispatients is wretched, and that, far from receiving adquate tinguishing the Scottish long stay hospital from the Americare, they are subject to verbal and physical abuse. Even can nursing home account for the disparity in care. Lack of theft of their personal possessions is endemic. medical leadership may be important. but recent reports Why should there be such a contrast? The evolution of the suggest that nurse led NHS nursing homes provide as high speciahty of geriatric medicine is a major factor. Aspects a standard of care as long stay units under the control of a include adequate medical evaluation of elderly patients, doctor. Again the lack of empathy of staff for patients may identification and treatment of disability, a multidisciplinary have as much to do with them having a different social and team approach to rehabilitation, and emphasis on preventethnic background from their patients. Such an issue does ing institutionalisation and returning patients to their own not arise in the homogeneous population of North-East homes. This philosophy has thrived in the environment Scotland. of the National Health Service where the geriatrician has I also detected flaws behind the rose-tinted report of life had responsibility for providing an area service, where in Scottsdale. The institution appeared doctor dominated nursing care of chronic disability has the same status as with an air of benign patemalism pervading the system. that of acute illness and where general practice, district Lack of complaints from patients might indicate acceptance nursing and local authority services provide effective home and institutionalisation rather than a high quality of life. It care. was also disturbing to note the high proportion of young In contrast, doctors in the United States earn their income disabled adults mixed with the elderly. We may have come by providing items of service for individual patients, and a long way in British Geriatric medicine. but it is important receive little incentive or encouragement to develop care that we do not rest on our laurels. programmes. Private nursing homes are run by proprietors In conclusion, this is a lucid and well written account of whose primary imperative is to make a profit for themselves an area of vitai importance to the future care of the elderly. and their shareholders. There is strong pressure, therefore, It would be all too easy, however. to dismiss it as a to minimixe costs. This can be achieved by recruiting staff straightforward indictment of the American system of care with minimal qualifications, by Ejecting any recreational for the elderly. What is required is a critical evaluation of project likely to cost money, and employing a director with which particulars of the system create the problem. Armed skills in cost cutting rather than patient care. Federal with this we shall be in a much stronger position to influence intervention has done little to improve the situation in that the major changes which we wig almost certainly experience payment is made to nursing homes for individual patients, in both the United States and Britain over the next few and inspection of homes concentrates on quipment, accomyears. modation and processes rather than outcomes. The report engendered within me a feeiing of pride and complacency about the care of the elderly in Britain. There Department GerirrlricMedicine W. J. MACLENNAN is a sting in the tail, however. This takes the form of an City Hospital epilogue updating the situation to 1990. The first depressing Greenbank Drive news is that despite the introduction of undergraduate courses and training programmes in the care of the elderly, Edinburgh EHIO SSB very little has changed in the United States. Few doctors Scotland
The Geriatric Patkntr Common Rohkms and Approaeha to Rehabilitation Management, edited by M. SINGLETON and E. BRANCH.The Haworth Press, New York, 1989. 105 pp., ISBN O-86656-875-1, hb. This is a collection of seven American articles on selected health problems of elderly people. Two are written by physical therapists, the others by: a nutritionist, a neuropathologist, a social worker, two orthopaedic speciahsts. and a geriatrician. There is no editorial comment or attempt at a synthesis. A short Foreword explains that from among the broad range of disabilities affecting ‘the geriatric
population’ the editors ‘have chosen to address some of the conditions more commonly encountered in clinical practice’. The 6rst article is addressed to physiotherapists and suggests that the profession is biased against elderly patients; it warns them, and other whose work spans a wide age range, to guard against ageist attitudes. One other article is concerned with understanding the patient’s social or emotional needs; after a basic description of some of the major physical and behavioural problems of Alxheimer’s disease it exhorts health professionals to be sensitive to the problems and anxieties of family caregivers and to support them in their tasls; it provides sensible advice for anyone new to the care
222
Rook Reviews
of dimentia sufferers and their families. Two articles review what is known about the determinants of conditions: one on bone loss in ageing women and the other again on Alzheimer’s disease. Roth are basic summaries of the extent of knowledge to date about the determinants of the conditions and would be useful to anyone (such as medical students) requiring an introduction of this kind. Moving from causation to patient assessment one short article describes the difficulties of assessing for malnutrition in older people and reviews assessment techniques and standards. Finally, two articles are particularly concerned with treatment; one on herpes zoster (shingles) and the other on balance deficits following a stroke. The former provides a useful summary of the ditferent types of drug and physiotherapy treatment for postherapetic neuralgia; the latter suggests that balance problems in stroke patients can be more fully understood and treated when the ‘neurological deficit is put into a biomechanical perspective’. The book is, therefore, a very selective collection, addressed to a variety
of audiences. It is hard to perceive any general themes which might justify or explain the bringing together of these articles apart from the fact that they all concern health problems of later life; for example, where the patient as an emotional and social being emerges it is interesting that one chapter exhorts us to treat elderly people as individuals whilst another contains an illustration of a semi-clad patient standing on a piece of foam rubber and wearing a lamp shade on his head. Some chapters appear to be addressed to physiotherapists but others to different kinds of professional; some are more suitable for people with little professional experience, others for the more specialised and experienced reader. It should be read selectively.
Preventing Alcohol and Tobacca Problems: Vol. I: The Addiction Market: Consumption, Production and Policy Development, Vol. II: Manipulating Consumption: Information, Law and Voluntary Controls. Avebury, Aldershot, 1990. Vol. I, 252 pp., Vol. II, 212pp.. f30 each.
clout. The alcoholic beverage industry has itself changed enormously over the years with a marked increase in the concentration of ownership. The largest five brewers gained control of 50% of the market and the top five tobacco firms controlled over 99% of the market between 1963 and 1985. Companies in both industries are set on integrating vertically and horizontally and are in addition frequently part of large multi-national companies whose economic power takes on a diverse and international dimension. A case study of particular clarity and fascination is devoted to the Scotch Whisky Industry. This considers amongst other things the consequences of reduced whisky consumption for employment in areas of rural Scotland. Many of these industries are no longer labour intensive and in fact the majority of the individuals likely to be. effected by a drop in production seem likely to be amongst workers in distribution of sales of these substances. Those who recommend measures designed for reduced level of alcohol consumption understandably stress the benefits which would follow such as improvement in personal health, the decline in the number of working days lost through alcohol related problems and increased safety on the roads. The attainment of these benefits is, however, not without cost because a reduction in alcohol consumption inevitably involves a reduced reaction demand for the products of the alcohol beverage industry and a consequent loss of employment and income for those involved. The consequences can be particularly dramatic for small Highland villages in Scotland which have been traditionally devoted to a single industry. Their needs require to be acknowledged in any policy formulation. The second volume concerns strategies for preventing or minim&g problems arising from alcohol and tobacco use. It examines voluntary controls and education and contrasts this with controls imposed by legislation using strategies such as liquor licencing or drink driving laws. Those of us concerned with public health often see voluntary regulation as a ‘soft option’ but if examined it has many merits. There is little point in introducing laws which are unenforceable, and do not enjoy wide public support. Legislation is cumbersome and the cost of law enforcement often high. Voluntary agreements can however be misused. Negotiations between the industry and the Government may become too intimate, even collusive. The Government becomes dependent on the industry for cooperation, for information and indeed in some situations for political support. Self regulation can also have the additional advantage of providing industries with a means of legitimating
These two volumes are the products of The Economic & Social Research Council Programme of the Addiction Research centre at the Universities of Hull and York in the U.K. It summarises their programme of research conducted between 1983 and 1988. The first volume contains an analysis of the alcohol and tobacco markets and examines economic and political factors which influences consumption. These most popular drugs have had rather different fortunes in the last quarter of this century, ‘consumption of alcohol waxed whilst tobacco consumption has waned’. They point out that the tobacco market has receded because the health message has been effectively sold to the public, despite contrary economic influences such as reduced real prices and increased purchasing power which might be expected to increase sales. At the same time the alcohol industry has increased its sales which they relate to the increased purchasing power of consumers and the reduced real price of wine and spirits. The real price of beer however has increased over the similar period. The first chapter describes the changes in the market for alcohol and tobacco against a background of changing prices, income and taxation. Alcohol taxes and their percentage of central government current account receipts have declined somewhat over the past 25 years while tobacco’s contribution to these receipts has slumped from 11.9% to 4%. The complexities of the relationship between price and demand are examined in subsequent chapters. The authors regularly stress the complexities of the issues involved and warn the reader against simplistic assumptions which may have unforeseen policy consequences. There are several fascinating and informative sections devoted to the role of administrators within government departments who tinker with economic factors, exclusively from the point of view of their own department often without regard to the consequences for other sectors of the community. The understandable self-interest of the alcohol and tobacco lobby also has a powerful effect on policy formation. To the authors’ credit they avoid painting a one-sided picture of the potential conflict between marketing and health promotion though it is clear where the ‘big battalions’ are massed in terms of influence and economic
Age Concern, Institute of Gerontology King’s College Cornwall House Annexe Waterloo Road Lmdon, England
JANET ASKHAM