Mohammed T. Abou-Saleh

514 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYTHE EFFECTS OF INSTITUTIONALIZATIONSince poor long-term outcome in schizophrenia is associated withlong institutionalization and cognitive impairments, could thedeficits be a consequence of a non-stimulating psychiatric hospitalenvironment or overtreatment with medication? One simple wayto examine the possible causal relationship between these factorshas involved comparing the cognitive and adaptive functioningdeficits in groups of elderly schizophrenic patients cared for indifferent types of institutions in widely differing parts of the world.In a cross-national study of cognitive impairment in pooroutcomegeriatric patients with schizophrenia 20 in London andNew York, remarkable similarities in cognitive dysfunctionbetween the US and UK patients were found, despite differencesin the structure of institutional care provided. Mean MMSEscores in New York were 10.5 and in London 10.6. When thepatients in the two centres were investigated with an adaptivefunctioning scale, however, differences emerged which wereprobably related to institutional differences. American patientswere more impaired in social initiation, but less impaired in socialcompetence and personal hygiene, than their English counterparts.WHERE ARE PATIENTS BEST LOOKED AFTER?It is probably unsafe to make generalized assertions about theways in which the needs of elderly schizophrenic patients are bestmet because they are a heterogeneous group in terms of enduringpsychotic symptoms, cognitive and adaptive deficits and family orother social support. In a cross-sectional study of 97 chronicallyhospitalized schizophrenic patients, 37 chronic schizophrenicresidents in nursing homes and 31 acutely admitted geriatricpatients with schizophrenia, patients in each of these groups hadvery different patterns of symptoms and impairments 21 . Whilstdifferences in positive and negative schizophrenic symptoms weresmall, nursing-home residents had the most severe adaptivedeficits. Prospective studies of chronic schizophrenic patientssuccessfully discharged to nursing homes, compared with thosewho are retained in long-term psychiatric care, have shown that itis not cognitive or adaptive deficits that prevent discharge butcontinuing belligerence and hostility 22 . Just as it appears unwise togeneralize about the care needs of patients, it is rash to assumethat all nursing homes or long-stay psychiatric facilities are thesame. When 159 long-term schizophrenic inpatients withinVeterans Administration hospitals were allocated to either acommunity nursing home, a Veterans Administration nursinghome or another long-stay psychiatric ward, or allowed to remainon their original ward, at 12 months the patients with the bestoutcomes were those who had been transferred to another longstayward. The worst outcomes were seen in those who had beendischarged to community nursing homes 23,24 . Rather than thelocation of care, particular features of the quality of care were thefactors most strongly associated with good outcome. Staffingcharacteristics, e.g. the staff:patient ratio and the rate of staffturnover, together with the mean functional ability of fellowresidents, were significantly linked to outcome. A similar studyfrom the UK came to superficially conflicting conclusions. Elderlylong-stay schizophrenic patients transferred to nursing homesshowed slower functional decline over the next 2–3 years thanthose who remained on the wards 25 . The important differencefrom the situation in the Veterans Administration study was thatin the UK study staff–patient contact was greater in communityfacilities than on the long-stay wards and this contributed tobetter outcome. Studies such as those reviewed above examineonly the grosser disabilities and deficits of elderly schizophrenicpatients and the few published investigations of quality of life givea rather depressing insight into exactly what the lives of thesepeople are like. In a 10 year follow-up of 40 older patients withschizophrenia, overall subjective quality-of-life ratings did notimprove from the low levels seen at the beginning of the study 26 .Ratings on a small number of items (contacts, inner experiencesand knowledge/education) had improved slightly, but the reasonsfor these improvements were just as likely to be that patients haddowngraded their expectations as that they were interacting moresuccessfully with their environment or that housekeeping servicesreceived had improved.MORTALITY IN CHRONIC SCHIZOPHRENIAExcess mortality among patients with schizophrenia is a consistentand accepted research finding that cannot be fullyexplained by the observation that 10% of patients will killthemselves 27 . In a prospective study of 88 schizophrenic patientswith a mean age of 62.6 years at study commencement, 39 haddied after 10 years’ follow-up—none through suicide 28 . Therelative risk of death among the patients was 1.33 (95% CI, 1.01–1.65). Six variables, some of which have important clinicalimplications, affected independent prediction of reduced survivaland these were: increasing age; male gender; the edentulous state;time since most recent neuroleptic withdrawal; maximum numberof antipsychotics given concurrently; and the absence of anticholinergictreatment.IMPLICATIONS FOR CLINICAL CARESince elderly patients with chronic schizophrenia have high levelsof disability and dependence upon caring services, their apparentinvisibility to mental health policy makers must largely beattributable to ageist assumptions that they should not expectmuch more than basic nursing home provision, and to a lack ofgeneral public concern about the safety of placing elderly (andtherefore ‘‘low-risk’’) psychotic patients in the community. Theyalso represent a group of patients who are poorly served byspecialist psychiatric services. Sometimes rather grandly termed‘‘graduates’’ because they are alumni of mental health services setup for younger patients, it is often not clear whether they havebecome the responsibility of local old age psychiatrists or whetherthey should continue to be looked after by the general adultpsychiatry teams with whom they have been in contact. In a call toarms to all mental health professionals who may be involved inthe care of these patients, Rodriguez-Ferrer and Vassilas have setout four objectives of importance in the establishment of aseamless and ideal service. First, general practitioners should becentral in the coordination of service provision and should beinvolved in the assessment of physical needs, as well as psychiatricones. Second, the organization and delivery of specialist mentalhealth services should take into account the fact that, in thefuture, the majority of these patients will live in residential andnursing homes. Third, purchasers of mental health services needto be aware of the effects of the quality of the physical and staffingenvironment of residential and nursing homes on patientfunctioning. Finally, services should maintain clarity at all timesas to exactly which agencies (psychiatric, social, voluntary) haveresponsibility for each individual’s care. Now that we have anagenda for the management of this hitherto-neglected group,together with novel antipsychotic agents that are less likely toinduce movement disorders and may even improve cognitivefunction 29 , this really does represent a clinical population forwhom recent research has positive implications. The most recentindications are that deinstitutionalization has been, on the whole,a modest success. At the end of a 5 year follow-up of 670 elderly