Mohammed T. Abou-Saleh

678 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYsuch units of modest size at strategic sites throughout thecommunity to be served (Figure 124.1).FUNCTIONSA day hospital may aim to provide one or more of a series of careoptions for the elderly attender. It may offer assessment andtreatment otherwise requiring admission, facilitate early dischargefrom inpatient care, provide rehabilitation, or help attendersdeskilled or disabled by long experience of illness. Additionally, itmay provide continuing support for patients with establisheddisabilities (with or without a known vulnerability to majordecompensations), arguably in itself a rehabilitative regimenattempting to prevent further deterioration and also providingcarer support. In practice, many day hospitals perform mixedfunctions and may not have formally determined aims. Theexperience of others can serve to inform the process of definingsuch objectives.Bergmann et al.’s 12 general hospital-based day hospital inNewcastle functioned as an assessment and early treatment unit,without initial home visits and very much in the manner of atertiary referral facility for other teams working out of existingmental hospitals. Alongside was a small ward with a similarABCDEKey:Catchment areaGeneral hospitalwith psychiatricunitMental hospitalDay hospitalFigure 124.1 Models of day hospital provision. (A) Large mentalhospital geographically distant from catchment area served, starting daycare on site. (B) Mental hospital supported by stand-alone day hospitalswithin catchment area. (C) Mental hospital beginning to give way todistrict hospital unit, both sites with inpatient and day hospital facilities.(D) General hospital with psychiatric unit supported by stand-alone dayhospitals. (E) General hospital with day hospital unit and supported byseveral units within the catchment area, each offering inpatient and dayhospital care.function, and the team also undertook liaison work—probablyrepresenting the best use for this day hospital within the city’s thenmental health provision. Even so, and despite a highly skilled andsingle-minded team, the successful pursuit of ‘‘assessment only’’ isdifficult to sustain. Bergmann reported that the day hospital’sadvice, after assessment, was taken or acted upon in disappointinglyfew cases. Whitehead 13 also stressed the assessment andtreatment potential of the day hospital, designating it perhaps thekey element in a community-orientated old age service. He was,however, providing a comprehensive range of services within oneteam, with home-based assessment and treatment available beforea decision regarding the use of the day hospital or a smallinpatient unit. His unsatisfactory experience of poor-qualitymental hospital wards determined his philosophy that recourseto inpatient care would be taken for very few patients.Such models of care are attractive, but were influenced by otherfactors: for Bergmann, longer-term care was available elsewhere, andWhitehead had a supportive nursing home sector sympathetic to hisvision 14 . Other authors have been uncomfortable with day hospitalsthat appear to function mostly to delay entry into long-term care 15,16 :however, for some individuals and their carers, this may be the veryhelp they want, and should be evaluated in this light.Arie 17 identified two groups of patients benefiting from longtermday hospital attendance: dementia sufferers living with carerswanting them to remain at home, but who needed help and somerespite from the carer role; and patients with relapsing illnessescomplicated by persisting ‘‘neurotic’’ symptoms when well. Thelatter were almost all women living alone. Others working in wellsitedand well-equipped day hospitals have confirmed theseimages of the successful long-term patient. Here, the male:femaleratio of dementia sufferers was often equal, and some attendedfrom rest homes. There was also an intermediate group, sufferingfrom mood disorder or neurotic symptoms associated with quitesevere physical disability (from stroke, parkinsonism, arthritis,chest or heart conditions), having nursing needs as great as thoseof dementia sufferers, but with psychological needs akin to other‘‘functional’’ patients 11 .The ‘‘mix’’ of day hospital attenders can be crucial. Individualsseverely damaged by dementia benefit from simple, structured andrepetitive activities that are unhelpful and unrewarding to theircognitively intact peers. Where dementia has caused a decline inphysical abilities, basic group physiotherapy techniques can bebeneficial, whereas other patients with complex physical andpsychological needs may only thrive with individually tailoredpersonal care interventions. Mixing patients with widely differingcognitive abilities can be unacceptable to both the better and theless able. Potential tensions can be reduced by using differentareas of the unit for different purposes, or by having day-specificactivities. Where several local day hospitals coexist, they maydevelop specialized roles 11 .Most practitioners with day hospitals available for their patientsare enthusiastic about their potential, but there have been fewrobust evaluations of the efficacy of day hospitals. Philpott’sreview 18 cautiously concluded that day hospitals remainedexperimental care delivery systems. Creed and colleagues, afterreviewing studies of day hospital care 19 , evaluated day hospitalactivities in the north-west of England 20 . They confirmed that dayhospitals are able to provide alternative care for many patients butthat not all such facilities can, or want to, provide the sameservice 21 . Longer periods of treatment may be offset by greaterefficacy in preventing relapse and maintaining independence 22 .The costs of day hospital care are probably lower than those forinpatient care. MacDonald et al. 23 undertook an extensive study ofoutcomes in matched groups of elderly people with mild to moderatedementia in four care settings in London. They found no significantdifferences in mortality or in changes on dementia scores. Theyconcluded that non-hospital day centres offered the best value.