Mohammed T. Abou-Saleh

REHABILITATION 741circumstances, perhaps especially physical health, may changedramatically; this demands a flexible response. The solution,carefully constructed and successful on one day, may need majorchange on the next as the situation radically alters. For this reason,rehabilitation with older people is rarely completely finished and‘‘maintenance’’ measures are often necessary. Careful planning ofcontinuing care, follow-up and continuing availability as problemsarise are essential features. The strength and determination ofpatients, relatives and support staff are considerably bolstered bythe knowledge that this approach is backing them up.REHABILITATION AND LONG-STAY CAREMany patients, predominantly demented individuals, will requirelong-term care but rehabilitation must remain a strong theme.Such deteriorating multiply-disabled demented patients require24 h care. They often exhibit difficult and disturbed behaviour andneed heavy physical care. Providing the best quality of life, givenoften quite limited resources, is the aim and a major strategy ispreventing unnecessary dependency and promoting the maximumretention of function. With descriptions 18 of the care of suchpatients in various settings, a frequent theme has been theavailability of skilled and expert staff from the multidisciplinaryteam to help maintain good function. Evaluation of such longtermcare programmes has proved complex and difficult 19,20 .There has been concern in the UK that such disabled patientswill increasingly be excluded from hospital care for fundingreasons, in favour of health authority contracted private nursinghome care or simply standard care in private nursing homes 20–22 .In the USA (and many other countries), much long-term care ofolder people has long been provided in the private sector. But inthe USA the Omnibus Budget Reconciliation Act (OBRA Act) 23requires nursing homes to ascertain and meet any needs fortherapy and treatment. In the UK the fear is that the drive in thebest hospital care to provide a good quality of life may be replacedin private nursing homes by a desire for a quiet life; passivity anddependency (possibly resulting from unnecessary tranquillizingmedication 24–26 ) could be more acceptable than the patient’sexercise of individuality, movement and self-expression.Reports of high levels of depression in homes for older people 27–30emphasize the worry about effective rehabilitation and care for olderpeople with chronic psychiatric disorder. Any institution providingshelter is at risk of providing a relatively impoverished environment15 and undue restriction of independence.Bennett 15 called unnecessary social inactivity and dependence‘‘the psychiatric equivalent of contractures’’. Hospitals (and socialservices) have provided much good practice. Accounts of goodlong-stay care for demented people emphasize the invaluableinput of occupational therapy, physiotherapy and person-centredapproaches 30,31 . Sensibly ensuring activity in a structured day andenriching the environment with, for example, music therapy, arttherapy, drama therapy 32 or reminiscence therapy 33 are importantwherever the setting.Community psychiatric nurse (CPN) support (indeed, availabilityof all the specialist team to give support) to such homes canbe feasible and helpful. But concern remains about how to monitoreffectively and maintain standards in private long-stay care 20 .Ultimately, good care here depends on the commitment of sufficientappropriately trained staff to help disabled old people experience tothe full their remaining scope for independence and capacity for joy.ATTITUDESAdverse feelings about older people have been noted by many 34 .Geriatricians have commented on unhelpful attitudes in healthprofessionals of all kinds, including GPs 13 . Modern medicaleducation is inculcating a better knowledge base for tomorrow’sdoctors and also better attitudes 35 . The educational potential ofpsychogeriatric services, not least exploiting the educationalopportunity afforded by rehabilitation (and other concerns) withthe most disabled, has been described 36 . Not only medicalstudents 37 , but all varieties of medical and other professionalstaff concerned with older people with mental health problems,and also carers and lay audiences, benefit from this educationaleffort. Public education especially is vital in engendering constructiveattitudes in society, on which ultimately will depend allefforts towards care in the community and the political will toprovide decent services.REFERENCES1. Nocon A, Baldwin S. Effective Practice in Rehabilitation: TheEvidence of Systematic Reviews. London: King’s Fund, 1992.2. Holden U, Woods RT. Positive Approaches to Dementia Care, 3rdedn. Edinburgh: Churchill Livingstone, 1995.3. Kitwood T. Dementia Reconsidered: the Person Comes First.Buckingham: Open University Press, 1997.4. Woods RT. In Woods RT, ed., Handbook of the Clinical Psychologyof Ageing. Chichester: Wiley, 1996; 575–600.5. House A, Dennis M, Mogridge L et al. Mood disorders in the yearafter first stroke. Br J Psychiat 1991; 153: 83–92.6. Cummings JL, Masterman DL. Depression in patients withParkinson’s disease. Int J Geriat Psychiat 1999; 14: 711–18.7. Evans JG. Commentary: curing is caring. Age Ageing 1989; 18(4):217–18.8. Evans JG. High hopes for geriatrics. J R Coll Physicians 1994; 28:392–3.9. Pattie A. Measuring levels of disability—the Clifton AssessmentProcedures for the Elderly. In Wattis JP, Hindmarch I, eds,Psychological Assessment of the Elderly. Edinburgh: ChurchillLivingstone, 1988; 61–88.10. Millard PH. Meeting the needs of an ageing population. Proc R CollPhysicians Edinb 1994; 24: 187–96.11. Bergmann K. Neurosis and personality disorder in old age. In IsaacsAD, Post F, eds, Studies in Geriatric Psychiatry. Chichester: Wiley,1978; 41–76.12. Pitt B. Psychogeriatrics, 2nd edn. Edinburgh: Churchill Livingstone,1982.13. Hodkinson HM. Rehabilitation of the elderly. In Medicine in OldAge, 2nd edn. London: British Medical Association, 1985.14. Hemsi L. Psychogeriatric care in the community. In Levy R, Post F,eds, The Psychiatry of Late Life. London: Blackwell Scientific, 1982;252–87.15. Bennett DH. The mentally ill. In Mattingly S, ed., RehabilitationToday, 2nd edn. London: Update Books, 1981; 119–22.16. Department of Health. The Hospital Discharge Workbook: A Manualon Hospital Discharge Practice. London: HMSO, 1994.17. Department of Health. Better Services for Vulnerable People, EL (97)62, CI (97) 24. London: HMSO, 1997.18. Shah A et al. Physical dependency and dementia in the NHScontinuing care wards and contracted NHS beds in voluntary nursinghomes. Int J Geriat Psychiat 1994; 9: 229–32.19. Kane RA, Kane RL. Long-term Care. New York: Springer, 1987.20. Turrell AR, Castleden CM, Freestone B. Long-stay care and theNHS: discontinuities between policy and practice. Br Med J 1998;317: 942–4.21. Wattis J, Fairbairn A. Towards a consensus on continuing care forolder adults with psychiatric disorder. Int J Geriat Psychiat 1996; 11:163–8.22. Social Information Systems. A State of Confusion: A Report to theAlzheimer’s Disease Society. Knutsford: Social Information Systems,1997.23. National Mental Health Association. Summary of the 1987 OmnibusBudget Reconciliation Act (OBRA). Washington, DC: NMHA, 1988.24. McGrath M, Jackson GA. Survey of neuroleptic prescribing inresidents of nursing homes in Glasgow. Br Med J 1996; 312: 611–12.