Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-04bIn the BeginningThe Late Felix PostIn 1943, after a year’s early training as one of the war-timerefugees of the Maudsley Hospital, Professor Aubrey Lewispassed me on to Professor D. K. Henderson and the RoyalEdinburgh Hospital for Nervous and Mental Diseases, where Iinitially worked in the private department. During one of hisrounds, Henderson said to me: ‘‘Post, do you see all these oldpeople here? Why don’t you write ’em up?’’ This I obediently did,and my article appeared in the Journal of Mental Science 1 . Thearticle started by demonstrating that the admission rate ofpatients over 60 to the Royal Edinburgh Hospital had risenbetween 1901 and 1941 more steeply than the proportion of thisage group in the Scottish population. Interestingly, at this earlydate, I had found no difficulties in the differential diagnosis of mycolleagues’ and my own patients. There were 22 senile, arterioscleroticand presenile dementia patients, 20 manic–depressivepatients, 25 patients suffering from involutional or senilemelancholia and 51 patients with schizophrenia. Assuming thatthe functional psychoses were the concern of general psychiatry,the rest of the paper dealt with the dementias and with an attemptto link the type associated with delusions and hallucinations toearlier personality characteristics. I noted that a high proportionof dementia admissions had been precipitated by terminalconfusional states, and that of 111 patients admitted over thepreceding 4 years with organic psychoses, only 23 were stilloccupying beds. I made the false prediction that in the future themain burden of the hospital services would be represented by thechronicity and survival of melancholic and paranoid patients. Idid not anticipate that electroconvulsive therapy (ECT) andantidepressive drugs, while producing lasting recoveries in only25% of cases, would make at least temporary discharge frominpatient care possible in most cases.Aubrey Lewis was more farsighted. He had published, with apsychiatric social worker 3 a paper describing the psychiatric andsocial features of the patients in the Tooting Bec Hospital forSenile Dementia, London, UK, and in 1946 predicted, in theJournal of Mental Science 3 that ageing and senility would becomea major problem of psychiatry.After army service, I consulted Lewis about possible positionsand he recommended me for the post of assistant physician at theMaudsley Hospital. I flattered myself that in me Lewis had seen afuture brilliant psychiatrist, but was soon to be disillusioned. Evenbefore the Bethlem Royal and Maudsley Hospitals were united in1948, Lewis had conceived the idea of using some of the Bethlembeds to establish a unit for patients over the age of 60. After aheated discussion with the Bethlem matron, Lewis obtainedagreement for the admission of senile patients to a hospital which,like the Maudsley, had previously admitted only patients thoughtto be recoverable. Uncovering his batteries, he asked me to takeon the development of this Geriatric Unit. Once again, I obeyed(to say without enthusiasm would be an understatement) and,right up to my retirement, I continued also to run a unit andoutpatient clinic for younger adults.A report in the Bethlem Maudsley Gazette 4 demonstrated thatboth the Bethlem staff and I had ‘‘caught fire’’. The article startedwith a tribute to Professor Aubrey Lewis and his almostrevolutionary idea of including experience in geriatric psychiatrywithin postgraduate training. The article went on to describe howpatients over 60 had gradually infiltrated the Bethlem wards toemerge as a unit for 26 women and 20 men. The two wards werestaffed by the same number of senior and junior nurses as theother adult wards, with two trainee psychiatrists changing every 6months to other departments. There was one psychiatric socialworker (PSW), later usually assisted by a trainee. The occupationaltherapy department had collaborated with the nursing staffto devise and carry out a daily occupational programme as well assocializing activities. The PSW ran a weekly afternoon ofhandicrafts, tea and talk near the Maudsley, where throughoutmy tenure I conducted a weekly follow-up and supportive clinic.The first year during which the unit had been in full swing was1952, and it was recorded that during that year there had been3.00 admissions to each geriatric bed compared to 3.74 admissionsto each general psychiatric place. Patients who had beendementing, but whose home care was no longer possible hadbeen excluded from admission, though not rigidly, as well aspatients with recurring illnesses that had been adequately treatedat the Bethlem-Maudsley or other hospitals. Of 133 patients, ninedied, only four had to be transferred to their regional mentalhospitals, seven were resettled in homes for the elderly, while 113could be returned to family care. One year after discharge,information was successfully obtained about 121 of 124 cases.Seven patients had died, including one suicide of a woman whohad discharged herself. Thirty ex-patients had to be readmitted toour or other hospitals, thirty-five were still outside hospital but byno means symptom-free, but 45 patients would be classified asrecovered. These relatively favourable results were due to 89patients having suffered from affective illnesses: 24 had symptomsassociated with brain damage, 10 were mainly paranoid and 10were regarded as having psychoneurosis. In spite of 4–6 weeks ofconservative management 52 patients had to be given ECT. Iconcluded the article by pointing to research needs and by opiningthat with 30–40% of patients admitted to British mental hospitalsbeing over the age of 60, training in the special problems of thisage group was essential for all entrants to general psychiatry.The history of the beginning would be incomplete without abrief account of further developments. My little textbook (rightlyout of print) and publications on the long-term outcome ofPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd