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1999 Martin Dunitz Ltd

International Journal of Psychiatry in Clinical Practice 1999 Volume 3 Pages 59- 61

59

Patients who changed my practice: Mental disorders in late life-issues of diagnosis and management

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JOHN SNOWDON Department of Psychological Medicine, University of Sydney, Australia Correspondence Address Dr John Snowdon, Area Director of Psychogeriatric Services, Central Sydney Health Service, Rozelle Hospital, Rozelle NSW 2039, Australia Tel: +61 295 569 100 Fax: +61 298 185 712

Received 28 April 1998; accepted for publication 15 July 1998

The author’s interest in old age psychiatry was fostered by cases such as the three he describes. This sub-speciality is dijjerent, challenging and enjoyable. (Int J Psych Clin Pract 1999; 3: 59-61)

Keywords old age depression management

behaviour disturbance nursing homes

INTRODUCTION

PATIENT I

meant to follow a career in general adult psychiatry. The move towards psychiatry of old age was influenced by experiences with various patients, and by circumstances in the area where I was working. I will mention three patients and the lessons I learned from them. To set the scene: psychiatry fascinated me when I was a medical student at St Thomas’ Hospital in London (mainly because of John Pollitt’s teaching and attitudes). Later, I worked at Cane Hill (an ‘asylum’) for a few months before starting training at the Maudsley in 1971. Ian Falloon and I worked for Felix Post and Raymond Levy as psychiatry of old age registrars for 6 months in 1973, at Bethlem. We did not have a defined catchment area, and all our work was in the hospital. In 1977, I came to Sydney to my first specialist (consultant) job as medical superintendent of a new general hospital psychiatry unit. A team of four community psychiatric nurses had been created two years earlier, as a result of initiatives by the short-lived Labour Government of Gough Whitlam; this team moved to Prince of Wales Hospital when the new unit was built, and I agreed to be the psychiatrist of that team - which then took on a catchment area. 1 also sought out a link to a hospital where a number of medical and surgical patients went for convalescence or rehabilitation following treatment at Prince of Wales.

In late 1977, I saved Mrs L! She was a tiny lady, aged 75 years, curled up in bed, who was perceived as resistant to all attempts to rehabilitate her. She had arthritis and had also needed a medical procedure. She denied being depressed or having problems with appetite, sleep, etc., but she was unsmiling and very thin. The team decided she would need nursing home care. I suggested trylng ECT, and her husband was keen to give it a go. He (like me) believed she’d soon fade away in a nursing home. After her ECT, Mrs L was chirpy and lively, and I visited her and her husband in their beautiful home overlooking the sea. She moved about in a wheelchair, and enjoyed life for several more years. The experience confirmed for me that understandable depressions can get better, even iJ there is no improvement in what we think the person is depressed about! We learned not to give up, even in a seemingly hopeless situation. I learned that visiting a person’s home enhances understanding of their medical and psychiatric history.

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PATIENT 2 Also in late 1977, I visited a nursing home where one of my hospital colleagues had upset the staff by discharging a patient, referred for admission because of behaviour disturbance, within a day. The patient had been charm itself while an inpatient. 1 was asked to trouble-shoot!

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60

J Snowdon

I cannot remember the patient, but I remember the experience of walking down the nursing home corridor. On the left side there were a number of rooms, each with two beds. Beside each bed was a person in night-attire, a traytable in front of them, and a tumed-on television. Everyone seemed to stare at me as I went past, not at the television. It was 11 a.m.! There was no diversional therapist, no programme of activities. It seemed as if the residents were being warehoused - kept out of the way. I learned again that visiting a person’s home allows much better understanding ofwhat might be causing them to act in a disturbed way. I was prompted to look at other nursing homes in Sydney, and to enquire who was advocating on behalf of elderly people. Who was attending to the mental health needs of nursing home residents? Why did nursing home staff seem demoralized? Why were they not demanding more medical interest and why did GPs and others so often attribute mental health problems of elderly people to ageing? I encouraged other referrals to our community team, and we sought to establish a day centre and other services for older people in our area. We proposed the development of a geriatric medical service and the building of un inpatient unit for elderly people. Similar initiatives were being taken in other parts of Sydney and elsewhere in Australia. It seemed that we were all learning the lessons at the same time. In the 20 years since then there has been a welcome mushrooming of care services for the aged. I got into it because there seemed such a need and a challenge, and because I enjoyed it.

PATIENT 3 In about 1980, I remember being called to a nursing home to advise on management for Mrs B, an 80-year-old lady who had been hitting nursing staff. When I visited, she was friendly and talkative, and kissed me from my hands upwards. She was restrained in her chair by a tray-table. At other times, other physical restraints had been used. However, this lady talked only in Russian, and there were no Russian-speaking staff or Russian residents in the nursing home. Further, I discovered that Mrs B could not remember recently acquired information or instructions for more than about 20 seconds. The nurses told me that they had told Mrs B (in English, presumably, or by gesture) that she was not to leave the home, but she kept doing so, to walk to her daughter’s place. Her room was near the front door, which had to be kept open because of the fire regulations; so they had to restrain Mrs B to avoid the risk of her wandering into the traffic: the nursing home is near a busy main road. Some nursing homes (even in 1998) cannot provide appropriate care for people with certain problems. In particular, people with dementia who ‘wander’, many of whom have always been energetic, enthusiastic and active individuals, should not be accommodated in nursing homes that cannot provide appropriate supervision. A triage process helps ensure that people with particular care needs get into

homes that provide such care. Some patients benefit from secure (locked) surroundings; they benefit from an absence Cq you ignore the locked doors) ofphysical or chemical restraint. Much can be learned by visiting nursing homes. I learned that hospitals can distort the truth while trying to get somebody out of an acute bed and into - anywhere! I learned that some nursing home staff are very much attuned to the feelings of elderly people, whether cognitively impaired or not; they care about dignity, respect and opportunities for choice. In general, nursing homes do their best to provide contentment and optimal quality of life. In 1977 there was little attention to activities, little concern with how people viewed themselves or what they did with their lives. Staff, relatives and residents seemed to view nursing homes as ‘the end of the line’, a terminal phase of existence, rather than as a new and different phase, with new opportunities, new challenges. In 1977, I well remember staff referring to a particular area as the ’babies’ room’. In 1999 it is different. I sense more pride in working in nursing homes, new expectations of the doctors who visit, and an impatience with those who show ‘ageist’ attitudes.

CONCLUSION I enjoy psychiatry of old age. I enjoy the privilege of visiting people (patients, relatives, carers) in their own homes. I have seen high and low living, and I have observed situations that would make anyone become depressed and/or paranoid. In the 21 years since I first saw Mrs L, I have seen many elderly people get better following assertive treatment, but 1 am aware that part, at least, of many elderly people’s depressions results from attitudes and their environment. Self-esteem is just as important to old as to young people. If people with disabilities and handicaps do not have opportunities for meaningful use of their time, and if they are no longer enabled to feel respected as individuals, who can wonder if they feel demoralized, sad and mournful? Antidepressants cannot make up for that. I learned, by my involvement

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1999 is International Year of Older Persons Visiting a person’s home leads to improved understanding of their problems Efficient triage helps to ensure that people are not admitted to residential care that is unsuited to their needs Good nursing homes care about residents’ dignity, self-esteem and opportunities for choice Advocacy for the needs of older people is a responsibility and a challenge for staff working in old age psychiatry

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with elderly patients, that we, in psychiatry of old age, can make a difference - not just with our pills, but by getting out there and properly understanding their situations, and advocating for them. Psychiatry of old age is a young discipline. In 1978, the British Royal College of Psychiatrists formed its Section of Psychiatry of Old Age: the College recognized old-age psychiatry as a speciality in 1988. In the United States,

geriatric psychiatry was recognized as a subspecialty in 1993. In the last 20 years, various countries, including Australia, have developed psychiatric services for older people, keen and enthusiastic, ready to take up the challenges. We have adapted our practices, responding to older people’s needs and circumstances, which tend to be different to those of younger adults. It is a different sort of psychiatry and works well!

Patients who changed my practice: Mental disorders in late life-issues of diagnosis and management.

The author's interest in old age psychiatry was fostered by cases such as the three he describes. This sub-speciality is different, challenging and en...
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