INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 9: 519-523 (1994)

THE DAY HOSPITAL IN OLD AGE PSYCHIATRY: THE CASE AGAINST

CHRISTOPHER FASEY Consultant in Old Age Psychiatry, Basildon Hospital, Basildon, Essex, UK

SUMMARY

The day hospital in old age psychiatry has many supporters and is widely felt to be a ‘good thing’. This article suggests there is an opposing view and that more hard data are required before the argument is resolved. Other models of care are mentioned which may be equally valid-comparison between different models is needed.

KEY WORDS-Day hospital, results, alternatives, cost effectiveness.

In the UK the Marlborough Day Hospital in Lon- don was the first psychiatric day hospital opened (Farndale, 1961). This was in 1946. Other psychi- atric, geriatric and psychogeriatric day care facili- ties followed and grew dramatically in numbers in the 1960s and 1970s. As old age psychiatry deve- loped as a specialty in the UK, the day hospital became central to many local services and was strongly advocated by professional leaders (Arie and Jolley, 1982; Jolley and Arie, 1992; Royal Col- lege of Physicians and Royal College of Psychia- trists, 1989). On March 31, 1990 there were over 20 000 regular attenders on the register of National Health Service (NHS) psychogeriatric day care faci- lities and over 1.7 million annual available place days recorded (Department of Health, 1991).

The roles claimed for psychiatric day hospitals are many and varied. These include the manage- ment of patients with neurotic disorders, depression and late life psychoses, where they pro- vide the environment in which assessment, moni- toring, treatmentltherapy, rehabilitation and maintenance take place. They are said to be an alternative to inpatient treatment (Creed et al., 1990) and to promote earlier inpatient discharge, being especially helpful for people with chronic or relapsing conditions. In old age psychiatry, how- ever, patients with dementia comprise the main users of the service. Direct physical care may be provided, also assessment and treatment of be- havioural and emotional disturbance, but their

Address for correspondence: St Martin’s Day Hospital, Little- bowne Road, Canterbury, Kent, UK.

main role is to provide day time respite for family carers. It is claimed that this can delay or prevent admission to institutional care.

A survey of the day care services provided by local authority social services departments (SSD) and district health authorities (Tester, 1989) high- lighted the difference in objectives between day hos- pitals (NHS) and day centres (SSD). Social services’ stated aims, in order of priority, were:

0 Prevention-helping people remain independent

0 Social care and stimulation 0 Developing/maintaining physical and mental

Relief, respite or support for carers 0 Assessment, monitoring, formulation of indivi-

0 Basic personal care 0 Rehabilitation and treatment 0 Social/psychological support to clients and their

families 0 Advice and counselling for individuals

Day hospitals (NHS) had similar objectives but emphasized that rehabilitation was the most important aim and relief for relatives and respite care were less important objectives. Tester expressed doubt as to whether this distinction was real, and questioned how closely practice reflected the objectives in reality. The day hospital may be no more than a day centre providing respite care for people with dementia who are considered ‘too severe’ for day centres because of the level of their dependence and the presence of behavioural prob-

in the community

skills

dual ‘packages of care’

CCC 08854230/94/0705 19-05 0 1994 by John Wiley & Sons, Ltd.

Received 14 May 1993 Accepted 20 October I993

520 C . FASEY

lems. Day hospitals are staffed usually by expensive health service professionals but provide very little in the way of specific care or treatment. Let us now examine whether there might be more effective ways of achieving the stated objectives.

IS THE DAY HOSPITAL THE BEST WAY OF ACHIEVING ITS GOALS?

A day hospital represents a large investment in capital, recurrent revenue costs and absorbs many skilled staff. Could other providing agencies, for example local authorities, voluntary agencies and the private sector, provide the same services more economically? What alternatives to day hospital care currently exist? Could highly trained staff be more usefully deployed providing domiciliary care or be better used providing more focused input into clients attending day care services run by other pro- viders?

The capital investment in a day hospital is high because the buildings are used only for a few hours each day. While attempts have been made to extend hours and use space more flexibly-one or two units provide some overnight respite care- nevertheless the professionals usually work con- ventional office hours. Often purpose-built with special therapy space, many facilities are seriously underutilized. Professional staff input is focused mainly on new assessments and there may be sur- prisingly little contact between doctors and thera- pists and long-term patients.

Transport is a perennial problem in day care (Shah, 1993). It is an expensive part of the over- heads. Often the service is limited or unavailable, particularly if special lifting equipment is needed. Sometimes only those living locally can attend. Unless the transport is ‘dedicated’, that is, it belongs to the unit, it can be unreliable. If transport is provided by the local ambulance service, as it often is in the UK, it may be very vulnerable to other demands on time and day hospital transport is usually the first to be cut in the event of industrial action. The journey is often uncomfortably long, cutting seriously into attendance time (Brearley and Mandelstram, 1992). These problems are worse in rural areas and older people are understandably reluctant to spend 2 or 3 hours every day receiving what Professor Arie has called ‘transport therapy’. There have been attempts to address this problem by the development of ‘travelling day hospitals’

(Walden, 1992) or day care at the work place (Auto Express, 1993).

Staff are the major cost. Nurses and other pro- fessional staff are a valuable resource who could be otherwise employed. Are their skills being used appropriately? While day hospitals should have a major role in rehabilitation and treatment, they may be more involved in ‘prevention’ of further handicap and hands-on care (Tester, 1989) than in active treatment. Observation in a day centre for people with mid to late stage dementia revealed that trained staff were involved in relatively unskilled tasks, for example accompanying to the toilet or keeping clients away from doors (Hassel- kus, 1991). One of the main purposes of activities was to keep the group together, to enable them to be managed easily and to avoid ‘trouble’. Allen (1990), in another study of a geriatric day hospital, suggested that nurses, while ‘kind and caring’, act predominantly in a custodial role and that ‘nursing skills are underused’.

Could professional staff in day hospitals be used more profitably elsewhere and, conversely, could people with other sorts of skills, without health care qualifications, be used to provide day care in other ways? Would redeployment of day hospital staff to domiciliary work and work in day centres in the community give a comparable or improved service to patients? There are few studies available comparing services which use a day hospital and those that do not. But there are some examples in the literature. In Denmark, health care pro- fessional staff have run ‘dementia groups’ within day centres from one to five times per week (Swane, 1992), using relatively few staff to provide social stimulation, respite and reduce admission to insti- tutional care. They also provide a forum in which home helps and assistant nurses are trained. In many districts in the UK, nursing staff and doctors visit and advise on the management of clients in day centres. This enables day centres to manage more difficult patients, especially those with com- plex medical problems. In the field of geriatric medicine it has been suggested that ‘standard’ geri- atric care (involving inpatient and outpatient facili- ties and community follow-up) is as effective as a day hospital (Eagle et al., 1991), although it is important to take account of what specific out- comes are being measured when looking at studies like this. Furthermore, domiciliary based physio- therapy is as effective, or better, in stroke rehabili- tation and more resource efficient (Young and Forster, 1992). Rehabilitation is probably best car-

DAY HOSPITALS: THE CASE AGAINST 52 1

ried out in the specific setting which the patient will use-their own kitchen, living room, and so on.

Many other agencies run day care services and their functions overlap with day hospitals. In Eng- land there were 745 day centre premises for the elderly run by local authorities (LA) in 1991 (Department of Health, 1992). Many day centre attenders have dementia. The care of people with dementia involves provision of lots of activity, general personal care and maintenance in the community. These are seen as social rather than medical goals and provision could be achieved by organizations more specifically geared up to these activities-social services, the voluntary sector and the independent private sector.

A study of LA provision showed that ‘generic’ day centres, i.e. those providing for all elderly peo- ple, with or without disabilities, are the cheapest option but specialist day centres give better care for people with severe disabilities and, while more expensive than generic centres, are cheaper than day hospitals (Gerard, 1988). Patients attending day hospitals and day centres had similar mortality rates and worsening of dementia over a 9-month study period but the day centre group showed improved dependency levels (Macdonald et al., 1982). There are no studies demonstrating that day hospitals support people with dementia better than specialist day centres.

IS THE DAY HOSPITAL EFFECTIVE?

One stated aim of day hospitals is to delay or pre- vent admission, but many demented people attend- ing day hospitals will be institutionalized sooner or later. In Edinburgh, only 9% of demented day hospital attenders were still in the community at a 3-year follow-up with 32% in hospitals or homes and 59% dead (Woods and Phanjoo, 1991). Similar results were reported from The Netherlands, with 44.2% in the community, 42% in institutions and 13.8% dead at 1 year and 4%, 29% and 67% respec- tively at 5 years (Diesfeldt, 1992). Both studies con- cluded that day hospitals had little effect on the need for institutional care. The attitude and well- being of the carers and the patient’s disability were more highly significant factors in predicting institu- tionalization than the support they received. In one prospective study, high scores on the General Health Questionnaire in carers were a major predic-

tor of a breakdown in community care over 12 months (Jerrom et al., 1993). Opening a day hospi- tal does not seem to affect the number of inpatient admissions in a service either (Ballinger, 1984). Day hospitals probably do not prevent admission to acute or continuing care facilities.

Is avoiding admission actually a useful goal? Some authors would say it is not. Mortality statis- tics in Devon showed lower than expected mortality for the spouses of demented patients after admis- sion to care, and mortality remained lowered after bereavement (Ryan, 1992). Admission sometimes has a positive effect on the survival of carers, pre- sumably effected by a reduction in the direct burden of care.

Another goal of day hospitals is to decrease the burden on carers by daily respite from the sheer hard work of caring. However, preparing the patient for the day hospital may increase workload (Berry et al., 1991) rather than diminish it. In the same study, respite care provided in their own homes by sitters coming in while the carer went out diminished the workload and gave greater opportunities for gainful employment.

The goals described above relate to long-term care. Day hospitals are also said to have a role in providing a setting for the assessment of dementia (Arie and Jolley, 1982). Assessment includes mental state examination, an assessment of abilities and performance of activities of daily living and physical examination/investigations. All these can take place in either outpatients or the patient’s home just as easily. Some physical investi- gations require hospital facilities, but these can be appended to an outpatient assessment (as currently happens in the South Downs NHS Trust) or covered by the occasional use of inpatient wards for the day (as in Hither Green Hospital, London) or by specially designated sessions in outpatient clinics. The day hospital can in theory offer obser- vation over time, but the observations are likely to be unreliable in that they do not reflect how the patient behaves in his own environment or with his own family. Increased disorientation comes with unfamiliarity, opening hours miss out on ‘sun- downing’ and nocturnal disturbance and be- havioural disturbance are often directed specifically at carers or are upsetting only to them. Close relatives and neighbours can give most of the information required for this kind of assess- ment. The development of a semistructured diary for the carer to keep is useful and longer ‘assess- ment’ by observation is probably unnecessary.

522 C. FASEY

FUNCTIONAL ILLNESS

Patients with functional illness, mainly depression, present different problems. Patients may need supervision of medication, and they may require specific psychological interventions, either on an individual or a group basis. In younger populations the day hospital has been shown to be a viable alternative to inpatient treatment for many patients (Creed et al., 1990) though not in all facilities (Creed et al., 1991). Patients with long-term needs and the recurrent readmissions of relapsing patients decrease the resources available for new referrals (Pryce, 1982), and this is a problem of services for older patients too. In Brighton, 13 out of 27 patients of one consultant have attended the day hospital longer than 1 year with functional illness.

Coincident physical illness and side-effects of medication and polypharmacy are special problems in older patients with depression (Salzman et al., 1992; Malcolm, 1992), and furthermore depression carries a poor prognosis (Murphy, 1983) and increased mortality (Murphy et al., 1988). In theory the day hospital can offer more intensive super- vision and continuing support for those with long- term symptoms. Attending a day hospital, however, disrupts familiar routines and many patients are not natural ‘joiners’, finding the social side of day hospital care little to their liking. There is no research comparing psychiatric treatment for depression for the elderly at home, in outpatients, in day hospitals or in other forms of day care. The question of whether day hospitals have a cost-effec- tive role in the care of elderly people with functional illness remains open.

DISCUSSION

The preparation of this article revealed a paucity of research on the efficacy of day hospitals in old age psychiatry. There are papers about the philoso- phy underpinning them (Arie and Jolley, 1982; Jolley and Arie, 1992) and the function of units, usually taking their value as accepted wisdom. Cri- tics like this author and Ball (1993) raise questions but do not answer them with research. Most research results quoted come from active propo- nents of day hospitals and there is an assumption that quoted styles of care can be translated directly from geriatric medicine, which shares with us prob- lems of people with chronic illness and disability and the need to focus services on carers. The needs

of people with functional psychiatric illness have been little discussed and there is a shortage of data. Outcomes for younger people may not be readily transferable to an older population.

It is no longer enough for service providers to say that the day hospital is necessary to a proper service and expect one to be forthcoming. In the new UK world of purchasers and providers, fund- holding GPs and community care legislation, day hospitals must demonstrate their value. More infor- mation is needed on the efficacy of day hospital treatment and in comparison with other options. The analysis must, of course, include cost-effective- ness. Many old age psychiatry services which cur- rently operate without day hospital facilities would be unhappy to transfer resources away from domi- ciliary provision and prefer to invest in providing professional health care inputs to day care provi- sion of other kinds run by other organizations. There is major doubt whether there is a role for day hospitals for patients with dementia and it is likely that a more flexible range of local day care services and styles of respite care would be prefer- able.

This author is sceptical of the value of day hospi- tals but the argument on both sides needs to be pursued not by philosophical discussion or per- sonal opinion but by research and audit. Proposed studies in the South East Thames Regional Health Authority (Beats et al., 1993) and by the National Audit Office will be useful in this context.

The debate over day hospitals has attracted powerful, dogmatic voices on both sides but local solutions on the balance of day care services and on the role of existing facilities are likely to produce better results than national guidelines. Different service models should depend on the population to be served and the personnel available to staff them.

ACKNOWLEDGEMENTS

I would like to thank Dr A. J. D. Macdonald for his helpful and constructive advice.

REFERENCES

Allen, D. (1990) Day hospital care. Nur. Elderly, Janu- ary, 19-22.

Arie, T. and Jolley, D. (1982) Making services work: Organisation and style of psychogeriatric services. In

DAY HOSPITALS: THE CASE AGAINST 523

The Psychiatry of Late Life (R. Levy and F. Post, Eds). Blackwell, Oxford.

Auto Express (1993) Car makers to take care of the aged. Auto Express 236,7.

Ball, C. (1993) The future of day care in old age psy- chiatry. Psychiatr. Bull. 17,427-428.

Ballinger, B. R. (1984) The effects of opening a geriatric psychiatry day hospital. Acta Psychiatr. Scand. 70, 400-403.

Beats, B., Trimble, D. and Levy, R. (1993) Day hospital provision for the elderly mentally ill within the South East Thames Regional Authority. Int. J. Geriatr. Psy- chiat. 8,442-443.

Berry, G. L., Zarit, S. H. and Rabatin, V. X. (1991) Caregiver activity on respite and nonrespite days: A comparison of two service approaches. Gerontologist 31(6), 830-835.

Brearley, P. and Mandelstam, M. (1992) A Review of Literature 1986-1991 on Day Care Services for Adults. Social Services Inspectorate. HMSO, London.

Cantley, C. and Smith, G . (1987) Day care for the elderly. In Why Day Care (G. Horobin, Ed.). Kingsley, Lon- don.

Creed, F., Black, D., Anthony, P., Osborn, M., Thomas, P. and Tomenson, B. (1990) Randomised controlled trial of day patient versus inpatient psychiatric treat- ment. Brit. Med. J . 300,1033-1037.

Creed, F., Black, D., Anthony, P., Osborn, M., Thomas, P., Franks, D., Polley, R., Lancashire, S., Saleem, P. and Tomenson, B. (1991) Randomised controlled trial of day and in-patient psychiatric treatment. 2: Corn- parison of two hospitals. Brit. J. Psychiat. 158, 183- 189.

Department of Health (1991) NHS Day Care Facilities. England- Year ending 31 March 1990. HMSO, Basil- don.

Department of Health (1992) Health and Personal Social Service Statistics for England. HMSO, Basildon.

Diesfeldt, H. (1992) Psychogeriatric day care outcome: A five-year follow-up. Int. J . Geriatr. Psychiat. 7,673- 679.

Eagle, D. J., Guyatt, G. H., Patterson, C., Turpie, I . , Sackett, B. and Singer, J. (1991) Effectiveness ofa geri- atricday hospital. Can. Med. Assoc. J . 144(6), 699-704.

Farndale, J. (1961) The Day Hospital Movement in Great Britain. Pergamon, Oxford.

Gerard, K. ( I 988) An appraisal of the cost-effectiveness of alternative day care settings for frail elderly people. Age Ageing 17,311-318.

Hasselkus, B. R. (1991) The meaning of activity: Day care for persons with Alzheimer disease. Am. J. Occu- pat. Ther. 46(3), 199-206.

Jerrom, B., Mian, I . and Rukanyake, N. G. (1993) Stress on relative caregivers of dementia sufferers, and pre- dictors of the breakdown of community care. Int. J. Geriatr. Psychiat. 8, 331-337.

Jolley, D. and Arie, T. (1992) Developments in psycho- geriatric services. In Recent Advances in Psychogeria- tries (T. Arie, Ed.). Churchill Livingstone, Edinburgh.

Macdonald, A. J. D., Mann, A. H., Jenkins, R., Richard, L., Goodlove, C. and Rodwell, G. (1982) An attempt to determine the impact of four types of care upon the elderly in London by the study of matched groups. Psychol. Med. 12, 193-200.

Malcolm, M. T. (1992) Medication used by elderly patients at home: Changes over 10 years. Int. J. Ger- iatr. Psychiat. 7 , 121-124.

Murphy, E. (1983) The prognosis of depression in old age. Brit. J . Psychiat. 142, 11 1-1 19.

Murphy, E., Smith;, R., Lindesay, J. and Slattery, J. (1988) Increased mortality rates in late life depression. Brit. J . Psychiat. 152, 340-346.

Pryce, I. G. (1982) An expanding ‘stage army’ of long- stay psychiatric day-patients. Brit. J. Psychiat. 141, 595-601.

Royal College of Physicians and Royal College of Psy- chiatrists (1989) Care of Elderly People with Mental Illness, Specialist Services and Medical Training. Royal College of Physicians, London.

Ryan, D. H. (1992) Is there a desolation effect after dementia? A comparative study of mortality rates in spouses of dementia patients following admission and bereavement. Int. J. Geriatr. Psychiat. 7, 33 1-339.

Salzman, C., Fisher, J., Nobel, K., Glassman, R., Wolf- son, A. and Kelley, M. (1992) Cognitive improvements following benzodiazepine discontinuation in elderly nursing home residents. Int. J. Geriatr. Psychiaf. 7,

Shah, A. (1993) Day hospital transport. Int. J . Geriatr. Psychiat. 8,270-27 1.

Swane, C. E. (1992) lrnproving environment and care for elderly people with dementia. Dan. Med. Bull. 39, 253-255.

Tester, S . (1989) Caring by Day: A Study of Day Care Services for Older People. Policy Studies in Ageing No. 8. Centre for Policy on Ageing, London.

Walden, D. (1992) Care in the country. Nurs. Elderly, MayIJune.

Woods, J. P. and Phanjoo, A. L. (1991) A follow-up study of psychogeriatric day hospital patients with dementia. Int. J . Geriatr. Psychiat. 6, 183-188.

Young, J. B. and Forster, A. (1992) The Bradford com- munity stroke trial: Results at six months. Brit. Med.

89-93.

J. 304,1085-1089.