LETTERS TO THE EDITOR 277

Editor’s note-The elderly in long-term care: Donnelly et al. and Kirk et al., Int. J. Geriut.

Psychiat. 4(5), 2991304,

Dear Editor

Differing approaches to the provision of care for old people who become ‘incompetent’ because of psychiatric and/or other disorders provide a poten- tially rich source for comparative studies. There are many variables that need to be taken into account and descriptions of successes or problems in one part of the world need a good deal of transla- tion beforc lessons can be applied with any cer- tainty elsewhere. In my view, an essential ingredient of the success of psychogeriatric services in the UK has been the approach of providing care and treat- ment to the patient as far as possible wherever he

305-309 or she is living at the time of referral. The ‘graded grains’ approach espoused by our colleagues from Northern Ireland and endorsed as the only way known to do things across the Atlantic may be good for the manufacturers and wholesalers of flour. I always wonder what they do with the lumpy bits that fail the test of perfection-these represent the bulk of patient material referred to us for help. In our hands it becomes a recipe for discontent, lives tarnished by the label of misplacement and unresolvable queues or waiting lists for transfer to more appropriate accommodation.

DAVID JOLLEY

The elderly in long-term care: Donnelly et al. and Kirk et al. Int. J. Geriut. Psychiat. 4(5),

299-304, Dear Editor

In general, the investigators’ approach (ie examin- ing rates of dementia in relation to dependencies across levels of care) is sound and sensible from policy and quality of care perspectives. The notion of treating patients within a continuum of care which reflects need based on specifying intensity of care is relevant to use of long-term care resources in a rational manner. However, a variety of factors such as availability of resources at any given time, geographical proximity to patients’ families, per- ceived quality of services and history of prior use of services influence the type of services used and may be independent of the current status of the patient.

The major problem that I had with the first article was the lack of information about the policies in effect for using each level of care. In the second article criteria were established for determining the appropriateness of placement. However, it was not clear how closely the research criteria resembled the actual policies of the health care facilities or whether they were artificially imposed by the inves-

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305-309- tigators. Despite these reservations, the authors deserve significant credit for establishing criteria and taking a hard-nosed look at ‘over-’ and ‘under- use’ of long-term care services. They were able to clarify why the EM1 patients who meet PG criteria might be managed adequately in an EMI, but their study may not have been able to take account of other factors which could necessitate a PG place- ment (eg psychosis not managed by medication) when the patient does not meet dependency criteria for a PG. Such explanations help to reduce the misplacement rate. Beyond this, it could have been helpful to expand on the implications of the remain- ing misplacements. For example, are social services available for patients who do not need higher levels of care? In addition to developing clearer guidelines for admission to these services, what kind of poli- cies are needed to insure that patients are trans- ferred to more appropriate levels of care when their needs change?

BARBARA J. BURNS Duke University Medical Center, North Carolina

LETTERS TO THE EDITOR 278

Delirium in the elderly: Macdonald et al., Int. J. Geriat. Psychiat. 4(6), 31 1-321

Dear Editor

The authors should be congratulated for drawing attention to the many gaps in our knowledge of delirium due largely to its neglect by researchers. I have little doubt that the terminological muddle in which this subject has been mired for decades has contributed to the gaps in our knowledge of it. This situation is changing, however, thanks in part to the introduction of DSM-I11 and also because of growing realization that delirium is a common condition in the hospitalized elderly. The National Institute of Mental Health in Wash- ington, DC organized a workshop on Aging and Delirium in June 1989 and many of the issues raised by Macdonald e t al. in their article were a subject of presented papers and subsequent discussion. Moreover, reviews of delirium in the elderly have been published in the United States lately (Beresin, 1988; Levkoff et a/., 1986; Lipowski, 1989).

Several points raised in the article call for com- ment. There is no disagreement among recent writers, including myself, that delirium is neither a disease nor a symptom but a syndrome, ie a set of clinical features regularly occurring together and due to a wide range of etiologic factors that cause widespread cerebral dysfunction. DSM-I11 classi- fies delirium as an organic mental syndrome and hence leaves out delirium-like states in which cere- bral dysfunction cannot be demonstrated by labor- atory means, notably by abnormal EEG. N o t a bene, the authors misquote me (p. 312, point 3). I stated that ‘the delirium-like cognitive disorders judged to be functional be referred to as ‘pseudodelirium’ until their nosological status has become clarified’ (Lipowski, 1983, p. 1427). I did not say ‘neurologi- cal’ status. Regarding the historical background of delirium, I have reported it in considerable detail in my book (Lipowski, 1990). The term ‘delirium’ was first used by Celsus in the first century AD. Descriptions of the syndrome can be found in the medical literature from Hippocrates on and its core clinical features have been consistently described since at least the sixteenth century. The concept of clouding of consciousness was already intro- duced by Greiner in 18 17.

It is true that the frequency of delirium in hospit- alized elderly patients is not known with certainty.

Recent studies indicate that between 15 and 20% of patients aged 65 years and over hospitalized on the medical wards are liable to be delirious (Lipowski, 1990). The stressful nature of delirium has been noted by recent authors (Lipowski, 1990). The management of the syndrome has not been the subject of systematic studies. The general measures recommended by countless writers since the second century AD and criticized by the authors do play an important part in the management of a delirious patient. They have even been shown to have some preventive value (Williams e t ul., 1985).

There is general agreement that research on all aspects of delirium is overdue. A reliable diagnostic scale is needed and one has already been proposed (Trzepacz e t al., 1988). Aging of the population and common polypharinacy in this age group have finally brought this syndrome to general attention.

Z. J. LIPOWSKI Clarke Insti tute of Psychiatry, Toronto

REFERENCES

Beresin, E. V. ( I 988) Delirium in the elderly. J. Geriutr. Psychiutr. Neurol. I , 12743.

Greiner, F. C. (1817) Der Truum und dus fieherhuftc. Irresyn. F. A. Brockhans, Altenburg.

Levkof, S. E, Besdine, R. W. and Wetle, T. (1986) Acute confusional states (delirium) in the hospitalized elderly. Ann. Rev. Gerontol. Gerhtr. 6, 1-26.

Lipowski, Z . J. (1983) Transient cognitive disorders (delirium, acute confusional states) in the elderly. Am. J. Psychiutr. 140, 1426-36.

Lipowski, Z . J. (1989) Delirium in the elderly patient. N . Engl. J . Med. 320,578-82.

Lipowski, Z . J. (1990) Delirium: Acute Confusional States. Oxford University Press, New York.

Trzepacz, P. T., Baker, R. W. and Greenhouse, J. (1988) A symptom rating scale for delirium. Psjichiutr. Res.

Williams, M. A., Campbell, E. B., Raynor, W. J. et ul. (1985) Reducing acute confusional states in elderly patients with hip fractures. Res. Nurs. Health 8, 329- 37.

23,89-97.

LETTERS TO THE EDITOR 279

Stress and carers for the dementing: Benjamin and Spector, Int. J. Geriat. Psychiat. 5, 25-3 1

Dear Editor

The interesting article by Benjamin and Spector on ‘The relationship of staff, resident and environ- mental characteristics to stress experienced by staff caring for the dementing’ is somewhat marred by the authors’ failure to distinguish between single episodes and relatively unchanging situations as well as dealing with disease variables in the same way as ‘life events’. Thus, a bereavement and a personality change in a patient are treated as vari- ables in the same category when they really differ considerably, since the first is episodic and truly independent of the illness whereas the latter is

neither. This makes the results difficult to interpret -a great pity because of the practical importance of this research in a relatively little investigated field and doubly so because of the methodologically far more rigorous approach adopted by the authors in an earlier article in the same issue of the journal (Benjamin and Spector, 1990), which employed the well-validated MEAP scale.

RAYMOND LEVY Institute of Psychiatry, London

REFERENCES Benjamin, L. C. and Spector, J. (1990) Environments

for the dementing. Int. J. Geriatr. Psychiat. 5, 15-24.

Environments for the dementing: Benjamin and Spector, Int. J. Geriat. Psychiat. 5, 15-24, 25-3 1

Dear Editor

I have read with great interest the articles by Benja- min and Spector on ‘Environments for the Dement- ing’. I am sure it is very important to endeavour to apply objective assessments to the care of dementing people (and others) as so often policies are evolved and implemented in the absence of proper evaluation.

The authors appear to have obtained a reason- able description of facilities using the MEAP. How- ever, there do not seem to be any other measures of quality of environment for comparison and the groups of residents in the various units inevitably differed in some ways. The overall CAPE scores used may conceal individual severe behavioural symptoms that can have a major effect on care needs. Also when considering community access, the ease of visiting by relatives and others is an important factor and can be a major problem with a remote locations.

When possible there is a case for studying the same groups of residents in different environments to see which features produce desirable effects. This can be difficult to achieve but can sometimes be feasible during service changes on a ‘before and after basis’ although this method is open to some criticism. Using measures which included a time- sample record of levels of interaction and general

ward behaviour, the effect of moving dementia patients into smaller groups was studied in older accommodation in a Dundee hospital (Presly et al., 1980). There was apparent benefit. A similar study of the transfer of patients from old ‘Nightingale accommodation’ to a new purpose-built ‘Planning Note One accommodation’ (SHHD, 1977), where there was no change in patient numbers, failed to show any benefit (McPherson et al, 1985). Oppor- tunities for this sort of study arise from time to time and objective measures of patient behaviour may be usefully combined with the sort of assess- ment described in Benjamin and Spector’s paper.

BRIAN R. BALLINGER Royal Dundee Lij’Hospital, Dundee

REFERENCES

McPherson, F. M., Ballinger, B. R. and Burns, D. B. (1985) The behavioural effects on geriatric psychiatry in-patients of a move to more spacious accom- modation. IRCS Med. Sci. 13,964.

Presly, A. S., Bsllinger, B. R., Fraser, D. and Lindsay, B (1980) An evaluation of the reduction of patient numbers in psychogeriatric wards. H d t h Bull. 38,32- 36.

Scottish Home & Health Department (1977) Hospital Pluming Note One. In-Patient Accommodation. HMSO, Edinburgh.