If we can better understand why people kill themselves, it should be possible to reduce suicide rates. The major aim of this article is to consider whether any factors associated with higher rates of suicide in old age are amenable to preventive interventions.

It is said that epidemiology is the basic science of prevention. Multiple interacting factors contribute to the causation of suicide, though commonly, in the individual case, a single circumstance or condition can be identified as the major precipitant of suicidal behaviour. Cross-sectional studies may reveal factors that correlate with high suicide rates in particular populations, while long-term studies can show associations between changes in suicide rate and in socio-environmental conditions.

Introduction

Since the last review of this topic in this journal, there has been a focusing of efforts to clarify the classification of manic syndromes and their neurobiologic basis. This has involved proposals for more refined subtypes, as well as descriptions of brain localization and co-morbidity. Our understanding of the epidemiology, genetics, clinical course and treatment of manic syndromes has not substantially altered over the last decade.

This paper addresses some ethical and legal issues which arise in the UK in the care of people with dementia, focusing on the law in England and Wales – updating and revising the 1997 and earlier version. The ‘end of medical ethics’ continues to be debated, with an attendant fear of doctors’ responsibility and authority being fatally eroded by administrators and cost controllers, concerned only with budgets and ‘bureaucratic parsimony’.

As a correlate of psychological well-being, insomnia continues to be regarded as a critical indicator of both mental health and quality of life, appearing as a prominent diagnostic feature in both DSM-IV1 and ICD-102 (particularly in relation to depression and anxiety states), and included in many of the most commonly used health outcome measures, including the Nottingham Health Profile and the SF-364. The symptom of disturbed sleep is also included in most of the available schedules for assessing the mental health of elderly people, including the GMS, CAMDEX, and the CARE. Whether specified as a diagnostic criterion or included in a diagnostic algorithm, the assumption is made that certain patterns of sleep disturbance are associated with, and consequently predict, certain types of mental illness. The evidence would suggest, however, that the strength of the association, and hence the validity of this assumption, may diminish across the human lifespan.

Spinal cord injury (SCI) is a catastrophe that affects the individual, the partner, the family and the community. Society is involved in the broader sense, in the funding of the treatment and long-term support of individuals with SCI. SCI causes complex medical, physical, psychological, social and financial interactions. Although the physiological impairment following a SCI typically affects the locomotor and sensory systems, there is nearly always a resulting dysfunction that affects most bodily systems. Both the multi-system physiological impairment/dysfunction and non-medical aspects of SCI remain in a dynamic state for the rest of the individual’s life. This means that lifelong treatment and monitoring is required by a dedicated multidisciplinary/interdisciplinary team of health and social care professionals.

Why measure?

Before we consider what to measure and how to measure outcomes in the rehabilitation of frail older adults, an antecedent question is, why measure these things? Without an answer satisfactory for both measurers and measured, much effort and ingenuity will be expended with resultant perspiration and exasperation and little else.

Traditionally, medical care, i.e. that identified by physicians, has assumed that its principal objective was patient care, i.e. that appreciated by patients. Outcomes of care from the viewpoint of the patient, of his or her informal supporters, of the involved health care professionals, and of the health care delivery system have to be clarified and made operationally explicit. This recognition requires definition and measurement. Thus a powerful reason for measuring outcomes for recipients and providers of health care, as well as the health care delivery system, is to know what is happening (the descriptive question) and with what effect (the analytical question).

There are estimated to be more than 18 million people world-wide suffering from dementia and, on entering the twenty-first century, demographic projections suggest that there will be a significant growth in elderly populations due to decreasing infant mortality, improved public health and safety, medical advances, better education and housing and increased service provision. These population shifts will predictably lead to a greater demand on medical and welfare services.

Despite the fact that a sizeable proportion of the elderly population will at some time develop cognitive problems, accurate diagnosis is difficult due to the multiple pathology involved in these impairments. With the introduction of pharmacological treatments for cognitive impairments, the emphasis on establishing if people are suffering from a dementing illness is crucial. Furthermore, patients who are categorized as ‘subclinical’ cases of cognitive impairment often have an underlying risk for further progression. Although all clinical definitions of dementia stress that there must be evidence of intellectual decline, the most common being memory failure, there is confusion surrounding the nature of cognitive deficits in the three most commonly applied criteria for dementia – The International Classification of Diseases (ICD-10), The Diagnostic and Statistical Manual for Mental Disorders (DSM–IV) and the National Institute of Neurological Disorders and Strokes (NINDS), Association Internationale pour le Recherche et l’Enseignement en Neurosciences (AIREN).

Much of Parkes’ thorough review of bereavement in the elderly in a previous issue of this journal is still highly relevant. Advances in our understanding of bereavement are surprisingly slow for a condition which is ubiquitous, and there are still disappointing gaps in our knowledge. A common difficulty for researchers in this field, and for clinicians reading their papers, is the problem of selection bias. Participants in studies on bereavement are often white and middle class. More often than not, grief research focuses on bereaved spouses rather than blood relatives or friends of the deceased. In addition, much research on bereavement originates from the USA, so the findings may not be as relevant in other countries. Lastly, of particular relevance to this paper, although many studies of grief purport to be of ‘older’ samples, closer inspection of the paper will often reveal a surprisingly young mean age; people over 75 are often excluded from bereavement research. These biases must be borne in mind when interpreting the findings from the studies discussed in this review.

The National Bed Inquiry indicated that up to 20% of older people might be inappropriately occupying acute hospital beds and could be discharged if alternative services were available. The report proposed the concept of ‘Intermediate Care’ as a scenario that might contribute to resolving issues around the use of acute hospital beds. The Department of Health (DoH) Circular to Health Authorities and Local Councils with regard to Intermediate Care and the publication of the National Service Framework for Older People have brought intermediate care into mainstream health policy.

The use of the term ‘family (informal) carer’, as it is currently conceptualized, is recent and is largely the product of increased attention in the academic and policy literature over the last two decades. Despite their fairly late arrival on the scene, family carers now occupy centre stage in UK government policy, having being described by the Prime Minister, Tony Blair, as the ‘unsung heroes’ of British life, who are essential to the fabric and character of Britain. Such recognition stems from the growing realization that family carers are the lynchpin of community care, providing 80% of all the care needed at an estimated saving to the UK government of some £40 billion annually.

Rehabilitation aims to reduce symptoms, restore function and minimize disability through an interventionist approach that is not always concerned with pathology, disease processes and cure. This approach will be described in the context of spinal pain in the elderly. The syndrome of lower back pain (LBP) is such a common symptom that it is an almost universal human experience. It is the third most commonly reported bodily symptom after headache and fatigue. In 1998, 40% adults were affected by an episode of LBP lasting more than a day, and 40% of those in pain sought medical help. The resources provided for research and clinical management of LBP are concentrated mainly on the working population. This is because of the profound biopsychosocial consequences and huge cost to society of the ‘back pain epidemic’. The direct health care costs of back pain have been estimated as £1632 million in 1998.

Introduction

A stroke patient puts on his shoes and then tries to put on his socks over his shoes. Entering the kitchen, this patient puts milk in the teapot, places the sugar bowl in the oven, and tries to drink from the milk jug. This patient is most probably apractic. Apraxia is one of the four classical neuropsychological deficits – such as agnosia, amnesia and aphasia – causing restrictions in the ability to carry out purposeful and learned activities. One of the first definitions of apraxia was given by Geschwind: ‘Disorders of the execution of learned movements which cannot be accounted for by either weakness, inco-ordination, or sensory loss, nor by incomprehension of, or inattention to commands.’

The proportion of older people in the UK is increasing in relation to the population as a whole. This trend is reflected in the age profile of patients in hospital and those requiring continuing care in the community – domicilary, residential and nursing home sector. The HAS Report identified that more than 40% of patients over 65 with disability will require admission to an acute hospital over a two-year period. Ensuring appropriate, equitable and quality care for this age group is therefore a priority.

Hospital readmission rates for COPD patients are high, with two-week readmission rates of 22% being recorded in one study of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). In a separate study, patients admitted with PaCO2> 50 mm Hg had a readmission rate of 40% at six months. There are no agreed clinical evidence factors that determine readmission. A few studies have reported that readmission is associated with an individual’s inability to cope with the disease, and that anxiety and socioeconomic status are important variables. Others argue that readmission relates to severity of lung function abnormality, changes in atmospheric pollution, and impaired quality of life (QoL).

Agism in the form of age-based health care allocation fosters the separation of the physiological part of a patient from the person who is the patient. It does so by ignoring the holistic best interests of the patient and instead focuses on providing certain procedures or therapies only when the patient’s age is less than or equal to a specified value (the allocation limit). Certainly not all forms of clinically relevant care and treatment are age-restricted in the scheme of aged-based health care allocation, but it is clear that this scheme functions on the arbitrary, and patients may miss out on optimal therapy presumably because it will be ranked as too expensive or too rare to provide to older people. Arbitrarily chosen age limits or those chosen based upon an estimation of humans’ natural lifespan have the effects of minimizing the patient’s clinical choices, devaluing the experiential skills and knowledge of the medical team, weakening the doctor-patient relationship, and commodifying medicine. Policies of this nature do not solve our current health care dilemma, rather they are an economic bandage over the still present (and unattended to) root cause.

There is considerable research on work satisfaction and stress of care staff on the one hand and on quality of care and well-being of older people on the other. However, very little research in continuing-care settings for older people (nursing homes, residential homes and long-stay wards) links perceptions of workers (work satisfaction and stress) with the process of care (quality of care) and outcomes for residents/patients (well-being). This is a notable omission, given the emphasis of government policy on improving quality of health and social care services for vulnerable elderly people in the UK. The White Papers, The New NHS and Modernising Social Services and the National Priority Guidance for Health and Social Services for 2000–2003, all emphasize the importance of services that are responsive to local needs and which maintain and promote independence. The Centre for Policy on Ageing has been commissioned by the Department of Health to develop national standards for nursing and residential home care services for older people. This work will build upon recommendations of the Burgner Report and Achieving a Better Home Life, which identified areas for benchmarking. The national standards proposed under the forthcoming National Service Framework for Older People will underpin new legislation to regulate care services.