Editorial

In the UK, one of the strategic aims for the health services is to reduce death by suicide. Older people are over-represented in national suicide figures in most developed countries so they are de facto a high risk group. For example, in the UK, people aged over 65 comprise about 15% of the population but this age group accounts for between 20 and 25% of all completed suicides.

Incontinence is a common and distressing condition of later life. Prevalence studies have reported rates of urinary incontinence from about 3% to 60%, depending on how incontinence is defined and the type of population studied. There is much less information about the prevalence of faecal incontinence. However, some studies have found approximately 2% of the general population and about 60% of the nursing home population to be incontinent of faeces. Although some studies have examined the impact of urinary incontinence on health status, the impact of faecal incontinence has not been investigated previously. Quantification of the prevalence and specific impact on health of common disorders such as incontinence will help commissioners and providers in the prioritization of diagnostic and therapeutic services for this distressing condition. With this in mind, we report the relevant results of the Tipping the Balance Survey, which quantified the prevalence and impact on self-perceived health, anxiety and depression of both faecal and urinary incontinence.

A pressure ulcer is the visible evidence of pathological changes in blood supply to the dermal and underlying tissues, usually due to compression of the tissue over a bony prominence. Pressure ulcers are one of several types of chronic ulcers of the skin, including venous stasis, diabetic ulcers, and arterial insufficiency ulcers. The differential diagnosis of pressure ulcers is imperative, since the management of each wound type differs substantially.

Myopathy is a convenient shorthand term meaning muscle disease or dysfunction. In other words, the myopathies are those conditions in which the patient’s symptoms and signs can be attributed to a pathological process affecting either the structure of muscle fibres or their associated interstitial tissues, or to disturbance of the biochemical or electrophysiological function of those fibres. Myopathies are rare in all age ranges. They may be inherited or acquired. Onset of inherited myopathies in the elderly, not surprisingly, is uncommon, but some of these diseases are asymptomatic or cause such minor symptoms that their significance is not appreciated by the patient, and thus they may not be recognized until late on in life. Their recognition may have implications for other, younger, family members. Many of the acquired myopathies afflicting the elderly are treatable, but the commonest, inclusion body myositis, is not, and incorrect diagnosis and inappropriate use of steroids may compound morbidity.

What is palliative medicine?

In 1987, the Royal College of Physicians recognized palliative medicine as a specialty, defining it as ‘the study and management of patients with far-advanced disease for whom the prognosis is limited and the focus of care is quality of life’. In 1990, the World Health Organization added its definition, ‘the active and total care of a person whose condition is not responsive to curative therapy’. The aim of palliative medicine is to control pain and other physical symptoms, together with integration of psychological, social, spiritual care and support. The ultimate goal is to help patients to achieve their best quality of life. Palliative medicine places emphasis on a holistic approach, offering care and support not just for patients but also for their families. Palliative medicine hence requires an interdisciplinary team approach. With the co-ordinated efforts of all disciplines (such as doctors, nurses, therapists, social workers, clinical psychologists, dieticians, pastoral care workers and volunteers), patients can be supported in living their remaining lives as actively as possible, and families can be assisted in coping with illness, death and bereavement. Palliative care neither intends to postpone death nor does so, but affirms life and regards dying as a normal process. When a patient faces an incurable illness, it is incumbent on the palliative care team to provide the best treatment and care, adding life to days when days cannot be added to life.

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.

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.

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.’

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.