A comparison of elderly day care and day hospital attenders in Leicestershire: Client profile,carer stress and unmet need

Traditionally, day care for elderly persons has been provided by health or social services; however, recently facilities have been developed by voluntary organizations. This study was conducted to examine the characteristics of elderly clients with mental health problems attending these various settings, and to identify any areas of unmet need. One hundred and twenty-nine clients attending ten different day care facilities and their carers were interviewed in a standardized manner.There were both similarities and important differences between clients attending day hospitals, social services and Age Concern day centres. Day centres had a higher proportion of cognitively impaired clients than day hospitals. Although there were similar rates of depression across all settings, the severity of depression was greater in those attending Age Concern day centres. Patients at day hospitals suffering from dementia were more likely to be psychotic or behaviourally disturbed. The reasons for these differences are discussed in detail. Carers and clients were generally satisfied with services, though professionals were less satisfied. There is a need for joint planning and commissioning of day care to provide maximum flexibility and co-ordination of services.     

Standards of care in day hospitals and day centres: a comparison of services for older people with dementia

BACKGROUND: Current policy in England emphasises the importance of caring for highly dependent older people for as long as possible at home. It is therefore crucial that day care services are effective and widely available. AIM: To compare the type and standard of care provided for older people with dementia in day centre and day hospital settings. METHODS: A cross-sectional postal survey design was employed. Representatives from three-quarters of identified specialist day care services for older people with dementia in the North West of England provided information on a range of indicators including: basic structural features; delivery of care; service content; and quality measures. RESULTS: Day hospitals tended to have more day care places and a greater number of attendees, but lower occupancy rates than day centres. Day hospitals reported higher standards of care in relation to systematic assessment and care planning, promotion of rehabilitation, carer involvement and individualised provision of care. They were also more likely to employ building design features to encourage independence and choice for people with dementia. A higher proportion of day centres provided services exclusively to older people with dementia and a greater proportion of staff in day centres had undergone specific training in caring for people with dementia. Day centres were also more likely to have effective transport arrangements in place. CONCLUSION: The standards developed for the study were sufficiently reliable to allow for an acceptable estimate of quality. Day centres and day hospitals appeared to perform two distinct, but complementary functions. These results provide key material for shaping the provision of day care for older people with dementia, especially given the absence of national standards in this area.     

Social services and health services day care in mental health: the social networks and care needs of their users

BACKGROUND: In view of the increasing integration of health and social care, there is an urgent need to know how health service day hospitals and social service day centres are being used, and by whom. AIMS: We aimed to compare users of day hospitals and centres in terms of their social networks, needs for care and demographics. METHODS: A cross-sectional, comparative study of service users at two day hospitals and four day centres compared their social networks, needs and characteristics. RESULTS: Day centre clients had much larger social networks, including a three-fold difference in total contacts and two-fold difference in confidants, but had more needs for care, particularly relating to psychological distress. They were also older on average than day hospital patients and were a more long-term group. CONCLUSION: It is vital to understand differences between health service day hospitals and social service day centres given the increasing integration of health and social care. The present study shows that the two user groups are significantly different. It is unlikely that the needs of most day care users could be met by either service interchangeably.     

Psychiatric day care: the users' perspective

The literature on consumer opinion about psychiatric day care is reviewed and a study of the views of day care attenders living in an inner city catchment area who are in prolonged contact with psychiatric services is presented. Attenders were broadly satisfied with their care. Analysis of their verbatim comments suggested that attenders perceived the value of attendance at a day unit in social rather than therapeutic terms. The implications of this finding are discussed.     

Social services day care and health services day care in mental health: do they differ?

BACKGROUND: The difference between the services provided by day hospitals and day centres is far from clear. The supposition that day hospitals would provide an acute service, while day centres would offer social support for a more chronic population has been contentious and there is little evidence of how they are currently used. AIMS: We aimed to ascertain the differences between day hospitals (partial hospitalisation) and social service day centres in functions and roles, as perceived by staff, service users and referrers. METHODS: The views of service users and staff at two day hospitals and four day centres were ascertained through questionnaires and interviews, along with those of staff of eight Community Mental Health Teams, who constitute the sole pathway to the two services. RESULTS: Day hospitals were perceived by both referrers and clients to offer short-term, more intensive 'treatment' to more acutely ill people in need of mental health monitoring. Day centres were perceived to offer longer-term support, particularly social support, to people more likely to have longer-term and psychotic illnesses. CONCLUSION: There is currently a clear distinction between day centres and day hospitals, in key features of their services and client groups. It would be unwise to treat them as interchangeable.     

Evaluating the effects of brief day hospital closure

The wellbeing of attenders of an old age psychiatry day hospital and their carers was assessed as the unit closed over a 2-week period. Decline in the wellbeing of carers and attenders was seen with a regression to preclosure levels. The results suggest the importance of the day hospital to the patients and their carers. The problems of evaluation at short notice are discussed.     

Don't seize the day hospital! Recent research on the effectiveness of day hospitals for older people with mental health problems

BACKGROUND: Day hospital (DH) care remains a core component of mental health services for older people. However, there has been an ongoing debate about the effectiveness and value for money of DHs in comparison to day centres (DC). AIM: The aim was to review the recent research on the effectiveness of day hospitals for older people with mental health problems. METHOD: A systematic search of relevant research literature over the last decade using the major electronic healthcare databases examining the quality and effectiveness of mental health DHs for older people. RESULTS: In the last decade the evidence for the effectiveness of DHs has continued to increase, but still lags behind research on DHs in general adult psychiatry and geriatric medicine. The review found that DHs appear effective at assessing and meeting needs and that a systematic approach to evaluating quality can be used to improve services. CONCLUSION: Recent research supports the effectiveness of day hospitals, but further studies are needed in order to provide a more robust evidence base.     

Social networks among users of mental health day care--predictors of social contacts and confiding relationships

AbstractBackground The social networks of people with mental illness have received much attention, but users of day care services have rarely been considered.Methods Users of day hospitals and day centres were surveyed cross-sectionally. Demographic and illness factors were tested for associations with network size, while intrinsic relationship factors were tested for association with confiding in a network member.Results There was some evidence that a longer duration of contact with services, more unmet needs, working, living in supported accommodation and needing help with psychotic symptoms were associated with having a larger network, while a longer duration of contact was associated with having more confidantes. Day centre users confided in people who were more likely to be friends or neighbours than professionals, and who were more likely to be the same sex.Conclusion For people in day care, the stereotype that people with longer-term mental health problems are socially isolated is contradicted by this study. The limited role of professionals in providing confiding relationships is striking.     

THE IMPACT OF DAY CARE ON PEOPLE WITH DEMENTIA

Day care services are now widely used by people with dementia. Research on day care has focused on benefits to caregivers. The impact of day care attendance on the person with dementia has been relatively neglected. Caregivers of new attenders at a dementia-specific day centre were asked to describe any change noted in their relative since attendance at the day centre had commenced. Forty-two per cent of new attenders included in the study showed a marked improvement in mood and/or behaviour, attributed by caregivers to day centre attendance, which was maintained in most cases 9 months after initial attendance. All those showing a marked improvement were female. There was a trend for day care responders to live alone though this failed to reach significance at the 5% level. Other factors such as age, degree of cognitive impairment, level of dependency and behavioural disturbance and frequency of day care attendance did not differentiate responders from non-responders. However, female responders tended to have less cognitive impairment than female non-responders. Although the number of subjects in the study is small, the findings have implications for service provision and may indicate directions for future research.     

The day hospital debate--a contribution.

OBJECTIVE: To compare the prevalence of difficult behaviours in confused older people attending a National Health Service (NHS) day hospital with those attending non-NHS day care facilities. DESIGN: A behavioural rating scale was completed and referral information collected for people with dementia attending day care services. SETTING: One day hospital and seven day care facilities in one UK health authority. PATIENTS: All 20 attenders at an NHS day hospital and 64 attending day care, the latter identified by the staff as 'confused'. MEASURES: A 15-item behaviour rating scale. RESULTS: The quantitative ratings showed more disturbance (restlessness, friction, sexual disinhibition), poorer memory and decreased mobility in the NHS attenders. These small differences concealed much greater qualitative differences in the methods of operation of the two types of facility, with the focus being on assessment and throughput in the day hospital and social support in the day care services. CONCLUSIONS: In the light of recent debate, this study has demonstrated small but measurable behavioural differences between an NHS day hospital and non-specialist day care. However, a focus on rating of behaviour alone conceals much greater differences in why people are referred, by whom and for what reasons. The day hospital has its own role and is not merely plugging a gap.     

Effect of combined support for people with dementia and carers versus regular day care on behaviour and mood of persons with dementia: results from a multi-centre implementation study

BACKGROUND: A previous study in Amsterdam showed that combined family support in the Meeting Centres Support Programme, in which dementia patients and their carers are both supported by one professional staff member, is more effective in influencing behaviour problems and mood of dementia patients living in the community than non-integrated support, such as day care only. OBJECTIVE: A multi-centre implementation study tests if similar effects are achieved in other regions of The Netherlands. METHODS: A pretest-posttest control group design was applied. 112 dementia patients who visited psychogeriatric day care in eight community centres across the country and in three nursing homes, and their carers participated in the study. The patients in the experimental group (n = 89) received support from the Meeting Centres Support Programme together with their carers, while the control group (n = 23) received day care only. Behaviour problems (agressive behaviour, inactivity, non-social behaviour) and mood (dissatisfaction, depressive behaviour) were assessed using standardized observation scales. Quality of life was assessed by interviewing the patients. RESULTS: After 7 months the Meeting Centres Support Programme, compared to regular day care, showed a moderately positive effect on the degree of total behaviour problems (effect size = 0.52), especially on inactivity (effect size = 0.37) and non-social behaviour (effect size = 0.60), a large effect on depressive behaviour (effect size = 0.92) and a moderate effect on self-esteem (effect size = 0.43). CONCLUSIONS: The Meeting Centres Support Programme proves to be more effective than regular day care in influencing behaviour problems, especially inactivity and non-social behaviour, and depressed mood. Participation in the programme also seems to have a positive effect on self-esteem, an important aspect of quality of life. These findings surpass the results of the Amsterdam study and confirm the surplus value of the combined family support in the Meeting Centres Support Programme as compared to regular day care for people with mild to severe dementia.     

Effects on care-givers of special day care programmes for dementia sufferers

Two groups of care-givers to dementia sufferers were interviewed to assess their psychological symptoms and the behaviour problems of the dementia sufferers. The first group were using special dementia day care while the second group were about to begin using it. The second group were re-interviewed three months later. Therefore two comparisons could be made; a with/without day care comparison and a before/after admission to day care comparison. Care-givers had a high level of psychological symptoms which were not significantly reduced by using day care. Full-time institutional care did reduce distress. Day centre clients continued to deteriorate as would be expected with a degenerative condition. While special dementia day care centres appear to play a useful role for many care-givers, they may provide too few hours relief per week to markedly reduce the care-givers' psychological symptoms. Family care-givers currently take the major role in caring for dementia sufferers in the community and the burden of care needs to be shared more equitably.     

A comparison of psychiatric day hospitals in five European countries: implications of their diversity for day hospital research

OBJECTIVE: As the use of "day hospitals" increases, conceptual models of these services are changing dramatically across Europe. Therefore, the need arises for mental health services research to assess this process cross-nationally in a standardised and systematic way. Such research approaches should seek to maximise the generalisability of results from high-quality (e.g. randomised controlled) single- or multi-site trials assessing specific models of day hospital care. METHOD: Using a self-developed structured questionnaire, the European Day Hospital Evaluation (EDEN) study group carried out national surveys of the characteristics of day hospitals for general psychiatric patients in Germany, England, Poland, the Slovak Republic and the Czech Republic, during the period 2001--2002. RESULTS: Response rates varied from 52 to 91 %. Findings show that day hospitals have no consistent profile of structural and procedural features. Similarities across countries focus on three main issues: on average, consideration of concepts oriented toward providing acute treatment are equivalent; disorders associated with disabled functioning in everyday life, high risk of somatic complications, and need for behaviour control are excluded to a comparable degree; and some core therapeutic activities are consistent with the main approaches of social psychiatry. Identified according to self-rated conceptions and extended with data from individual hospital's statistics on the clientele in 2000, three clusters of limited selectivity subdivide the services. One category focuses mainly on rehabilitative tasks; two categories are oriented toward providing acute treatment as an alternative to inpatient care, but combine this either with rehabilitative tasks or with equal additional functions of shortening inpatient treatment and providing psychotherapy. The distribution of services across these three clusters varies significantly in the five European countries. CONCLUSION: Future day hospital studies should always clarify the type of services being assessed. To fully consider the impact of their results, the current national and international health policy environment of these services should be taken into account. Such surveys require enhanced methodology, however, in order to identify clear, distinct categories of services characterised by overlapping programme functions, and to increase the generalisability of valid results from single- or multi-site trials.     

Demented and chronic depressed patients attending a day hospital: stress experienced by carers

Objective. The main hypothesis was that carers of elderly patients attending a day hospital with chronic depression experience considerable stress. A subsidiary hypothesis was that this stress is equivalent to that experienced by carers of dementia patients attending the same day hospital. Design. All attenders of the day hospital with a diagnosis of depression or dementia coresident with their principal carers. Setting. An urban psychogeriatric day hospital in the UK. Patients. A consultant diagnosis of dementia or depression with a history of present illness in excess of 12 months in patients over 65. The total sample was 57, 32 dementia and 25 depression (19 major depressive episode). Measures. Dementia patients: Mini-Mental State Examination (MMSE), Clifton Assessment Schedule (CAPE). Depressed patients: MMSE, Montgomery–Asberg Depression Rating Scale (MADRS) and Brief Psychiatric Rating Scale (BPRS). Carers: Semi-structured questionnaire, General Health Questionnaire (GHQ-30) and Relatives Stress Scale (RSS). Results. Dementia patients were older than depressed (75.66 vs 71.84). The two groups were of comparable severity. The dementia carers were significantly more stressed on the GHQ and RSS than depression carers but these carers also exceeded the threshold for psychiatric ‘caseness’. Important negative views about life upset and carer burden were expressed by both groups. Conclusions. The main hypothesis but not the subsidiary one is supported. More sophisticated study of the burden of caring for chronic depressive illness is required. © 1998 John Wiley & Sons, Ltd.     

Alzheimer's disease in real life--the dementia carer's survey

BACKGROUND: Informal care from relatives provides the foundation of care for people with Alzheimer's disease (AD). It is important to understand the conditions under which carers perform their, often neglected, task. The dementia carer's survey aimed to identify carers' needs, differences between countries with regard to dementia care and the level of satisfaction of carers with utilised services. METHODS: The survey was conducted through Alzheimer Europe's member organisations in France, Germany, Poland, Spain and UK (Scotland). The survey was in the form of a questionnaire, and topics addressed included: demographics of carers and people with AD; time spent caring; disclosure of diagnosis; symptoms prompting diagnosis; diagnostic process; current and most distressing symptoms; carers' information requirements; evaluation of services. RESULTS: Each country had approximately 200 responders. Time spent caring increases with disease severity, and 50% of carers of people with late-stage dementia spent more than 10 h/day caring. Activities of daily living and behaviour were cited as the most problematic symptoms, reported by 68% and 50% of carers, respectively. Provision of information on all aspects of AD was felt to be inadequate, with key services such as home support not available to the majority of carers. Only 17% of carers considered the level of care for the elderly in their country as good. CONCLUSIONS: Further development of services and information provision are required to help carers in their everyday caring, including coping with problematic symptoms influencing areas such as activities of daily living and behaviour.     

Nursing home placement, day care use, and cognitive decline in Alzheimer's disease

OBJECTIVE: People with Alzheimer's disease are often placed in a nursing home, sometimes after using adult day care services. How affected persons function during this potentially difficult transition is not well understood. The aim of this study was to examine the associations of day care use and nursing home placement with the rate of cognitive decline in Alzheimer's disease. METHOD: The participants were 432 older persons with Alzheimer's disease who were recruited from health care settings in the Chicago area. At baseline, they lived in the community and were using day care services a mean 1.7 days per week. At 6-month intervals for up to 4 years, they completed nine cognitive tests from which a composite measure of global cognition was derived. RESULTS: On average, cognition declined at a gradually increasing rate during the study period. Nursing home placement was associated with a decrease in the level of cognition and an acceleration in the rate of cognitive decline. Day care use at baseline was not related to cognitive decline in initial analyses, but it interacted with nursing home placement such that higher level of day care use substantially reduced association of placement with accelerated cognitive decline. Education interacted with placement such that more schooling was associated with a greater increase in cognitive decline upon nursing home placement, but prior day care use also attenuated this association. CONCLUSIONS: Nursing home placement is associated with accelerated short-term cognitive decline in Alzheimer's disease. Prior experience in adult day care may lessen this association.     

Needs for oral care among people with intellectual disability not in contact with Community Dental Services

Previous research has found an unmet need for oral care among people with intellectual disability. The key factors which have been indicated are low expectations, fear of treatment, lack of awareness among carers and problems in accessing dental services. The withdrawal of many general dental practitioners (GDPs) from the National Health Service (NHS) may have exacerbated the latter problem in the UK. The aims of the present study were: (1) to assess the extent of unmet clinical needs in a group of adults with intellectual disability living in the community who were not in contact with the Community Dental Service (CDS); and (2) to explore their perceptions of teeth and contact with dentists to identify how oral care can be improved. Interviews were completed with subjects and/or carers and a dental examination was completed. There were higher levels of untreated caries (decay), and gingival or periodontal (gum) problems among the sample than in either the general population, or in a previous survey of CDS users at day centres and residential facilities. The subjects were largely unaware of dental problems, and used the appearance and absence of pain to judge the condition of their teeth. They depended greatly on their carers for decision‐making and support with regard to visiting the dentist and tooth‐brushing. Carers requested training in oral care and the use of dental services, and support in dealing with clients who have problems tolerating tooth‐brushing. The subjects had experienced a wide variation in the treatment provided by dentists, but had not found it difficult to access a dentist despite recent reductions in the availability of NHS dental care. They expressed a particular need for a good relationship with their dentist and for their dentist to have personal skills in relating to people with an intellectual disability. Dental screening checks and oral care training for carers should be made easily available. Care plans should include tooth‐brushing and dietary issues for all clients who have their own natural teeth. There are significant training issues for dentists in developing personal skills in total communication, disability awareness and attitudes which value people with intellectual disability.     

The service experiences of people with presenile dementia: A study of carers in one London Borough

Fifteen carers of people with presenile dementia in the London Borough of Sutton were interviewed about their experiences of the services that had been provided to them. The carers were generally satisfied once they had been referred for specialist help and they would have liked more support and information around the time of diagnosis. When asked about what additional services were required, carers were particularly concerned about the lack of appropriate day care for their relative. Carers whose relative had been admitted to long-term care reported finding the process of admission distressing. High levels of stress were found among all the carers. The importance of providing emotional support to this group of carers is emphasized.     

From general day hospital treatment to specialized treatment programmes

Approximately one third of day hospitals in Europe can be designated as predominantly psychotherapeutic. They address mainly patients with personality disorders (PD), but also eating disorders and chronic mood and anxiety disorders without PD. As day treatment programmes tend to become associated with mental health centers, their treatment intensity also tends to become reduced. Available data suggest that approximately 10 hours of treatment a week is sufficient. Is such treatment more effective than specialized outpatient treatment? This research question will probably set the agenda in the years to come. In response to this challenge, day treatment should become more specialized. Data from the Norwegian Network of Psychotherapeutic Day Hospitals (n = 2.205) demonstrate that the majority of day treatment patients suffer from borderline and avoidant PD. Programmes for patients with borderline PD are well developed. The authors call for programme development for patients with avoidant PD.