A recurring question--how many beds for dementia?

Experience at Crichton Royal in dealing with dementia over a thirty year period has been used to develop two models of bed requirements for dementia sufferers. The first based on results from the periods 1957 to 1959 and 1974 to 1976 and the second on experience in the years 1974-75 and 1984-85. The variables considered were demographic change, admission of a constant proportion of the at risk group and changes in individual patient survival between groups of patients admitted. Projections based on the earlier model suggested that the SHAPE provision of 10 beds per 1000 of the over 64 population would be insufficient to maintain established standards of care. The later model, however, finds SHAPE numbers appropriate. The reasons for the change of view--inaccuracy in estimate of increasing male survival and significant under-estimates of population growth--nullify each other. The conclusion is that SHAPE is a useful model provided the demographic changes and patient survival change are carefully monitored.

Further change in the pattern of mental illness in the elderly.

The methods of Roth's 1948-49 Graylingwell study, previously applied to a Crichton cohort of elderly patients of the years 1974-76, were repeated in 1984-86. The results support the continuing validity of Roth's classification of mental illness in the elderly, but changes in the diagnostic distribution of the cohort, previously observed in the 1970s study, are further in evidence in the 1980s one. Admissions of dementia cases continued to increase both relatively and absolutely, while the trend of increasing survival in dementia also continued.

Psychogeriatrics 1974 to 1984. Expanding problems and fixed resources.

The impact of a 16% increase between censuses in the population aged 65 and over, on a psychogeriatric department whose bed complement remained static between 1974 and 1984, has been studied. Demand for service, as measured by new referrals, rose by 150%, while admissions fell by 14%. The increase in new referrals was uniform across the diagnostic spectrum, but the fall in admissions was not. Functional admissions fell in all age-groups except that of women of 85 and over, while organic-case admissions other than for cases of dementia virtually collapsed. Overall admissions for dementia rose to the predicted level, but the distribution of the increase was irregular and unexpected. Admissions of males and females aged 65-74 and females of 85 and over fell relatively and absolutely, while those of women aged 75-84 and men of 85 and over were little changed. Only admissions of men aged 75-84 alone increased in real terms.

Strategies for control of infectious diseases common to developed and developing countries.

The problems are the same in the developed and the developing world although conditions differ sharply from place to place. The way of life, habits, custom of a people affect the incidence and severity of infectious disease. Economics affect the way infectious disease is tackled. Examples are given of common diseases in different countries.

Change in the pattern of care for the demented.

The experience of 82 demented female patients, admitted to Crichton Royal in the period 1957-59, is compared with 107 similar female patients from 1974-76. All finally died in the hospital, or at the closure of the study in November 1981 were long-stay patients there. Results show that on average, each patient in the more recent group spent 24 per cent longer in hospital; the results, however, were only statistically significant in the very elderly--over 85. Further study of the 1970s failed to demonstrate that day care and intermittent holiday admissions had any effect on the length of time the patient spent in hospital on final admission. Using the study data, models of future needs are worked out on the basis of bed requirements for patients admitted without prospect of discharge.

Viral hepatitis in children: a study in Libya.

Serum surveys in Gharian and Derna, Libya, assessed by radioimmunoassay, indicated that 100% of children of seven years and older, were HAV immune, as were 60-70% of three-year old children revealing that infection occurs below the latter age. HBV infection occurs erratically in time and appears to be uncommon in young children, affects school children somewhat more frequently and adults more so. Non-A non-B hepatitis also occurs but in the absence of specific tests it is impossible to assess its incidence.

Changing patterns in mental illness in the elderly.

The study of Graylingwell Hospital conducted by Roth (1955) has in part been replicated in order to study the changing patterns of mental illness in the elderly over a 25-year period. Important changes in the diagnostic distribution and outcome of cases admitted have occurred. Functional illness has given way to dementia, not as a proportion of patients admitted but in the number of beds employed for their care 6 and 24 months after their index admission. Discharge rates for all diagnostic groups except acute confusional states, have undergone considerable change and death rates have fallen. The study has concentrated on the residual in-patient population, paying particular attention to increasing demand for beds for the dementing group. These changes have been quantified and reflect a four-year increase in bed requirements for cases of dementia at two years. Despite a striking reduction in requirement for functional cases, there is an overall increase in bed requirement of 38 per cent at the two-year mark.

Plague: review of ecology.

Yersinia pestis, the organism which causes plague in man and animals, circulates from host to host in nature by means of one of many flea vectors. There are about 340 mammals known to be susceptible to plague and over 30 fleas which are known to carry the organism. The habits of flea and host, usually a rodent, must to some extent coincide before infection can be established, and these habits are affected by the temperature and humidity of the environment, by vegetation cover, by season, indeed by everything that is included in the term 'landscape epidemiology'. The ease with which fleas either block or not after feeding is important, but sheer numbers in a focus may sometimes be more important. Some rodents are so highly susceptible that whole colonies may be wiped out by plague, yet alongside these susceptible animals there are usually other resistant hosts which maintain the infection in an area between epizootics.

Plague in camels and goats: their role in human epidemics.

In 1976, in a small, remote Libyan village, one apparently sick camel was slaughtered and skinned, and the camel meat was distributed for human comsumption. A few days later, 15 villagers suffered a severe febrile illness. Of the five individuals who had participated in the killing and dispensation of the camel, all were dead within four days. When samples of serum from nine of the remaining patients were examined, seven were found to be positive for plague as determined by the passive hemagglutination test. Another six persons became ill after killing two goats, and the serum of one goat contained antibodies to Yersinia pestis. Because all of the remaining patients except one were treated early enough, they recovered. These incidents confirm previous reports that the camel and the goat are susceptible to naturally occurring plague infection and have a significant role in the dissemination of human plague.

Pregnancy hepatitis in Libya.

The death-rate from hepatitis in pregnant women in Libya is high. Of 922 hepatitis patients treated during 1975, 377 were males and 545 were females. The case fatality-rate was 0.53% for males and 7-67% for females. In 293 pregnant women it was 12-97% compared with 1-6% in 252 non-pregnant women. In pregnant women deaths occurred mainly in the last trimester. Although 18-4% of the male patients and 15-2% of the women were hepatitis B surface antigen (HBsAg) positive, no patient shown to be antigen-positive died. The frequency of hepatitis in the second half of the year fell both in pregnant women and in the general population, suggesting a warning hepatitis-A epidemic. The exact cause of the high mortality in pregnant women is not clear, but it may have a nutritional basis.

PIP: An outbreak of hepatitis especially virulent in pregnant women in Tripoli, Libya in 1975 is described. The case-fatality rate was 12.97% in 293 pregnant women, 1.6% in 252 nonpregnant women, and 0.53% in 377 men. Deaths in pregnant women usually occurred in 3rd trimester, often at the onset of labor. There was no evidence that pregnant women with jaundice were admitted in preference to non-pregnant women, or that age or parity was related to infection. Hepatitis B antigen was tested by counter immunoelectrophoresis and later by reverse passive hemagglutination and radioimmunoassay. The overall prevalence was 16.6%. In pregnant women it was 11.1%. None of the pregnant women who died were positive for HBsAg. Coma and an abrupt deterioration were often seen in the pregnant women who dies. The women ate a diet devoid in protein from meat, eggs or fish. The epidemic died down in the second half of the year. It was conjectured that virulent a non-A-non-B hepatitis virus caused this outbreak.