Acquired hearing loss and psychiatric illness: an estimate of prevalence and co-morbidity in a geriatric setting.

Hearing impairment and mental disorders are common among residents of nursing homes and homes for the aged; however, the relationship between sensory deficit and psychiatric illness has been little investigated in this population. The prevalence of hearing impairment, psychiatric illness, and co-morbidity was investigated in a sample of 102 elderly residents from consecutive admissions to a home for the aged. Examining the coincidence of these disorders showed evidence of an association between hearing loss and paraphrenia, and hearing loss and dysphoric states, but not between hearing and cognitive impairment. The results of this survey provide only suggestive evidence regarding aetiology, but strongly support conjoint assessment of the elderly.

Gender differences in living conditions found among male and female schizophrenic patients on a follow-up study.

In four provinces of Canada schizophrenic patients who had received psychiatric treatment not less than 18 months and not more than 10 years earlier, were interviewed. Findings suggest that the female schizophrenic patient, having a later age of onset than the male patient, and being more likely to form a stable spousal union, appears to enjoy a protected status which confers with the benefits of higher income levels, better housing and lessened likelihood of being placed in residential care. A further demonstration of the advantaged circumstances of the female patients may well be their superior showing on functional outcome indicators, where they out-performed males on all indices except physical activity at significant levels of differentiation.

The Clarke Institute experience with electroconvulsive therapy: II. Treatment evaluation and standards of practice.

Contemporary standards of practice of electroconvulsive therapy with respect to the treatment procedure, clinical indications, and dosage (number of treatments per course) are summarized. The actual clinical practice at one psychiatric hospital over a 16-year period, comprising 22,647 treatments, was compared to those standards. The most significant findings in this series were the over-representation of patients with a diagnosis of schizophrenia and the absence of any clinically significant difference in the treatment dosage for schizophrenia and affective disorders. The significance of these findings is discussed with respect to their identification of patient subgroups that warrant case auditing. In addition, the results are used as a basis for a critical examination of the rationale for the presently recommended maximum treatment dosages.

Social functioning and self-care in hospitalized psychogeriatric patients.

Evaluations of social disability have been found useful in determining factors of diagnostic, therapeutic and prognostic significance in the management of psychogeriatric patients. A random sample of 100 psychogeriatric patients aged 65 or over admitted to three Toronto hospitals were studied prospectively. Standardized clinical and social interview schedules were used to assess patients' mental state, self-care capacity, social isolation, burden on the family and household contribution before admission. These assessments were carried out to determine their significance with respect to diagnosis and outcome. Self-care capacity, as measured by the Activities of Daily Living Performance Test or by informant report, was related to diagnosis and outcome measures in this sample. Social isolation was significantly correlated with length of hospital stay. Burden on the family was not found to be significantly associated with diagnosis or outcome although there was a tendency for patients with organic disorders to present more difficulties for their families. The severe burden imposed on relatives suggests the need for utilization of community social and medical services to provide relief for families of psychogeriatric patients. The implications for management are considered in the light of the above findings.

Man or machine in psychiatric diagnosis.

The authors describe the previous studies of the stability of psychiatric diagnoses over time that have found such diagnoses to be unreliable, stating that the assumptions underlying these studies have been tested and disproved. On the other hand, the use of standardized interview techniques and categorization by computer yield reliable symptom ratings and precise diagnoses. The authors discuss the importance of these findings to the selection of the most appropriate treatment modality for individual patients.

Social disability in chronic psychiatric patients.

The authors measured the social functioning of 147 chronic psychiatric patients using a rating scale originally devised for use with the mentally retarded, the Adaptive Behavior Scale (ABS). They found that social deficits were more widespread and generally more severe among chronic psychiatric patients than among institutionalized mentally subjects. Chronic undifferentiated schizophrenic patients showed the most comprehensive deterioration; other groups, such as neurotic patients, women, and the elderly, had more limited impairments. The authors suggest that the ABS can be useful in establishing the limits of social functioning of chronic psychiatric patients.

Alternatives to the mental hospital: use of residential facilities for long-term psychiatric care.

We examine the use of the mental hospital and alternative residential facilities by 149 chronic psychiatric patients in Ontario. All major movements of patients since the time of first admission were recorded, including the number of episodes and duration of hospitalization and placement in alternative facilities and in the community. Clinical and social variables thought likely to influence use were correlated with duration, placement, and mobility. In spite of the lack of formal criteria for placement, relatively discrete and homogeneous populations were found in each facility and clear patterns of use could be distinguished. For many patients, their present placement represents their most typical setting and implies a particular route through the psychiatric services. We describe factors relating to different types of movements, and emphasize the continuing importance of the mental hospital in long-term psychiatric care.

Psychogeriatric hospital admissions from the community and institutions.

In a sample of 100 psychogeriatric admissions to three Toronto hospitals, the elderly in other institutions, including old age and nursing homes, and those living alone in the community were over-represented. Patients who had lived with relatives, on the other hand, were found to be at low risk for psychogeriatric hospitalization. These three groups of patients were compared using information obtained from psychiatric and social interviews with patients and informants, usually close relatives. Identification of specific needs for the various groups and the implication of these differences for the improvement of psychogeriatric care and prevention of unnecessary hospitalization are discussed. Institutional residents suffered more major physical illness, were less able to maintain functional independence, were referred more often for harmful behavior, were more socially isolated, and had a poorer outcome than community patients. Patients living along lacked familial support, but were not otherwise more socially isolated that those living with relatives, and showed no other deficits. The subjective and objective burdens on the patients' families before admission were considerable. The results are consistent with previous literature on the elderly.

Hospitalization for mental illness: evaluation of admission trends from 1941 to 1971.

A study of the diagnostic composition of the inpatient population of Ontario and Canadian psychiatric facilities has shown an important change in hospital-treated illness over the period 1941-71. Patients with nonpsychotic disorders accounted for 54% of all admissions to Ontario public mental hospitals in 1971, compared with only 8% in 1941. The trend was similar for both first admissions and proportion of readmissions, and was similar for psychiatric units of general hospitals. In contrast, the overall rate of first admission for psychotic disorders to inpatient facilities remained remarkably constant over time, as did the proportion of readmissions among all admissions. The findings dispel the notion that the increasing proportion of readmissions is due largely to a rapid turnover of former long-stay psychotic patients (the "revolving-door phenomenon"). The findings could not be attributed to a changing prevalence of types of psychiatric illness, increased availability of psychiatric inpatient facilities or comprehensive medical insurance.

Long-term psychiatric care in Ontario: the Homes for Special Care Program.

During the last decade in Ontario large numbers of patients with chronic psychiatric disorders have been discharged from the mental hospitals and are now scattered throughout other psychiatric facilities. The Homes for Special Care Program offers privately run but government-funded accommodation for severely disabled patients with relatively stable and socially acceptable behaviour, who require residential or nursing care but are thought unlikely to benefit from further hospital treatment. Salient features of the program include the formal discharge of patients from hospital and their legal reinstatement as "persons", the cessation of active psychiatric treatment, and the provision of ongoing care and supervision by largely untrained personnel. Medical care is provided by general practitioners and the program looks to volunteer agencies to provide recreational and other activities for residents.

The evaluation of chronic psychiatric care.

During the past two decades the reduction in the size of the mental hospital population in this country has closely followed statistical predictions for bed requirements both in Canada and in the province of Ontario. The decrease has been most pronounced among chronic non-retarded patients. While these patients are now less evident in hospital statistics, it is suggested that improvements in their state may be more apparent than real, owing to differences in the terminology and numerators employed in presenting mental health statistics. Further, concern has been expressed about the quality of care received by former chronic patients now scattered through the community in a variety of after-care programs. Readmission rates have greatly increased in absolute terms and as a proportion of total admissions. The evaluation of the management of chronic psychiatric patients is discussed.