The behavioural characteristics of local authority home residents referred to a geriatric psychiatry service.

With increasing demands upon a geriatric psychiatry service, the priorities for day care and long-term hospital care have had to be re-examined. As a result, old people already in local authority residential care are receiving lower priority than those still in the community. In this study we suggest that certain behavioural characteristics and, in particular, incontinence, may present the caring staff of residential homes with special difficulties. We conclude that adequate assessment is essential to ensure that residents are suited to the level of facilities supplied.

Lithium induced nephrogenic diabetes insipidus: changes in plasma vasopressin and angiotensin II.

Nephrogenic diabetes insipidus associated with high basal levels of plasma arginine vasopressin developed in a patient during lithium therapy. Fluid deprivation was accompanied by an increase in the concentration in peripheral venous plasma of vasopressin and angiotensin II, a rise in plasma osmolality and a modest rise in urine osmolality. Infusion of arginine vasopressin produced comparable levels of plasma vasopressin to those found during fluid deprivation, with no overall change in plasma angiotensin II and little change in urine volume or osmolality. It is suggested that angiotensin II may be responsible for the difference in ability to concentrate urine under these two conditions. Following death by self-poisoning, renal histology revealed distinct structural changes in the distal tubules: such lesions have not previously been described in man and it is suggested that the occurrence of nephrogenic diabetes insipidus while on lithium therapy may be related to tubular damage.

The validity of emergency recommendations for compulsory psychiatric care.

Retrospective scrutiny of the documents authorising 240 consecutive emergency detentions to a Glasgow psychiatric hospital over a three-year period revealed that 15 per cent were incorrectly completed. Fourteen documents (5.8%) failed to meet a list of minimum requirements supplied by the Central Legal Office and were therefore invalid. Invalid documentation was associated with a failure to use the recommended form. In practice, these documents were recognised at the hospital of detention and patients were either properly detained, informally admitted, or in three cases, discharged. It is suggested that doctors who make Emergency Recommendations without using the printed form should always discuss the wording of their letter with the receiving psychiatrist who should in turn be familial with the six minimum requirements of the Central Legal Office.

Factors determining the use of the emergency recommendation for compulsory psychiatric care.

The factors determining the use of Section 31 admissions and reclassifications at a district psychiatric hospital were investigated prospectively over an eight month period. Thirty-six per cent of patients failed to meet the criteria laid down for full detention and, particularly with reclassification, Section 31 was invoked to secure treatment. While the Emergency Recommendation is not used as the legislators intended, a seven day detention order appears more relevant to modern psychiatric practice than the full detention procedure.

Glasgow women medical students: some facts and figures.

A questionaire was sent to 343 women medical undergraduates at the University of Glasgow, and 317 replied. Of the respondents, 36% had a member of their family in medicine and 15% had either one or both parents a doctor: 45% had a working mother. Half of all the students had doubts about medicine as a career, and the proportion of these rose with seniority. Doubts were mainly due to the length of the medical course but the girls also recognized the difficulty of combining a medical career with family life. There was a significant correlation between having doubts about a medical career and having a mother who worked.Half the girls said they would prefer to work in hospital after qualification-the favourite specialties being paediatrics and obstetrics; only a quarter said they would like to do general practice. The need for careers advice which links actual career openings and the wish of most women to combine medical work with marriage and child-rearing is emphasized. The majority of the students saw a doctor's primary role as the giving of advice and reassurance.

A geriatric psychiatry day hospital service: a five-year review.

Psychiatric day hospitals for the elderly have been regarded either as an alternative to in-patient care or as a long-term supportive facility for patients with chronic psychiatric disabilities. In a five-year review of such a unit it was found that the unit's main function had become that of providing an immediate short-term supportive facility to demented patients, mainly in the 75-years-and-over age group, and to their relatives, until such time as beds in the long-stay psychogeriatric wards of the hospital became available. The implications of this change in role of day hospitals are discussed in the light of present facilities and the predicted increase in the size of this section of the population.

Compulsory admission to hospital: an operational review of the Mental Health (Scotland) Act 1960.

The working of the Mental Health (Scotland) Act 1960 is examined by analysis of compulsory admissions both nationally and to one Glasgow hospital. Comparisons are drwn with England and Wales. Despite a six-fold increase in admissions since 1945 the use of compulsory powers has remained almost constant. It is suggested that an annual number of 45 compulsory admissions per 100,000 population may represent an inevitable basic level as foreseen by the Royal Commission in 1957. Section 31 ('Emergency Recommendation') secures 80 per cent of Part IV admissions, and Section 24 ('Full Recommendation') is employed in only 25 per cent. Part V accounts for only 300 admissions per annum, mostly remands for psychiatric report. Two suggestions are made for possible future amendments to the Act.

Role of local authority homes in the care of the dependent elderly: a prospective study.

A two-year prospective study of 11 local authority homes showed no increase in the degrees of behavioural disabilities or the prevalence of dependency or dementia among the residents. This finding, which differed from trends reported in other studies, was unlikely to be due to the design of the study and occurred in the absence of a co-ordinated service for the elderly. It was probably the effect of changes in the admission policy of the social-work services and suggests that, in some parts of Britain at least, residential homes are no longer absorbing additional numbers of dependent or demented old people in need of institutional care.

Reality orientation with elderly patients in the community: an empirical evaluation.

There is now good evidence that elderly mentally impaired patients can be re-orientated for time, place and person using the technique of reality orientation (RO). To date, all empirical trials demonstrating this have been carried out on elderly institutionalized patients. This technique however might be of greater value to those elderly dementing patients still living with relatives in the community but attending geriatric psychiatry day hospitals, where they could receive RO in a consistent and systematic way. The results of an empirical study of RO with a group of such patients is reported. These showed that day hospital patients could be effectively re-orientated and that concomitant with changes in level of orientation of the patients, there were parallel changes in the patients' behaviour at home, reported stress on relatives and in relatives' mood.

Measuring behavioural disturbance of elderly demented patients in the community and its effects on relatives: a factor analytic study.

In recent years increasing interest has centered on the elderly psychogeriatric patient living in the community and the part played by relatives in supporting these patients. There is a need, however, for ways of assessing the behavioural disturbance shown by such patients at home and the effect this behaviour has on relatives. Ratings by relatives of the behaviour at home of elderly dementing patients attending a geriatric psychiatry day hospital, together with the relatives' own ratings of the degree of stress and upset being experienced were obtained. Using the technique of factor analysis was shown that the patient's behaviour and the relative's reaction could be analysed into a number of separate categories and that these were differentially related to each other. Thus, for example, personal distress in the relative was related mainly to the amount of apathetic and withdrawn behaviour shown by the patient, whereas negative feelings held by the relative towards the patient were related only to the degree of disturbance of the patient's mood. The construction of scales measuring these different aspects of patient's behaviour and relative's reaction is described.

An unusual case of self-induced electrolyte depletion.

A case of anorexia nervosa, presenting with unexplained hypokalaemia, is described. The patient was also secretly addicted to purgatives and diuretics. During an attempted metabolic balance study she secretly disposed of food and excreta, which were smuggled from the hospital by her sister. The patient induced her husband to bring his own stools into the ward, these then being substituted for her own. The interrelationships of the electrolyte disturbances, elevation of plasma renin, renin substrate, and hyperaldosteronism are discussed, particularly in connexion with the pathogenesis of peripheral oedema in anorexia nervosa.