Mohammed T. Abou-Saleh

682 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYIt may sometimes be the case that the role of a day care facilityis more reactive than proactive, and one pragmatic view is that theshape of day care develops partly to plug gaps in local services 13 .It may be worth noting also that the literature about the aims andbenefits of day care is written almost exclusively by health careprofessionals about patients; certainly among younger patientgroups, the most valued aspects of day care may not accord at allclosely with those that might be highlighted by staff 14 .EFFECTIVENESS OF DAY CAREThere has been no evaluative research on the effectiveness of daycare for the functionally ill elderly. If one can validly extrapolatefrom findings in younger patients, then compliance with medicationcan be enhanced by focused interventions with day hospitalattenders 15 . Similarly, extending findings from the dementedelderly might suggest that the often very stressful activity ofcaring for a depressed or psychotic relative would be relieved bythe patient entering day care.While it remains an under-researched area, there has been moreevaluation of the effects of day care attendance among thedemented elderly, although many of the hypothesized functions ofday care have not been meaningfully scrutinized. For example,while many old age services regard assessment as a pivotal role oftheir day hospitals 9,16,17 , another view is that this can be conductedjust as well as an outpatient and/or in the patient’s home 10 . Thereare no data to support either standpoint.Reports of specific cognitive or non-cognitive benefits of daycare among demented patients have not been consistent orconfirmed, and tend to be based on anecdote 18 . Where ratings ofchange are made by carers, then such ratings may be influenced byimprovements in the carers’ well-being as a result of theirdependants’ day care attendance. If day care is indeed specificallybeneficial to patients, then the improvements may be more subtlethan can be measured with existing rating measures, andDonaghy 19 has noted that a validated quality of life measure forthe demented elderly would constitute a significant advance. It isperhaps noteworthy that professionals now working with thedemented elderly predict that day care would enhance their ownquality of life should they develop dementia 20 .While day hospitals developed largely as an alleged alternativeto long-term inpatient or other institutional care, 17 this hypothesizedrole may be outdated and there is little evidence that theyfulfil this function. Patients admitted into long-stay care followingday hospital attendance have been found to be no more disabled,cognitively or behaviourally, than those who had no experience ofday care 21 , suggesting that there was no delay in institutionalization.New day care facilities in an area do not appear to changethe requirements for long-stay care 16 . It may be, however, that daycare can shorten stays in acute inpatient facilities by acting assomething of a ‘‘half-way house’’ between hospital and homewhile community links are re-established 17 . Mintzer et al. 22 inSouth Carolina, found that there was equal improvement in theagitation of demented patients who had a short admissionfollowed by home assessment plus ‘‘partial hospitalization’’ andthose who experienced a lengthier hospital stay.The strongest evidence for the effectiveness of day care is inimproving the well-being of carers. Earlier studies, such as that byGilleard 23 , tended to be naturalistic but demonstrated improvementsin the psychological well-being of carers after theirdependant commenced day care attendance. These improvementswere not related to changes in the problems presented by theirdependant and seemed to derive, therefore, from ‘‘time out’’ fromthe stresses of the care-giving role. More recently, quite welldesignedcontrolled studies have been conducted. In Australia,Wells et al. 2 conducted a ‘‘before and after’’ day care comparisonof supporters, and also a comparison of supporters receiving andthose waiting for day care. They found no differences incaregivers’ well-being but reflected that the average period ofrelief (11.9 hours/week) may have been insufficient to conferbenefits. In a recent large study, Zarit et al. 24 found thatsupporters of demented day care attenders (minimum of 2 days/week) felt less overloaded, strained, depressed and angry than didsupporters whose dependant had no access to day care. The issueof what the ‘‘effective dose’’ of day care might be to enhancecarers’ well-being remains a fairly open question 18 .COST-EFFECTIVENESS OF DAY CAREGiven the relative dearth of evaluative studies on the effectivenessof day care, it is unsurprising that cost-effectiveness is also anunderstudied area. With regard to the dementing elderly, theScottish Chief Scientist Working Party 25 concluded, in 1988, that‘‘the available research indicates that virtually nothing is knownabout the economics of day hospitals’’, and since then little usefulinformation has accrued 18 . The study by Mintzer et al. 22mentioned above, did conclude that their use of ‘‘partialhospitalization’’ was clearly a cost-effective method of instigatingand continuing treatment for agitated patients with dementia. InSweden, Wimo et al. 3 compared 55 demented patients in day carewith 45 waiting list controls and noted a statistically nonsignificanttrend suggesting that day care may be more costeffectivethan other types of service provision. In their review of 16adult day centres across the USA, Reifler et al. 26 considered thatone of the keys to cost efficiency was improved utilization, whichrelated to meeting ‘‘customer demands’’, such as the need fortransport and opening for a longer day between 7.30 a.m. and6 p.m. Perhaps specific to health and social care systems in theUSA, these authors make other suggestions as to how thefinancial viability of day care facilities can be enhanced.DAY HOSPITALS OR DAY CENTRES?Studies of demented attenders at day hospitals and at day centrestend to find that those at the former are rather more dementedand more behaviourally disturbed, but that the similarities aremore striking than the differences between the two groups ofattenders 27–29 . This gives rise to the view that a proportion ofdemented attenders at day hospitals could have their needs metmore cost-effectively at day centres, as has also been suggested foryounger adults attending day hospitals in north-west England 30 .This view is strengthened by findings that supporters of thedemented elderly attending day hospitals do not derive morepsychological benefit than those whose dependant goes to a daycentre 28,31,32 . Comparisons against day centres of other suggestedfunctions of day hospitals, such as assessment and treatment ofnon-cognitive symptoms, have not been conducted. Furthermore,no randomized trials of day hospital vs. day centre care have beenconducted among demented subjects, and while such studieswould be difficult to conduct, they are likely to be feasible, giventhat they are possible among the physically disabled elderly 33 .PROBLEMS AND ISSUES IN DAY CAREAs has been indicated above, there is a considerable need toaddress the issue of the effectiveness and the cost-effectiveness ofdifferent day care programmes and of the specific components ofthese programmes, even although this is an undeniably complextask. Other common issues in day care will be touched uponbelow.