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Online Essay Club No.31: Day Hospitals

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Q: &quot:lol:ay hospital care for patients with dementia does not alter the prognosis of the disease and is, therefore, a waste of resources'. Critically discuss this statement with reference to the literature.

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[From the Examiners' marking scheme]


The question has two components, the relative value of day hospitals in the care of patients with dementia and a discussion of prognosis. These two issues may be addressed together but each must be tackled for the candidate to pass. With increasing emphasis on cost effectiveness and evidence based practice, it is important to question the organisation of services. The candidate needs to be aware of the benefits that day care may provide while commenting about different ways that services may be organised. It should be acknowledged that there can be difficulties in measuring some of the benefits which are believed to occur in different settings. There is information on the relative costs but not the relative benefits of services provided in different ways. The advocates of day hospitals see them as part of a comprehensive district service alongside other hospital and community components (Howard). At best day hospitals provide a holistic assessment and management including support to patients and informal carers.



The diagnosis of dementia carries with it inevitable cognitive, psychosocial, and eventually physical decline but the two years from diagnosis to death suggested by Roth in 1955 in many cases may be much longer (Blessed and Wilson).

Although disability in dementia progressively worsens at much the same rate whatever the setting of care, the experience of the dementia and the quality of life for patient and carer can be greatly altered by appropriate management during the disease process.

Alteration in disease prognosis is not the only aim of patient management, and other factors need to be mentioned in order to achieve a pass mark.

The case for day hospitals

Patients with dementia may suffer from any number of psychiatric and behavioural signs and symptoms and frequently from comorbid depression which will be more appropriately understood and treated in a health setting. The objectives of the day hospital are rehabilitation, maintenance, assessment, medical, nursing and social care. These 'high intensity activities' are rehabilitative and restorative. The day hospital is also involved in low intensity activities of support, education, and monitoring.

High levels of distress and frank depression are found among carers of demented patients which can be relieved by attendance at a day hospital. The degree of benefit is related to the expectations of the carer. These expectations may be influenced by intensive outreach work from the day hospital prior to the admission. While day hospital care is associated with a significant reduction in emotional distress for the majority of relatives, failure to relieve a significant reduction in emotional distress is predictive of institutionalisation within six months (Gilleard).

These two main points in favour of day hospital care need to be made to achieve a pass mark. Further subsidiary points should be mentioned to obtain a good pass.

Day hospitals have a long tradition in the UK. The first one opened in 1946. 'Better Services for the Mentally Ill' advocated norms of provision in each district and they have been supported by professional leaders in both general and old age psychiatry. In younger populations, the day hospital has been shown to be a viable alternative to inpatient treatment for some patients (Creed). Studies in dementia have concluded that day hospitals have little impact on the need for institutional care (Woods and Phanjoo, Diesfeldt). However, these conclusions are complicated by the observation that the establishment of a day hospital may represent an extra resource for a population of patients not already in receipt of services (Ballinger, 1994).

Day hospitals may be used flexibly. They provide the possibility for fairly intensive observation over time and so may be part of a system for monitoring the new antidementia drug. The day hospital may be used for investigation and assessment, brief treatment programmes and longer periods of support and management. They may be seen by the patient as more user friendly than the outpatient setting. They can be used to cover a short period of crisis rather than inpatient admission with the benefit of maintained community links. Long term support from a day hospital may be a more acceptable and cheaper alternative to residential care.

Problems with day hospitals and discussion of alternatives

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Day hospitals are expensive in terms of capital and staff resources and it has been questioned whether those resources may be better focused/ deployed (Fasey). The capital investment in a day hospital is high because the buildings are only used for a few hours each day. Some units have extended the opening hours of the day hospital and used the space flexibly, eg, for overnight respite

Some have argued that the functions of a day hospital may be taken over more cheaply by a day centre. The objective of most day centres is to provide care and companionship with social, recreational, and occupational activities. These overlap to some extent with day hospital objectives and in many districts nursing and medical staff visit and advise on the management of patients in day centres.

These two points need to be made to achieve a pass mark with subsidiary points to achieve a good pass.

All forms of day care may be bedevilled by transport difficulties. Some units now use their own staff and transport. In geographically large catchment areas there has been some development of 'travelling day hospitals'.

The respite which day hospitals afford carers may be provided in the patient's home, eg, through a sitting service.

As yet, there are no measures of day hospital activity and efficiency which can really claim to identify and measure the therapeutic - psychological and social - aspects of care delivered. There is a paucity of research into the efficacy of old age psychiatry in day hospitals in comparison to that which has been conducted in general psychiatry facilities. Research is needed, not only into day hospital care per se, but into the most appropriate model of day hospital care.


In order for the candidate to pass, they must present a case for and against day hospitals, to have some discussion of prognosis and to come to a credible and coherent conclusion on the basis of their preceding paragraphs.

Possible references include:

Ballinger B. 1984. The effects of opening a geriatric psychiatry day hospital. ACTA Psychiatry Scand, 70, 400-403.

Blessed G. and Wilson, I.D. 1982. The contemporary natural history of mental disorder in old age. British Journal of Psychiatry, 141, 59-67.

Creed et al. 1990. Randomised controlled trial of day patient versus inpatient psychiatric treatment. BMJ, 300, 1033-1037.

Diesfeldt H. 1992. Psychogeriatric day care outcome: a five year follow up. International Journal of Geriatric Psychiatry, 9, 519-523.

Fasey C. 1994. The day hospital in old age psychiatry: the case against. International Journal of Geriatric Psychiatry, 9, 519-523.

Gerard K. 1988. An appraisal of the cost effectiveness of alternative day care settings for frail elderly people. Age Ageing, 17, 311-328.

Gilleard C. 1987. Influence of emotional distress among supporters on the outcome of psychogeriatric day care. British Journal of Psychiatry, 150, 219-233.

Howard R. 1994. Day hospitals: the cases in favour. International Journal of Geriatric Psychiatry, 9, 525-529.

MacDonald et al, 1982. An attempt to determine the impact of four types of care upon the elderly in London by the study of matched groups. Psychol Med 12, 193-200.

Murphy E. 1994. Editorial: the day hospital debate. International Journal of Geriatric Psychiatry, 9, 517-518.

Roth M, 1955. The natural history of mental disorder in old age. Journal of Mental Science, 101, 281-301.

Woods J.P. and Phanjoo A.L. 1991. Follow up study of psychogeriatric day hospital patients with demenia. International Journal of Geriatric Psychiatry, 6, 183-188.

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