Aug 15, 1981 - specialist back-up than they have, and encouragement in the development of their own higher skills in the interpretation of aging phenomena.
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syringing and bed sore debridement were the most effective of his therapeutic interventions, he might well believe that medicine is successful in proportion to the development of technical skills, particularly from the vista gained from the Cardiovascular Center, New York. In respect of psychogeriatrics, as one of those general practitioners allotted a place by Tom Pickering, after nurses and social workers, in the provision of general supportive care, perhaps I may express my view? Dr Pickering argues that the process of "senility" is irreversible. I think that he means senescence, but I suppose that he would agree that the role of the psychogeriatrician, and the general practitioner for that matter, is to determine whether in fact he is observing an inexorable decline or the manifestation of a disease process. He would agree, I feel sure, that against centuries of social conditioning it is not easy to distinguish senile traits from senile changes. Indeed, while cardiology is more of a closed shop in its specialised training, the psychogeriatrician must be saturated by more phenomena, for equally long periods, if he is to succeed. In fact, only this year two of my patients, diagnosed as suffering from "senile dementia," were saved from progressive decline by so humble a person as a general practitioner, who noted that they underwent long periods of bradycardia as a result of regional myocardial ischaemia. The apparent mental changes were reversed by the insertion of pacemakers of the fixed-rate type. Other patients, with thyroid dysfunctions discoverable only by estimation of precursor hormones, have also been rescued from general supportive treatment by the primary care team, and so have patients with pernicious anaemia and thin subdural haematomas missed by hospital colleagues on first admissions. More common conditions, such as depression, present more difficult distinctions; but the advances in geriatric medicine have brought low-pressure hydrocephalus and other concepts into our thinking which are a great test of medical skill and awareness. We do respect the advanced plumbing and photographing of the circulation that inspires cardiology, but recognise that until recently the United States has lagged behind Britain in the development of geriatric medicine as a discipline, and certainly as a service. Nevertheless, Verwoerdt's recent publication there states, "In many respects, the senium is still a terra incognita. We need to know a great deal more about the psychosocial and intrapsychic processes involved in attaining a sense of integrity, the causes and mechanisms of its failure, the clinical expressions of such decompensation, and, most importantly, therapeutic modalities."' This presents us with an awesome challenge for the twenty-first century, and general practitioners must not submit themselves to becoming geriatric nannies, as Dr Pickering proposes. They require more specialist back-up than they have, and encouragement in the development of their own higher skills in the interpretation of aging
phenomena. M KEITH THOMPSON Croydon, Surrey CRO 7HL
'Verwoedt A. Clinical geropsychiatry. 2nd ed. Baltimore: Williams and Wilkins, 1981:336-7.
SIR,-In concluding his letter (1 August, p 377) on the future of cardiology and psychogeriatrics, Dr Thomas Pickering states that to a relatively detached observer it seems clear that
the NHS has got its priorities wrong; and he gives it as his opinion that the rapid expansion of psychogeriatrics in contrast to the stagnation of cardiology is a sad testament to the dominance of politics over logic in the organisation of medical care. Allow another relatively detached outside observer (a retired consultant psychiatrist with special interest in the elderly) to put him right. Psychogeriatrics is expanding not on account of political intrigues or expediency but because nurses, social workers, and general practitioners as well as general psychiatrists, have with few exceptions been found wanting in the task of adequately caring for old people with mental disorders and their much-afflicted families without specialised guidance and leadership. Even now, psychogeriatrics requires considerably more than syringing ears and debriding bed sores. There may not have been many technological advances, though there may soon be considerable technological developments in the treatment of senile dementia. There have already been many significant developments produced by specialised workers in the diagnostics and therapeutics of all mental disorders of old age, as well as more human understanding, than are dreamt of in Dr Pickering's philosophy. FELIX POST London SW19 7QR
SIR,-Poor Dr Thomas Pickering (1 August, p 377)-poor, poor thing-having left the specialty of geriatric medicine, where there is still a real need for pioneering, to go to an area where the doctors nzeed more money to develop yet more high technology and then to realise that his career choice is being affected by what society really nieeds-poor, poor thing-ah! what a shame. BRIAN LIVESLEY D)epartment of Geriatric Medicine, St Francis Hospital, L,ondon S1F22 8D)F
SIR,-We must all be very grateful that Dr Thomas Pickering (1 August, p 377) with his detached viewpoint from the United States has alerted us to the danger we are in. I am sure that many people, like myself, with narrow British perspectives have not realised the harm done to cardiology by the rapid growth of psychogeriatrics. However, the warning has been given and we must respond urgently. A top priority must be the re-education of the leaders of the profession. Not only the Royal College of Psychiatrists (who clearly have strong vested interests) but also the Royal College of Physicians are misguidedly recommending one consultant psychiatrist with a special responsibility for the elderly for each health district.' If implemented this will produce a horrifying total of 200 psychogeriatricians all consuming resources and blighting the development of radionuclide cineangiography. Fortunately shortage of psychogeriatric training posts provides a breathing space in which these pernicious trends can be reversed. I suggest that parties of senior fellows from both colleges are sent on reorientation courses at the Cornell Medical Center to provide them with the broader perspective necessary for realising the error of their ways. Once the policies have been changed it will be relatively
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simple to rehabilitate and retrain existing psychogeriatricians, perhaps allowing a recalcitrant few the option of following, with suitable salary protection, their real vocation as social workers. G P A WINYARD Department of Community Health, London School of Hygiene and Tropical Medicine, London WC1E 7H T
RIoyal College of P'hysicians, College Committee on Geriatrics. J R (oll Phvsicians Lond 1981 ;15 :141-67.
Caring for the aged SIR,-We refer to your leading article (6 June, p 1817) in which you discuss the implications of the new white paper on the elderly.' You state that our Leicestershire study2 showed that a quarter of those in residential homes were in need of nursing care. In quoting this figure we believe that you misrepresented our findings. We made no statement about need for nursing care among residents in our original study and indeed, unless it has been inferred from our measure of incapacity in activities of daily living, it is difficult to see how such an estimate was made. A follow-up study of residents judged by staff to have been misplaced at the time of the original survey3 did estimate need for different levels of care, but this was restricted to the small proportion (7 " ,) of misplaced elderly people. Over 300 patients in homes for the elderly did have major problems with basic activities of daily living (ADL scores over 7), though only 160 residents in these homes were seen by care staff as misplaced. This seemed to us to indicate that many of the homes for the elderly managed by social services departments now accept levels of handicap which were previously thought to be more appropriate for care in hospital. In Leicestershire considerable efforts have been made to cope with these increasing levels of disability in social service homes; for example, in 1979-80 17 out of 40 officers in charge of homes were Stateregistered nurses and a further 10 had other nursing training. While we do not wish to minimise the importance of the increasing burden of higherincapacity residents faced by staff in part III accommodation, we wish to draw your attention to the erroneous conclusions that have been drawn from our work. MICHAEL CLARKE LIAM DONALDSON University Departmenit of Community Health, Leicester Royal Infirmary, Leicestcr LE2 7LX
Department of Health anid Social Security, Welsh Office, Northern Ireland Oflice. (Growing older. London: HMSO, 1981. (Cmnd 8173.) 2Clarke M, Hughes AO, D)odd KJ, et al. Health Trends 1979;11:17-20. Dodd KJ, Clarke M, Palmer RL. Health T7rends 1980; 12:74-6.
**There can be little doubt that much of the work done by care staff of residential homes is nursing' and the score- used in the Leicestershire study (ref 2 above) measured dependency. In the residential homes 14", scored 7 or more and 25". scored 5 or more. In commenting on those seen to be misplaced the authors stated that "the people most often seen as being misplaced appear to be very dependent and in need of intensive geriatric or psychiatric nursing care." Furthermore, although only 14,, of residents in homes for the elderly had
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a score of 7 or more, the homes were providing care for practically the same number of heavily dependent old people as were found in the geriatric wards. It therefore seemed safe to assume that the 25(,, who scored 5 or more were in need of nursing care, and this was reinforced by the statement that a quarter were incontinent during the previous week. The use of staff assessments as an indicator of need masks the severity of the problem, for an untrained staff may accept responsibility while not recognising mismanagement. For example, the nursing and medical problems are greatest with those who are immobile but they are not seen to be a problem, while wandering patients often are. ' The trend in Leicestershire to appoint trained nursing staff is welcome, but Andrews3 drew attention to the fact that it is the apparent intention of the DHSS to reduce the amount of nursing in the homes.-ED,
BM7. Millard PH, Bailey R. Br Medy 1981 ;282:1237-8. Snyder LH, Rupprecht P, Pyrek J, Brekhus S, Moss T. Gerotntologist 1978;18:272-80. 'Andrews J. Br Medy 1980;280:792.
Prescribing for the elderly
15 AUGUST 1981 different type of general practice. Very simply, the basis is that prescribing is the result of consultation, which is best carried out by meeting the patient and not by telephone or by letter. Once this basis is established many of Dr Bliss's criticisms are quite inapplicable and the receptionists are not encumbered with the difficulty of writing prescriptions between making appointments and the hundred and one other jobs they undertake. Nor does the doctor sign sheafs of prescriptions without having checked them, which Dr Bliss seems to think is quite usual in Kent. Another benefit is that it is most unlikely that the doctor will be writing prescriptions for unnecessary vitamins and sleeping pills, as apparently happens in hospital. Of course, patients who are unable to visit the surgery have to be visited at home; but this need not be an ordeal for either the patient or the doctor. Dr Bliss, I think, not only has been unfortunate in the practices with which he is acquainted but is even more unfortunate in the practitioners whom he has met. On the one hand, my patients do not order drugs any more than consultants direct me to prescribe drugs. I am always most appreciative of consultant opinion and very rarely disagree, but I do consider that it is the general practitioner's responsibility to be the final arbiter in the treatment of his patients when they are at home. It may be that general practitioners who are brusque with their patients and who find their task of prescribing unpleasant in actual fact do accept orders from their patients and directives from consultants. Lastly, I would plead with Dr Bliss not to introduce yet another sheaf of paper for the poor patients to carry about from hospital to doctor and doctor to hospital. I am sure that if any general practitioner wishes to inform a consultant of an alteration in the patient's therapeutic regimen he would do so with a courteous letter rather than by giving the patient a prescription booklet. Similarly, I am sure that if the consultant was going to recommend some other treatment for the patient he would rather do so through a letter containing an explanation than through the patient with his booklet duly completed. I think that one of the benefits of prescribing as a result of consultation is that the patient gains the impression that drugs are prescribed after due thought and careful consideration and are not to be treated lightly. As well as developing respect for the drugs the patient also develops a respect for a doctor who has the courtesy at least to see him before
SIR,-Since appropriate use of carefully chosen drug combinations improves compliance,' the need for simplified regimens for essential drugs as urged by Dr M R Bliss in his article "Prescribing for the elderly" (18 July, p 203) would be certainly agreed by all physicians working with the elderly. But many would strongly disagree with sweeping statements he makes-for example, diazepam should not be prescribed for the elderly at all and antihypertensive drugs are scarcely ever necessary, if at all, for the elderly. I can easily recall cases where diazepam has been safe and immensely helpful, irrespective of its long half life, in calming anxious and difficult elderly patients for their successful rehabilitation. Similarly, patients suffering symptoms from grossly elevated blood pressure do require definite antihypertensive therapy, and I do not know of any geriatrician who could pledge himself to dismiss the use of antihypertensive drugs simply because the patient was elderly (over 65 years). There is no convincing evidence that elderly people with good brain function are less likely than younger people to comply with a given regimen.2 Despite the best packaging, labelling, and instructions by doctors for those elderly people who have failing eyesight or memory, the only sure answer remains the supervision of their drug intake by a relative, neighbour, prescribing. district nurse, or the matron in the old peoples' Hull HU3 6EP home. K GUPTA Geriatric Department, London Hospital (Mile End), London El 4DG I
Anonymous. Drug Ther Bull 1980;18:37.
2O'Hanrahan M, O'Malley K. Br MedJ 1981;283 :299.
497 No repeat requests are taken by telephone except personally by the doctor. Cards may be delivered to the prescription department or sent by post, and no repeat is issued by the prescription writers without a card. Patients are asked to allow 48 hours for a repeat to be completed. Each patient's repeat items are entered on index cards kept in the prescription department and the appropriate one is got out each time the patient requests a scrip. If a patient does not have a card it is probably because he or she has just started to have a repeat; and then the FPC5 or FPC6 is got out. Every repeat is entered either on notes or on the index card, and prescriptions are written in full with all instructions and quantities written clearly. They are then distributed to the doctors and are signed individually by the doctors at the end of morning or evening surgeries. We find that patients do not often go to the
hospital pharmacy but bring their scrips straight to us, and we then give them one month's supply if that is appropriate. We give only those hospital prescriptions which we consider necessary and certainly leave off things like vitamins and sleeping tablets. PATRICIA M AIKMAN Melton Mowbray, Leics LE13 INX
New evidence linking salt and hypertension
SIR,-Your recent leading article (20 June, p 1193) and subsequent correspondence (4 July, p 57) underlines the fact that there is probably now enough evidence to advise as a health measure a reduction of salt in the British diet. The DHSS booklet in the "Prevention and Health" series entitled Eating for Health stated in 1978, ". . . there is some confirmation from human studies that to eat little salt may be beneficial in preventing an increase in blood pressure." The trouble is that it is impossible to know what one's salt intake is unless one eats wholly natural, unprocessed food; and not everyone can do this. A study of the food labels of prepared foods on supermarket shelves reveals that practically every prepared food contains added salt, from canned vegetables, packet soups and sandwich spreads right down to cake mix, margarine, breakfast cereals, peanut butter, etc, etc. Other foods contain the sodium ion in other forms, such as sodium glutamate, sodium citrate, and saccharine sodium. The labels, however, do not state, nor are they required by law to state, the amounts of the various ingredients. Obviously some of these ingredients are more important to know about than others; but G H SWANSON information on calories, salt, and saturated fat would certainly be helpful. Until such times as food labelling in this country is required to be quantitatively specific, it will be impossible for anyone to know their SIR,-I really must protest at the way Dr level of salt intake. It is not enough to advise M R Bliss accuses all doctors of lack of care in one's patient to cut down or cut out "added" prescribing for the elderly (18 July, p 203). salt as much of his salt is added for him willy
In our practice of 12 doctors we have three who are clinical assistants in geriatrics and we have a SIR,-I found Dr M R Bliss's article (18 July, specific prescriptions department. This department p 203) both interesting and helpful and would is open from 8.30 am to 6 pm, Monday to Friday. like through your columns to thank him for it. We employ women who fill the equivalent of three I should also like to sympathise with him in his full-time posts and one half-time, one of the experience of general practice and to inform women being a qualified dispenser and another 300 him that there are other ways of conducting partly trained. They deal with approximately has repeat who Each patient a day. prescriptions general practice, although this may not be prescriptions has a repeat card which is authorised immediately apparent from his collection of by the doctors, and is checked at regular intervals. statistics from various sources. Patients are given one month's supply of tablets at a The method that I use is not particularly time, and the date of the last supply is always original but may serve to remind him of a checked by a query to the doctor if it is too soon.
nilly. H MACANESPIE Department of Community Medicine, Ruchill Hospital, Glasgow G20 9NB
Preventing food poisoning by bacterial toxins SIR,-We wish to comment on the answer of your expert to the question about the heatstability of bacterial toxins and whether it is
