Smoking

Tobacco smoking is often part of the culture of long-stay institutions. Over 70% of long-stay patients smoke. The highest prevalence (74%) is in those with psychotic disorders, 52% of whom are heavy smokers, consuming over 20 cigarettes per day (Reference Meltzer, Gill and PetticrewMeltzer et al, 1996). The Government has made smoking reduction a high priority for health improvement. A target has been set to reduce the rate of smoking in the general population of England and Wales from 28% to 26% by 2005 (Department of Health, 1999b ).

In long-stay institutions, preparations for making changes to influence smoking behaviour might include surveying smoking facilities, smoking behaviour and the attitudes of staff and patients towards smoking (NHS Executive, 1999) (Box 3). This information would form a basis for the development of a strategy for smoking cessation, with appropriate resources, policies and procedures. Guidance about smoking facilities and policies has been published by both the NHS Executive (1999) and the Health Development Agency (2001). Priority should be given to providing smoke-free areas for non-smoking patients. Tobacco must not be used as a reward or incentive for patients.

Reference West, McNeill and RawWest et al(2000) have prepared smoking cessation guidelines for use by health professionals, based on a meta-analysis of research evidence. The researchers conclude that smoking cessation interventions are a cost-effective way of preserving life and reducing ill health. They found that brief advice from a general practitioner led 1–3% of patients to stop smoking for 6 months. Clinicians should therefore give advice about smoking cessation and document this in the records.

In trials, nicotine replacement therapy increased the chances of smoking cessation by 18%, compared with controls, whatever the setting and regardless of the type of nicotine replacement therapy used (Anonymous, 1999). All trials included some form of psychological support. Bupropion is an effective aid to smoking cessation, but it may interact with some forms of psychotropic medication. It is contraindicated for patients with epilepsy and with bipolar affective disorder (Anonymous, 2000).

Specialist smoking cessation clinics increase the success rate of smoking cessation by combining behavioural and pharmacological therapies (Reference West, McNeill and RawWest et al, 2000). Most success is achieved by specialist clinics, run by specially trained staff employed solely for this purpose. Clinics should offer individual and group treatments. Groups are most effective when there are 15–30 participants, meeting weekly for at least 6 weeks, and when patients take nicotine replacement therapy or bupropion (Reference West, McNeill and RawWest et al, 2000). At the beginning of sessions, abstinence should be monitored by checking for expired carbon monoxide.

There is a paucity of research evidence on smoking cessation in psychiatric patients. In the USA, one non-controlled trial of 50 out-patients with schizophrenia found that 42 patients achieved smoking cessation and 12 were abstinent at 6 months follow-up (Reference Addington, el-Guebaly and CampbellAddington et al, 1998).

The ingested products of tobacco combustion may induce liver enzymes, which return to normal after smoking cessation. There is a risk that patients who stop smoking may develop side-effects to their psychotropic medication (e.g. clozapine), so that the dose has to be reduced. Smoking is a serious risk to the health of long-stay patients, so consideration should be given to supporting multiple attempts at smoking cessation.

Diet and nutrition

Diet plays a fundamental role in the development of many diseases, including coronary heart disease, obesity, diabetes and some forms of cancer. The Committee on the Medical Aspects of Food and Nutrition (Department of Health, 1994) has recommended a reduction in dietary fat and salt and an increase in complex carbohydrates. The Food Standards Agency recommends that at least five portions of fruit or vegetables should be consumed per day and at least two portions of oily fish should be eaten per week (Food Standards Agency, 2001). Patients should be given advice on healthy eating and be provided with healthy dishes on the menu.

The NHS Plan has set standards for food in NHS hospitals (Department of Health, 2000a ). These standards, together with approved recipes, appear in the NHS Recipe Book (Department of Health, 2001d ; for website see Box 1). All long-stay NHS institutions must provide the recommended nutritional intake in food and a range of popular dishes that are likely to be eaten. Menus should include clearly marked ‘healthy options’, i.e. main-course dishes with <15 g of fat, desserts with <5 g of fat and <10 g of added sugar, and a daily salt intake of 4–6 g. The menu cycle should be varied and be longer than 2 weeks, to reduce ‘menu fatigue’.

Nutritional needs vary with gender, age and level of activity, and are an important consideration in menu planning, timing of meals and portion size. Patients may have special dietary requirements (which should be included in care plans) such as the need for texture-modified meals for patients with chewing or swallowing problems. The dietician and other health professionals should work closely with the catering department to review the diet and to make improvements. Further information can be obtained from http://www.betterhospitalfood.com.

Confectionery is the most common addition to the diet of long-stay patients, and may substantially increase energy intake. We recommend that the range of goods available from the patients’ shop and at social functions should include healthy options. Thirst is a problem for many patients taking psychotropic medication. Patients may consume large quantities of carbonated and caffeine-containing drinks. Patients should have access to drinking water throughout the day, unless there are risks such as polydipsia.

Physical activity

Physical activity has many beneficial effects on health. It can improve cardiorespiratory fitness, body strength, flexibility, balance, body shape and posture. Regular exercise will alter body composition by increasing muscle and reducing body fat. The elderly benefit from exercise with improved fitness, muscle strength and bone conservation, which contribute to the prevention of falls (Reference Forwood and LarsenForwood & Larsen, 2000). Other beneficial effects of exercise are improved self-esteem, socialisation and sleep (Reference Honeybourne, Hill and MoorsHoneybourne et al, 2000: pp. 199–233). Reference DaleyDaley (2002) described some beneficial effects of exercise therapy on the mental state of patients with depression and schizophrenia.

Exercise limits the proportion of lean tissue lost during dieting and assists with maintaining weight loss. It reduces the risk of cardiovascular disease and decreases the mortality rate in coronary heart disease. Regular exercise delays the onset of hypertension and reduces blood pressure. Physical activity has a beneficial effect on the control of diabetes and reduces the risk of colon cancer.

The current recommended guideline for physical activity is 30 minutes of moderate-intensity activity such as brisk walking, heavy gardening and heavy housework on at least 5 days per week (Department of Health, 1996). Opportunities for exercise may be limited for some long-stay patients and for others exercise may not be a realistic option. A survey of physical activity and exercise facilities might aid the future planning of services (Box 4).

Staff enthusiasm plays a major role in encouraging patients to be more active. It is usual practice for fitness instructors to assess individuals before starting them on an exercise programme. The assessment might include measurements of resting pulse rate, blood pressure, body fat, and calculation of the body mass index (BMI), defined as weight divided by height squared, kg/m². Tests are also available for flexibility, strength and cardiorespiratory fitness. The fitness instructor may provide progress reports to the clinical team and for care programme approach meetings. Plans for physical activity could be incorporated into care plans.

Many long-stay patients have been inactive for years. A pre-exercise group or individual sessions can give them the confidence, skills and knowledge to begin gentle exercise. Appropriate sportswear may be needed. A systematic review of strategies to promote physical activity found that interventions encouraging walking and not requiring attendance at exercise facilities were more likely to lead to increases in physical activity (Reference Hillsdon, Thorogood, Foster and MacAuleyHillsdon et al, 1999). Physical activity may take place during occupational therapy and some forms of employment. An imaginative approach to exercise, with a range of available options, is most likely to be successful.

Weight management

Obesity is defined as having a BMI >30 (Table 1) and it has reached epidemic proportions in the UK. Some people have a genetic predisposition to obesity, but the fundamental cause is excessive calorie intake. Obesity is a major risk to health, and mortality rises with increasing weight. Excess weight is associated with an increased incidence of cardiovascular, respiratory, gastrointestinal and metabolic disorders, as well as certain forms of cancer. The health risks of obesity are increased with central deposition of adipose tissue, and waist size is a measure of the risk to health (Reference Lean, Han and MorrisonLean et al, 1995) (Table 2).

An intentional weight loss of 10 kg in obese people can confer significant health benefits. According to Reference JungJung (1997) these include a 20% fall in total premature mortality, a 30% fall in deaths due to diabetes, a 40–50% fall in cancers due to obesity and up to a 30% reduction in triglycerides.

Obesity is prevalent in many long-stay patients, and it is exacerbated by physical inactivity and sometimes by medications with the side-effect of weight gain (Reference Allison, Mentore and HeoAllison et al, 1999). Monthly monitoring of weight and waist size should alert staff to significant changes and the need for investigations (Box 5). More frequent monitoring is advisable when medication that carries a high risk of weight gain is given (e.g. clozapine, olanzapine, lithium carbonate and sodium valproate). The Maudsley Prescribing Guidelines, which are about to appear in their seventh edition (Reference Taylor, Paton and KerwinTaylor et al, 2003; for website see Box 1) contain useful information on psychotropic medication with the potential for causing weight gain.

Effective strategies for weight management include a combination of dietary restriction, increased physical activity, behavioural modification and psychological support. Guidelines for weight loss recommend a reduction of 0.5–1.0 kg per week to preserve muscle. The most reliable way of achieving weight loss is with a hypocalorific diet of 500–600 kcal/day (2090–2510 kJ/day) less than the person’s estimated energy requirements, together with a modest increase in exercise (Anonymous, 1998). A reduction in energy intake may be achieved by reducing total dietary fat content and by increasing complex carbohydrates in the diet. The aim should be to change long-term eating habits. Support from others and weekly weighing are important factors in successful weight management.

Pharmacological treatments with sibutramine or orlistat should be considered for those who meet the criteria set by NICE (National Institute for Clinical Excellence, 2001a , b ). Very low calorie dietary products can be used as substitutes for meals, but as a safeguard, they should be used only under the supervision of a physician, on selected patients with a BMI >30. High-protein diets restrict the consumption of healthy foods and generally do not meet nutritional requirements. Behavioural methods used by certain slimming clubs may not be suitable for vulnerable patients. Surgery is available for severe obesity, but only as a last resort.

Weight loss or being underweight may be the first sign of an underlying serious illness that requires investigation. Patients who are underweight should be given nutritional advice and support when needed.

Primary care

Most long-stay patients receive physical health care from psychiatrists, who are not usually trained as general practitioners. Primary care services delivering acute and chronic disease management according to NSF standards should be arranged for long-stay patients (Reference Fisher and RobertsFisher & Roberts, 1998). Initially, the focus should be on patients with a high risk of coronary heart disease, for example men over 50, with a BMI >30, who are smokers. Patients with a history of myocardial infarction, stroke, diabetes mellitus, hypertension and raised cholesterol should be identified. Comorbid substance misuse should be assessed and managed according to locally agreed procedures and policies.

Screening

Long-stay patients should be given relevant information about screening, be encouraged to take part and be given the opportunity to attend a screening facility. It is important to recognise the sensitivity of some patients to the gender of the medical practitioner or nurse carrying out the screening procedure. The NHS has screening programmes for cervical, breast, colon and prostate cancer, glaucoma and type 2 diabetic retinopathy. Details are available at http://www.nelh.nhs.uk/screening. It is important that patients are offered screening at the appropriate intervals and, whenever possible, are registered for automatic recall for screening. Patients may be taught self-examination techniques for the detection of breast or testicular masses.

Other specialist services

Oral health affects comfort, eating, speech and appearance (Reference Cormac and JenkinsCormac & Jenkins, 1999). The dental status (decayed, missing and filled teeth) of long-stay patients was found to be similar to that of the general population, but oral hygiene was not as good (Reference Lewis, Jagger and TreasureLewis et al, 2002). Oral hygiene should be part of routine care, along with regular visits to the hygienist and dentist.

Eyes should be assessed regularly by an optician, for visual acuity and ocular problems such as glaucoma. Specialist tests are available for those with learning disabilities (Reference McCulloch, Sludden and McKeownMcCulloch et al, 1996). Hearing should be tested using audiometry, and hearing aids should be provided if needed.

The pharmacist has an important role in advising about medication, side-effects and monitoring, especially with complex regimens. A dietician should be available to assess dietary needs and advise on the management of those who are under- or overweight. Speech and language therapists have expertise in the assessment and management of swallowing problems. Chiropodists should see patients with foot conditions, and special care should be taken with the feet of diabetic patients. Physiotherapy may be needed.

Vulnerable patients

Patients with learning disabilities may need help to access care. Sensory impairments are common (Reference Wilson and HaireWilson & Haire, 1990), as are epilepsy, dental problems and skin problems. Women with learning disabilities tend to have an early menopause and menstrual problems (Reference Martin, Cassidy and AhmadMartin et al, 2001). Physical disabilities may occur in association with underlying genetic disorders such as Down’s syndrome. All patients with learning disabilities in residential care must have an annual health check and a health action plan in place by June 2005 (Department of Health, 2002). Health action plans are designed to meet the patient’s health care needs and are prepared by patients, with help from staff when necessary. Health action plans could be useful to all patients in the planning of their physical health care.

Elderly long-stay patients have the same spectrum of health problems as other long-stay patients and elderly people in the general population. The NSF for Older People (Department of Health, 2001b ) addresses specific issues in relation to prevention of falls and strokes. Advice from the pharmacist will be particularly useful, as pharmokinetics change with age and drug interactions and side-effects are more likely.

For patients with schizophrenia, the NICE guidance (National Institute for Clinical Excellence, 2002) sets standards for health promotion, regular health checks and screening for side-effects of medication. Of particular concern are the adverse effects of antipsychotic medication, notably extrapyramidal side-effects, hyperprolactinaemia, hyperglycaemia and weight gain.