The viewpoint of the elderly psychiatric patient

ment. This may be due to an assumption that their reports are unreliable. Much of the research in this area has been carried out in the USA, although there have been reports from the UK and elsewhere (Freeman & Kendall, Hansson et al, 1985; Lazare et al, 1975;Mclntyre et al, 1989;Weinstein, 1981). Elderly people represent at least one-third of the patients of most psychiatric services, but little is known of their views, although many of them have functional illnesses or mild organic brain disease, and could therefore offer valid opinions. The present report surveyed the opinions of elderly psychiatric patients in two psychiatric services in Tayside.

There is now an increasing emphasis on the views of the consumers of health care, but little is known of psychiatric patients' opinions on their care and treat ment. This may be due to an assumption that their reports are unreliable. Much of the research in this area has been carried out in the USA, although there have been reports from the UK and elsewhere (Freeman & Kendall, Hansson et al, 1985;Lazare et al, 1975;Mclntyre et al, 1989;Weinstein, 1981).
Elderly people represent at least one-third of the patients of most psychiatric services, but little is known of their views, although many of them have functional illnesses or mild organic brain disease, and could therefore offer valid opinions. The present report surveyed the opinions of elderly psychiatric patients in two psychiatric services in Tayside.

The study
The subjects were in-patients in Murray Royal Hospital, Perth and Royal Dundee Liff Hospital and the associated day hospitals. In Dundee one ward was exclusively for the over 65 age group, and was an 18 bed, mixed sex ward; the others served the full adult age range, four of these being single sex wards, and one mixed sex. In Murray Royal Hospital there was one ward for the over 65 functionally ill elderly, with 10 beds.
The day patients in the Dundee services attended two day hospitals with 20 and 30 places respectively, separate from the main in-patient site, but those from Perth attended an integrated in-and day-patient facility.
Dundee has two psychiatric wards for the whole age range within the nearby general hospital, but Perth does not, and this caused difficulties in administering the relevant question.
All patients over 65 in admission wards and day hospitals in the six months from November 1989 to April 1990wereincluded. Patients wereexcluded with a score of 7 or less on the information/orientation section of the survey version of the Clifton Assessment Schedule (Pattie & Gilleard, 1975), and where the clinical condition prevented interview, for example, a severe psychotic illness.
The 103patients included 45 day patients (32 from Dundee and 13 from Perth), and 58 in-patients (25 from Dundee and 33 from Perth). There were 70 women and 33 men and the mean age was 75.3 years (age range 65-90). All of the in-patients had been admitted in the previous year, but 18 of the day patients had been attending for more than a year, the maximum period of attendance being seven years.
A standardised questionnaire* was administered, by two of the authors (MMS and JMMcL), who were trainee psychiatrists and not directly responsible for the patients' care. There were a number of questions concerning the following items: the age and sex of patients in the ward, location of the ward, dining and occupational therapy facilities, in-patient accommo dation (single or shared), diagnostic mix, continuity and frequency of contact with medical staff, patients' awareness of diagnosis, and number of patients in the ward or day hospital.

Findings
Age composition of ward. Twenty-five patients expressed a preference for a specialist ward for those over the age of 65 years, 33 opted for a ward with the full range of ages, and 45 had no strong preference.
Sex composition. Thirty-eight patients preferred a single sex ward, 23 a mixed sex ward, and 42 had no strong preference.
Location of ward. Twenty-one patients favoured a general hospital site, 32a psychiatric hospital campus, and the remainder (39) had no strong preference or gave no opinion.
Dining location (in-patient only) (n = 58). Both of the two patients who dined within the ward wished to do so. Of those (56) patients who dined outside the ward, in a central dining room, the majority (38) wished to * The questionnaire administered is available on request from Dr McLennan. continue doing so, or had no strong preference. However, a minority (18) wanted to eat within the ward.
Occupational therapy (in-patient only) (n = 57). The majority (6) of patients (7) who received OT in the ward preferred this, or had no strong preference. Of those (50) who received OT outside the ward, in a central OT department, approximately half (26) pre ferred this, or had no strong preference, but the other half (24) would have preferred OT within the ward.
Ward situation (in-patient only) (n = 58). All (29) of those patients located in ground floor wards pre ferred this or had no strong preference. Of those (29) who were located in upstairs wards, a majority (17) were content with this situation, or had no strong preference, but a significant minority (12) would have preferred a ground floor location.

Rooms (in-patient only) (n = 58).
In order or pref erence, 24 patients preferred a single room, 13 preferred a dormitory, 12 preferred a shared room, and 9 had no strong preference.

Continuity of medical care (in-patient only) (n = 103).
Over half of the patients (65) wanted to have the same doctor caring for them during their illness, including out-patient, day hospital and in-patient treatment. A sizeable minority (35) expressed no strong preference, and only three patients wished to be cared for by different doctors.

Comment
Several criticisms can be made of this study: the patients were aware that the questionnaire was administered by doctors, which may have influenced their responses; however it was made clear to the patients that this would not influence their clinical management. The study involved small numbers, and caution is required in interpreting the results. Patients may not have understood the significance of some questions, and responses may have been influenced by illness.
There are several points which emerge. Thedemand for separate wards for older patients was limited to a minority of patients and was not sought by any patient in wards serving all adult age groups. This raises the question of the desirability of a rigid separation of facilities for the over-65s. Perhaps, where feasible, patients should be offered the choice of a specialist ward for the elderly ora ward serving the full adult age range. Many patients expressed a preference for a single sex ward, although some opted for a mixed sex ward, and again perhaps a choice should be offered 665 where possible. However, patients' wishes and thera peutic benefit may not always coincide. Most patients with functional diagnoses did not wish to be cared for alongside individuals with severe memory problems, which isconsistent with the policy of many services to separate these groups.
Some patients preferred a general hospital but this applied to only a fifth of patients in the psychiatric hospital, and 31% of all patients expressed a pref erence for the psychiatric hospital. This suggests that a high quality 'mental health campus' is acceptable to many patients (Mental Hospitals in Focus, SHHD) although many individuals may not have fully grasped the concept of general hospital psychiatry. Most in-patients wanted occupational therapy in the ward, single accommodation, ground-floor accommodation and dining outside the ward.
The majority of both day and in-patients wanted continuity of care by doctors. They also felt that they were receiving insufficient information about their condition, and should be seen by their doctor on a weekly basis. On the whole, patients felt that the present numbers in the ward or day hospital were satisfactory.
In general, most of the respondents were reason ably happy with the present arrangements but some had reservations about certain features of care. Although the numbers are small, the findings point for caution in the imposition of particular patterns of care, and the desirability of offering choice.