A holiday for long-stay psychogeriatric patients

In recent years there has been increasing interest in long-stay psychogeriatric patients. Hilton et al (1989) and Anderson (1990) have described the pro fileand characteristics of this population, confirming clinical impressions of the severe degree of cognitive impairment and high dependency levels among such patients. At the same time, there has been a trend towards more active intervention in the type of care provided, moving away from the traditional custodial approach and towards more supportive continuing care models. Following a decision by nursing staff on Chingford Ward, Goodmayes Hospital to take a small group of patients to the seaside for five days, the opportunity arose to assess the possible benefits of a holiday for them. This innovative care plan was based on nursing observations that the patients improved in their daily living activities and behaviour following day trips out from the hospital. Schwoon (1980) has described a holiday for younger long-stay psychiatric patients, and we report here our experiences of being on holiday with elderly long-stay psychiatric patients.

In recent years there has been increasing interest in long-stay psychogeriatric patients. Hilton et al (1989) and Anderson (1990) have described the pro fileand characteristics of this population, confirming clinical impressions of the severe degree of cognitive impairment and high dependency levels among such patients. At the same time, there has been a trend towards more active intervention in the type of care provided, moving away from the traditional custodial approach and towards more supportive continuing care models.
Following a decision by nursing staff on Chingford Ward, Goodmayes Hospital to take a small group of patients to the seaside for five days, the opportunity arose to assess the possible benefits of a holiday for them. This innovative care plan was based on nursing observations that the patients improved in their daily living activities and behaviour following day trips out from the hospital. Schwoon (1980) has described a holiday for younger long-stay psychiatric patients, and we report here our experiences of being on holiday with elderly long-stay psychiatric patients.

The study
Eight patients were selected by the nursing staff to go on holiday to Pontins, Brean Sands, Somerset for six days in September 1989.We chose a matched control group of another eight patients from the same ward, using the CAPE levels of dependency and nursing observations of social functioning. Although the non-holiday patients formed a more dependent group on the CAPE assessment, this difference was not significantly different applying the Mann Whitney test. One patient became physically ill a week before the holiday. The study population, therefore, finally consisted of ten women and four men. Their mean age was 82.5 years and the mean length of stay in hospital, 37 months. All had a diagnosis of senile dementia. Both groups were assessed using the full CAPE (Pattie & Gilleard, 1979) and the COPEWELL (Whelan & Speake, 1980) questionnaires on the day prior to, and after their return from holiday. Four nurses of different grades from the ward accompanied the holiday group.

Findings
Interestingly, significant changes in both measure ment scales were recorded between before and after going away even though the holiday was relatively short. The biggest change was found in the social disturbance subscale of the CAPE, with the holiday group's mean score falling from 3.8 to 0.7, which was significantly different using the Kendall coefficient of concordance (P < 0.05). Bycontrast, the non-holiday group's mean score remained relatively constant with values of 3.7 and 3.1 (not significant). An example of the change in this subscale was that patients became less objectionable during the day and night. The subscales for apathy and communi cation difficulties also showed trends towards improvement: the apathy subscale mean score fell from 7.4 to 6.4, and the communication difficulties from 1.2 to 0.7. Another distinct trend was seen in the overall dependency score on the CAPE: five patients moved to a less dependent scale following the holiday. The COPEWELL questionnaire showed results which validated the above changes, with five patients improving in self-help skills, e.g. personal grooming, and three patients improving in their interpersonal skills. There were no changes in the level of cognitive functioning.
The nursing staff" kept a detailed diary of the holiday and commented on the patients' behaviour two weeks after the return from holiday. Most of the patients were noted to be both apprehensive and excited at the beginning of the holiday. From the start of the journey, the patients expressed more interest in the environment around them. The diary entry reads '... that first evening in the social club, Mrs V, Mrs B and Mr J were all functioning noticeably differently compared to their usual ward behaviour. They were commenting on the food, the standard of cooking and joined in the dancing. Mrs D, however, started to clear up in the restaurant and Mrs H started to wander off, but could be per suaded back to the group after a short walkabout'.
Throughout the holiday, the social occasion of having a meal together was appreciated and the 149 nursing staff no longer needed to encourage the patients to eat, as happened in the hospital environ ment. Opportunities to go out for a drink together and attend the local entertainment were events which all the patients seemed to enjoy. Many of them became concerned about their appearance and bought new clothes. One patient stopped being incontinent during the day.
In the area of communication, the patients started to take the initiative in opening conversations and would talk about more appropriate subjects. The holiday seemed to trigger some of the patients' wishes to talk about their pasts. Two enjoyed the chance of talking with other people and being in the company of young children and babies.
The general public's reaction was positive. One woman on the camp site, whose mother had dementia, commented that it was encouraging to see such people having a holiday. One of the patients did become more confused and in the early part of the holiday expressed a wish to return home; in the latter part of the week, she thought she was at home. Her son visited one evening and was very pleased to see his mother in a holiday setting. She in turn told the nursing staff about the enjoyment her brother's visit gave her! On three occasions, she required medication for increased agitation.
Two weeks after the holiday, nursing observations indicated that five of the patients had gone back to their pre-holiday behaviour of being less communi cative, more apathetic and refusing to eat at meal times. The two other patients were very sad on their return to the hospital and very much wanted to be with the nursing staff in a holiday setting. Both slowly returned to their pre-holiday behaviour. However, the nursing staff felt that the holiday had been a success and were keen to take another group of patients away. Their observations are consistent with the findings of the study regarding changes noted in the areas of communication, apathy, personal grooming and interpersonal skills. The staff concluded that the positive benefits of the holiday were being in a more 'homely' environment, allowing patients to receive greater individual attention and have increased control of their lives. The staff felt the patients had greater variety in their daily lives and could begin to look forward to different events in the day. We remember vividly our experience of spend ing a day with the patients which was crowned by eating fish and chips on the pier.

Comment
The changes elicited were unexpected, and yet these improvements might have been predicted before the study, as taking patients into a less institutionalised environment has been well established as creating positive benefits in the quality of life of both patients and carers. What has not been shown before is our finding of being able to effect such immediate improvements in long-stay elderly patients with severe degrees of impairment and dependency.
We hope that further study of such initiatives may help formulate the type of care needed in the management of long-stay psychogeriatric patients.

A cknowledgements
We would like to thank the nursing staff of Chingford Ward for this experience.