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Alms and a reason for living:

I was fascinated to read the article drawing attention to the increase in life expectation amongst old people fortunate enough to find accommodation in an alms house: Almshouse residents may live up to two and a half years longer, study finds | Social housing | The Guardian


Of course it is probable that the selection process will have an influence – the residents who had presented themselves to alms housing may have been better equipped for life than others who did not. Never-the-less it allows us to make the point that the quality of accommodation and the care available within it have important impacts on the health and survival of people, especially old people and those with dementia.


When I began training in psychiatry in the 1970s, we read The Textbook of Psychiatry by Mayer-Gross, edited by Elliott Slater and Martin Roth. That taught us that life-expectation for anyone with dementia admitted to mental hospital at that time was short: more than half would be dead within a year and virtually everyone by two years. This was the sort of grim prognosis a naïve young psychiatrist might give to a family. We were talking about the experience of people admitted to mental hospital. I am not sure we had any figures relating to people being identified in the community or via outpatient clinics.


Mental hospital care for people with dementia was mostly in single-sex wards with of the order of 50 patients housed within large dormitories and day areas. There were few members of staff and very little therapeutic activity. Temperature control in many wards was poor or non-existent. I was told that one hospital never had a problem in finding a bed for someone with dementia, because all beds were cleared over winter – until the Hospital Advisory Service required them to maintain a minimum temperature of 70 degrees. This led to a reduced death rate in winter and a waiting list for admission.


Important studies from the Crichton Royal Hospital showed that survival for people admitted with dementia over a series of cohorts, increased progressively. This was attributed to improved quality of the physical environment and care made available, including therapeutic activities. Changes in survival in demented hospital inpatients 1957–1987 - Wood - 1991 - International Journal of Geriatric Psychiatry - Wiley Online Library


More recent studies confirm that a diagnosis of dementia in the community is associated with reduced life expectation compared with controls A Controlled Study of Survival With Dementia | JAMA Neurology | JAMA Network


Since long-stay hospital wards have all-but disappeared from the NHS, most deaths of people with dementia in institutional care, now occur in care homes. The evidence is that more than half die within a year of admission and that survival is falling year on year: Microsoft Word - Length of stay in care homes - Forder and Fernandez Bupa report jan 2011 (kent.ac.uk)



We have sound evidence that providing good physical accommodation and good quality care and activities are rewarded by improved survival of older people with and without dementia. This effect is more powerful than any claimed for anti-dementia medicines, and it is within our ability to provide it. Falling survival rates in care homes are often attributed to changes in the demographics and health profiles of those admitted – older, frailer and with more advance dementia. The pressure to do things cheaply – with a push for profit at the expense of quality – means we cannot be comfortably confident about this.


For ordinary older people and people with dementia, good old fashioned care should be the standard



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