Editor—Older people requiring residential care are being classified according to a taxonomy that has existed, in custom and practice, since the National Assistance Act 1948. A minority of care homes and nursing homes is designated for elderly mentally infirm people; most are for people who are not elderly mentally infirm, or, in the case of nursing homes, for frail elderly people. The term “elderly mentally infirm” is undefined and extraordinarily plastic. It is sometimes limited to people with dementia, sometimes extended to other mental illnesses.
Homes for such patients are more highly staffed and can demand higher fees than other homes, but they are rare, and often full. Elderly mentally infirm patients wait in hospital beds longer. Social workers tend to imply that elderly mentally infirm means, additionally, having behavioural problems. Patients with quiet dementia are thus excluded from specialist care. Registration departments at local or health authorities do not, however, embrace this nuance and may insist that any non-specialist home resident found to have dementia is transferred to accommodation for elderly mentally infirm people. Most homes therefore turn a blind eye to dementia.
Neither is the position clear at The Department of Health, which regards care for dementia as a specialist function of residential care, rather than being arguably its main activity (F E Matthews, T R Dening, unpublished data).1 The first direct survey of non-elderly mentally infirm residents of nursing homes in England has found a prevalence of probable dementia of 74%, not related to duration of stay.2 This allows us to ignore the implications of dementia for the staffing levels, training, and support of staff in most homes. We consign people without cognitive impairment to homes in which they will be surrounded by people with dementia, but about whom nothing can be said. The need not to recognise dementia permeates medical and nursing staff in acute medical and orthopaedic wards.
We think that dementia care has become the main business of almost any residential or nursing home for older people—improving dementia awareness and care skills in all care home staff, inspection and registration staff, hospitals, purchasers and politicians is urgent. We should develop specialist homes for people without significant dementia, in which their autonomy and self fulfilment can be more easily safeguarded. The term elderly mentally infirm should disappear. Prevarication and dishonesty must be stripped away from policy and the decisions being made about the fate of individual patients. Restricting the recognition of dementia to a minority of homes is a dangerous fiction which does little for people in residential and nursing care.
References
- 1.Department of Health. National minimum standards—care homes for older people. London: Stationery Office; 2001. [Google Scholar]
- 2.Macdonald AJD, Carpenter GI, Box O, Roberts A, Sahu S. Dementia and use of psychotropic medication in “non-EMI” nursing homes in South East England. Age Ageing. 2002;31:1–7. doi: 10.1093/ageing/31.1.58. (in press). [DOI] [PubMed] [Google Scholar]