Day services available to older people with mental health problems include day centres and day hospitals. Psychiatric day hospitals for older people tend to be managed and provided through health services and run by multidisciplinary teams consisting of the various mental health professionals. Day centres tend to be managed and funded through local authorities, social services or voluntary organizations with fewer or no health professionals. The first psychiatric day hospitals were opened in the Soviet Union in the 1930s, probably as a result of inpatient bed shortages, and by the early 1950s many had been opened worldwide in developed psychiatric services⁴. In the United Kingdom, the first psychiatric day hospital was the Marl-borough Day Hospital in London, opened in 1946⁵. Other psychiatric day care services for older people followed, with dramatic increases in the 1960s and 1970s⁶. The main factor in the growth of day hospitals was attributed to the development of new psychiatric treatments such as neuroleptics. They enabled the mentally ill to be treated in day hospitals, providing a high level of care during the day, but returning to their homes each evening.

The development of effective community support systems is essential for the successful shift from inpatient to community care for mental health services. The identified needs of severely mental ill individuals in the community include medication monitoring and therapy; psychosocial treatment, day and vocational activities; supported and supervised residential services⁷. Day hospitals with their various functions are ideally placed to play a significant role in assessment and community care.

The psychiatric day hospital provides short- and medium-term care to the mentally ill, with the option of receiving at times intensive psychiatric care without hospitalization. In the 1970s, a fully integrated psychiatric service for older people was described by Donovan et al. (1971) to include a day hospital serving four functions⁸. These functions were:

1. The outpatient investigation and treatment of older patients with physical and psychiatric disorders.

2. The continued observation of patients discharged from hospital.

3. To prevent deterioration from self neglect, loneliness or apathy.

4. To offer respite to carers, hence delaying or preventing inpatient admission.

Holloway (1988) described four main functions of day hospitals for mentally ill persons⁹. They are similar to those above and include:

1. An alternative to admission for people who are acutely ill and cannot be maintained as outpatients.

2. A service for support and monitoring in the often difficult transition between a stay in an inpatient ward and life at home.

3. A source of long-term structure and support for those with chronic handicaps, preferably in a friendly, low pressure environment.

4. A site for relatively brief, intensive therapy for people with personality difficulties, severe neurotic illnesses or in need of short-term focused rehabilitation.

In recognition of their important place in the care of older people, guidelines for current service provision for older people with mental health problems have included the provision of day hospital places^10,11.

For older people, Corcoran et al. (1994) described two objectives of the day hospitals established in Ireland as being¹²:

1. To provide acute psychiatric treatment, thereby functioning as an alternative to admission for patients of over 65 years with functional psychiatric illness.

2. To treat patients with behavioural disturbances associated with dementia.

These objectives are similar to those described above for generic psychiatric day hospitals, though the distribution of diagnoses is different^8,9. This is especially so in the case of persons with dementia, who are more likely to be found in a day hospital for older people than in a generic psychiatric day hospital. With such varied clientele, outcome and needs in various day hospitals will depend to a large extent on the type of patients being served, and available resources. One benefit of the above-listed functions taking place in day hospitals is that attenders are not taken away from home into hospital, but return home each day. This ensures that routines which may be difficult to re-establish after a long stay in hospital are less disrupted, other than due to illness, and so probably reduces the risk of institutionalization. Furthermore, reports obtained from home, by relatives and carers, give day hospital staff an extra tool in monitoring progress of attenders. For patients with cognitive impairment, maintaining them at home while attending the day hospital is likely to reduce problems of disorientation, resulting from movement into new environments like inpatient wards, as day hospital patients return to the familiar surroundings of their homes each day.

Shah and Ames (1994) described potential functions of an old age psychiatry day hospital as including: assessment, treatment, rehabilitation, long-term support, development of social networks and support of carers¹³. According to Rosenvinge (1994), characteristics of older patients’ needs most likely to be met in a psychiatric day hospital can be grouped into functional and organic illnesses¹⁴. They include:

1. Assessment and management of acute functional illness.

2. Maintenance treatment of high-risk or vulnerable patients.

3. Continuation of treatment of discharged inpatients.

4. Assessment and management of patients suffering from dementia.

5. Provision of long-term support for those with severe dementia.

6. Treatment possibilities in dementia, such as advances in drug treatments requiring close supervision.

These characteristic needs are likely to be found in a wide variety of patients who are likely to benefit from day hospital care.

Woods and Phanjoo (1991), in a retrospective study of day hospital patients with dementia, observed the outcome of care after three years¹⁵. Circumstances of discharges were classified into planned and unplanned. Of the 145 discharges, 65 (45%) were unplanned, with reasons ranging from emergency admission in 14 (9%), to death or physical illness in 40 (28%) and refusal to attend in 11 (8%) patients. Of the planned discharges from the day hospital, only 11 (8%) were discharges to the community, with the remaining 69 (48%) transferred to long-term care in hospital or nursing\residential homes. Though not a randomized controlled study, the authors suggested that outside factors, such as the presence or absence of spouses or others who have taken on the role of carers affected outcome among day hospital attenders. Day hospital patients with spouses were observed to be less likely be admitted to residential or nursing homes than those without spouses. Reasons that they proposed to account for the differences were that the patients with dementia remained longer with their spouses, and that when care was required, the severity of problems presented with at the time would require long-term hospital care rather than placement in residential or nursing homes. The findings of their study would suggest that it is essential that day hospital studies take into consideration such external factors as living spouses, carers and social support networks of patients.

In a study reviewing the impact of closure of a geriatric day hospital, following closure due to staff industrial action, Bhat-tacharyya et al. (1980) found few ill effects on patients over a six week period¹⁶. Ratings of mobility, self care, continence, mental state and need for services such as general practitioner, ‘meals on wheels’, day care or home help revealed minimal differences before and during the day hospital closure. Of the 55 patients in the study, most had cerebrovascular disorders, arthropathy and/or cardiovascular disorders, and only 9 patients had problems with dementia or depression.

In a similar study in older patients with mental health problems, Rolleston and Ball (1994) observed the impact of a two week closure of a psychiatric day hospital¹⁷. Data on well-being of patients and their carers were collected over eight weeks, to include three weeks prior to closure, two weeks of day hospital closure and three weeks following re-opening of the day hospital. They used two brief questionnaires, designed for patients and their main caregivers respectively, asking whether they felt the same, better or worse than usual, during the preceding week. They found a trend towards decline in well-being during the day hospital closure, which returned to pre-closure levels for both carers and patients on re-opening the day hospital. These findings would suggest that the day hospital was of benefit to both carers and patients. However, this study suffers from the arguments against many day hospital studies, in that they are not randomized controlled studies, hence no consideration is taken for confounding variables, such as the festive season during which closure took place, compliance with medication and/or the social network available to replace the day hospital over the same period.

Corcoran et al. (1994) noted that day hospital treatment enabled the older people with functional illnesses to be treated in the community with low usage of beds, and provided short/medium-term care for patients with dementia who had little support from statutory services¹²