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Admissions policy for an institution for the senile: a study of formal and informal criteria for admission… MacLean, Jean Ethel 1962

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ADMISSIONS POLICY POR AN INSTITUTION POR THE SENILE A Study of Formal and Informal C r i t e r i a for Admission to Valleyview Hospital Essondale, B . C . , 1960-61 by JEAN ETHEL MACLEAN Thesis Submitted i n Par t i a l Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK i n the School of Social Work Accepted as conforming to the standard required for the degree of Master of Social Work School of Social Work 1962 The University of B r i t i s h Columbia In presenting this thesis in p a r t i a l fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make i t freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia, Vancouver 8 , Canada. Date ^TW^ i v ABSTRACT Programs and f a c i l i t i e s necessary for the proper care and treatment of the senile are many and varied. This study i s concerned with one of the in s t i tu t iona l resources: the pol ic ies and procedures governing admis-sion to Valleyview Hospital , an in s t i tu t ion designed spec i f i ca l ly for the aged with other d i s a b i l i t i e s of s e n i l i t y . To apply "operational" tests to po l icy and procedure, a sample of (30) applicants from the waiting l i s t were selected for study, the purposes being (a) to determine what factors were operative i n securing admission, (b) how the stated c r i t e r i a for assessing p r i o r i t y of admission were u t i l i z e d . A number of special personal circumstances affected the appropriateness of the group. Apart from th i s , i t was found that the formal c r i t e r i a for acceptance of applications to the hospital are employed with reason-able consistency, when measured against the time an individual applicant spends on the waiting l i s t . It was also found that when a community agency i n i t i a t e d the applicat ion, admission was granted after r e l a t i v e l y short periods on the waiting l i s t , i f there was no other resource readi ly avai lable. Prom this study, the roles of the socia l worker i n pre-admission services can be delineated as (a) helping the applicant to f ind other forms of care over the waiting period, (b) helping the Medical Superintendent to assess p r i o r i t i e s for admission, and (c) helping applicants and families to accept the need for hospi ta l izat ion when this i s j u s t i f i ab le . Recommendations for needed changes i n procedures and i n l eg i s l a t ion are made, par t i cu lar ly in the present cumbersome application arrangements, which require c e r t i f i -cation of the applicant as mentally i l l before an appl i -cation can he placed on the waiting l i s t . Development i n the community of specialized types of hoarding and nursing homes for the care of the less severely handicapped by emotional and behavioural disturbances i s also recommended. i i TABLE 01 CONTENTS Page Chapter 1. The Aged and Mental I l lness The increasing aged population. Social changes affecting the aged. The aging process. The problem of mental i l lnes s among the aged. The Geriatr ics Divis ion of the Provincia l Mental Health Services. Method of study 1 Chapter 2. Admission Pol ic ie s of Valleyview Hospital History of the Geriatrics Div i s ion . Admission po l i cy . C r i t e r i a for admission, with case examples. Admission procedures. Medical factors i n assessment of p r i o r i t y . Social factors. Legal factors. Administrative factors 22 Chapter 3« Characteristics of Val lewiew Applicants Description of typica l applicants. Analysis of study group. Social resources. Financial status. L iv ing accommodation. Information avai lable. Length of time on waiting l i s t . C r i t e r i a used i n admission of patients. Applicants not admitted. Applicants admitted. Conclusions 42 Chapter 4. Hole of the Social Worker i n Pre- Admission Service Analysis of c r i t e r i a . Determination of appropriate admissions. Contributions of the soc ia l worker. F a c i l i t i e s for the care of the seni le . Recommendations for changes in procedures and l eg i s l a t ion 65 Appendix: A. Bibliography TABLES IN THE TEXT Table 1. Population trends i n B r i t i s h Columbia 2 Table 2. Study group - hy age 45 Table 3 . Marital status of study group hy sex 46 i i i Page Table 4. Person or agency signing the "A" form for the committal papers on the study group 47 Table 5» L iv ing arrangements at time of application 51 Table 6. Information available when application was under consideration 53 Table 1. Comparison of length of time on waiting l i s t and amount of information available . . 5*+ Table 8, Main considerations affecting admission of patients 56 Table 3. P r i o r i t y rat ing compared with days elapsed between date of application and date of admission 57 Table 10. A comparison of length of time on the waiting l i s t with person signing the "A" form 59 Table 11. Source of application compared with appropriateness of admission 68 V ACKNOWLEDGEMENTS I would l ike to extend my appreciation for the invaluable assistance of Dr. B. P. Bryson, Mr. Michael Wheeler, and Dr. Leonard C. Marsh, i n carrying out this study. ADMISSIONS POLICY POR AN INSTITUTION POR THE SENILE A Study of Formal and Informal C r i t e r i a for Admission to Valleyview Hospital Essondale, B . C . , 1960-61 CHAPTER I THE AGED AND MENTAL ILLNESS Changes i n the structure of the populations of the countries of Western Europe and North America have given r i se to a great many problems, one of the most urgent of which i s the large and increasing number of persons surviving into old age with accompanying hazard of economic dependency, physical and mental deterioration, and socia l i so l a t ion . The extent and significance of this problem can only be seen i n reference to the h i s t o r i c a l and demographic changes of the past two centuries. During the nineteenth century the populations of the countries of Western Europe and North America experienced a very considerable expansion. Early i n the twentieth century, however, a sharp decline i n the b i r th rate set i n . This was offset to some extent by a reduction i n infant and c h i l d mortality, hut, neverthe-less , the proportion of aged persons to younger persons has r i sen dramatically. 2 Table l . 1 Population Trends i n  B r i t i s h Columbia Year Persons Aged 65 Years and Over, per 1000 Population Per Cent 1940 64.9 8.1 1955 142.8 10.9 I960 158.6 10.0 1961 186.2 7.0 According to one authoritative source, i t i s possible to dist inguish several typ ica l cycles of popu-la t ion growth. In the f i r s t stage, a high birth-rate i s i n approximate balance with a high death-rate. Most of A f r i c a , Indonesia and parts of South America are presently at this stage of population growth. After this stage, the popu-l a t ion starts to expand, as the death-rate begins to decline while the birth-rate i s s t i l l quite high, as i s the case i n many Asian countries. In the th i rd stage, the birth-rate begins to decl ine, but not to the extent that i t again equals the death-rate. Thus the population s t i l l grows, though not so rapidly as i n the second stage. This 1 Walden, C. C , Urquhart, A. I. and Gouge, J . W., Population Trends i n Canada. B. C . Alberta and Saskatchewan. B. C. Research Council , Vancouver, January 1957* 2 "Mental Health Problems of Aging and the Aged," Sixth  Report of the Expert Committee on Mental Health. World Health Organization, Geneva, 1959. 3 i s the case i n the USSR, Eastern Europe and Japan. Eventually, the birth-rate f a l l s to the point of equal-l i n g , and equalizing a low death-rate, and the population reaches a stable l e v e l . The countries of Western Europe and North America are reaching the end of the t h i r d phase, and just entering the fourth, or more stable l e v e l , which w i l l not be f u l l y real ized for several decades yet, according to the present birth-rate trends and current mortality f igures. Therefore, the proportion of people over the age of 65 years must be expected to go on r i s i n g for a con-siderable time. Para l le l ing the tremendous increase i n the pro-portion of persons over 65 years of age over the past hundred years there have been s t r ik ing changes i n cul tura l attitudes and ins t i tu t iona l arrangements surrounding the problems of the dependent aged. Within Western Europe, u n t i l about the end of the eighteenth century, there existed a predominantly r u r a l , patr iarchal type of socia l organization. Families were, for the most part , large, and recognized obligations existed within the extended kinship group to care for aged and dependent members. Since the proportion of old people was f a i r l y small, thi s presented no insurmountable problem. Moreover, i n a rura l economy,' not characterized by hand labour, the old person 4-could carry on productively at h i s accustomed tasks long after h i s counterpart today i s fo rc ib ly " re t i red" or finds i t impossible to secure work because of his obso-lescent s k i l l s . With the r i se of industr ia l i za t ion and urbani-zation at the end of the eighteenth and beginning of the nineteenth centuries the whole structure of family l i f e began to change. Housing patterns changed from the sel f-contained unit providing space, however l imi ted , for a l l members of a family i n the setting i n which they and the ir parents for generations had l i v e d , through the eras of apartment and tenement l i v i n g to today's small, sub-d iv i s ion house, providing space only for the nuclear, two-generation family. Increasing mobil ity has undermined tradit ions of "rooted" community l i v i n g . Parents and adult chi ldren frequently l i ve far apart; usually at least i n separate areas of a c i t y , as the adult children tend to move out to suburban developments. It has become very d i f f i c u l t i n most cases for an adult ch i ld to give the kind of care and supervision many old people require. The f i r s t hal f of the twentieth century has seen great changes i n the expectations which people hold regarding the degree of respons ib i l i ty for self-support i n old age, both for their own, and for parents and re la t ives . The nineteenth century was noted for equating self-support 5 with, moral worth. It was expected that the upright individual would provide for his own old age, and that of his dependents hy means of his own industry. Indus t r ia l i -zation takes away the worker's control over his producti-v i t y , so that he may very well have no chance to save for his old age. Many persons are unable to face the pos-s i b i l i t y of a lengthy, unproductive old age, and make no provision for i t . In response to these changes the govern-ment has gradually extended i t s services and controls over many areas formerly regarded as the exclusive responsibi-l i t y of the family, interested neighbours or chari ty . Gradually, the concept that society has a concern and respons ib i l i ty for the dependency which often accompanies old age has grown up with a result ing network of services which help, i n part, to f i l l the vacancy l e f t hy the breakdown of the self-contained, sel f-regulat ing, respon-s ib le , extended family system. Para l l e l ing these changes i n expectations regarding respons ib i l i ty for the care of the e lder ly , many changes i n the socia l and economic opportunities available to the older person have occurred. A society that bases i t s delegations of status on the acquis i t ion of the exterior signs of material success cannot f a i l to affect adversely those of i t s members who f a i l to , or can no longer, maintain evidence of continuing prosperity. Many aspects of North American culture tend to decrease 6 the status and minimize the potential or available a c t i -v i t i e s and satisfactions of older-age groups i n our society. Retirement means, i n perhaps the great majority of cases, a loss of meaningful ac t iv i ty which has pro-vided much sat is fact ion and prestige i n the past. It also means deprivation of a source of socia l contact, and a more or less severe curtailment of income. The high population mobil ity that characterizes the North American culture tends to increase the i so la t ion of the indiv idual ; this i s par t i cu lar ly s ignif icant for the aging individual who lacks resources, and, often, physical strength and psychological f l e x i b i l i t y to pursue new socia l contacts aggressively. On another l e v e l , the very cul tura l climate i n which he now l ives has changed r ad i ca l ly from that to which he was accustomed i n his youth and middle age. The external world may appear as vast ly different i n i t s customs and attributes , even when he remains i n a setting long famil iar to him. The aging ind iv idua l , a l l too often, becomes progressively more isolated from contact with his surroundings as these become more and more devoid of interest or sat is fact ion to him. The Aging Process Clear ly , the l i f e s i tuation of the aged person i n North American society i s subject to a number of stresses both different and more severe than any experienced 7 by the individual i n his ear l i e r l i f e . Besides the socia l and economic reverses that the aging person may meet, and which have already been referred to , there are physio-log i ca l and psychological aspects of the aging process that are inevitable for everyone, although each indiv idual ' s reaction w i l l , necessarily, d i f f e r . According to one de f in i t ion : •L The term 'aging process ' , as applied to l i v i n g organisms, i s the genetical ly determined, progressive, and essent ia l ly i rrevers ib le diminution with the passage of time of the a b i l i t y of an organism or one of i t s parts to adapt to i t s environ-ment, manifested as diminution of i t s reserve capacity to withstand the stresses to which i t i s subjected, and culminating in , the death of the organism. Many characterist ic physiological and anatomical changes occur i n the aging process, some of which are reflected i n altered functioning i n the e lder ly ind iv idua l . Losses i n hearing and v i s ion diminish contact with r e a l i t y , which may be manifested i n subtle ways. Por example Dr. p Ewald Busse cites the common c l i n i c a l observation that patients who are a f f l i c ted with a r e l a t i v e l y sudden loss 1 Busse, Ewald M.D. , "What i s a Rea l i s t ic Attitude i n Regard to Research i n Aging?" F i r s t National Conference of  the Joint Council to Improve the Health Care of the Aged. Washington, D. C , 1959, p . 6. 2 Busse, Ewald M.D. , " C l i n i c a l Problems Underlying Administrative Practices i n Treatment and Care of the Aging Pat ient , " Eleventh Annual Mental Health Inst i tute , mimeo-graphed. . 8 of heaxing frequently become discouraged and depressed, and that suspiciousness and paranoid behaviour may appear l a te r . C. Eisdorfer"1" found that there was a s ignif icant difference i n the Rorschach responses of normal subjects and i n those with impaired hearing or with impaired hearing and visual d i s a b i l i t i e s , although there was no discernible difference i n those subjects who had uncor-rected impaired v i s ion when compared with normal subjects. (None of these subjects approached to ta l blindness, and o a l l were functioning i n the community.) Ramsde.ll divided hearing into three leve l s . The f i r s t i s the socia l l e v e l , used to comprehend language. The second leve l or warning l e v e l , i s that which includes sounds having the connotation of danger. The th i rd or background l e v e l , i s the primitive level of hearing, which plays a role i n our emotional functioning. The deaf person has lost this bridge to r e a l i t y , and feels the loss of this contact with the l i v i n g world about him. Cerebral ar ter iosc lerot ic changes are almost uniformly found i n the brains of aged persons, but there seems to be no consistent correlat ion between the degree 1 Eisdorfer , C , "Rorschach Developmental Levels and Sensory Impairment i n an Aged Population," (to he published). 2 Ramsdell, D. A . , "The Psychology of the Hard-of-Hearing and the Deafened Adult" i n Davis, H . , ed . , Hearing and  Deafness. Murray H i l l Books, Inc . , New York, 1947. of ar ter iosc lerot ic change, and changes i n observed functioning. D. Rothschild^" demonstrated that the brains of e lder ly people who have shown normal mental functioning u n t i l the time of death often contain senile plaques. These senile plaques are s imilar to those found i n patients with so-called senile dementia. Although he found that the number of plaques tend to correlate with the degree of mental impairment, the correlat ion i s far from a consistent re l i ab le one. Accompanying this generalized waning i n physical adaptabil ity and resources i s a corresponding decrease i n the amount of psychic energy available to the aging person for the purpose of maintaining his defenses against p repressed impulses. Dr. Maurice Linden describes how the elder-rejecting attitudes so current i n our culture may he applied by the e lder ly person to himself, resul t ing i n se l f - re ject ion , and i n i t i a t i n g a progressive breakdown of personality structure. The cyc l i c sequences of soc ia l and psychological events that produce elder-discarding attitudes i n our society 1 Rothschild, D . , "Pathological Changes i n Senile Psychoses and the ir Psychobiologic Signif icance," American  Journal of Psychiatry. 1957, v o l . 95, P. 757. 2 Linden, Maurice M.D. , "Emotional Problems i n Aging," The Jewish Social Service Quarterly, v o l . 31, No. 1 (Pal l 1954). 10 eventuate i n the lonely and depressed state that progresses into the ' seni le dec l ine ' . A feel ing of i so l a t ion , friendlessness, uselessness, lowered se l f esteem, and reduced se l f confidence follows. The anxiety and terror thus generated develop into a passively suicidal frame of mind. Much mental energy i s then mobilized by the emotionally disturbed aged for the purpose of attempting to re-establish shattered defenses. The mind thus occupied with repairing i t s e l f becomes further isolated from the external environ-ment. At the same time the deep panic within accompanied hy frenzied efforts at reconstruction propel the individual to a state of exhaustion. This i s seen c l i n i c a l l y as torpor, lassitude, waning alertness, memory impairment, confusion, disorientat ion, and feeble restlessness. According to Dr. Linden , the emotional d i s -turbances of aging are neurot ical ly and cu l tura l ly induced, and as such, are to a certain degree accessible to treatment, both psychiatric and soc ia l , and to changes i n soc ia l attitudes toward the aged. H. Warren Dunnam has pointed out that the rates of admissions to mental hospitals of persons 65 years of age and older are much higher for the Middle At lant ic states, the New England area and the Pac i f ic states than for any other regions i n the United States. This f inding, 1 Linden, on. c i t . 2 Dunham, H. Warren, "Sociological Aspects of Mental Disorders i n Later L i f e , " i n Kaplan, Oscar J . , ed . , Mental Disorders i n Later L i f e . Stanford University Press, Stanford, Ca l i forn ia , 19*7. 11 lie states, "points to the fact that i n the older and more urbanized sections of the country where the in s t i tu t ion of the family has undergone i t s greatest strains and tensions are to he found the largest numbers of older people suffering from mental disorders. The high rate i n the Pac i f ic area i s , no doubt, a pa r t i a l re f lec t ion of the number of older people who have migrated to this section from the Middle Western states. Conversely, the low rates i n those divis ions most rura l in character possibly re-f lec t the t rad i t iona l tendency of an agr icul tura l people to care for i t s aged." 1 He found the same picture repeated when he analysed the rates of admissions to mental hos-p i t a l s for ar ter iorsc lerot ic disease and senile psychoses. The Problem of Mental I l lness Among the Aged The aged i n our society are subjected to a number of stresses, both internal and external. Decline i n physical capacity, including important losses i n a b i l i t y to communicate with the outer world, may be, considered an inevitable concomitant of the aging process, although advances i n medical knowledge and technology can often al leviate defects i n some degree at least . Cul tura l ly , the aged are subjected to what are often even more threatening losses, such as the dissolution of family t i e s , 1 Dunham, on. c i t . . p . 120. 12 the loss of jobs for men, and the important roles of wife and mother, for women; economic deprivation and changes i n standards of l i v i n g and the losses of prestige and sel f-respect that so frequently accompany retirement. The ego of the aging person, therefore, i s con-fronted with an almost overwhelming job i n i t s attempts to maintain a psychic homeostasis. Pathological symptoms appear as a result of the ego's attempts to maintain i t s in tegr i ty . Weinberg1 divides the symptoms that most f re-quently occur i n the mentally i l l aged into three cate-gories; exclusion of s t imul i , conservation of energy, and regression. Exclusion of s t imuli he thinks, results from the organism's lowered capacity to deal with complex s t imul i , both physical and psychological . Exclusion of s t imul i , together with conservation of energy, tend to narrow the indiv idua l ' s a b i l i t y to react appropriately to changing circumstances. Regression—the gradual decline to much ea r l i e r , even infant i le modes of adjustment and behaviour—tends to make the individual more and more dependent on others, and i n need of care and supervision. It i s readi ly apparent that no one cause can be 1 Weinberg, Jack, "Personal and Social Adjustment," i n Anderson, J o h n E . , ed . , Psychological Aspects of Aging. American Psychological Association, Inc . , Washington, D. C , 1956, p . 19. 13 found to explain decline i n functioning i n the e lder ly i n our culture. It i s d i f f i c u l t to f ind any agreement among writers on the subject as to the point at which the decline i n functioning amounts to mental i l l n e s s . A study i n C a l i f o r n i a 1 i n 1950 indicated that 35 per cent of the patients who were over 60 years when admitted to a state mental hospital were non-psychotic. A study hy J . Florwers p and Walter Fox i n 1957 examined a group of 40 patients aged 65 and over which was 19•7 per cent of a l l admissions during the period studied. Of these 40 admissions, only 45 per cent were jus t i f iab le admissions, i . e . with a definite need for mental hospital care. Thirty-seven and a hal f per cent were reported as of questionable j u s t i f i -cation, because the pre-admission history was not con-firmed by the pat ient 's condition at admission. Seventeen and a hal f per cent were without ju s t i f i ca t ion for admis-sion to a psychiatric f a c i l i t y . A further group of 40 admissions^ were examined by Peters and Pox i n 1958, and after these patients had undergone observation on the wards, i t was found that 50 per cent were non-justif iable 1 "Background Material on the Aging Population," Mental Hospitals Institute on the Psychiatric Problems of  the Aging and of the Aging Mental Defective, mimeographed. 2 Ib id . 3 Ib id . 14 admissions, and were i n need of nursing or boarding-home care only. In view of these findings, and s imilar findings i n numerous other studies, i t i s obvious that a very real problem exists i n defining and providing adequate and suitable forms of care for the varied types of breakdown i n socia l and mental functioning among the aged i n our population. One portion of the problem i s the determin-ation of c r i t e r i a for admission to a mental hospital for the aged. How can i t best be decided whether admission to a mental hospital i s a suitable, necessary and benef ic ia l form of treatment for a part icular , aged individual? What are the procedures of admission to this kind of hospital? How does the hospital see i t s function, and how can i t specify which individuals are to be admitted as patients? I f the hospital must resort to a wai t ing- l i s t for appl i -cants, how does i t assess p r i o r i t y of need? In order to suggest some answers to these questions, this thesis w i l l examine the provisions made i n B r i t i s h Columbia for the care of the mentally i l l , aged, and w i l l describe admission po l ic ie s and procedures i n effect with the Geriatr ic Divi s ion of the Provincia l Mental Health Services. 15 The Geriatr ic Divis ion There are three units i n the Geriatr ic Divis ion of the Provincia l Mental Health Services, Valleyview Hospital at Essondale, Dellview Hospital at Vernon, and Skeenaview Hospital at Terrace. Dellview Hospital has accommodation for 110 male patients and 139 women. Skeenaview Hospital has accommodation for 300 male patients only. Valleyview Hospital has presently a bed capacity of 808, including 278 male beds, and 530 female beds. Two older buildings, Valleyview 1 and Valleyview 10 are pre-sently unoccupied and awaiting renovation. When this i s completed an additional 100 beds w i l l he avai lable . There are, therefore, a to ta l of 1357 beds i n the Geriatr ic Div i s ion , of which 688 are for men, and 669 are for women. A l l these units operate under the Mental Hospitals Act for the specif ic purpose of providing care and treatment for e lder ly men and women, suffering from mental, emotional or behavioural disturbances consequent to senile or ar ter iosc lerot ic brain disease. Dellview and Skeenaview Hospitals were formerly mi l i t a ry hospitals converted for the use of ger iatr ic patients . Both hospitals offer ample space for patients who are able to.walk, and both provide opportunities for l i ght work on the i r grounds for those who can benefit from i t . There are no trained recreational or occupational 16 therapists on either staff , hut the nursing staff attempt some programming i n these areas, and groups of volunteers are act ive. Medical practit ioners i n the community under contract to the Mental Health Services give medical care and supervision. Patients must he transferred to general hospitals i n the community whenever any extensive medical treatment i s necessary. Valleyview Hospital Valleyview Hospital i s the largest unit of the three, with sixteen wards, housed i n eight buildings . The beautiful Valleyview Building was opened i n May, 1 9 5 9 * It was designed to serve as the Admitting and Infirmary bui lding, providing 328 beds, equally divided for men and women into six wards, two of which are spec i f i ca l ly admitting wards. The other four wards are infirmary wards for patients whose physical condition necessitates a considerable degree of nursing care. Valleyview Building also houses the administrative off ices , X-ray and labor-atory departments, physiotherapy and occupational therapy departments, the main kitchen and dining room, house-keeping services, business of f ice , beauty parlour and the dent is t ' s o f f ice . The Auditorium and Chapel are i n a separate bui lding and provide f a c i l i t i e s for rel ig ious services and a wide array of socia l and recreational a c t i v i t i e s . The recreational department i s housed i n a 17 separate bui lding, the Valleyview Lodge. In this building the Canadian Mental Health Association volunteers run a small restaurant, lounge, and tuck shop where patients may go to dine i f they wish. This i s a par t i cu la r ly pleasant f a c i l i t y as patients may also entertain the ir v i s i to r s there rather than i n the v i s i t i n g rooms provided on the w ards. Valleyview Lodge was at one time a Nurses' Home for the Home for the Aged, and later became the site of the administrative offices for the hospi ta l . The C M . H . A . hopes to convert the upper f loor to a res ident ia l centre for v i s i to r s who come from long distances to see Valleyview patients . V i s i t i n g of patients hy friends and relat ives i s strongly encouraged. Daily v i s i t i n g hours are from 2-4-p.m. every day, and from 7-9 p.m. on Tuesday evenings. V i s i to r s are encouraged to take patients out for car rides or weekends home. Weekend and longer leaves of absence are granted whenever the pat ient 's doctor feels i t may he benef ic ia l . The administrator of the hospital i s Dr. B. F . Bryson, the Medical Superintendent. Under him are three physicians who carry respons ib i l i ty for the medical care of the patients. Consultative services from the con-sultant staff at Crease C l i n i c and the Provincia l Mental Hospital are avai lable, and patients are transferred to 18 Crease C l i n i c or P.M.H. whenever extensive investigation or surgery are necessary. There i s a ful l-t ime Protestant chaplain, who i s assisted hy the part-time services of a Roman Catholic pr iest from the community. The Business Manager has a staff of four; there are a dentist , x-ray technician, and three occupational therapists . There are two recreational therapists , a vacancy for a physio-therapist , a druggist, and a laboratory technician. There are establishments for three socia l workers, and the positions are f i l l e d . There i s also a qual i f ied d ie t i c i an , housekeeper, and a medical records stenographic pool of four. The Director of Nursing i s both a registered nurse and a graduate psychiatric nurse. Under her i s the Assistant Director or Nursing, a psychiatric nurse. There are nine supervisors, s ix of whom are registered nurses, and three of whom are psychiatric nurses. There are three Head Nurses who are registered nurses, and eleven Charge Nurses who are psychiatric nurses. There are a to ta l of 187 psychiatr ic nurses on the ward staffs , of whom 104 are women and 46 are men. No male nurses or aides work i n the women's wards, a few female nurses and aides work on the men's wards• The specif ic function of the Geriatr ic Divis ion has been summarized i n a memorandum by the medical 19 superintendent. Although the approach to the treatment of emotional disorders of the e lder ly person di f fers l i t t l e to that of the younger psychiatric patient, the special problems, both physical and mental which come with aging, make i t desirable to have special ger ia tr ic wards for the i r care. The older person requires a slower pace of l i f e , and much patience and understanding i s demanded of the staff who must be tolerant of the physical in f i rmi t i e s , and the mental con-fusion and memory disturbances which come with normal aging. Treatments and rehabi-l i t a t i o n i s sought for every patient admitted and every effort i s made to pre-serve mental and physical health, to treat specif ic emotional disturbances and to f ind ways to stimulate the patients to develop interests , no matter how simple, which w i l l give each patient a sense of belonging and friendship, a feel ing of security and well-being, and a renewed be l ie f that he i s needed and can s t i l l contribute to the welfare of his f r i e n d s . . . There are always more requests for admission to the Geriatr ic Divis ion of the Provincia l Mental Health Services than can he immediately accommodated. A l l applications for admission to Valleyview Hospital of patients 70 years of age and older must, under Order-in-Council No. 1124, be approved hy the medical superintendent of Valleyview Hospital . Under certain circumstances, how-ever, the admission of a patient 70 years of age or older, to Crease C l i n i c or to the Provincia l Mental Hospital may he approved hy the responsible medical superintendents of those hospita ls . 20 The Annual Report of the Mental Health Services of the Province of B r i t i s h Columbia for the twelve months ended March 31, 1961, l i s t s a to ta l of 406 new appl i -cations for admission to the Geriatr ic Div i s ion . Of these requests, 304 were for admission to Valleyview Hospital , as the patients concerned were from the Lower Mainland and Vancouver Island. Requests for admission to Dellview Hospital were 91» mainly from the Okanagan and Kootenay areas. From the northern sections of the province, there were 11 applications for admission to Skeenaview Hospital . Method of Study This thesis examines the-policies and procedures of admission to Valleyview Hospital , and describes i t s f a c i l i t i e s for the care of aged persons who are mentally i l l . It describes the formal and informal c r i t e r i a for admission, and describes the contributions which the socia l worker can make i n assessing p r i o r i t i e s for admission, and i n arranging alternate forms of care where these may he seen as preferable. For this study, t h i r t y cases were selected from the waiting l i s t of December 31, 1961, which i s one-third of the applicants at that time. Thir ty cases were selected as the greatest number of which any detailed examination could he made. A "random" select ion, of every th i rd name 21 on the l i s t , was decided upon. An examination was made of relevant socia l data i n each case, i . e . , age group, sex, marital status, a v a i l a b i l i t y of interested re la t ive or f r iend , f inancia l status, l i v i n g arrangements, and information available at appl icat ion. Each case was c la s s i f i ed as to length of time elapsed between date of applicat ion, date of admis-sion, and formal c r i t e r i a under which admission was approved. An effort was made to determine whether any other c r i t e r i a were involved i n ensuring early admission. A review of the patient 's s i tuat ion was made on June 30, 1961 to determine progress after admission, and whether the apparent need for admission was validated after hospital investigation of the patient. This material was obtained from a study of each pat ient ' s application f i l e , hospital f i l e where admitted, Social Service Department f i l e where contact had been made, consultation with medical and nursing staff, and personal interview with patients and relat ives where necessary. The purpose of th i s review i s to assess the c r i t e r i a under which applicants are accepted for admission and to develop from this a more informed appraisal of both pre-admission assessment and treatment of appropriate applicants• CHAPTER II ADMISSION POLICIES OP VALLEYVIEW HOSPITAL In 1936 a recognition of the need to give separ-ate care for older, mentally i l l patients, combined with a very urgent need for more bed space for mental patients, led to the development of the Provincia l Home for the Aged, situated one mile east of the Provincia l Mental Hospital on the Essondale grounds. This was known as the Provincia l Home for the Aged, Port Coquitlam, B. C. The Provincia l Home for the Aged Act was proclaimed, and the Medical Superintendent of the Provincia l Mental Hospital was named as the Medical Superintendent of the Provincia l Home for the Aged. A number of buildings were released from the Boys' Industrial School for the use of the new branch of the Mental Hospita l . Three wards, a nurses' home and a kitchen and dining room were housed i n four separate buildings. In 1946 a more modern building was erected for two women's wards, and i n 194? another building on the same plan was b u i l t to provide two additional wards for men. In 1948 the Vernon Home for the Aged was opened, 23 giving accommodation for 239 patients, 129 female and 110 male, with a medical superintendent appointed. In 194-9 two new wards for women were b u i l t at the Port Coquitlam uni t . In 1950 the need became apparent to establish some control over the many elderly patients being admitted to mental hospitals i n B r i t i s h Columbia. Accordingly, an amendment to the Mental Hospital Act was passed hy Order-in-Council Number 1124 on May 16, 1951» which stated, i n part , "No person over the age of seventy years shal l he admitted to any"public mental hospital i n the Province unless the Medical Superintendent i s sa t i s f ied that such person requires care and treatment i n a hospital for the mentally i l l . " This amendment i s s t i l l i n force today. Its effect i s to add a brake on actual admissions to the hosp i ta l . There are always so many more applications than there are beds available that the hospital cannot accept a l l immediately; many are far more urgent than others, so there i s a need for the medical superintendent to establish p r i o r i t i e s . In addition, many confused, disoriented old persons, though cer t i f i ab le , and therefore, theoret ica l ly at least , mentally i l l , do not need mental hospital care, hut can he placed quite successfully i n other forms of care, according to the ir individual need. 24 In 1950 the Terrace Home for the Aged was opened, giving accommodation to 300 male patients only. Dr. T. G. Caunt was appointed full-t ime Medical Superintendent with ju r i sd ic t ion over the Port Coquitlam, Vernon and Terrace Homes for the Aged. This was the f i r s t time that the Homes for the Aged had not been administered ent i re ly from the Provincia l Mental Hospital . Dr. Caunt was also assigned the respons ib i l i ty for implementing the amendment noted above. In 1952, i n October, Dr. B. P. Bryson became Medical Superintendent for the Homes for the Aged. In 1954, i n rea l iza t ion of the need for many more beds and improved f a c i l i t i e s at the Home for the Aged i n Port Coquitlam, plans were l a i d for a 300 bed Admitting and Infirmary Unit . In March, 1959, this new building was occupied, and was named the Valleyview Building. During th i s year the concept of "Unit izat ion" was stated by Dr. A. Davidson, the Deputy Minister of Mental Health Services. "Unit izat ion" i s the process by which the varying units , formerly central ly administered, would become re l a t ive ly independent ent i t i e s , within the overal l structure of the Mental Health Services Branch. The hospital was re-organized to the extent that i t s admini-strat ion and staffing became more sharply differentiated from that of the Provincia l Mental Hospital and Crease 25 C l i n i c than had previously been the case. The hospitals at Port Coquitlam, Vernon and Terrace now form an inde-pendent unit of the Provincia l Mental Health Services, under the administration of Dr. Bryson. On January 1, I960, the Provincia l Home for the Aged Act was repealed, and the unit was brought under the jur i sd ic t ion of the Mental Hospitals Act . New names were established for the three units . The Provincia l Home for the Aged, Port Coquitlam, became Valleyview Hospital , Essondale, B. C , The Vernon Home for the Aged became Dellview Hospital , Vernon, B. C , s t i l l with a bed capacity of 239, and the Terrace Home for the Aged became Skeenaview Hospital , Terrace, B. C , s t i l l with a bed capacity of 300. A number of advantages accrued when the Provincia l Homes for the Aged Act was repealed, and the homes came under the jur i sd ic t ion of the Mental Hospital Act . Trans-fers of patients between, for example, the Provincia l Mental Hospital and Valleyview Hospital , or between Valleyview and Dellview and Skeenaview, became much simpler, and could be arranged according to the needs of the i n d i -vidual patient, ^his occurs because now that a l l patients are being treated under the same leg i s la t ive act, they do not require re-committal or re -cer t i f i ca t ion to conform with the requirements of the Homes for the Aged Act . In addition, patients can be granted the privi lege 26 of probation, when, i n the opinion of the Medical Superin-tendent, they have improved suf f ic ient ly during treatment i n hospital to receive a probational discharge. The advantage of th i s l i e s i n the fact that for s ix months following this form of discharge they may return to hos-p i t a l without the need for any further cer t i fy ing documents or waiting period, i f , i n the opinion of the Medical Superintendent their condition i s such that they require immediate re-hospi ta l izat ion. A further advantage i n coming i n under the Mental Hospitals Act l i e s i n the fact that the pr ivi lege of appeal became available to persons i n the ger ia tr ic units , a pr ivi lege which was not granted under the Provincia l Homes for the Aged Act . That i s to say, that at any time after three months after committal to the mental hospital any patient may request to he examined by two doctors who are not members of the staff of the staff of the mental hospi ta l , and who have no con-nection with the i n s t i t u t i o n . If i n their opinion i t i s desirable, they may revoke the committal to the mental hospi ta l . The patient i s then, automatically, free to return to the community. The changes i n name, from the Provincia l Homes for the Aged to Valleyview, Dellview and Skeenaview Hospital c rys ta l l i zed a change i n concept of the functions of the ins t i tu t ions , from being a "repository for old people", to an active treatment centre. The introduction 27 of the t r anqu i l l i z ing medications, and their widespread use i n the past decade has made a tremendous change i n treatment of a l l mentally i l l patients. Weakening of the ego-structure with i t s defenses i s often a part of the aging process, and the part icular benefit of this form of medication l i e s i n i t s effect on the flare-ups of anxiety, anger and aggression that are so often seen i n these patients. A no less important result of the success of the ataractics i s the changed, more hopeful attitudes of staff toward patients who were formerly seen as uncontrollable behaviour problems. Thus the concept of active treatment rather than custodial care has come to he a more atta in-able goal. Admission Po l i c i e s : Who i s E l i g i b l e for Treatment? E l i g i b i l i t y for admission to the ger iatr ic hospitals for the mentally i l l , has been defined as a l l residents of B r i t i s h Columbia who have been judged to be suffering from mental i l lnes s and changes associated with old age, and for whom v a l i d cert i fy ing documents have been received and who have been approved for admission by the Medical Superintendent of Valleyview Hospital , acting under the authority delegated him by the Mental Hospitals Act . These persons are, i n the opinions of the two 28 cert i fy ing doctors, and the committing judge, suffering from chronic brain syndrome due to senile or arter io-sc lerot ic brain disease associated with neurotic, psychotic or behavioural reactions. Residents of B r i t i s h Columbia over seventy years of age cannot be admitted to a mental hospital u n t i l the Medical Superintendent of that hospital has given his approval as outlined i n Order-in-Council No. 1124. This order-in-council spec i f i ca l ly exempts mentally i l l persons considered to he dangerous or mentally i l l convicts . Unfortunately i t does not define "dangerous", but the po l i cy i s that where persons are considered hy a community agency, such as the referr ing doctor, magistrate, the police or the soc ia l agency concerned, to he l i k e l y to be r e a l l y aggressive towards others, careless with f i r e or otherwise capable of endangering themselves or others, every effort i s made towards granting immediate admission to Valleyview Hospital . Where th i s cannot be arranged, because of a bed shortage, admission i s usually granted by the Provincia l Mental Hospita l . Where a patient i s suffering from what his doctor judges to be a more or less acute psychiatric i l lnes s which might he treated best i n Crease C l i n i c , admission may he f i r s t sought there. Admission There are two types of admission to the ger iatr ic 29 units of the Provincia l Mental Health Service, (a) from the community or (h) from other units of the Provincia l Mental Health Services. In the o f f i c i a l pol icy statement for the Mental Hospitals for the Aged, admission pol icy i s defined* There are always many more applications for admission to hospital than can he serviced immediately, and so there i s always a backlog of applications on the waiting l i s t . P r i o r i t i e s for admission have been set up, so that the more urgent cases do not have to undergo the lengthy waiting period to which less urgent cases are subjected. The p r i o r i t y granted an application for admission depends on the following factors: (1) The urgency of the case s i tuation i n re la t ion to : (a) Behaviour and condition of the patient. (h) Effect of the patient 's condition and behaviour on marital partners, chi ldren, other family members, neigh-bours or community i n general. (c) Financial burden on family of patient 's present care and supervision. (2) A v a i l a b i l i t y of beds i n the Geriatr ic Div i s ion . (3 ) Length of time the pat ient ' s name has been on the waiting l i s t . 30 The following cases i l l u s t r a t e the application of these factors. Case 1 Mrs. New's name was placed on the waiting l i s t for admission to Valleyview Hospital hy her husband. She was 7*4, and l i v i n g alone with her 70 year old husband i n a Fraser Valley community. One of the Victor ian Order nurses who had been seeing Mrs. New once a week for two years had instigated the application procedure, when she brought Mrs. New's condition to the attention of a doctor. The nurse stated that she was usually, though not always, able to persuade Mrs. New to take a hath and change her clothes. This was the only occasion on which Mrs. New received any personal care, as she was quite unable to care for herself , and refused any offers of help from her husband. She was physical ly very active, .and would often wander about on the highway. The nurse.said that Mrs. New would occasionally go out on the street naked, and would urinate by the roadside. After the application forms had been sent i n , the hospital socia l worker v i s i t e d the News i n their home. Mrs. New was wandering about alone i n the house, and eventually came to the door. She greeted the worker pleasantly, and took her into the bedroom to introduce her 31 to the "lady i n the mirror" who was, of course, hersel f . She was dressed only i n a cotton dress, open down the front, and a man's old tweed jacket. Her feet and legs were hare. Mr. New came home after about hal f an hour. He was an act ive, pleasant man of 70, who described himself as "getting a l i t t l e forget ful " . He said that whenever he went into town to shop his wife would wander away. Some-times she would s l i p out the door and trot down the street towards the highway i f he went into another room. His main worry, however, was that he had to go into hospital for some extensive surgery, and there was no one to care for his wife. Mrs. New might have been a candidate for boarding home care had she not been i n the habit of running away. Where this has developed as a pattern i n the home, i t i s unl ikely that transfer to a boarding home w i l l do anything hut accentuate the tendency. This i s too great a r i sk for a hoarding home operator to take i n the case of a physical ly active woman. She was therefore c l a s s i f i ed as requiring early admission under Cr i ter ion 1(a). Case 2 Mr. Smith's application was i n i t i a t e d hy his daughter, who signed the "A" form. He was l i v i n g alone 32 with, his f r a i l wife, who had refused to consider placement of her husband, as she f e l t strongly that i t was her duty to care for him and she feared the loneliness of l i v i n g by hersel f . According to the daughter, her father had always had a had temper, but after a few small, recent strokes, had become v io lent . He frequently h i t and kicked his wife, who, however, would never complain against her husband, and who t r i e d to hide her bruises from the chi ldren. A l l the children were married and with the ir own family re spons ib i l i t i e s ; none could give the constant supervision the ir father now required. A week before the application was made, the father had attacked a v i s i t i n g son, nearly succeeding i n knocking him downstairs. The family was afraid that he might seriously injure or k i l l his wife. They had attempted to f ind a nursing home, but could f ind none which would accept him. Medication had been prescribed for him, hut he refused to take i t , and the wife was unable to administer i t . Mr. Smith was c la s s i f i ed as requiring early admission under Cr i ter ion 1(h). Case 3 Mr. French's "A" form was signed hy his son. 33 He was married, and had been a patient i n a private nursing home for s ix months, before his transfer home. His behaviour had changed rad ica l ly following a stroke, and his wife could not care for him, because of his aggressive, confused behaviour, although he no longer r e a l l y required nursing home care. The son's reason for requesting admission was that, although the mother would not sign the "A" form, she would impoverish herself hy attempting to pay for her husband's care i n the nursing home, as he would have to be removed there again shortly. The Social Welfare Branch could do nothing u n t i l the couple's resources were ex-hausted; then they could finance Mr. French's nursing home care, and place Mrs. French on Social Assistance. Mr. French's necessary care and treatment would place a severe burden on the family's finances, and he was c l a s s i f i ed as requiring admission under Cr i ter ion 1 (c ) . Case 4-Mrs. Norr i s ' s application was i n i t i a t e d by a police department, as no known relat ive or fr iend could he found. Mrs. Morris had been found wandering, nearly naked and i n a condition of starvation, and had been taken to a hospi ta l . She spent only a few days there however when the police arranged for her committal to 34 the Provincia l Mental Hospita l . As she was considered more suitable for Valleyview care, the Medical Superin-tendent agreed to accept her as a transferred patient, under Cr i te r ion 2. Case 5 Mrs. Andrew's application for admission was signed hy her son. She resided i n a small town at some distance from the hospi ta l , so the branch office of the Department of Social Welfare was requested to prepare an evaluation of her socia l s i tuat ion. The assessment i n d i -cated that she l i ved with her son, a War'Veteran's Allowance pensioner who was s t i l l able to care for her. He stated that his mother refused to give up her pension cheque to help pay their expenses, and refused to move to a nursing or boarding home, so ce r t i f i c a t ion was required. The d i s t r i c t soc ia l worker found that there was no urgency i n this woman's need for care and treatment, so she was placed on the waiting l i s t with p r i o r i t y under Cr i ter ion 3, and w i l l presumably be admitted when a bed, not urgently required elsewhere, i s avai lable. She was not admitted during the study period. Admission Procedure There i s a definite procedure i n making appl i -cation for admission to the ger iatr ic un i t . One form 35 ent i t led "Application for an Order for the Admission of a Patient to a Public or Private Mental Hospital or to a Provincia l C l i n i c of Psychological Medicine", or, more simply, as Form A t i s completed by the responsible re lat ive of the patient . If no relat ive i s available to sign this form, i t may he submitted hy a fr iend of the prospective patient, or by a hospital administrator, socia l worker, police of f icer or any person i n the community having knowledge of the indiv idual ' s need for care. This form requests information of the patient, i . e . , his educational and occupational background, date and place of b i r t h , children and re la t ives , f inancia l resources, and known behaviour. A second form, Porm B i s completed by each of two doctors, who are not i n practice together and who are not related to the patient. This form i s ent i t led "Medical Cert i f i ca te" and requires each doctor to state that he has examined the patient within seven days from the date of signing the applicat ion, and that he i s of the opinion that the patient i s a mentally i l l person within the meaning of the Mental Hospital Act , and that the condition of the patient i s such that he should receive care and treatment within a mental hospi ta l , and not i n a c l i n i c of psychological medicine. Each doctor i s required to state the facts on which he bases this opinion, e.g. 36 what the patient', said and d id , and what his appearance and manner were. The "A" form and the two "B" forms are sent to the Medical Superintendent of Valleyview Hospital , and comprise the application for the,patient *s admission. On receipt of these forms, the Medical Superintendent writes to the person who sent i n the forms, either the patient 's doctor, or the re la t ive , as the case may he, stating that the pat ient ' s name has been placed on the waiting l i s t , and that not i f i ca t ion w i l l follow as soon as a bed i s avai lable. When a bed does become available to the appl i -cant, the Medical Superintendent writes again to the responsible person, informing him that the patient may be admitted, and enclosing the "A" form and the two "B" forms. I f the date on which the patient i s to be admitted i s not more than one month la ter than the date on which the "A" form and the two "B" forms were signed, the person arranging the pat ient 's admission has the patient seen by a "Judge" who for this purpose may he a Judge or Registrar, or Deputy Registrar of a Court of Record, or a Stipendiary Magistrate or a Police Magistrate or a Justice of the Peace. The Judge must sign a form ent i t led "Order for Admission of a Mentally 111 Person to a Public or Private Mental Hospi ta l " , or, more simply, Porm C. This form requires the Judge to state that he has read the appl i -cation (Porm A) and the cert i f icates (Porms B) presented 37 to him, and found that the application and the cert i f icates comply with the provisions of the Mental Hospitals Act i n a l l respects, and that he has personally examined the pro-spective patient and i s sat i s f ied that he i s mentally i l l and requires care and maintenance i n a mental hospi ta l . The Judge then orders that the individual he removed to the mental hospi ta l , to he delivered into the care of the Medical Superintendent. These four forms, one Form A, two Forms B and one Form C are presented to the Medical Superintendent on the pat ient ' s a r r iva l i n hospi ta l . Where more than one month has elapsed between the signing of the f i r s t three forms and the acceptance of the patient for admission, these must be completed again, before the patient i s presented to the Judge, and the application f ina l i zed . This set of four forms, pro-perly completed and signed, then constitute the legal committal of the patient. However, because of the pro-visions of Order-in-Council No. 1124, a patient, 70 years of age or older, although lega l ly committed, could not be admitted to any mental hospital i n the province without the consent of the Medical Superintendent of that hospi ta l . Most ger ia tr ic patients are admitted d i rec t ly to Valleyview Hospital , and transferred to one of the other units i f desired at a la ter date. Some, however, at the discret ion of the Medical Superintendent, may be admitted 38 di rec t ly to Skeenaview or Dellview Hospitals . Attempts are made to place patients i n the unit nearest their re lat ives or friends, hut where there are no interested re la t ives , or fr iends, some patients, usually those con-sidered non-rehabil itable, may he transferred to Vernon or Terrace to make room i n the crowded Valleyview f a c i l i t i e s . Medical Factors i n Assessment of P r i o r i t y In selecting applications for approval, the Medical Superintendent makes his decisions on the basis of the c r i t e r i a for admission outlined on page 29 • The f i r s t of the three c r i t e r i a has three sections, i . e . the urgency of the case s i tuation i n re la t ion to (a) the behaviour and condition of the patient, (b) the effect of the patient 's behaviour on others, and (c) the f inancia l burden on the family of the patient 's present care. Medical and socia l assessments are both relevant and necessary i n evaluating an application under these c r i t e r i a . Cr i ter ion 1(a) i s both medical and soc i a l . On the medical form B the cert i fy ing doctors are required to state facts about the patient which are indications of mental i l l n e s s . The cert i fy ing doctors are not required to state a specif ic diagnosis on the B forms, hut f re-quently do i n answering the question which requests evidence or support of the claim that the mental condition 3 9 of the patient i s such that a c l i n i c of psychological medicine i s not a suitable place for his care and treat-ment. However, even thi s i s not too helpful i n assessing the pat ient 's need for care and treatment i n the ger iatr ic d iv i s i on , as i n fourteen of the t h i r t y B forms f i l e d i n the applications of the group selected for th i s study, the medical reasons given for the pat ient ' s need for care i n the ger ia tr ic d iv i s ion of the Provincia l Mental Health Services were i n such terms as " s e n i l i t y " , "chronic s e n i l i t y " , "o ld age" and "confused, obstinate and aggres-s ive" . Medical or psychiatric diagnosis serve to f u l f i l l an e l i g i b i l i t y requirement, rather than a c r i t e r i o n for p r i o r i t y for admission. Social Pactors i n Assessment of P r i o r i t y In Cr i ter ion 1(a) "condition" of the patient i s purely a medical concern. "Behaviour" i s noted only insofar as i t substantiates a medical diagnosis of mental i l l n e s s . "Behaviour" of the applicant i s a prime focus of interest , however, for the socia l worker i n the pre-paration of a pre-admission assessment. The "Outline of Social History for Mental Hospitals for the Aged", which i s the form outline for socia l his tor ies sent out to branch offices of the Department of Social Welfare when their aid i s requested i n preparing a pre-admission assessment, detai l s the description of the patient and of 40 his present socia l s i tuation which are required. These soc ia l his tor ies are of great help to the Medical Superintendent i n assessing p r i o r i t y of an applicat ion. Cr i ter ion 1(h) i s of major importance i n the socia l worker's pre-admission assessment. The Valleyview Hospital s o c i a l Service Department reaches out to the com-munity, either through the hospital socia l worker, or through enl i s t ing the aid of the Department of Social Welfare, to determine the effect of the applicant's condi-t ion and behaviour on those who care for , or come into contact with, him... Cr i ter ion 1(c) i s evaluated solely by the soc ia l worker, as f inancia l circumstances are not explored hy either the cer t i fy ing doctors or the magistrate. A state-ment of the pat ient ' s finances i s requested of the respon-sible relat ive or friend who signs Form A, but this gives no indicat ion of the burden which may rest on the patient 's family. Legal Factors i n Assessment I No legal factors enter spec i f i ca l ly into the assessment of p r i o r i t y for admission, as the magistrate's Form C does not form a part of the application f i l e . 41 Administrative Factors i n Assessment Administrative factors i n assessment are apparent i n C r i t e r i a 2 and 3, which refer , respectively, to the internal s i tuat ion i n the hospital regarding vacancies, and to the chronological seniori ty of the pat ient ' s appl i -cation. There are always a number of aged, long term patients i n the Provincia l Mental Hospital who would bene-f i t from the slower pace and more comfortable arrangements of the Geriatr ic Div i s ion . When beds are available i n Valleyview, Dellview or Skeenaview Hospitals , the Medical Superintendent may accept patients from the Provincia l Mental Hospital or from Crease C l i n i c , although they are not formally entered on the waiting l i s t . These patients do not require re -cer t i f i ca t ion , and are termed "transfers ." CHAPTER III CHARACTERISTICS OP VALLEYVIEW APPLICANTS Valleyview patients tend to f a l l into three broad categories. The f i r s t are old persons who manifest overt psychotic behaviour. Persons i n th i s class may he hyperactive, aggressive and abusive, or may, on the other hand, be su ic ida l or depressed to the point of refusing to eat u n t i l adequate medication i s given. A very few are act ively hal lucinating or extremely suspicious and persecutory. In the Mental Health Services Annual Report for I960, 1 i t was stated that there were a to ta l of 280 admissions to Valleyview Hospital , of whom 175 were diagnosed as psychotic, and 105 as without psychosis, hut with other mental or emotional disorders, such as mental deficiency, chronic brain syndrome with behavioural reaction, chronic brain syndrome and simple s e n i l i t y . The psychotic patients de f in i te ly require treat-ment i n a mental hospi ta l , and they are the group who 1 B r i t i s h Columbia, Annual Report of the Mental Health Services, Queen's Pr inter , V i c t o r i a , 1961, p . 137« 43 benefit most from the psychiatric treatment, medication and special therapies given i n Valleyview Hospita l . The second group are non-psychotic, but arter io-sc lerot ic brain changes, physical d i s a b i l i t i e s and emotional factors such as re ject ion and i n a b i l i t y to accept changing socia l status result i n the type of patient who i s primari ly a behaviour problem. This group i s ambu-latory hut requires varying degrees of supervision of dressing, bathing, and feeding. Many of these would soon wander away i f they were not restrained by locked doors, and this presents a real d i f f i c u l t y i n community care as hoarding and nursing homes are not permitted to lock the ir doors. Some are incontinent and some are noisy and disturb others, but adequate medication can control this l a t ter group for the most part . A sizable proportion of this group could he cared for i n boarding homes i f this type of in s t i tu t ion could provide good supervision. These old people are often very d i f f i c u l t and demanding but i t has been the experience of Valleyview Social Service Department that many applicants can be well settled i n a good rest home where the operator i s w i l l i n g and able to give the kindness and conscientious care required. A th i rd group require not only the personal care outlined above, hut also nursing care. They may be com-plete ly bed-ridden or may have to be assisted to deck-chairs 44 as they are unable to walk unassisted. Except for a few very noisy individuals , they d i f fer l i t t l e from the majority of patients i n nursing homes. Some have been Valleyview patients who have gradually deteriorated to this l e v e l ; some are admitted i n this condition from the community. Of the fourteen wards i n Valleyview Hospital , four are infirmaries , devoted ent ire ly to the care of this type of patient and a number of other deck-chair patients are cared for on two other wards. The great majority of Valleyview patients are more or less confused, forgetful and incapable of complete sel f-care. On admission patients, par t i cu la r ly those l i v i n g alone or with an elderly spouse, may he i l l cared for , d i r ty and malnourished. Very few have been properly prepared emotionally for the ir admission, and many are apprehensive and resentful . Analysis of the Study Group In order to assess the c r i t e r i a which are i n effect for admission to Valleyview Hospital , t h i r t y cases were selected from the waiting l i s t of December 31, I960. This number represents one-third of the to ta l waiting l i s t at that time, and was chosen as the greatest number which could he examined i n d e t a i l . A systematic selection was made hy choosing every th i rd name on the l i s t . 4 5 The f i r s t aspect to he studied was the age-groups into which the applicants f e l l and Table 2 shows the study group divided into age-categories by periods of f ive years, and further divided by sex. Table 2 . Study Group - hy Age and Sex Age i n Years Sex 6 5 - 6 9 7 0 - 7 4 7 5 - 7 9 80-84 8 5 - 8 9 90+ Total M 0 2 5 1 3 0 11 F 2 3 4 7 2 1 19 Total 2 5 9 8 5 1 3 0 There were nineteen women and eleven men i n the group studied. Average age for the whole group was 7 8 . 6 years; average age for women was 7 8 . 6 years and average age for men was 7 8 . 5 years. The greatest number of applicants were between their seventy-sixth and e ighty-f i f th years; eighteen of the t h i r t y applicants were i n this age group. Applicants were almost evenly spaced at either extreme with seven applicants between their s ixty-s ixth and seventy-fifth years, and six applicants between the ir eighty-sixth and n inety- f i f th years. 46 Table 3» Marital Status of Study Group by Sex Status Sex Married Widowed Single Separated Divorced Total M 3 3 3 2 11 F 9 9 1 0 19 Total 12 12 4 2 30 Those who were married, or widowed, made up three-quarters of the group, and were equally divided between those with a l i v i n g spouse, and those who had lost a spouse. Single persons who had never been married made up less than one-seventh of the group. One man was divorced and one had been separated from his wife for many years. It i s interest ing to note that, of the seven patients who were noted on admission to be severely mal-nourished or i n a state of starvation, only one was mar-r i e d . A l l s ix of the others had been l i v i n g alone i n their own homes, or i n rooming houses. In addition, two of these were severely i l l with tuberculosis . According to the accepted po l i cy , the "A" form can he signed hy a re l a t ive , fr iend or hy any person who 47 has knowledge of the aged person's need for mental hospital care. Efforts are made hy agencies to locate a re lat ive or f r iend, hut often the "A" form has to he signed hy an agency o f f i c i a l who may have l i t t l e or no pr ior knowledge of the applicant. Table 4. Person or Agency Signing the "A" Form  for the Committal Papers on the  Study Group Status Signer Married Widowed Divorced Single Total Spouse 7 - - - 7 Child 4 7 - - 11 Social Agency - 1 1 - 2 Police 1 1 - 1 3 Hospital Admini-strator 2 1 3 Lawyer - 1 - 1 2 Other Relative - - - 2 2 Totals 12 12 2 4 30 Of the group studied, twenty had interested and available re la t ives . It i s interest ing to note that four applications were signed hy sons or daughters, although a 48 husband or wife was available. In three of these cases the husband or wife was a patient i n a nursing home, and either too i l l to be asked to sign, or incapable of making such a decis ion. In one case the daughter signed the application form as the wife refused to do so, although there was reason to believe her l i f e was i n danger because of her husband's abusive and aggressive behaviour. There are undoubtedly many examples of this i n the community where feelings of loyal ty and unwillingness to sever even a most unsatisfactory relationship prevent application being made for persons who should he receiving mental hospital care. In one of the cases where the application was submitted by the loca l police force, the husband was unable or unwill ing to acknowledge his wife's need for treatment, although she was found wandering the streets, starving and nearly naked. In the other two cases signed by the police force, there was no interested relat ive and no socia l agency involved. The administrator of a general hospital w i l l sign forms where there i s no interested re lat ive or agency, and where the patient does not require acute hospital care, but cannot be moved to a nursing home because of his mental condition and disturbed behaviour. Of the group studied, thirteen had had contact with a socia l agency before admission; three with f i e l d 49 offices of the Department of Social Welfare, s ix with Ci ty Social Service Department of Vancouver, two with Burnaby Social Service Department and one with Vancouver General Hospital Social Service Department, and one with the Royal Columbian Hospital Administration. None had had contact with any community chest agency other than one applicant who had received service from the Victor ian Order of Nurses. Nine applicants were i n receipt of the supplementary bonus but had had no contact with a socia l agency i n so far as our records showed. The following i l lu s t ra te s the f inancia l status of applicants i n study group: Private income 3 applicants Private income plus Old Age Security 8 applicants Old Age Security plus Social Assistance 18 applicants Old Age Security plus War Veterans Allowance 1 applicant Total 30 applicants Nineteen of these people were l i v i n g at the bare subsistence l eve l provided by Old Age Security plus Social Allowance, or Old Age Security plus war veterans allowance. Of the three with private means, two of these were under seventy, and one was an eighty-five year old woman who was quite well-off and who had apparently never applied for 50 Old Age Security. The f inancia l information given on the "A" form i s often very scanty, and u n t i l the applicant has been admitted, i t i s impossible to confirm or expand. After admission, the f inancia l affairs of the patient automatically come under the jur i sd ic t ion of the O f f i c i a l Committee i n V i c t o r i a and i t has proved extremely d i f f i c u l t for the hospital socia l service department to obtain ade-quate information from this department u n t i l planning for discharge i s being considered. If a re lat ive wishes to reta in control of a pat ient ' s f inancia l a f fa i r s , a compli-cated and expensive legal procedure must he ins t i tuted , after which, at the discret ion of the court, a re lat ive may be named Quasi-committee and continue to administer the pat ient ' s a f fa i r s . This was not done for any of the applicants studied. It i s therefore i n many cases almost impossible to determine the income of applicants not on supplementary assistance. Four women and three men were l i v i n g alone just pr ior to application; four women were l i v i n g with their husbands and two men were l i v i n g with their wives. Two women were l i v i n g with married chi ldren. This makes a to ta l of sixteen persons, ten women and six men, who were not ins t i tu t iona l ized pr ior to admission. Of the persons who were i n boarding or nursing homes pr ior to admission, s ix were women and three, men. Only three had had the 51 Table 5» L iv ing Arrangements at Time  of Application Male Pemale Totals Alone i n own home 3 3 6 Alone i n rooming house 1 1 2 L iv ing with spouse i n own home 2 4 6 L iv ing with a married ch i ld 0 2 2 In boarding or rest home 2 1 5 In nursing home or private hospital 1 5 6 In general hospital 2 1 3 In Provincia l Mental Hospital 0 2 2 Total 11 19 30 cost of this care supplemented through the Department of Social Welfare, hut although one patient on Supplementary Assistance was apparently ent i t led , her family was paying the cost of her care. Of the three who were admitted from general hospi ta l , two were male and one female. One man was admitted to Valleyview Hospital because he required tube feeding and at the time application was made, there was no 52 vacancy i n a private hospital that could give t h i s . He had been l i v i n g with his daughter before admission to the general hospi ta l . One man had been a chronic patient i n a general hospital for some time; one woman had been l i v i n g alone pr ior to her admission to the general hospital after having been found wandering on the streets i n a state of starvation. Two women were transferred from Provincia l Mental Hospital after stays of twenty-one days and seven days respectively. One had been l i v i n g alone before the police had arranged her committal to Provincia l Mental Hospital , after having been found wandering the streets; the other had been l i v i n g alone and taken by the police to a general hospital where committal was arranged to Provincia l Mental Hospita l . The Medical Superintendent approves applicants for admission on the basis of the information available to him. This may be the minimum of the application papers, or may include let ters or phone ca l l s from doctors, re lat ives and community agencies or even f u l l socia l h i s tor ie s , with professional socia l work evaluations of the applicant's need for care. The following table shows the contacts between the medical superintendent and persons concerned with the applicant's need for care pr ior to approval for admission. 53 Table 6. Information Available When Application  was Under Consideration Application Forms only 5 Application Forms plus Doctor's l e t te r or C a l l 4 Application Forms plus Relat ive 's l e t t e r or C a l l 6* Application Forms plus l e t t e r from socia l agency 7 Application Forms plus Social History 8 Total 30 * 2 were also accompanied by a doctor's l e t t e r . The following shows the time elapsed between the date of applicat ion, and the date of admission, for the study group: 1 - 5 days 6 - 1 5 days 16 - 30 days 31 - 60 days 61 - 180 days Not accepted within 180 days Total 5 applicants 6 applicants 4 applicants 3 applicants* 4 applicants 8 applicants 30 applicants * 1 applicant was on the waiting l i s t for 228 days hut only 42 days elapsed after not i f i ca t ion of change i n f inancia l status. Sa-lable 7• Comparison of Length of Time on Waiting L i s t  and Amount of Information Available Length of Time on Waiting L i s t - Days Available Information 1-5 6-15 15-30 31-60 61-180 Not Admitted Total Application Forms only- _ — _ — 1 4 5 Forms plus doctor•s l e t te r or c a l l 2 1 2 4 Forms plus r e l a t ive ' s l e t te r or c a l l 2 1 1 2 6 Forms plus l e t t e r from social agency 1 1 1 1 7 Forms plus socia l history - 1 2 2 2 1 8 Total 5 6 4 3 4 8 30 1 both from administrator of a general hospi ta l . 2 socia l agency concerned was a police department. This indicates that where additional information i s available from doctors or socia l workers, time on the waiting l i s t may be appreciably shortened. Examination of a l l information available at the 55 time of the Medical Superintendent's approval for admission of an applicant disclosed the c r i t e r i a for acceptance, as outlined i n Chapter II , i . e . The Procedure of acceptance of an applicant for admission depends upon the consideration of the following factors i n order of importance: 1. The urgency of the case s i tuat ion i n re la t ion to: (a) Behaviour and condition of the patient. (b) Effect of patients' condition and behaviour on marital partners, chi ldren, other family members, neighbours or community i n general. (c) Financial burden on family of pat ient ' s present care and supervision. 2. A v a i l a b i l i t y of beds i n the Geriatr ic Div i s ion . 3 . Length of time the pat ient 's name has been on the waiting l i s t . Only twenty-four of the group studied can he c l a s s i f i ed i n Table 8, as s ix members of the group were not ad.mj.tted hy the date of termination of the study. None of the group studied were admitted under c r i t e r i o n ( 3 ) . The admission pol icy of the hospital i s that length of time on the waiting l i s t i s considered only where two 56 Table 8. Main Considerations Affecting  Admission of Patients Kind of Consideration Determining Admission Number of Patients Admitted l a Behaviour and condition 8 lb Effect of patients' condition and behaviour on others 9 l c Financial burden on family 3 2 A v a i l a b i l i t y of beds 2 3 Length of time on waiting l i s t 0 Total 22 applications of equal urgency i n a l l other respects are being evaluated. Table 9 indicates that for the group studied a relationship can be established between the p r i o r i t y ratings of the admission pol icy statement and time elapsed between application and admission; the higher the c r i t e r i o n , e.g. l a or lb contrasted with the others, the shorter w i l l he the waiting period between date of application and date of admission. 57 Table ?/• P r i o r i t y Rating Compared with. Days Elapsed  Between Date of Application and Date  of Admission Priority-Days on Waiting L i s t Ratings 1-5 6-15 16-30 31-60 61-180 Totals l a 3 3 1 - 1 8 lb 2 2 2 2 1 9 l c - - - 1 2 3 2 - 1 1 - - 2 3 - - - - - -Total 5 6 4 3 4 22 Applicants not Admitted A l l the unsuccessful applications were signed by a re l a t ive , i . e . three spouses, four children and one s i s ter were involved. One applicant was i n a nursing home at the time of applicat ion, and one i n a licensed boarding home. One was l i v i n g with a daughter, three were l i v i n g with spouses and two were alone i n the ir own homes. One application was placed by a s i s ter who feared that the applicant's estate could not hear nursing home charges inde f in i te ly . On being advised hy Valleyview Social Service Department that supplementation for nursing 58 home care could he obtained when necessary, the re lat ive agreed to apply for this at a la ter date and the application was placed on inactive status. One application was made hy a son when his mother whom he was looking after refused to sign her old age security and supplementary assistance cheques. A D i s t r i c t Social Worker was able to arrange for the cheques to he made out to the son i n t rust . This appeared to he a satisfactory arrangement, and the son f e l t that he could continue to care for his mother. Two applicants were admitted to a private mental hospi ta l . One was treated successfully and was discharged home. The other was considered to he i n no urgent need of admission as funds were adequate for this form of care to continue for an indefinite period. One applicant had just been placed i n a rest home from his own home by a municipal socia l worker and as i s so often the case, was very disturbed over the change i n his s i tuat ion. After a month, however, he sett led we l l , and as he was f e l t to be presenting no problem in the rest home, his application to Valleyview Hospital was considered to be inact ive . Three applicants were placed hy the ir families i n rest homes when they became aware of the waiting period necessary before admission to Valleyview. A l l three 59 adjusted very well and the ir applications were considered to he inactive for the time being. Applicants Admitted Twenty-two applicants of the study group were admitted to Valleyview Hospital during the six month study period. The following table relates the length of time on waiting l i s t to the person signing the "A" form. Table 10. A Comparison of Length of Time on Waiting  L i s t with Person Signing "A" Form Length of Time - i n Days Signer 1-5 6-15 16-30 31-60 61-180 Not Admitted Within 180 Total Police 2 — 1 _ 3 Admini-strator of Gen. Hospital 1 2 3 Social Service Agency 1 1 2 Lawyer 2 - - - - - 2 Spouse - 1 - - 3 3 7 Child - 2 3 1 1 4 11 Other Relative - - - 1 - 1 2 Total 5 6 4 3 4 8 30 60 The results of this table indicate that early admission can more readi ly he procured hy community agencies who request i t , than through efforts of the relat ives alone. This i s understandable as an application form signed by an o f f i c i a l i s an indicat ion that there i s no relat ive w i l l i n g to assume any respons ib i l i ty for the applicant. An application inst i tuted by the police may he i n l i e u of legal charge where i t i s f e l t that the person concerned i s not r e a l l y responsible for the actions which brought him to their not ice . Again, they may inst i tute committal where a d i f f i c u l t e lderly person i s c lear ly not receiving adequate care i n the community and i t i s f e l t that there i s no f a c i l i t y other than the mental hospital which can care for him. Administrators of general hospitals apply when an e lder ly patient presents rea l management problems on their wards or when the person i s no longer i n need of acute care and no nursing home bed can be procured by the hospital or City Social Service Department or the loca l soc ia l welfare of f ice . Social agencies apply for admission of a person only when they fee l no f a c i l i t y i n the community can offer the care needed. There i s , therefore, evidence to indicate that an application from a community agency i s seen as one of 61 f a i r l y high p r i o r i t y . This i s ent i re ly reasonable as obviously the persons concerned are i n urgent need of a type of care which for the time being at any rate, cannot he obtained elsewhere. Of the t h i r t y applicants selected from the December waiting l i s t , twenty-two were admitted during the following six months. Examination of a l l the f i l e s revealed that seven patients died within six months of admission. Three of these seven patients were admitted from a general hospi ta l , a l l three died within two weeks of admission and i t i s therefore possible to speculate that at the time application was made for their admission they were already i n terminal i l l n e s s . A l l three were admitted within one week from the date of application i n order to free an acute-care bed. Although a l l three were de f in i te ly confused on admission, i t would seem very poor planning on the part of the general hospital administrator to request transfer of a dying patient to a mental hospi ta l . Three patients who died between one to four months after admission should have been t r i ed i n a nursing home before application was made or accepted for the mental hospi ta l . The patient who died within s ix months of admission was very aggressive and grossly confused on admission, and was an appropriate admission. 62 Fifteen of the twenty-two patients admitted to Valleyview were alive s ix months after admission. Exami-nation of the f i l e s , personal interviews and consultation with medical and nursing staff revealed that ten of the f i f teen required care i n a psychiatric f a c i l i t y , hut that three should have been t r i ed i n a nursing home and two i n a rest home before admission to Valleyview could he seen as desirable. One of the former would have been t r ied i n a nursing home i f a bed i n a nursing home which could handle tube-feeding had been available at the time when he was ready for discharge from a general hospi ta l . According to the hospital socia l service, no such bed was available at the time, and he was therefore admitted d i rec t ly to Valleyview. Two patients were found on admission to be suffering from tuberculosis and were promptly transferred to the infectious diseases section of the Provincia l Mental Hospita l . One did not present much d i f f i c u l t y i n the way of management, and could probably have been treated as e f fect ively i n any hospital providing care for the tuber-cular , the other hand been cared for i n a nursing home which found i t s e l f unable to care for her any longer. Her disturbed behaviour, however, quickly subsided on adequate medication and care for her physical i l l n e s s . Conclusions 63 There were t h i r t y persons i n the group studied; eight of whom were never admitted to Valleyview Hospital during the s ix month study. A follow-up of these appl i -cants revealed that they a l l adjusted well i n hoarding or nursing home placements. Twenty-two were admitted to Valleyview Hospital during the six month period studied. Seven of these died within s ix months of admission. The three who died within one month of admission were a l l admitted d i rec t ly from a general hospital where they had been under treatment. In the group of f i f teen hospital ized patients who were al ive at the end of s ix months, together with the four who died within one to s ix months of admission, a to ta l of nineteen, there were eleven persons who were considered as de f in i te ly requiring mental hospital care. There i s evidence to indicate that s ix patients could have made a satisfactory adjustment i n a nursing home, and two i n a licensed hoarding home, had placement been t r i ed before admission. One of the group judged suitable for nursing home care would have been placed had there been a vacancy i n a nursing home which could provide tube-feeding. One patient could also have been placed i n nursing home had finances been adequate, or had he been e l i g ib le for supple-mentation hy the Department of Social Welfare. In this 64 case, however, the couple's assets were such that nursing home care would quickly reduce the spouse to penury and necessitate changes i n her standard of l i v i n g which would have been very hard for her to accept, par t i cu lar ly as she herself was showing signs of depression* In one case the d i s t r i c t soc ia l worker involved thought that the applicant, a woman l i v i n g alone i n a rooming house, would refuse transfer to a nursing home and become very disturbed i f i t was enforced and so requested admission. However, the lady turned out to he re l a t ive ly easy to care for and she could probably have adjusted well i n a nursing home. In some cases the legal committal procedures and locked doors of Valleyview are u t i l i z e d to obtain care for an old person unable to recognize his need for care, and unwill ing to accept placement i n a hoarding or nursing home. One other patient had been placed i n a rather poor nursing home, and the relat ives refused to consider transfer to another. In four other cases there had been no contact with a social agency and no attempt at placement. CHAPTER IV THE ROLE OP THE SOCIAL WORKER IN THE PRE-ADMISSION SERVICE The purpose of th i s study has been to examine the c r i t e r i a , formal and informal, for admission to the Geriatr ics Divi s ion of the Provincia l Mental Health Services, To this end the study group was analysed i n terms of age, sex, marital status, a v a i l a b i l i t y of interested relat ive or community agency, f inancia l status, and l i v i n g arrangements at the time of applicat ion. The formal c r i t e r i a , used i n assigning p r i o r i t i e s were stated, and a comparison made between the stated c r i t e r ion and the time elapsed between the date of applicat ion, and the date of admission. Prom Table 9 there i s evidence to show that where i t appears that admission i s urgently needed because of the applicant's condition and behaviour, admission i s very much more rapid than for an applicant whose application i s seen as urgent only because of the f inancia l burden his care i s placing on his family. The importance of Cr i ter ion 1(h) i s less easy to assess, as there was an even d i s t r ibut ion i n point of time elapsed before admission among the applicants who 66 qual i f ied on this c r i t e r i o n . Cr i ter ion 2 involved two patients who had been admitted to the Provincia l Mental Hospital and who were seen as suitable patients for Valleyview Hospital . Both, however, were f a i r l y recent arr iva l s i n the Provincia l Mental Hospita l . There were no admissions i n the group studied under Cr i ter ion 3, i . e . length of time on the waiting l i s t which would seem to be of minimal importance i n the deter-mination of acceptance of applicants. In an effort to determine whether other factors than the formal c r i t e r i a might have an effect on approval of applicants for admission, several p o s s i b i l i t i e s were considered. One of these was the person or agency signing the "A" Porm and, i n Table 10, i t was shown that when the Pol ice , the Administrator of a general hospi ta l , a socia l service agency, or, as i n two cases, a lawyer who was the only person available to administer an applicant's a f fa irs , were involved, nine out of ten applicants i n this category were admitted i n less than f i f teen days, although only one-th i rd of the applicants i n the tota l study group f e l l into this category. Only three applicants whose forms were signed by relat ives were admitted i n f i f teen days or less , although two-thirds of the to ta l group were i n this category. 67 None of the persons whose applications were signed hy o f f i c i a l s had any relat ive or fr iend w i l l i n g to assume respons ib i l i ty for planning. Actual ly , seven persons had no known re l a t ive , one had been separated from his wife for many years, and two had relat ives i n distant parts of the country, who could not he reached i n time after the case had come to the attention of an agency. The role that the family plays i s pointed up by the fact that where spouses, children or other relat ives were avai lable, there was no "emergency" admission (under s ix days) and only three i n less than sixteen days. In two cases, family members placed the applicant i n a private mental hospi ta l , and i n four cases the applicant was placed by his or her relat ives i n a rest home. In one case the woman settled down at home, after help was given hy the d i s t r i c t socia l worker i n arranging for f i n -ancial trusteeship, and i n one case the applicant remained i n her nursing home, after her s i s ter was assured that f inancia l help could be arranged when i t became necessary. The following table compares the appropriateness of admission with the source of r e f e r r a l . An appropriate admission was considered to he one which examination of the f i l e s , personal interviews and consultation with medical and nursing staff revealed to be requiring care i n a psychiatric f a c i l i t y . An inappropriate admission was one 68 i n which medical, nursing and socia l work staff considered should have been placed in a hoarding or nursing home pr ior to admission as the patient could almost certa inly have been cared for i n either of the l a t ter settings. Table 11. Source of Application Compared with  Appropriateness of Admission Source Appropriate Admission Not Admitted Total Required Nursing Home Care Required Boarding Home Care Police 2 - 1 - 3 Admini-strator of a Hospital 3 3 Social Agency 1 - 1 - 2 Lawyer 2 - - - 2 Spouse 2 2 - 3 7 Child 3 4 - 4 11 Other Relative 1 - - 1 2 Total 11 9 2 8 30 One s t r ik ing aspect of Table 11 i s that as far as this study group i s concerned, the poorest judgment i n 69 requesting admission of patients to Valleyview appears to have been shown hy the administrators of general hospitals . In none of these cases was a socia l worker involved. The results of the comparison, however, would give one some grounds for speculation that persons who come to the notice of community agencies may he generally more deteriorated, mentally or phys ica l ly , at the point at which application i s made, than i s the case with those whose families make the applicat ion. This suggests that deterioration i s noticed much ear l ier hy families and that plans are made for care at a less advanced stage of mental or physical deterioration than for those who must r e ly on community agencies. The study group i s too small to warrant a more definite conclusion hut the subject i s one which deserves further study. It would seem l i k e l y therefore, that the fact that a community agency i s responsible for i n i t i a t i n g the application for admission does have some hearing on the time which the applicant's name i s on the waiting l i s t before acceptance. L iv ing arrangements at the time of application could not he considered a c r i t e r i o n , since they correspond f a i r l y closely with the possession of a responsible r e l a -tive or other person, i . e . persons l i v i n g alone tended to he f a i r l y isolated i n terms of family t i e s , persons l i v i n g 70 i n supervised settings invariably had either an interested family member or socia l worker, or other interested person avai lable . A c r i t e r ion therefore i s the quantity and quality of supervision being given. In summary, i t appears that the formal c r i t e r i a for acceptance of applications to the hospital are employed with reasonable consistency, when measured against the time an individual applicant spends on the waiting l i s t . Other factors also play a s ignif icant part, such as, for example, the almost to ta l i so la t ion of an old person who has no one to look after his welfare and so comes to the attention of a community agency, and the fact that there i s no alternative placement to offer him. Another factor which emerges from this study i s the number of what might he termed i n appropriate admis-sions. The most s t r ik ing of these are the cases who were on the point of dying when they were admitted. Horabaczewski1 studied admissions to the Saskatchewan Hospital , i n Weyburn, and found that over a 20 month period, among admissions of patients over 60 years of age, 183 were suffering from c l i n i c a l conditions without psychosis, 1 Horabczewski, J . , "Admissions of Geriatr ic Cases to Mental Hospita l s , " Canadian Medical Association Journal, v o l . 78 (January 1958), pp. 22-27. 71 including uraemia, cerebrovascular accidents, chronic starvation and mild confusion and amnesia of the aged. Sixty of these died within 60 days of admission. Only 98 were admitted with psychotic disorders requiring hos-p i t a l i z a t i o n i n a psychiatric f a c i l i t y . He feels that the prime respons ib i l i ty l i e s on the medical and social welfare services i n preventing inappropriate admissions hy better diagnosis, and by improved services to the e lder ly . From the fact that of a to ta l of twenty-two admissions i t was f e l t that eleven should have been placed i n boarding or nursing homes pr ior to admission, i t i s clear that, the information supplied to the medical super-intendent with the application forms, i s inadequate. It i s to be hoped that the whole process of committal w i l l become obsolete i n the near future, as, for the great majority of patients i t serves no useful purpose. A very few aged persons may require committal, but th i s should be the exception, not the only procedure. It i s extremely d i f f i c u l t to dist inguish between medical and socia l grounds for application for admission. Every individual case i s different; every case shows some deterioration i n mental and physical capabi l i t i e s , some losses i n a b i l i t y i n socia l functioning, and some degener-ation i n socia l s i tuat ion. Lawrence Kolb states 72 . . . there i s a preponderance of authoritative opinion that public mental hospitals are being burdened hy an increasing number of old people who should he cared for elsewhere. In other words, people who become feeble phys ica l ly , have f a i l i n g memory or some s l ight change i n personality, and are f inan-c i a l l y unable to care for themselves are sent to mental hospitals because no relat ive i s w i l l i n g or able to care for them and there i s no other place for them to go. The diagnosis of psychosis i n these cases may he,technical ly correct hut i t i s e th ica l ly wrong. Applications for admission, therefore, may be technical ly correct in the sense that the person concerned shows changes i n mental functioning which render him e l ig ib le for c e r t i f i c a t i o n . This study has shown, however, that ce r t i f i ab i l i ty .does not necessarily mean that he can be cared for only, or even best, i n a mental hospi ta l . This decision should be made hy the doctor who knows the pat ient ' s mental and physical care needs, and the socia l worker, who knows how these needs may best be met. Contribution of the Social Worker i n Pre-Admission Services The socia l worker i n a mental hospital for the aged can make a varied and v i t a l l y important contribution pr ior to the applicant's admission. The socia l worker obtains an evaluation of the patient 's need for care, and 1 Kolb, Lawrence, "The Mental Hospital izat ion of the Aged; i s i t being Overdone?" American Journal of Psychiatry. American Psychiatric Association, Baltimore, v o l . 78, p. 628. 73 to ta l socia l s i tuat ion. If i n the worker's opinion, the applicant's need i s urgent, and no other resource can he found, a recommendation i s made to the medical superinten-dent, who w i l l then give consideration to early approval of the applicat ion. Many relat ives are, not unnaturally, very d i s-turbed after requesting admission of a beloved mother or father; many people, whose feelings towards their parents are s t i l l an ambivalent mixture of affection and resentment, suffer a great deal of gui l t over their decision. The socia l worker, hy focussing on the r e a l i t y s i tuat ion, giving information about the aging process, and offering support and acceptance of their feel ings, can do much to al leviate this g u i l t . Helping the patient to accept the need for hos-p i t a l i z a t i o n i s equally important, and much anxiety can be a l leviated by describing the hospital and i t s f a c i l i t i e s , as well as by defining i t s goals of rehabi l i ta t ion and treatment. This i n i t i a l contact with a staff person often serves as a bridge over the actual admission and d i f f i c u l t f i r s t weeks of orientat ion. When the socia l worker feels that the applicant's condition i s such that c l a s s i f i ca t ion of his application as urgent i s unnecessary, she w i l l explore resources within the community which might provide care over the waiting 74 period. These may take many forms, such as direct re fer ra l to a public agency for f inancia l assistance, or for placement i n a hoarding or nursing home where the applicant i s e l i g ib le for f inancia l supplementation for care. Where the applicant's or family's resources are suff icient the family may he advised on suitable place-ments, and helped to involve themselves i n the planning, and then to help support the aged person i n a new placement. Where the family i s unable to do th i s , the hospital socia l worker may he d i rec t ly involved i n placement, or may he able to refer to a community agency. The hospital socia l worker can make re ferra l to community agencies for provision of v i s i t i n g nurse service, f r iendly v i s i t o r s , or a housekeeper where this i s seen as helpful . In a number of cases, provision of one or more of these services has resulted i n such an improvement in the applicant's s i tuat ion, that admission can be postponed inde f in i te ly . Not the least of the services which the socia l worker can give her aged c l ients i s consultation with the boarding or nursing home operator or with the family on how the needs of the aging person can best be met i n the individual case. Another function of the hospital socia l worker 75 i s the • interpretation to other professionals, par t i cu lar ly doctors, of the specif ic functions of the mental hospital for the aged. A surprising number of doctors are unaware of the nature and kinds of exist ing community f a c i l i t i e s for the care of the aged, and of provisions for f inancia l supplementation where this i s needed. Frequently sug-gestions made to re lat ives and to doctors for re ferra l to socia l agencies i n the community result i n successful placements. F a c i l i t i e s for Care of the Senile The exist ing f a c i l i t i e s of Valleyview Hospital have been explored to demonstrate the services now con-sidered essential in the care of the aged, mentally i l l person. Every kind and degree of physical and mental inf i rmity can he found among i t s patient population and treatment resources are f a i r l y complete. Unfortunately, except for the f a c i l i t i e s provided by the Department of Veterans' Affa ir s at Shaughnessy Hospital , there are no publ ic ly operated establishments i n the Province of B r i t i s h Columbia offering adequate care to the aged person whose soc ia l functioning has deteriorated beyond the point of sel f-care. The one private mental hospital i n the province i s beyond the reach of a l l hut the wealthy; most of the private hospitals and nursing homes are almost uniformly unable to provide the range and quality of service 76 necessary for these patients. Thus, unless an aged individual i s wealthy, ent i t led to the services provided for veterans, or cer t i f i ed as mentally i l l and admitted to the Geriatr ic Divi s ion of the Provincia l Mental Health Services, he has access only to the l imited services of the pr ivate ly operated nursing and hoarding homes. These homes are for the most part inadequate for the care of anything hut minimal disturbances i n mental and socia l functioning; sometimes they are inadequate for the care of certain physical in f i rmi t i e s . Many persons now seen as inevitable candidates for Valleyview Hospital could he cared for i n boarding or nursing homes were the operators adequately trained and motivated to give this type of service. Quite recently a graduate psychiatric nurse with several years experience i n working with disturbed old people opened a hoarding home, staffed with psychiatric nurses. This hoarding home i s offering the type of under-standing care required for this type of patient, and i s handling successfully old persons whose families and other boarding homes staffed with untrained people have f a i l ed to contain. At the present moment our welfare inst i tut ions l icens ing requirements differentiate only between hoarding homes offering personal care, such as supervision of feeding, dressing, and bathing, and nursing homes offering 77 nursing care. These l a t te r may offer high standards of physical nursing care to the physical ly severely debi l i ta ted , hut are not infrequently unable to cope with the behavioural problems presented by confused, demanding old people. The need i s not only for more boarding and nursing home f a c i l i t i e s , hut also for specialized hoarding and nursing homes which could care for the less severe types of emotional disturbances i n old people, retaining these patients i n the community for longer periods, and giving sat is fact ion to patients and families at considerably less expense than i s incurred hy the community i n main-taining a patient i n a mental hospi ta l . Recommendations for Changes i n Procedures and Legis lat ion A basic concern of socia l work i s the welfare of the ind iv idua l . A l l too frequently, however, the i n d i v i -dual's need cannot be met because the suitable resource does not exist i n the community. This i s par t icu lar ly true of the aged person i n our time. When deterioration in physical , mental or socia l functioning, or any combination of these begins to he apparent, great d i f f i c u l t y may arise i n obtaining care for him. The family i s unable to care for him; no in s t i tu t ion suited to his part icular need may exis t . The socia l work assessment of an indiv idual ' s problem included his resources, internal and external, as 78 well as his needs. In planning for the c l i e n t ' s treatment, the socia l worker can u t i l i s e only the resources which actual ly exis t . The plan which i s f i n a l l y put into action may he far from the c l i e n t ' s real need, where there i s no satisfactory way of meeting t h i s . It was stated i n the section on e l i g i b i l i t y i n Chapter One that pr ior to admission to the Geriatr ic Divis ion of the Mental Health Service, an individual must he judged, i n the opinion of two cert i fy ing doctors and a committing judge, to be suffering from chronic brain syndrome due to senile or ar ter iosc lerot ic brain disease associated with neurotic, psychotic or behavioural reaction, and must be approved by the Medical Superintendent. A l l persons for whom proper application has been made have therefore been so judged hy the cer t i fy ing doctors. The in s t i tu t ion of Order-in-Council No. 1124- i s i n i t s e l f an acknowledgement that this does not necessarily secure suitable placement for the aged person i n need of help. Ultimately, i t i s the Medical Superintendent of the Geriatr ic Divis ion who makes the decision to admit any ind iv idua l , but he i s influenced by a l l the information which i s available to him, and par t i cu lar ly by the infor-mation that this admission i s necessary because no other suitable form of care can he found for this ind iv idua l . Therefore, i t would seem reasonable to suggest 79 that, so long as the committal procedure exists , appl i -cations should he processed f i r s t through the branch offices of the Department of Social Welfare, or the municipal socia l service off ices . A socia l worker's assessment of the indiv idual ' s need for this form of care, and the urgency of the need, would he of great use i n assessing p r i o r i t i e s for admission. In the present s i tuat ion, whereby two doctors must cer t i fy the patient to he mentally i l l , and requiring treatment i n a mental hospi ta l , some almost insuperable d i f f i c u l t i e s ar i se . For one thing, rest homes are not permitted to accept mentally i l l patients, and nursing homes may do so only under special permission. The two doctors' cert i f icates place the applicant i n a most d i f -f i c u l t pos i t ion . He may not he accepted hy Valleyview for a lengthy period, and he i s not r ea l ly e l i g ib le for any other form of care which exists i n the community. The fact that eight out of the cer t i f i ed applicants to Valleyview Hospital i n the group studied, were never admitted, hut found other forms of care quite successfully, only two of which were i n a private mental hospi ta l , indicates just how inappropriate this requirement i s . One strong recommendation that the writer would make, therefore, i s the early abol i t ion of the present l eg i s l a t ion governing procedures for admission to the 80 Geriatr ic Divis ion of the Provincia l Mental Health Services. Porm " A " , as the application form from the responsible re l a t ive , i s both useful and innocuous. The referr ing doctor's part of the procedure, however, would he far more useful as a simple medical re ferra l to the Medical Superin-tendent, for consideration of the applicant's placement i n Valleyview. This would eliminate the stigma and awkwardness of c e r t i f i c a t ion of mental i l lnes s i n people who may never have to come to a mental hospi ta l . At the present time there does not seem to he much chance that legal committal procedures for admission to mental hospitals w i l l vanish overnight. A committal for th i r ty days only, however, would give the hospital staff opportunity to decide whether a patient needs to he detained against his w i l l i n a mental hospi ta l , and would re-affirm the freedom of the individual to choose his way of l i f e , as far as the great majority of patients are concerned at any rate . It has already been pointed out that eight of the study group sett led well i n other forms of care. Had they not been protected by the Medical Superintendent's power to approve admissions to the hospi ta l , and the even more effective bulwark of the waiting l i s t , they would inevitably have been hospital ized. This i s not to suggest that Valleyview Hospital i s i n any way a poor or an 81 inadequate hospi ta l . It i s only f a i r to say that for i t s purposes i t i s an excellent in s t i tu t ion ; certa inly i t s services and i t s physical f a c i l i t i e s are far superior to what can he obtained for the elderly i n the community. Wherever an individual retains any power to choose, and to he aware of his surroundings, i t can only he wrong to commit him forceful ly to a way of l i f e he does not want, i f there i s an alternate form of care he can approve. The r ight to self-determination i s a basic tenet of socia l work, and i t i s the wri ter ' s be l ie f that where an individual can prof i t from care and treatment i n a mental hospital he should be kept there only with his w i l l i n g co-operation, i f a resource exists elsewhere which could also serve his need. Widespread changes i n community f a c i l i t i e s must develop before adequate care can he obtained for the elderly i n our society, but, even more importantly, there must he recognition of the need to change our attitudes, which permit exist ing l eg i s l a t ion to go unchallenged. A broad program of soc ia l planning to improve the s i tuat ion of our aged i s urgently needed; a constructive f i r s t step would be the removal of the stigma of mental i l lne s s from those whose condition i s not accurately described hy this c l a s s i f i c a t ion , and whose successful treatment i s certa inly not aided hy i t . BIBLIOGRAPHY Books Anderson, John E . , ed. Psychological Aspects of Aging. American Psychological Association, Inc . , Washington, D. C , 1 9 5 6 . Burgess, Ernest W. Aging i n Western Societ ies . University of Chicago Press, Chicago, I 9 6 0 . Davis, H . , ed. Hearing and Deafness. Murray H i l l Book Inc. , New York, 1 9 4 7 . Kaplan, Oscar J . , ed. Mental Disorders i n Later L i f e . Stanford University Press, Stanford, Ca l i forn ia , 1 9 4 7 . Lansing, Albert D . , ed. Problems of Aging. 3 r d ed. Williams and Wilkins, Baltimore, 1 9 5 2 . Tibbi t s , Clark, ed. Handbook of Social Gerontology. University of Chicago Press, Chicago, I 9 6 0 . Understanding the Older C l ient . Family Service Association of America, New York, 1955* A r t i c l e s , Theses and Reports Ar t i c l e s D a v i l l , F. T. and Jones, Charles. "Evaluation of a Medical Admission Ward for Old Patients i n a Psychiatric Hosp i ta l . " Ger ia tr ics , Lancet Publications, Minneapolis, v o l . 13 (September 1 9 5 8 ) . Gilbert , J . E . "The Mental Health Situation i n Canada Today." Medical Services Journal. Canada, v o l . 1 4 , No. 7 (July-August 1 9 5 8 ) . 83 Grabski, Daniel A. "Geriatr ic In-Patients - Ine Precipi tat ing Gause of Admittance to the State Mental Hosp i ta l . " Ca l i fornia Medicine. O f f i c i a l Journal of the Cal i fornia Medical Association, San Prancisco, Ca l i forn ia , v o l . 94, No. 3 (March 1961). Horabczewski, Joseph. "Admissions of Geriatr ic Cases to a Mental Hospi ta l . " The Canadian Medical Association  Journal. The Canadian Medical Association, Toronto, v o l . 78, No. 1 (January 1, 1958). Kolb, Lawrence. "The Mental Hospital izat ion of the Aged: Is It Being Overdone?" The American Journal of  Psychiatry. The American Psychiatric Association, Baltimore, v o l . 112 (February 1956). Linden, Maurice. "Emotional Problems i n Aging." The Jewish Social Service Quarterly, v o l . 13, No. 1 (Fa l l 1954). Rothschild, D. "Pathological Changes i n Senile Psychoses and the ir Psychohiologic Signif icance." The American  Journal of Psychiatry. The American Psychiatric Association, Baltimore, v o l . 93 (1957). Theses Clark, Richard James. Care of the Mentally 111 i n B r i t i s h  Columbia. Master of Social Work thesis , University of B r i t i s h Columbia, 1945. Elmore, Eugene. Discharge Planning i n Homes for the Aged. Master of Social Work thesis , University of B r i t i s h Columbia, 1959. Reports Annual Report for the Twelve Months Ended March 31st. 1960. Department of Health Services and Hospital Insurance, Mental Health Services Branch, Province of B r i t i s h Columbia, Queen's Pr inter , V i c t o r i a , 1961. Background Material on the Aging Population. Eleventh Mental Hospitals Institute on the Psychiatric Problems of the Aging and of the Aging Mental Defective, I960, mimeographed. 84 Bradford, Marjorie. Study of the Meeds of Older and Chronically 111 Persons. Council of the Corporation of the City of Ottawa, 1955. Busse, Ewald. "What i s a Real i s t ic Attitude i n Regard to Research i n Aging?" P i r s t National Conference of  the Joint Council to Improve the Health Care of the Aged, Washington, D. C , 1959. Eisdorfer , C. "Rorschach Developmental Levels and Sensory Impairment i n an Aged Population." Mimeographed. "Mental Health Problems of Aging and the Aged." Sixth  Report of the Expert Committee on Mental Health. World Health Organization, Geneva, 1959. (The Nation and Its Older People. Report of the White House Conference on Aging. 1961. U . S. Department of Health, Education and Welfare, Washington, D. C , 1961. Report on Patients Over 65 i n Public Mental Hospitals . American Psychiatric Association, Washington, D. C , 1959. Walden, C. C , Urquhart, A. I. and Gouge, I. W. Population  Trends i n Canada. B. C . . Alberta and Saskatchewan. B. C. Research Council , Vancouver, January 1957. Walker, Helen. A P i l o t Study of Older Patients at  Cleveland State Hospital . Joint Committee on F a c i l i t i e s for the Aged and Disabled, Cleveland, 1953. o 

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