As a junior hospital doctor in the 1980s, I spent three months working in the Department of Medicine for the Elderly at St James's Hospital, Dublin. It was the days before the severe cutbacks in hospital beds and we were the team that admitted all patients over the age of 65 with an acute illness.
A stroke was one of the more frequent reasons for admission. It is hard to believe now, but there were no CT scans to help decide whether the stroke was caused by a haemorrhage or a clot. There was no test to assess whether a person's swallowing was impaired and no endoscopic tube technology with which to provide alternative feeding until the patient's swallow reflex returned.
What we did offer, however, was the expertise of a multi-disciplinary team of specialised nurses, physicians and therapists, who worked together to prevent further medical complications and whose input speeded up the elderly person's rehabilitation to the best standards of the day.
So, what has changed in the interim? Apart from changes in medical technology, the multidisciplinary team has become even more specialised and effective; several trials have shown that people with stroke who are managed in specialised stroke rehabilitation units are more likely to be alive and living at home a year after the stroke than those managed in general wards. Being looked after in a stroke unit also reduces the time you spend in hospital.
Less than optimum stroke care can result in pneumonia, heart failure and skin breakdown in pressure areas. In the words of Dr J. Bernard Walsh, chairman of the Irish Society of Physicians in Geriatric Medicine, the key to good care is "anticipating and preventing the complications of stroke".
Dr Walsh points to another major change which has taken place in the past decade. The bulk of admissions are now emergency rather than elective cases and the elderly form an increasing percentage of those admitted via Accident and Emergency (A&E) Departments. In the St James's Hospital catchment area for example, people over 65 represent 14 per cent of the local population and yet accounted for 46 per cent of acute emergency admissions in 2000.
The impact of an increasing elderly population on the work load of a hospital is reinforced by other figures which show that 10 per cent of patients under 65 presenting to St James's A&E department require admission, while 41 per cent of those over 65 do so.
All of these changes have occurred in a 20-year period, during which the number of beds in the Eastern Region Health Authority has dropped by 31 per cent. And while the ERHA has announced plans for an extra 1,276 beds by 2011, none of these has been designated as beds for the elderly.
Another worry is the trend towards intermediate care for the elderly, which although no one will officially say so, is seen as a solution to "bed blocking" by older patients. A real concern is that such units will not provide the specialist rehabilitation which helps the elderly return home sooner and in greater numbers after an illness. It is not simply an issue of the elderly being moved on to free a hospital bed - the type of treatment they need can only be provided in an acute hospital setting.
A recent editorial in the British Medical Journal, written in response to the publication of "The National Service Framework for Older People" in the UK, is scathing in its criticism of intermediate care.
Referring to one of the Framework's key performance indicators - that the annual increase in acute admissions for people aged over 75 will be less than 2 per cent - the editorial says: "No evidence is offered to suggest that this percentage will match clinical need. The proposal is institutionalised ageism. . ."
Older people deserve the same treatment as those aged under 65 for conditions such as cancer and heart disease. They merit special treatment to reduce disability from falls, which are especially prevalent in this age group. We should be discussing the need for nationwide falls clinics, with ready access to scanning for osteoporosis and full rehabilitation, rather than making plans to "shift" the sick elderly to some nebulous and potentially underresourced form of intermediate care. Stroke patients deserve optimum facilities also.
In the Irish situation, according to Dr Walsh: "There is a need for more acute and rehabilitation beds on acute hospital campuses. Offsite rehabilitation will not be able to provide the treatment for complex problems that can occur in patients with stroke. If we want to get the best results for patients, we need to provide a specialised stroke intervention service."
The next Health Strategy is being formulated at present; those who can influence its provisions for the elderly must do so.
But this is an issue on which we must all take a more informed and active interest, if only for the selfish reason that most of us who reach the age of 65 will require these specialised services in the future.
Contact Dr Houston at mhouston@irish-times.ie or leave messages at tel 01-6707711, ext 8511.