whom only 4 are men; this, one recitals and variety; there is a Mon- perience - please share them." learns, is just the ratio of women to day lecture series on the Canadian- Sharing. Helping. Learning. Teach- men residents here - 7:2. Jewish experience. And there are ing... Doing. In a typical day at the Wagman classes in pottery, jewelry making, This emphasis on keeping the eld- Centre, residents and members can weaving, macrame, dressmaking and erly involved and busy, not merely shop, chat over coffee, have a full crochet. shepherded in some tranquil twilit kosher meal, exercise, paint, swim, pasture, is what characterizes the read, listen to music or just sit Please share Baycrest Centre for Geriatric Care - around in the bright lobby with its With all of this going on it would a high level of function. and its many plants. be difficult not to participate, but skylight This is the second of three articles. Special programs advertised in residents and members are encour- Part three will examine the attitudes brochures and wall notices offer aged to initiate much of this activity. of the centre's staff, residents and slim-and-trim exercises, folk-dancing Ads ask: Are you a manicurist? Can members toward geriatric care and classes, shuffleboard, skittles and you make sandwiches for the cafe- will feature some "what I have bowling. A Tuesday night series teria? Sell cosmetics? Run a cleaning learned" wisdom of older citizens of features plays, classical guitar, piano depot? "You have life and work ex- Baycrest.

Health care for chronic abusers

J.M. WElLER John is a typical chronic alcohol type of patient emergency depart- In a study at Hotel-Dieu in 1975, abuser-40, divorced, without a ment staff see on a regular basis. entitled "A study of drug abuse cases family, unemployed' and on welfare. Dr. Wayne J. Spotswood of Hotel- presenting to an emergency depart- The police pick him up and deliver Dieu Hospital in Kingston, quoting ment", Dr. Spotswood and two other him to the emergency department of a 1972 study on emergency depart- researchers, Ronald Matthews and the hospital. He has been there ments in Hamilton by J.R. MacKen- Donna Brown, found alcohol abusers many times. Although only semi- zie says the study noted a 300% place significantly heavy demands on conscious, incoherent and uncooper- increase in emergency patients from emergency departments. Of 8060 ative, he is examined by a doctor 1961 to 1971. Drug abuse patients patient visits during the 2-month and a laceration to his head is (comprised mostly of alcohol abusers) study, 3.5% were for treatment of treated. He is diagnosed as acutely comprised a significant portion of drug abuse, mostly in the form of intoxicated. this greatly expanded volume, he alcohol. Dr. Spotswood said this fig- John's medical record reveals he told CMAJ. ure represents only recorded abusers. suffers from gastroenterologic dis- orders and chronic malnutrition. Following several hours in the emer- gency department, John is hospital- ized overnight. The next day he is 4 taken to the detoxification centre where he stays a couple of days be- fore ending up back on the street. John has consistently refused re- habilitation assistance. It's not long before the police literally pick him up off the street again and the vicious circle starts all over. Thousands of chronic alcohol abusers, mostly men such as John, are not only hurting themselves but also putting serious pressure on hos- pital emergency departments across Canada. Physicians agree that up to 30% of people seeking medical at- tention in emergency departments have alcohol-related medical prob- lems and perhaps as many as 5% are chronic alcohol abusers-the Alcohol abusers place heavy demand on emergency departments CMA JOURNAL/SEPTEMBER 23, 1978/VOL. 119 633 Hospital in Vancouver said there are two detox centres near the hospital and they have substantially reduced the number of cases at the emergency department. Aggressive treatment system He said to further reduce unne- cessary pressure on the emergency department, the staff has adopted an "aggressive treatment system" for chronic alcohol abusers who do not have serious medical problems. "We examine the patient and if - as is the situation in many cases - he has only a minor injury, we quickly treat the problem and send him to the detox centre. We don't keep a patient overnight unless it is necessary," Dr. Scholtz said. While the detox centres and the "aggressive treatment system" help, chronic alcohol abusers still place pressure on emergency departments. Dr. Scholtz said the situation in the Back on the street - the vicious circle starts again future might worsen because the British Columbia police departments are curtailing their "drunk tank pro- gram". This will likely put even more pressure on detox centres and inevitably, emergency departments too. Dr. Spotswood said Hotel-Dieu's only detoxification program is keep- ing chronic alcoholics in hospital overnight. He said this not only puts pressure on the emergency depart- ment, but also seriously affects the whole hospital operation. "Chronic alcohol abusers are ex- pensive to care for, time consuming and often most difficult to treat,.. he said. "Sometimes their abusive man- ner and lack of cooperation make it almost impossible to treat them." All the doctors in the CMAJ sur- vey agreed that detox centres relieve emergency departments of much of the nonmedical treatment of chronic alcohol abusers. But some doctors cautioned that they can only be ef- fective if operated under strict guide- lines so that only emergency assist- ance is offered to the man who re- fuses rehabilitation help. Otherwise detox centres could become "easy marks" for chronic alcoholics. Dr. Spotswood said he would prefer the detox facility be part of the hospital - working in direct contact with the emergency department. In any event, he pointed out, the detox must not become a "convenient flop house" for chronic alcohol abusers. Skidrow drunks suffer injuries and malnutrition Public inebriates (chronic alcohol venereal diseases) not frequently Henry Walton suggest the most seri- abusers who generally lead a skidrow diagnosed in more affluent alco- ous consequence of can existence) suffer more diseases and holics. be malnutrition. This arises because are more acutely affected by these She said the study indicated these a chronic alcoholic does not eat diseases than average chronic al- more-serious, physical disease pat- enough because of gastroenteric coholics. terns result from the public ine- complications brought on by chronic Diseases commonly diagnosed in briate's sociologic and environmental drinking and because what he does chronic alcoholics include pneumo- lifestyle. eat does not nourish him as it nia, bronchitis, cancers of the upper "A public inebriate's frequently should. digestive and respiratory tracts, heart unhealthy physical condition is de- Kessel and Walton said alcoholics diseases, of the liver, peri- termined by his chronic drinking and are frequently drawn into a vicious pheral neuritis, diabetes and chronic also his poor eating, sleeping and circle of deteriorating health - with brain deterioration. personal hygiene habits," she said. all their health deficiencies feeding Dr. Ashley said another reason each other - resulting in irrevers- A 1976 comparison study of these men suffer more-severe physi- ible physical impairment. public inebriates and other alcoholics cal disease pafferns than other al- by Dr. Mary Jane Ashley of the Uni- coholics is because they drink more A 2-month study conducted by versity of Toronto, revealed that non-beverage alcohol - substances Dr. Wayne Spotswood in the emer- skidrowers (almost all men) display such as shaving lotion, shoe polish, gency department of Kingston's more of these diseases, with more hair spray and rubbing alcohol. Hotel Dieu Hospital in 1975 also severe symptoms, than alcoholics Malnutrition is another major ail- revealed the more serious physical who live within the mainstream of ment that damages the health of disease pattern experienced by public society. They are also liable to others public inebriates. In their book "Al- inebriates as compared to other al- (such as infections, tuberculosis and coholism", Drs. Neil Kessel and cohol abusers.

"These men should be detoxified partment medical care of chronic al- He said it is sporadically attempted as quickly as possible and moved cohol abusers, but, according to Dr. and the success rate is very low, per- out. Otherwise the detox might just J.E. Monagle, acting director of haps less than 5%. He said such make life easy for them, and in the community health services at the treatment might take some pressure long run injure their chances of re- Department of National Health and off hospitals but a chronic alcohol habilitation." Welfare, it is impossible to estimate abuser cannot be expected to im- the exact cost. prove his condition unless he changes Stuck with the bill Major Harvey Haakonson, MD, his lifestyle. who works in preventive medicine The cost of treating chronic alco- for the Canadian forces, believes the hol abusers in hospital emergency high cost of such medical care might Danger of relapse departments is generally paid by be reduced, or at least better directed, municipal and provincial welfare and if society institutionalized chronic al- Dr. Spotswood said a chronic al- medical programs, assisted by federal cohol abusers. coholic who comes out of forcible funding. However, on some occa- "When a man gets into this rut rehabilitation and finds nothing sions, hospitals are stuck with the (chronic alcohol abuse) society has changed in his normal environment cost of such treatment. really only two choices - either - no family, no job, and no hope Dr. John Bennett, coordinator of leave him alone, providing essential for a brighter future - will almost CMA's Council on Community medical care when necessary until he certainly fall back in with old friends Health, said all hospitals are some- kills himself, or forcibly institution- and familiar drinking patterns. times unable to collect for certain alize him." Dr. Haakonson said this Rehabilitation for chronic alcohol medical services. He said some of would not necessarily mean putting abusers must come within a frame- these unpaid bills result from the chronic alcohol abusers in a lockup work of everyday life if they are to treatment of chronic alcohol abusers situation. It could involve putting develop self-respect and a desire for who have no health coverage. The them in a controlled environment normal lives, Dr. Spotswood sug- cost of treating such a patient can under proper therapeutic supervi- gested. quickly escalate, particularly in a sion. Such an institution could be at Ms Loretta Carrera, head nurse small hospital, Dr. Bennett said. He least partially self-supporting if the of the Ottawa General Hospital's explained that in a small hospital a men worked at a production needed emergency department, suggested that nurse may be called away from her by society. a solution to the problem of emer- duties, a physician specially called "Even if this form of treatment is gency medical treatment for chronic in or surgery and laboratory facilities only partially successful, it will re- alcohol abusers might be a separate used. duce pressure on emergency depart- medical clinic dedicated to their There is a lack of statistics on ments and consequently reduce hos- needs. She said most emergency de- chronic alcohol abusers. Millions of pital costs," he added. partments are just too busy to give dollars are spent each year on the Dr. Spotswood was sceptical about anything more than essential medical hospital inpatient and emergency de- the value of forcible rehabilitation. assistance to these patients.E CMA JOURNAL/SEPTEMBER 23, 1978/VOL. 119 635