Dear Dave
I welcome the demise of the AMT, but adopting the MMSE has a new caution. Recently the Journal that published the Folsteins original paper was taken over and the new owners are trying to enforce copyright. It now costs $1 each time you use it. There has been a lot of debate about this in the International Journal of Geriatric Psychiatry. Threats of legal action have been received by those who have put the MMSE on web sites etc. See the MJP and UCL link for details:

Regards
Jed Rowe

Dear Editor

In recent years there have been significant changes to the structure and function of the NHS - and not least, to the language that is used. Re-configuration, re-location, re-designing and modernisation are new words for the old-fashioned "closing down"; stakeholders (or is it steak holders?) - all those who get their teeth into a service!; capacity building - providing premises to house all members of staff; joint working - using illegal substances; introduction of market forces, competition, foundation hospitals - mean what they say! And what about the Long Term Conditions Alliance for Scotland?

The introduction of specialist registers has seen the demise of the the general physician and surgeon and new contract arrangements for general practitioners has encouraged the introduction of nurse-led clinics with the loss of the holistic approach to patient care. Managed clinical networks could become a minefield for older people with co-morbidity i.e. old-fashioned multiple pathology.

But, all may not be lost - we still have Physicians in Geriatric Medicine, supported by teams of Allied Health Professionals - and a holistic approach should be sustainable for our older patients.

The "medical model" of health care may have been discredited, but there is still a place for some of the fundamental principles of Geriatric Medicine.

1. Diagnosis before prognosis, with assessment of co-morbidity - assessment of a person`s physical, mental, social and economic problems which can be associated with disease and/or disability. The former will require medical or surgical treatment and the latter, rehabilitation.

2. Rehabilitation - perhaps the old name for what is now called "step down", "step up" and "intermediate" care.

3. Review of the older person`s medicines and general health whenever their health status changes - wherever they may be cared for; at home, NHS premises or private/voluntary sector accommodation.

4. Rapid response pre-admission assessment visits, wherever the patient may be, including other hospital wards, will prevent inappropriate admission and prevent delayed discharge. Such visits avoid the patient`s need to wait for an out-patient appointment and the artificial atmosphere of a clinic`s setting.

Physicians in Geriatric Medicine have much experience of joint working and may have created managed clinical networks without realising it - so, despite the demise of the medical model, let`s revive it under the guise of Modernisation of Care of the Older Person.

Dr C Cohen
Hon. Fellow
Dundee University