The State of Mental Healthcare in Nursing Homes- A Review by Dr. Leo J. Borrell
(Source: Reichman WE, & Conn DK: Nursing Home Psychiatry: Is it Time for A Reappraisal? Am J Geriatr Psychiatry 2010:18;12)
Studies over the past twenty years have recognized the pervasiveness of mental illness among residents of nursing homes. Dementia, behavioral and psychological symptoms of dementia (BPSD), and depression characterize the resident population. Seitz and colleagues1 reported on the prevalence of major psychiatric disorder in long-term care derived from a number of carefully screened epidemiological studies. Dementia in nursing home residents was 58% whereas the prevalence of BPSD was 78%. Major depressive disorder had a median prevalence of 10%, and the median prevalence was 29% for depressive symptoms. Minimum data set results reveal that 46.5% have dementia, 47% have depression, 30% show behavioral symptoms, 3% have mental retardation, and 20% have other psychiatric disorders. Nursing home residents are becoming bewilderingly more complex than in the past and more difficult to address.2 It is incumbent to comprehensively assess our readiness to meet this substantial challenge.
To what extent has the field of geriatric psychology improved since the introduction of the US Omnibus and Reconciliation Act of 1987 (OBRA 87) We are more vigilant and appropriately cautious about the use both of physical restraints and of psychotropic medications, we still have quite a way to go. Diagnostic clarification and psychopharmacology is the dominant intervention offered by psychiatrists. This narrow emphasis is not serving the nursing home population adequately. The available antidementia compounds, cholinesterase inhibitors and memantine, do have demonstrable, but limited impact on relieving BPSD.
Geriatric psychiatrists will be offering inadequate clinical value in the nursing home if the psychotropic medications currently available are not safe and are not sufficiently effective. Ninety-seven percent of residents were experiencing at least one symptom. Agitated behaviors were especially persistent and apathy tended to increase over time, although there was a decrease in affective symptoms. Early identification of depression is of great importance to the well-being of nursing home residents. Mitchell et al.3 from the United Kingdom report on a meta-analysis of the diagnostic accuracy of different versions of the Geriatric Depression Scale.3 Screening programs in nursing homes must be adequately resourced so that their clinical utility can be property evaluated and demonstrated.4
Stevenson and colleagues5 noted that 26% of residents were prescribed an antipsychotic medication. Of particular concern was the finding that 40% of those receiving an antipsychotic had no documented appropriate indication for such use. Among the 13% of residents who received a benzodiazepine, 42% had no appropriate indication identified.
In this situation, the specific contributors to the display of mental illness in the nursing home are: the physical environment, the processes of case, and the behavior of people (care providers and other residents). Literature on environmental design concluded that there is sufficient evidence accumulated to come to a consensus on guiding principles for the design of long-term care environments for people with dementia that maximize function and mental well-being. The use of single rooms, unobtrusive safety measures, varied ambience, and controlled levels of stimulation are all supported by the literature as useful interventions. There is less agreement on the usefulness of other interventions (e.g., enhanced signage, homelikeness, provision for engagement in activities of dialing living, small size, and access to outside space).
Over the past two decades, research has examined nonpharmacologic interventions that benefit nursing home residents with dementia. A recent review of psychosocial interventions in dementia care specific to nursing homes concluded that the most effective interventions utilized behavior management techniques, cognitive stimulation, or physical activity interventions. Evidence also supports psychotherapies such as reminiscence and cognitive behavior therapies for residents with symptoms of depression and other related symptoms.6
The mental health of nursing home residents can be enhanced in an environment offering high-quality medical care guided by some basic principles of ensuring well-being.7 Various models of psychogeriatric services in nursing homes reported on nine controlled trials and concluded that liaison-style services that employed educational approaches, treatment guidelines, and ongoing involvement of mental health staff are more effective than a purely case-based consultation model.8 Snowdon9 recently described a variety of models of mental health service provision including solo practitioners. The value of consultation via interactive videoconferencing, particularly for nursing homes located in remote areas and for nations that limit funding for residential care, was also highlighted. Recommendations are provided that include adequate screening for mental illness, designation of staff members who take responsibility for identification, and, if necessary, referral to a mental health specialist. Active involvement of the primary care physician and effective liaison between the facility and mental health teams is a required essential feature. A number of reports have highlighted the benefits of having nurse specialists provide significant frontline consultation and care.10, 11 Moyle et al. have recently reviewed the literature on this topic and made a series of useful recommendations.12
They are as follows:
1. Nursing homes should have an established staff development program related to resident mental health care needs.
2. Prior training in mental health care should be a key selection factor when hiring new staff.
3. A process of staff evaluation should be in place and homes should facilitate staff attendance at education and training sessions.
4. A reward system should be in place for staff who undertake educational programs. It is also particularly important to support unregulated staff to achieve competency in the mental health care needs of older individuals.
5. Curriculum designers must take into account the special needs and schedules of LTC staff.
1. Steiz D, Purandare N, Conn D: Prevalence of psychiatric disorders among older adults in long-term care homes: a systematic review (Published online ahead of print June 4, 2010). Int Psychogeriatr 2010; 1-15.
2. Gillespie SM, Katz PR: An overview of residents, care providers, and regulation of medical practice in the long-term-care continuum, in Psychiatry in Long-Term Care. Edited by Reichman WE, Katz PR. New York: Oxford University Press, 2009, pp. 449-464.
3. Mitchell AJ, Bird V, Rizzo M, et al.: Which version of the geriatric depression scale is most useful in medical settings and nursing homes? A diagnostic validity meta-analysis. Am J Geriatr Psychiatry In press
4. Pachana NA, Helmes E, Byrne GJ, et al.: Screening for mental disorders in residential aged care facilities (Published online ahead of print April 6, 2010). Int Psychogeriatr 2010: 1-15.
5. Stevenson DG, Decker SL, Dwyer LL. et al.: Antipsychotic and benzodiazepine use among nursing home residents: findings from the 2004 National Nursing Home Survey. Am J Geriatr Psychiatry. In press.
6. Bharucha AJ. Dew MA, Miller MD, et al.: Psychotherapy in long term care: a review. J Am Med Dir Assoc 2006; 7:568-80.
7. Canadian Coalition for Seniors’ Mental Health: National guidelines for seniors’ mental health. The assessment and treatment of mental health issues in long term care homes (focus on mood and behaviour symptoms). 2006. Available at: http//www.ccsmh.ca. Accessed September 1, 2010.
8. Draper BM, Low L-F: Evidence-based psychogeriatric service delivery, in Psychogeriatric Service Delivery. Edited by Draper BM, Melding P, Brodaty H. New York: Oxford University Press, 2005, pp. 75-123.
9. Snowdon J; Mental health service delivery in long term care homes (Published online ahead of print June 18, 2010). Int Psychogeriatr 2010: 1-9.
10. Ballard, C, Powell I, James I, et al.: Can psychiatric liaison reduce neuroleptic use and reduce health service utilization for dementia patients residing in care facilities? Int J Geriatr psychiatry 2002;17:140-145.
11. Eish JS, Brozovic B, Colling K, et al.: Nurse practioners geropsychiatric consultation service to nursing homes. Geriatr Nurs 2000;21:150-155.
12. Moyle W, Hsu MC, Lieff S, et al.: Recommendations for staff education and training for older people with mental illness in long-term aged care. Int Psychogeriatr 2010; (Epub ahead of print).