Psychiatric problems in the nursing home. St. Louis University Geriatric Grand Rounds

Psychiatric consultation in the nursing home: referral patterns and recognition of depression

OBJECTIVE

To assess the accuracy of referrals to psychiatric consultants for depression (or depression-related disorders) among nursing home residents.

METHODS

Retrospective review of psychiatric consultations for nursing home residents in six facilities for a 3-year period. Reasons for referral, assigned diagnoses, rates of accuracy, sensitivity and specificity were examined to assess patterns of referral and recognition of clinical variants of depressive disorders.

RESULTS

Referrals for depression comprised 19.7% of all requested consultations. Of patients referred for depression, 74.2% were diagnosed with a depressive disorder. Of all residents diagnosed with depressive disorders, 53.5% were referred for other reasons. Men were referred for evaluation of depression significantly more often than women. However, rates of diagnosis of depression did not appear to differ significantly between men and women.

CONCLUSIONS

Nursing home staff often failed to recognize depression. Depressed residents are primarily referred for disruptive behaviors. Referrals for depression may be a secondary concern.

Aggressive behaviour in the elderly

In this paper, the literature on aggressive behaviour in the elderly is reviewed, with emphasis on: definition; study samples; patient groups; study designs and methodology; data collection; instruments used to measure aggressive behaviour; social, clinical, demographic and biological correlates; prevalence and rates; precipitants; outcome; site; timing; daily and seasonal variation; patterns of usage of hospitals and other institutions; stuffing levels, staff morale, staff attitudes, staff training and other staffing factors.

Lessons from geriatric psychiatry in the long-term care setting

Of all long-term care settings, the nursing home has served as the most productive laboratory for the study of the mental health problems of late life. Lessons from geriatric psychiatry research and practice in the nursing home have relevance to general psychiatry and to other health care settings, informing us about (a) psychiatric disorders in medically ill and disabled populations; (b) subsyndromes and subtypes of depression; (c) behavioral disturbances in patients with brain injury; (d) the effects of government regulation and education on mental health care; and (e) essential roles for psychiatrists in changing health care systems. Selected areas of knowledge based on geriatric psychiatry research and experience in long term care are reviewed in this paper, and their applications for the field of psychiatry in general are explored.

Involuntary transfers and discharges of nursing home residents under federal and state law

When, as projected, nearly one out of every four Americans is age sixty-five or more, one out of every four Americans over sixty-five will spend time in a nursing home, and caregiver families scarcely exist, we will no longer be able to avert our eyes from the grim options faced by our senior citizens. Nor will we be able to continue to operate under the comforting but often false illusion that our convenient dispositions are actually serving the best interests of the elderly.

Management of dementia-related behavioral disturbances: a nonpharmacologic approach

OBJECTIVE

To describe practical nonpharmacologic approaches to dementia-related behavioral problems for enhancement of the function and care of elderly patients with dementia.

DESIGN

We reviewed the pertinent medical literature and summarized strategies and available resources for management of geriatric patients with dementia and behavior problems.

RESULTS

For optimal care of older patients with dementia, key concepts of related behavior problems must be understood. Agitation and aggression, resisting help with care, wandering, incontinence, sleep disturbance, and emotional lability can become difficult management issues with such patients. In some patients, these disruptions can lead to overmedication and nursing home placement. Herein, practical nonpharmacologic measures for management of behavior problems that arise among community-dwelling and institutionalized elderly patients with dementia are discussed. Attention is directed to the medical, psychologic, environmental, and social factors that may contribute to unwanted behaviors.

CONCLUSION

Nonpharmacologic approaches can help ameliorate behavioral problems and assist in the overall care of elderly patients with dementia.

A nursing protocol to assess causes of delirium. Identifying delirium in nursing home residents

Because delirium is often a harbinger of underlying physical illness in frail elders--which can cause further morbidity and functional decline--it is essential to accurately assess the causes of delirium. Nurses working in nursing homes are in the best position to make these assessments and advocate for the appropriate management of delirium. The implementation of the proposed nursing protocol may empower nurses and, thus, improve outcomes of nursing home residents suffering from delirium.

Description of a Program for Psychiatric Consultations in the Nursing Home

The authors describe a psychiatric consultation program ad-ministered by a geropsychiatric clinical nurse specialist in a nursing home and present data on its effectiveness. Residents referred for psychiatric consultation were similar with regard to demographic characteristics, but were more cognitively intact. The most common reasons for referral were depressive symptoms, agitated behavior, and perceptual distortions. Interventions involving medication were the most frequently used, followed by relocating the resident, staff interventions, and psychotherapy. Treatments that involved moving the resident were rated as less effective. Overall, significant improvement was noted in slightly more than half of all residents referred for psychiatric consultation.