[Geriatric psychiatry and dementia]

Behavioural disorders linked to dementia are common. The intertwining of psychiatric and neurodegenerative pathologies means caregivers are faced with complex situations on a daily basis. The expertise of the geriatric psychiatry teams helps to guide the clinical reasoning and to find the best nursing approach in order to understand the symptom and support the patient.

[Trialogical Evaluation of a Gerontological Psychiatric Consulting and Liaison Service]

Objective: The presented project shows the effects of a gerontological psychiatric consulting and liaison service (C&L) on nursing home residents and the care team. Methods: The implementation of the C&L was evaluated using a quasi-experimental design in longitudinal section of residents', nursing, medical and family perspective using quantitative and qualitative methods. Results/Conclusion: The results provide evidence for the positive effects of C&L especially in relation to the "common action" within the care team.

The Role of Psychogeriatrics in Healthy Living and Active Ageing

A healthy and active life is a key issue for elderly citizens, above all when psychological complications such as depression and anxiety disorders, late delusion or loneliness can be observed. Moreover, medical pathologies in elderly patients often have a multi-factorial etiology and many psychopathological dimensions and psychosocial risk factors are underestimated. From the perspective of clinical health psychology, psychogeriatrics could play an important role in promoting active ageing and a healthy lifestyle in elderly persons through tailored clinical approaches based on specific research and advanced professional training in this area. More research is needed in order to study which determinants affect the process of an active and functional ageing. Possible research ageing areas are: 1) evaluation of psychosocial risk-protective factors related to the individual's biography and personality. 2) Evaluation of enrichment programs and clinical protocols focused on the management of different topics such as health system areas, behavioral areas, social and physical environment areas, psychological factors and economic determinants. The goal of Psychogeriatrics endeavors to develop and evaluate interventions designed to stimulate improvement in friendship, self-esteem and subjective well-being, as well as to reduce loneliness among older citizens. 3) Evaluation of self-management programs in chronic disease conditions (such as obesity, diabetes, hypertension, poor nutrition, physical inactivity, alcohol abuse and tobacco smoking), that could enhance risk factors for health in elderly citizens. Typical key elements of self-management, such as decision making, problem solving, motivation, self-efficacy, resource utilization, and citizen's empowerment have to be studied.

Psychogeriatric care: building rural community capacity

INTRODUCTION

Since the late 1980s, British Columbia (BC) Canada has been undergoing a process of regionalization of health services which includes decentralization and the demand for self-sufficiency with respect to caring for people with mental health issues. In BC, regionalization has meant the continued downsizing of its one large provincial psychiatric hospital Riverview, which has resulted in relocating patients from this hospital to cities and towns throughout BC, and the establishment and/or renovation of psychiatric tertiary-care facilities to treat local community members who experience mental ill health. In the context of the relocation of psychiatric tertiary care, communities in northern BC face the specific challenge of having to provide these specialized services in remote settings, not only for people transferred from Riverview, but also for the increasing number of people 'aging-in-place' in a region that has the fastest growth of older adults in BC. Little is known about the capacity of these remote communities to manage change, develop broader models of care, and integrate people with psychogeriatric mental health issues with residents at existing facilities.

METHODS

This study employed a qualitative research design which involved field research in the rural community where people were transferred, and interviews and focus groups with key people involved in the transfer process. In the analysis of the data a gender-based lens was applied to clarify the differing needs and concerns of male and female patients and to attend to possible needs relating to culture and ethnicity.

RESULTS

The findings illustrate persistent 'hinterland-metropolis' and 'front-line versus administrative staff' tensions, with respect to resource distribution and top-down governance, and demonstrate the need for more transparent and comprehensive planning by health authorities with respect to instituting mental health reforms in a northern context, as well as improved communication between administrative and front-line staff. The research suggests that it is important to attend to the differing needs of women and men in the context of psychogeriatric care, as well as to other factors such as ethnicity and culture, in order to provide appropriate care. Finally, building community capacity to deal with the complex needs of patients is severely hampered not only by facility and regional health authority staff turnover, but also the stresses inherent to working in northern communities which include geographic, social and economic challenges.

CONCLUSION

Increased local engagement is a way to identify and address challenges related to relocating psychogeriatric care to northern and remote settings, and to enhance psychogeriatric care provision in similar locales. While provincial and regional level 'big picture' planning is a necessity, study participants highlighted the critical role of local perspective and expertise.

[Quality of life and life project, two inseparable concepts?]

The construction of a life project within a long-stay unit for people living with chronic psychiatric disorders must take into account a dimension of care centred around the quality of life and the care provided "here and now". Here, the concept of care finds its full meaning. The example of a long-stay psychiatric unit.

[The ward atmosphere and satisfaction in four psychogeriatric wards]

BACKGROUND

We wanted to investigate the treatment milieu in two psychogeriatric hospitals by use of the Ward Atmosphere Scale (WAS), a self-report questionnaire that has been used in studies of the treatment climate in several psychiatric wards.

MATERIAL AND METHODS

22 patients and 54 staff members in four psychogeriatric wards rated the WAS. The staff's perception of the working environment was also examined (the Working Environment Scale, WES-10).

RESULTS

Both patients and staff had higher scores for "order and organization" and lower scores for "anger and aggressive behaviour" than mean scores of the Norwegian normative sample of wards (mainly for patients with psychosis). Three wards obtained higher patient scores for "support" and three obtained lower ones for "staff control". The psychogeriatric patients seemed to be more satisfied with the wards in general and with the staff, whereas the staff's satisfaction and evaluation of the working environment was similar to that of the Norwegian normative sample.

INTERPRETATION

The common trend of the four wards, convincingly shows that the psychogeriatric ward atmosphere differs from that of the wards mainly for psychotic patients. The WAS seemed to be suitable to describe this environment.

Mental health care for our ageing Australian population

OBJECTIVE

In the context of the National Strategy for an Ageing Australia, the aim of this paper was to highlight some of the challenges for aged mental health services as our population ages.

CONCLUSIONS

The demand for greater consumer participation in treatment planning and provision, and the increasing complexity of managing medical and psychiatric comorbidity in our 'old-old' population will be major drivers for improving our models of clinical practice and forging stronger partnerships between the public and private sectors.

Combined medical-psychiatric inpatient units

Considering the large number of elderly patients in acute hospitals who receive medical as well as psychiatric treatment because of relevant comorbidity, adequate interdisciplinary treatment models have to be developed and applied. The Centre for Elderly, a cooperation project between the departments of geriatric and psychogeriatric medicine in a community hospital in Germany, was founded in 2000. In addition to traditionally structured units, the centre consists of interdisciplinary units. Patient-, staff- and hospital-related characteristics influenced by the reformation of both departments were evaluated by comparing hospital-based registry data records containing age, gender, main and minor diagnoses, length of stay and patient transferrals within the centre. Experts working at the centre were asked to take a stand on the development of the treatment quality, allocation of patients, diagnostic procedures, consultation services and information transmission. The number of admissions to the Centre for the Elderly increased within one year. The distribution of the main diagnose groups remained unchanged, with an overlap between the geriatric and psychogeriatric department consisting of the main diagnoses dementia and depression. The length of stay and the number of transferrals decreased significantly in both departments. The majority of the interviewed employees stated that the treatment quality and the allocation of patients were improved. We conclude that interdisciplinary treatment between the departments of psychiatry and geriatric medicine may contribute to the medical needs of subgroups of elderly inpatients suffering from medical-psychiatric comorbidity.

[Gerontopsychiatry in the community--results of a gerontopsychiatric outpatient network]

OBJECTIVE

Evaluation of a three-year pilot project which aims to improve the quality of care of gerontopsychiatric patients. The project goal was to expand regionally organized outpatient services.

METHODS

We examined the profile (n=1004) and course (n=790) of patients treated at the Kaufbeuren regional Gerontopsychiatric Centre on the basis of sociodemographic, clinical, and care-requirement variables.

RESULTS

There was a diagnostic predominance of dementia and depression. During the running time of the pilot project, only 13 % of the patients had to be admitted to inpatient care.

CONCLUSIONS

The results suggest that the quality of gerontopsychiatric care improves through consistent efforts that are outpatient-oriented, mobile and multiprofessionally organized.

Aggressive behaviour by people with dementia in residential care settings: a review

This paper considers the phenomenon of aggressive behaviour perpetrated by people with dementia in residential care settings. Aggressive behaviour is defined in the context of people with dementia, and the problem of ascertaining the incidence of aggression among people with dementia is discussed. The emotional impact of assaults on nurses and other professionals is highlighted, and differing perspectives on the causation of aggressive behaviour are considered. Management strategies derived from the physical/pharmacological; environment management; behaviour modification and person-centred approaches are reviewed. Our conclusion is that while certain strategies appear to reflect good and common sense practice, in particular those deriving from the person-centred approach, there is no clear research evidence for the general effectiveness of any one management approach, and each has drawbacks of a practical or ethical nature. There is also little empirical information about how professional carers actually manage aggressive behaviour in practice.

Creating a community-based memory clinic for older people

This article describes the development of a multidisciplinary, nurse-led memory clinic. The clinic has grown out of research activity to become an important component of a community service for older people with dementia and other mental health problems. A detailed analysis of the interaction between the clinic and the community mental health team, as practised in this model of care, is presented for consideration.

A tiered model of psychogeriatric service delivery: an evidence-based approach

BACKGROUND

Previous models of mental health care for older persons have not considered the full spectrum of mental disorders.

AIM

To describe a tiered model for comprehensive evidence-based planning of service delivery for mental disorders in late life.

METHOD

The model depicts tiers of mental disorders in ascending order of severity and consequent interventions required.

RESULTS

Interventions aim both to avert individuals from moving up tiers (prevention) and to move individuals down tiers (treatment). Individuals in the lower tiers have no mental disorders and prevention strategies are targeted at known risk factors. In the middle tiers, individuals with mild-moderate mental disorders will mainly be treated in primary care, often in collaboration with specialist mental health services for older people. Individuals in the top tiers with severe mental disorders usually require institutional care.

CONCLUSION

The tiered model provides a basis for planning comprehensive service delivery.

Geriatric medicine and geriatric psychiatry clinical services affiliated with U.S. academic medical centers

U.S. academic medical centers are providing many geriatric medicine (GM) and geriatric psychiatry (GP) clinical services at Veterans Health Administration (VHA) and non-VHA sites. This article describes the distribution and scope of GM and GP clinical services being provided. Academic GM leaders of the 146 U.S. allopathic and osteopathic medical schools were surveyed online in the spring of 2004. One hundred four program directors (71.2%) responded. These medical schools provided 1,325 GM and 376 GP clinical services, which included 654 VHA and 1,014 non-VHA GM and GP services, affiliation with 21 Programs of All-Inclusive Care for the Elderly, and 12 other specialized services. The mean number+/-standard deviation of distinct clinical services at each medical center was 16.4+/-8.2. More geriatrics faculty full-time equivalents, more time spent on training fellows, and designation as a GM Center of Excellence were associated with providing a wider range of geriatric clinical services. Using data from the survey, the first directory of GM and GP clinical services at academic medical centers was created (http://www.ADGAPSTUDY.uc.edu).

IPA survey of brief cognitive screening instruments

BACKGROUND AND OBJECTIVES

Cognitive screening is a "first step" in detecting dementia and other neuropsychiatric syndromes and hence represents an important public health and clinical initiative. A plethora of cognitive screening instruments has been advocated in recent years, but the extent to which these instruments are used or their effectiveness is not well known. An International Psychogeriatric Association (IPA) survey was designed to determine which cognitive screening instruments were used most frequently by clinicians with special expertise in the neuropsychiatric aspects of old age and also to determine the ones considered most useful by these specialists.

METHOD

Under the auspices of the IPA, the survey was mailed in the fall of 2004 to all IPA members as well as members of the American and Canadian Associations of Geriatric Psychiatry. The survey inquired about demographic information, the frequency of use of cognitive screening instruments, and the value attributed to the cognitive screening instruments. Participants also had an opportunity to provide written commentary.

RESULTS

A total of 334 completed surveys were processed. The majority of respondents were geriatric psychiatrists (58%). Of the 20 different instruments that were listed on the survey, only six were selected as "routinely" or "often used" by the survey respondents. These instruments in declining order were: (1) the Folstein Mini-mental State Examination; (2) the Clock Drawing Test; (3) Delayed Word Recall; (4) the Verbal Fluency Test; (5) Similarities; and (6) the Trail Making Test. "Effectiveness" and "ease of administration" were the test characteristics most highly predictive of frequency of use. Open-ended comments highlighted patient factors that continue to provide challenges, including ethnicity/culture, language, education/literacy, and sensory impairment. Respondents concluded that "no single test is adequate."

CONCLUSIONS

Psychogeriatricians worldwide routinely use a relatively small number of brief cognitive screening instruments. Further evaluation is necessary as the need increases for cognitive screening guidelines that inform public health initiatives related to dementia and neuropsychiatric syndromes.

A new service in the intermediate care of older adults with mental health problems

This article describes the a new multidisciplinary, nurse-led service for older adults with mental health problems, the Home Treatment Team (HTT) which has just begun in the Older Adults Directorate of Central and North West London Mental Health Trust (CNWL). The team aims to provide mental health care and treatment in the home for adults aged over 65, offering an alternative to hospital admission and facilitating early discharge. These functions place the service in the intermediate care category (Department of Health (DH) 2001), an area which is not well documented in the care of older people with mental health needs.

[Quo vadis geropsychiatry? Perspectives for a new "state of the art"]

The number of older geropsychiatric patients is increasing dramatically. "The Big Three -- Dementia, Depression, Delusion" are challenging our care system. Today 80 % of those affected live at home, with 5-8 % receiving care in facilities. There is very little between. What is lacking: cross-facility co-ordination, co-operation, systems of reference with overall responsibility, ease of access, particularly of clarification and consulting services, mobility of psychical support, massive support for relatives, and specialised, graduated services for various areas of life and needs. A vision of an integrated supply of services is delineated, the intertwining of private, mobile and inpatient modules adumbrated. Simultaneously the problems with transitions, education and case conferences, specialists, conference of the supporters and quantity structure of services are addressed. Solutions are suggested and the solvability of this important socio-political problem of the next decades demonstrated.

Perceptions of the role of the community psychiatric nurse

AIM

This small-scale study explores the self-perceived differences between the contributions of community psychiatric nurses (CPNs) and other members of a multidisciplinary community mental health team for older people.

METHOD

Four CPNs and five other professionals completed questionnaires consisting of a series of open-ended questions (initially designed for a semistructured interview) in order to collect qualitative responses. The questionnaires were analysed on a thematic basis.

RESULTS

CPNs' skills seemed to be recognised and valued by their multidisciplinary colleagues. However, the CPNs did not always appear to appreciate this, while the attributes identified by CPNs were not always the same as those identified by their colleagues. There did not appear to be any consensus among the CPNs yet their colleagues seemed to feel the CPN role was reasonably clear.

CONCLUSION

This study suggests the CPN role involves taking a relationship-based, person-centred approach in which adaptability and flexibility are key characteristics. The results are largely consistent with other findings and demonstrate the need to nurture the contributions made by CPNs as autonomous practitioners in multidisciplinary settings providing care for older people with dementia.

Exploring the role of the mental health nurse in community mental health care for the aged

There is currently considerable discussion about the impact of the aging population on the demand for health care services, however there is considerably less attention paid to the impact of mental health issues on the needs of the aged population. Nurses comprise the largest professional group within the mental health workforce in Australia. The availability of a high quality mental health nursing workforce will therefore be crucial to meeting the health needs of aging clients in the future, accompanied by an increased pressure to increase the proportion of care delivered in the community. There is however, a paucity of literature on the role and contribution of community mental health nurses specialising in the aged care field. The aim of this paper is to present the findings of a project designed to examine the role of mental health nursing within aged persons' community mental health teams in Victoria, Australia, with particular emphasis on the biopsychosocial interventions used. Fifteen participants from three community mental health services in Victoria participated in a focus group interview to share their insights and experiences. Data analysis revealed two main themes, the role of the nurse, and the specific functions of the nurse. This data is presented as a beginning contribution to the paucity of literature currently available in this important area.

The utility of CPD for older adult mental health nurses

AIM

To investigate how mental health nurses working with older adults perceive the benefits and realities of developing the outcomes of current continuing professional development training into actual clinical practice.

METHOD

A structured questionnaire was used with a convenience sample of nursing staff. Qualitative analysis was performed using a grounded theory approach in order to identify emergent themes, concepts and categories of data. Four randomly selected nurses were subjected to a voluntary semistructured interview using the questionnaire as a basis for information gathering.

RESULTS

The main reason for attending courses was developing skills. Of those attending courses, 42 per cent of qualified and 35 per cent of unqualified staff had a personal development plan (PDP) or individual performance review (IPR). Significantly, all unqualified staff who had not been on a course had no PDP or IPR. Learning was described as applicable to practice by 85 per cent of unqualified and 70 per cent of qualified staff. However, 28 per cent of unqualified staff and 20 per cent of qualified staff felt their practice had not changed as a result of their learning.

CONCLUSION

CPD can be a positive experience, providing nurses with the opportunity to direct their professional development.

Psychiatric outpatient consultation for seniors. Perspectives of family physicians, consultants, and patients/family: a descriptive study

BACKGROUND

Family practitioners take care of large numbers of seniors with increasingly complex mental health problems. Varying levels of input may be necessary from psychiatric consultants. This study examines patients'/family, family practitioners', and psychiatrists' perceptions of the bi-directional pathway between such primary care doctors and consultants.

METHODS

An 18 month survey was conducted in an out-patient psychogeriatric clinic of a Montreal university-affiliated community hospital. Cognitively intact seniors referred by family practitioners for assessment completed a satisfaction and expectation survey following their visits with the psychiatric consultants. The latter completed a self-administered process of care questionnaire at the end of the visit, while family doctors responded to a similar survey by telephone after the consultants' reports had been received. Responses of the 3 groups were compared.

RESULTS

101 seniors, referred from 63 family practitioners, met the study entry criteria for assessment by 1 of 3 psychogeriatricians. Both psychiatrists and family doctors agreed that help with management was the most common reason for referral. Family physicians were accepting of care of elderly with mental health problems, but preferred that the psychiatrists assume the initial treatment; the consultants preferred direct return of the patient; and almost 1/2 of patients did not know what to expect from the consultation visit. The rates of discordance in expectations were high when each unique patient-family doctor-psychiatrist triad was examined.

CONCLUSION

Gaps in expectations exist amongst family doctors, psychiatrists, and patients/family in the shared mental health care of seniors. Goals and anticipated outcomes of psychogeriatric consultation require better definition.

The Young Gerontological Nurse Clinician Program: an innovative geropsychiatric nursing recruitment strategy

Historically, graduate nurses are not attracted to older adults or geriatric care. Innovative strategies, such as the Young Gerontological Nurse Clinician Program (YGNCP) initiated by the John A. Hartford Center for Geriatric Nursing Excellence at the University of Iowa, are needed to promote geriatric nursing as a challenging and rewarding practice focus. The YGNCP, which provides early, positive, self-directed experiences for nursing students under the direction and supervision of faculty and expert clinical mentors, shows excellent potential for recruiting nurses to clinical and leadership positions in geriatric and geropsychiatric care.

New graduate orientation program in a geriatric psychiatric inpatient setting

With the geriatric population increasing, so will their needs for mental health care. However, attracting nurses to work with mentally ill older adults can be challenging. This article describes and illustrates methods successfully used by one hospital to attract, orient, and mentor new graduate nurses to work in geropsychiatric nursing--the New Graduate Residency Program (NGRP). The importance of supportive collaborative roles within nursing leadership staff is emphasized. Although the NGRP is a viable option for meeting the needs of older patients, additional strategies are needed to increase the numbers of geropsychiatric nurses overall, and these are discussed.

A geropsychiatric unit without walls

The continued population growth of people over the age of 65 correlates with the growth in the number of older people who experience a mental health crisis or frank mental illness. Currently there is a paucity of treatment programs that are specialized for the geropsychiatric patient. Given the limitations of finances and human resources as well as the constraints sometimes imposed by regulatory agencies, interdisciplinary health care workers are challenged to provide optimum care in traditional settings. This article describes how an inpatient psychiatric unit can be modified to replicate some of the best practices of a designated geropsychiatric unit with positive results.