This 21 -bed geropsychiatric unit is part of the Johnston R. Bowman Health Center for the Elderly, a geriatric facility within RushPresbyterian-St. Luke's Medical Center. Here the psychiatric diagnoses most frequently encountered inelude major depression, dementia, bipolar disorder, anxiety disorders, and psychosis. The geriatric program is a multidisciplinary team consisting of physicians, nurses, social workers, occupational therapists, recreational therapists, and chaplains (Corbett, 1988).
No studies could be found where a geriatric-psychiatry unit had evaluated. However, the creation of specialized medical units for geriatrie patients has been proven to be worthwhile. Applegate (1983), Lefton et al (1983), Rubenstein et al (1984), and Collard et al (1985) have all provided evidence that patients on specialized medical geriatric units show greater improvement cornpared with those on nongeriatric units. Missner et al (1989) assessed geriatric patients' cognitive and functional status at admission and discharge and found an improvement in both cognitive and functional status for patients from the geriatric unit,
The concept of therapeutic milieu guided this research study. Gutheil (1985) lists three common elements of milieu therapy: staff and patients have an interactive impact on each other; defenses, regressions, and other mental operations are experienced by patients and staff, but usually in different ways both qualitatively and quantitatively; and the milieu process is dynamic, ongoing, and it requires vigilance and attention to preserve its therapeutic effect. Wilmer (1981) states that only therapeutic communities that generally focus on the here and now tend to be flexible and nonauthoritarian while still mamtaining authority, and offer some hope of providing valuable therapeutic contributions.
The therapeutic milieu is central to the treatment program of the geropsychiatric unit of Rush-Presbyterian-St. Luke's Medical Center. Individual treatment plans are fashioned within the context of the therapeutic milieu. Interdisciplinary meetings are held weekly for each patient. Regular groups held on the unit are a major part of the milieu and include community meeting, exercise group, women's group, psychotherapy, occupational therapy, art therapy, cooking group, religion and health group, reminiscence group, current events group, patient education, and sensory stimulus group. Staff use nonauthoritarian communication approaches and encourage patient participation in care planning and implementation. Patient government, a component of therapeutic milieu commonly used in long-term psychiatric settings, is not practiced due to our diverse population and shortterm treatment stay. Staff awareness of the therapeutic milieu plus staff cohesiveness, which serves as a role model for the patients, are important parts of preserving the therapeutic effect.
The purpose of this pilot study was to measure the effect of the therapeutic milieu on the cognitive and functional status of the geropsychiatric patient. It was hypothesized that there would be a positive change in the geropsychiatric patient's cognitive and functional assessment scores between admission and discharge, and 2 weeks after discharge.
The pilot study was conducted on the geropsychiatry unit over a period of 6 months. Initially, every patient admitted to the unit was included in the study. However, after 3 months, the research team altered the study criteria to include every second admission. This criterion was changed due to the increased frequency of admissions and discharges and the decreased length of stay. A total of 57 subjects successfully completed the study out of the 87 subjects admitted. Inability to complete the study resulted from subjects' acute medical crises, patient refusal, or the inability of researchers to collect the data within the time frame allowed.
Of the 57 subjects in the sample, 11% were men and 89% women. The average age of the participants was 78.5 years. The most frequent diagnosis was major depression (75%), with bipolar disorder (13%) and psychosis or psychotic depression (12%) following. The most common concurrent medical diagnoses included dementia (33%), hypertension (10%), and noninsulin dependent diabetes mellitus (8%). Multiple medical diagnoses were common. The length of hospital stay ranged from 8 to 52 days, with an average of 28 days.
The Mini Mental Status Exam (MMSE) was used to assess the cognitive function of the geriatric patient (Folstein, 1975). The MMSE tests orientation, registration, recall, and language. The MMSE was administered within 24 hours after admission and again within 48 hours of discharge. These windows were selected to measure the change in cognitive function over the course of hospital stay. To ensure inter-rater reliability, the nurses on the research team underwent a series of sample administrations before the study began, including two nurses giving the exam to the same subject and then comparing scores. In addition, meetings were held bimonthly to maintain an average inter-rater reliability of 86.3%.
The Geriatric Psychiatry Nurse Rating Scale (GPNRS) (Tindale, 1987) was used to assess functional changes over the course of the hospital stay. The GPNRS is a teamoriented assessment tool specifically designed to measure functional change for geropsychiatric patients. It includes 16 categories ranging from the ability to feed oneself and complete activities of daily living to the ability to communicate. To ensure the content validity of this scale, the subject's primary nurse was consulted to determine the subject's ability to function in the 16 categories. The research team administered the GPNRS three times: within the first 5 days of admission, within 5 days prior to discharge, and within 2 weeks after discharge. For the postdischarge interview, the researchers telephoned the patient's primary caregiver to obtain the needed information. The windows for the GPNRS were wider than those for the MMSE because a longer period was needed to observe the subject to adequately assess all 16 categories.
Level of Change in MMSi Stores: From Admission To Discharge
The data supported the hypothesis that there would be a positive change in geropsychiatric patients' cognitive and functional assessment scores during and after hospitalization.
Figure 1 shows the amount of change in the MMSE scores between admission and discharge. The range of MMSE scores on admission was between 1 and 30, with an average of 22. The range of scores on discharge was between 2 and 30, with an average of 24. The largest percentage of the sample (40%) demonstrated a slight improvement, an increase of between 1 and 5 points.
Figure 2 shows the amount of change in the GPNRS scores between admission and discharge. The range of scores on admission was between 3 and 32, with an average of 17. The range of scores on discharge was between 0 and 28, with an average of 9. Again, the largest percent of the sample showed a slight improvement, a decrease of between 1 and 10 points. Note the difference between the two scales: when MMSE improves, scores decrease, whereas the reverse is true for the GPNRS.
Figure 3 shows the amount of change in GPNRS scores between discharge from the hospital and the 2week follow-up assessment. The range of scores was between 1 and 33, with an average of 7. The same five categories were used as in Figure 2, and again, the largest percentage of the sample (68%) demonstrated a slight improvement of between 1 and 10 points. A total of 20% had already begun to demonstrate a slight decline within the 2week period. The MMSE was not included in the 2-week follow-up assessment as it could not be conducted over the phone or with the primary caregiver.
IMPLICATIONS FOR CARE __________
This study addressed the problem of how to evaluate a geropsychiatric treatment program more objectively. Data suggested a positive change in the geropsychiatric patient's cognitive and functional assessment scores.
The authors strongly recommend that geropsychiatric units make the MMSE part of the initial database collected on admission. This database would give staff an objective measure of each patient's initial cognitive status. In addition, staff could differentiate between dementia and pseudodementia by comparing the admission and discharge scores. For example, in dementia, the MMSE scores do not change markedly during hospitalization, whereas in pseudodementia, a marked improvement is usually found in the discharge score.
Level of Change In GPHHS Stores: From Admission To Discharge
Level of Change In GPNRS Stores From Discharge To 2-Week follow-up
Implications for care can be seen from the MMSE profiles. For example, the data verify a decline in the MMSE scores for those patients who received electroconvulsive therapy. Therefore, staff could expect that those patients receiving electroconvulsive therapy would need a more supportive and structured milieu during their treatments. Conversely, the data showed consistent improvement in the MMSE scores for psychotic, depressed patients. Thus, staff could anticipate that those patients would need a more challenging milieu as their hospitalization progressed.
Other implications for care were found with the data collected from the GPNRS. The data suggested a consistent improvement in the functional abilities of severely depressed patients as their symptoms of depression began to improve. Staff could then expect that these patients could meet increased expectations as their depression lifts. The data also suggested an impressive functional improvement in demented, depressed patients. Thus, staff could expect a functional improvement in these patients even though they continue to need a structured, supportive milieu.
To obtain more accurate data for the GPNRS, the authors felt a wider window was needed than the first 5 days after admission. The authors suggest that an initial assessment be done on the first day with an update on the seventh day. Also, reliability was questionable for the postdischarge data because this assessment was often done either by staff who did not know the patient well or by caretakers at home who seemed overly optimistic. Future researchers should consider having the same staff member personally evaluate the patient on and following discharge.
An important by-product of this study is that the unit Quality Assurance Committee plans to use the GPNRS as a patient outcome indicator, using both admission and discharge scores. In addition, when staff have a concrete, early assessment of the patient's functional status, they can more accurately determine whether initial discharge plans are appropriate.
This pilot study suggested that patient outcome on a specialized geropsychiatric treatment program can be measured by the methods described above. The major question that remains is now that the effectiveness of the program has been documented, what is its most effective aspect? An additional puzzle is the decline of 20% in functional capacity only 2 weeks after discharge. These and other questions should form the basis for future research studies. In particular, this pilot study should be repeated on another geropsychiatric unit and with a larger number of patients.
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