There is now overwhelming evidence from previous studies, many of which are cited in this edition of Psychiatric Annals, that the prevalence of psychiatric illness and the levels of behavioral disturbance in residents of nursing homes are very high. For example, three recent studies have reported that 91% to 94% of nursing home residents suffer from mental illnesses with dementia being the most common diagnosis.1"3 In addition, these studies have also reported high levels of behavioral disturbances, with 66% to 91% of residents exhibiting at least one maladaptive behavior. These data have led some authors to conclude that the nursing home has replaced the state psychiatric hospital as the primary source for residential psychiatric care for the elderly.4
Despite these high levels of psychiatric illnesses, few patients residing in nursing homes receive any formal psychiatric or mental health consultation. In a national nursing home survey, only 2.3% of nursing home residents had contact with a mental health professional during the previous month.5 Several factors have been proposed to explain the apparent barrier to the receipt of mental health care in this setting. These include the frequent lack of mobility of these patients so that they are unable to attend outpatient clinics, poor Medicare reimbursement for nursing home consultation, and the historically widespread view that such patients are untreatable and/or terminal. The current high unmet demand may become even more pronounced given the projected aging trends of our population, particularly in the very old.6 In 1988, the American Psychiatric Association Task Force on Alzheimers Disease concluded that psychiatrists had unique skills that make them indispensable to the care and management of patients with Alzheimer's disease and urged them to adjust their practices so that they could provide care for these patients in nursing home settings.7
The 1987 Omnibus Budget Reconciliation Act (OBRA)8 makes it more likely that nursing homes will request the services of psychiatrists in an attempt to meet the regulations included in this legislation. OBRA specifies, for example, that the prescription of neuroleptics in nursing homes has to be deemed appropriate by a physician, and more and more nursing home and primary care physicians are requesting the help of psychiatrists in making this determination. Even though this request for psychiatric services may be quite focused, it does give the psychiatrist the opportunity to demonstrate the benefit of psychiatric consultation for the residents of the nursing home.
OBRA also requires that patients with severe nonorganic mental disorders not be placed in nursing homes unless they require nursing care, in a laudable attempt to prevent "warehousing." However, in view of the magnitude of mental disorders found in nursing homes, it appears that this particular mandate is not having the effect of reducing the needs for mental health services in these settings. An unfortunate side effect of this legislation may be to provide less funding for these services in the erroneous assumption that mental illness is not common in nursing homes.9
The remainder of this paper will discuss the potential role for psychiatrists in nursing home settings.
THE PSYCHIATRIST AS "CONSULTANT"
Herst and Mouton10 have identified the consultant role as "the most familiar model" for provision of psychiatric services to nursing homes. They also contend that it may be the most effective and inexpensive means of providing quality psychiatric care. The psychiatrist/consultant benefits patients primarily by providing an accurate psychiatric diagnosis and making appropriate treatment recommendations. Underdiagnosis and misdiagnosis of psychiatric illness is common in nursing homes. Teter et al11 reported that of 63 patients who received psychiatric diagnoses using a semistructured evaluation format, two thirds had no psychiatric diagnosis recorded in their charts. Barnes and Raskind12 found that of 64 nursing home patients who met DSM-IIIR criteria for dementia and who had been evaluated as part of a study of memory loss in patients in nursing homes, 30% had no diagnosis recorded in the chart, 8% had an inaccurate diagnosis, and 39% had an inadequate, nonspecific diagnosis.
In addition to the problem of misdiagnosis, the geropsychiatrist can provide expertise in multimodal treatment approaches. There is now considerable evidence that psychotropic medications are overused or inappropriately used in nursing home populations,13"15 and that this practice can be associated with functional impairment as a result of the side effects of the medication. In one study, half of the nursing home residents receiving neuroleptic drugs were considered ineligible by HCFA guidelines.16 It was unclear, however, whether this represented true overuse or simply poor documentation. In a study examining the prescribing practices of 306 physicians attending in nursing homes in the Los Angeles area, Beers et al17 reported that those physicians who consulted regularly with psychiatrists had significantly fewer inappropriate prescriptions.
Significant problems have also been reported with the overuse of physical restraints in nursing home populations. In addition to increasing morbidity, Miles and Irvin18 have calculated that at least 1 of every 1000 nursing home deaths is due to the use of physical restraints and that this contribution is underrecognized, underreported, and avoidable. Physical restraints are also associated with the loss of autonomy and dignity of the resident. Nonpharmacological approaches to behavioral problems are often more appropriate for behavioral control. The psychiatrist should be adept at recognizing contributions of comorbid conditions and medication toxicity to behavioral disturbance. Other nonpharmacologic approaches are discussed in more detail in an accompanying paper in this journal.19
Group therapies may be particularly suited to the nursing home setting. These groups may take a variety of forms, from a structured activity group to a therapy group focusing on emotional or interpersonal issues. These groups must be targeted toward the appropriate functional capacity of the patient population being served. Group therapy may be led or co-led by the psychiatrist, or the psychiatrist may train group leaders among the other staff members. Ongoing supervision of the group leader should be provided in the latter case, especially when less concrete issues or structured tasks are being used. Even demented individuals may benefit from groups focusing on support, reality-orientation, recreation, and social interaction.20 Other group formats may include reminiscence or life review as proposed by Butler,21 or groups focusing on issues of grieving or loss.
Although brief individual supportive psychotherapy may be used frequently by a consultant, more intensive individual therapy is usually not possible in this setting due to time and reimbursement constraints. Psychosocial interventions, such as support groups focused toward family members of nursing home residents, may be helpful for both family members and patients. It may also reduce displaced anger directed toward the facility by family members who feel guilty about placing their loved one in an institution.
Several models for providing psychiatric consultation have been described. The simplest one is for the psychiatrist to provide individual consultation on a scheduled basis in which the nursing home staff present problem cases.22 One variant of this model is to provide primary consultation to the nursing home through the services of clinical nurse specialists with the geropsychiatrist providing ongoing supervision of the nurse and on-site consultation when needed.23
More comprehensive approaches have been proposed involving the establishment of multidisciplinary teams of psychiatrists, psychologists, nurses, social workers, occupational and recreational therapists, as well as representatives from other nursing home staff.24 In large and well-funded nursing home facilities, these teams can be constructed from the full-time staff of the nursing home with the psychiatrist acting as team leader.
A more common model, often associated with community mental health centers, is to establish a small multidisciplinary team of nurses and social workers who visit the nursing homes in their catchment area on a regular basis and who establish care plans for individual residents in conjunction with the nursing home staff!25 In this model, the geropsychiatrist often acts as the consultant/backup to this team. Some academic centers have incorporated training of psychiatric residents or geropsychiatric fellows as part of their nursing home consultation.26
THE PSYCHIATRIST AS "EDUCATOR"
The majority of staff in nursing home settings have been characterized as having "poor training, low pay, high turnover rates, and low job satisfaction."27 Consequently, staff education has been identified as an important element of a consultation model.23'28 TourignyRivard and Drury22 evaluated the benefits of monthly psychiatric consultation to a 50-bed nursing home. They noted that all staff surveyed commented on the benefits of the educational component and concluded that positive changes were "due primarily to the impact of the consultation on the staff, rather than as a result of the resident-consultant interaction itself They also reported an increase in referral of depressed patients, which the authors interpreted as reflecting staffs increased sensitivity to "the emotional needs of the resident."
Szwabo and Stein29 noted high levels of burnout in the staff of long-term care facilities associated with negative public views of nursing homes, low pay, confrontation of personal fears of aging, and limited training. They propose that these factors have a negative influence on the care being provided to the residents, including indifference to the residents' complaints, stereotyping, infantilization, and physical or verbal abuse. By providing education to staff about the psychiatric problems and appropriate therapeutic strategies, the psychiatric consultant may reduce stress by increasing their sense of mastery. In addition, the consultant may assist the staff workers in developing their own techniques of coping and stress reduction.
Sakauye and Camp26 also perceived staff education as a central component to their consultation model. One of their major themes has been to enhance staff understanding of the etiology and management of the behavioral disturbances exhibited by the nursing home patients, particularly those residents with dementia. By increasing understanding of the disease process, the staff are able to manage these behavioral disturbances in a more appropriate manner. For example, staff often attempt to correct problem behavior in demented patients by trying to reason with them when a more indirect approach such as distraction may be more productive.
THE PSYCHIATRIST AS PRIMARY CARE PHYSICIAN/ ADMINISTRATOR
As had been argued in the past for mental hospitals, it has been suggested by some authorities that psychiatrists may function well in nursing home settings as primary care physicians or administrators because of the high levels of mental illness and behavioral disturbances found in nursing home residents.
According to Gurlund et al,30 in the role as primary care physician, the psychiatrist may be in a better position to reduce the administration of multiple medications that may have cumulative deleterious effects on mental status, may recognize more accurately physical symptoms due to depression, may use psychotropic medications more appropriately, and may be able to reduce morbidity and mortality by lowering the frequency of sedative and other adverse side effects of medication. Psychiatrists may make ideal medical directors because their psychotherapeutic skills may assist staff members in dealing empathetically with difficult patients and in accepting their roles as caretakers. This role may be particularly useful in dementia special care units. Stream and Katz have summarized the responsibilities of a psychiatrist in this role as including formulating policy, guiding program development, advising on environmental design, coordinating clinical services, offering staff support and education, and assisting in compliance with regulatory requirements.31
RESEARCH IN NURSING HOMES
Despite the very high levels of mental illness in nursing homes, until recently, very little psychiatric research was being conducted at these facilities. This is now changing. Examples of recent studies include the epidemiologie studies previously cited in this paper.1"3 In addition, a large multicenter trial is currently underway to evaluate the efficacy of buspirone in reducing agitation in demented patients in nursing homes (K. Sakauye, personal communication). However, there remains a great need for further research, particularly with regard to interventions to help the depressed and agitated patient. Information on pharmacological or nonpharmacological treatment approaches for nursing home patients from controlled studies is still minimal.
High prevalence rates of mental illness and historically low involvement of mental health professionals suggest a great need for an increased psychiatric presence in the nursing home setting. The psychiatrist may influence patient care not only by direct consultation and treatment of patients, but also through staff education and support. The guiding principles of a psychiatric consultation program to nursing homes were elegantly summarized recently by Sakauye and Camp.26 These included emphasizing the humaneness of patients, assuming that no behavior is random, looking for depression or psychosis as a source of problems, reducing medication or medication doses, creating a home-like environment, and using the residual skills of the demented patient to create a therapeutic program.
1. Rurner BW, Kafonek S, Filipp L, et al. Prevalence of mental illness in a community nursing home. Am J Psychiatry. 1986; 143:1446-1449.
2. Chandler JD, Chandler JE. The prevalence of neuropsychiatrie disorders in a nursing home population. J Geriatr Psychiatry Neurol. 1988; 1:71-76.
3. Tariot PN, Podgorski CA, Blazina L, Leibovici A. Mental disorders in the nursing home: another perspective. Am J Psychiatry. 1993; 150:1063-1069.
4. Schmidt LJ, Rheinhardt AM, Kane RL, et al. The mentally ill in nursing homes: new back wards in the community. Arch Gen Psychiatry. 1977; 34:687-691.
5. Burns BJ, Wagner HR, Taube JE, et al. Mental health service use by the elderly in n ursing homes. Am J Public Health. 1993; 83:331-337.
6. Russell L. An aging population and the use of medical care. Med Care. 1981; 19:633-643.
7. Caine ED, Borenstein JA, Goldstein MZ, APA Task Force on Alzheimer's Disease. The Alzheimer's disease imperative: the challenge for psychiatry. Am J Psychiatry. 1988; 145:12. Editorial.
8. Omnibus Budget Reconciliation Act of 1987, Public Law 100-203.
9. Drinka PH, Howell T. The burden of mental disorders in the nursing home. J Am Geriatr Soc. 1991; 39:730-733. Letter.
10. Herst L, Moulton P. Psychiatry in the nursing home. Psych ¿at r Clin North Am. 1985; 8:551-561.
11. Teeter RB, Garetz FK, Miller WR, Heiland WF. Psychiatric disturbances of aged patients in skilled nursing homes. Am J Psychiatry. 1976; 133:1430-1434.
12. Barnes RF, Raskind MA. DSM-III criteria and the clinical diagnosis of dementia: a nursing home study. J Gerontol. 1980; 36:20-27.
13. Ray WA, Federspiel CF, Schaffner W. A study of antipsychotic drug use in nursing homes: epidemiologie evidence suggesting misuse. Am J Public Health. 1980; 70:485-491.
14. Beardsley RS, Larson DB, Burns BJ, Thompson JW, Kamerow DB. Prescribing of psychotropics in elderly nursing home patients. J Am Geriatr Soc. 1989; 37:327330.
15. Thapa PB, Meadow KG, Gideon P, Fought RL, Ray WA. Effects of antipsychotic withdrawal in elderly nursing home residents. JAm Geriatr Soc. 1994; 42:280-286.
16. Garrard J, Makris L, Dunham T, et al. Evaluation of neuroleptic drug use by nursing home elderly under proposed Medicare and Medicaid regulations. JAMA. 1991;265(4):463-467.
17. Beers MH. Fingold SF, Ouslander JG, et al. Characteristic and quality of prescribing by doctors practicing in nursing homes. JAm Geriatr Soc. 1993; 41:802-807.
18. Miles SH, Irvine P. Deaths caused by physical restraints. Gerontologist. 1992; 32:762-766.
19. Hall GR, Gerdner L, Zwygart-Stauffacher M, Buckwalter KC. Principles of non-pharmacological management: caring for people with Alzheimer's disease using a conceptual model. Psychiatric Annals. 1995; 25:430438.
20. Gerber GJ, Prince PN, Snider HG, et al. Group activity and cognitive improvement among patients with Alzheimer's disease. Hosp Community Psychiatry. 1991; 42:843-845.
21. Butler R. Psychiatry and the elderly: an overview. Am J Psychiatry. 1975; 139:893-900.
22. Tournigny-Rivard MF, Drury M. The effects of monthly psychiatric consultation in a nursing home. Gerontologist. 1987; 27:363-366.
23. Santmyer KS, Roca RP. Geropsychiatry in long-term care: a nurse-centered approach. J Am Geriatr Soc. 1991; 39:156-159.
24. Lieff JD, Brown RA. A psychogeriatric nursing home resocialization program. Hosp Com.mu.nity Psychiatry. 1981; 32:862-865.
25. Pavkov JR, Walsh J. For nursing homes: a mental health charting instrument. J Gerontol Nurs. 1981; 7:13-20.
26. Sakauye KM, Camp CJ. Introducing psychiatric care into nursing homes. Gerontologist. 1992; 32:849-852.
27. Spore DL, Smyer MA, Cohn MD. Assessing nursing assistants' knowledge of behavioral approaches to mental health problems. Gerontologist. 1991; 31:309-317.
28. Borson S, Liptzin B, Nininger J, Rabins P. Psychiatry and the nursing home. Am J Psychiatry. 1987; 144:1412-1418.
29. Szwabo PA, Stein AL. Professional caregiver stress in long-term care. In: Grossberg GT, Szwabo PA, eds. Problem Behaviors in Long-Term Care: Recognition, Diagnosis, and Treatment. New York, NY: Springer Publishing; 1993.
30. Gurland B, Toner J, Mustille A, et al. The organization of mental health services for the elderly. In: Lazarus LW, ed. Essentials of Geriatric Psychiatry: A Guide for Health Professionals. New York, NY: Springer Publishing; 1988.
31. Streim JE, Katz IR. The psychiatrist in the nursing home, part II: consultation, primary care, and leadership. Psychiatric Services. 1995; 46(4):339-341.