As the American population ages, the associated risk of developing dementing and other disabling physical conditions is leading to increased attention to the role of long-term institutional care in managing patients with those conditions. Approximately 1.5 million, or 5% of the population over age 65, currently live in nursing homes; 20% to 50% of those over age 65 will eventually live in nursing homes at some point before death.1 The prevalence of psychiatric disorders in nursing homes is estimated to be as high as 80%. 2 There are several suggested explanations for this finding, which may reflect a general trend in nursing home populations. Among patients with dementia, the presence of noncognitive psychiatric symptoms such as agitation, delusions, and depression can increase the likelihood of nursing home placement.3 Moreover, studies in medically ill populations indicate that depression can predict persistent disability in conditions as diverse as cardiac disease,4 stroke,5 and hip fracture.6 This chronic disability can lead to nursing home admission.
Nursing home care developed out of the tradition of the almshouses and mental asylums of the 19th century. Subsequent changes in public policy have resulted in the evolution of a medically oriented care model. Contemporary nursing homes closely resemble general hospitals in architecture, epidemiology, and models of care.7 Patients are evaluated and treated by doctors and nurses in a nonacute medical setting. However, given the high prevalence of psychiatric disorders such as dementia and depression in nursing homes, the reality of nursing homes is that they more closely resemble the chronic mental institutions of past generations.
The management of psychiatric disorders such as dementia and depression lags far behind that of physical disorders in both sophistication and optimism in many nursing home settings. Therapeutic nihilism, often based on erroneous misconceptions of the aging process and mental illness, can lead to a purely custodial approach without regard for rehabilitation or active treatment. Nursing home care models that fail to address the psychiatric needs that so often arise in this population omit a major source of disability. The high prevalence of psychiatric disorders among nursing home residents is striking in that nursing home care typically is administered by internists or family practitioners and nurses with medical-surgical training. In the presence of significant behavioral and cognitive disturbances such as depression, hallucinations, delusions, and agitation, staff may feel overwhelmed by symptoms that they have not been trained to manage. In response, they may resort prematurely or inappropriately to physical restraints and sedating medications, resulting in limited benefits and unnecessary side effects and potential morbidity. Accurate psychiatric diagnosis and effective treatment is therefore a fundamental aspect of nursing home care.
The high prevalence of dementia in nursing homes has been recognized for over 30 years. Goldfarb8 found that 87% of nursing home residents had "chronic brain syndrome." The 1985 Nursing Home Survey9 found that 63% of residents had a dementing illness. The diagnostic reliability of this study was limited by the use of retrospective review of nursing records and interviews with nursing staff conducted by nonclinicians. Rovner et al2 studied 454 new admissions to eight nursing homes in the Baltimore area in an attempt to analyze psychiatric morbidity in nursing home residents and its effects on quality of life. Overall, 364 (80.2%) of the new admissions had a diagnosable psychiatric disorder, dementia being the most common (?z = 306, 67.4%). Primary dementia of the Alzheimer type accounted for 172 cases (37.9%). Multi-infarct dementia accounted for 81 cases (17.8%). Of the nondemented patients, 58 (12.8%) were depressed, and 11 (2.4%) had schizophrenia. Rovner et al2 also found that 122 (40%) of the demented patients suffered from noncognitive psychiatric symptoms such as depression or delusions, which complicated their management.
Tariot et al10 attempted to replicate these results by randomly sampling 80 nursing home residents, 73 (91%) of whom were found to have at least one psychiatric diagnosis. Dementia was present in 37 (46%) of the residents, and depression was present in 6 (7.5%). These and previous studies involving direct examination by clinicians suggest that dementing disorders are frequently underdiagnosed, misdiagnosed, or diagnosed in a way that fails to recognize treatable aspects of the illness.
Behavior problems occur in up to 64% of all nursing home residents.11 These noncognitive complications of dementia are themselves a risk factor for nursing home placement, accounting for the high prevalence of such behaviors in nursing homes.3 Rovner et al2 found that 40% of the demented patients in their nursing home sample had additional psychiatric symptoms such as delusions or depression. Behavioral symptoms are the most frequent reason for psychiatric consultation in nursing homes.12
Agitation appears to be related to cognitive impairment independent of age, gender, or duration of illness.13 The most common forms of agitated behaviors were general restlessness, pacing, complaining, repetitive sentences, negativism, requests for attention, cursing, and verbal aggression.14
Wandering as a behavior may be divided into four subtypes: exit-seekers, self-stimulators, akathesiacs, and modelers.15 Exitseekers attempt to leave the premises, while self-stimulators may simply manipulate doors as an activity in its own right. Akathesiacs wander due to restlessness, which may be perceived as agitation by others. Modelers follow other people around in an imitative fashion.
Delusions, occurring in up to 41% of patients with Alzheimer's disease, are a risk factor for violence in this disorder.16 Persecutory delusions are the most common psychotic symptom in Alzheimer's disease.17 Delusions usually occur around the fifth year of illness when the Mini-Mental State Exam18 score is around 12. 19
Depression, a complex condition ranging from simple uncomplicated bereavement to severe idiopathic mood disturbances, is frequently present in older adults. Most researchers have found an increasing risk of depressive symptoms with advancing age,20 especially in women.21 The Epidemiologic Catchment Area (ECA) Project, however, suggests that the discrete disorder of major depression is less common in later life.21 This discrepancy of findings has more to do with diagnostic criteria, because depressive disorders in the elderly may have atypical presentations that might not conform to standard criteria.22
The 1985 National Nursing Home Survey9 was conducted by review of medical records and nursing reports. The prevalence of depression was found to be 11%. In Katz and Rovner's23 review of 20 studies involving 4720 nursing home residents, they found that clinically important depressive symptoms were present in 30% to 50% of residents, while major depressive disorder was present in 6% to 25% of residents. Parmelee et al24 studied 277 residents of a multi-level care institution involving both a nursing home and apartment complex. Major depression was found in 24% of the cognitively intact and 10% of the cognitively impaired nursing home residents. It was present in 7% of the cognitively intact and 2% of the cognitively impaired apartment dwellers. This suggests that the highest risk for depression is in cognitively intact nursing home residents who have the greatest physical disability and burden of medical illness.
The incidence of depression in nursing homes has been studied far less than prevalence. Katz et al25 found a 14% incidence of major depression over a 6-month period, while Foster et al26 found a 14% annual incidence of any depressive disorder, the majority being minor depressions.
While behavioral and psychotic disturbances associated with dementia may lead to excessive treatment responses, depression is quite frequently undertreated. As few as 10% of nursing home residents who suffer from depression are treated with antidepressants; a larger percentage receive neuroleptics or benzodiazepines, and most receive no treatment at all.27 Rovner28 found that major depression was an independent risk factor for mortality, increasing the likelihood of death by 59% within 1 year after diagnosis. Moreover, depression in cognitively impaired individuals may cause cognitive dysfunction above and beyond the underlying dementia. This reversible dementia syndrome of depression is often clinically indistinguishable from irreversible dementia syndromes.
Depression tends to be manifest somewhat differently in the elderly, with more weight loss, psychomotor disturbances, and hypochondriasis, rather than guilt and sadness.22 This more "organic" presentation, complete with associated cognitive deterioration, may convince staff members that the individual is experiencing a natural, expected progression in his or her dementia. This can lead to underdiagnosis and undertreatment of a reversible condition, resulting in further disability. Because 60% of treated cases have recovered significantly at 1-year follow up,29 the failure to adequately treat depression represents neglect, which can lead to increased complications, even death.
PSYCHOTROPIC PRESCRIPTION PRACTICES IN NURSING HOMES
The high prevalence of behavioral disturbances among nursing home residents reflects the proportionately high prevalence of dementia and other psychiatric disturbances in this population. Accordingly, prescription of psychotropic medications is quite frequent in nursing homes. Rovner et al2 found that 34% of nonpsychotic demented nursing home residents received neuroleptics. Restlessness and wandering are a common reason for neuroleptic use,30 which can increase the risk of hip fractures31 and lead to further cognitive impairment.32 This raises concerns regarding the inappropriate or indiscriminate use of these medications.
While antipsychotic medications can be effective in the short-term management of agitation and wandering in demented patients, excessive and inappropriate use of these medications is common in nursing home settings. In order to curb the inappropriate and excessive use of psychotropic medications in nursing homes, the 1987 OBRA regulation restricted the use of neuroleptic and sedativehypnotic medications in nursing homes. Federal regulations now require that nursing home residents receiving neuroleptics have a specific psychiatric diagnosis and behavioral indications documented in their charts. This has resulted in a 36% decrease in neuroleptic usage without a concomitant increase in benzodiazepine prescriptions.33 Moreover, neuroleptic use can be reduced in nursing homes without compromising patient care.34 The use of behavioral and environmental interventions may reduce behavioral disturbances without the use of medications or physical restraints.
Nursing homes have evolved from the almshouses and mental institutions of the 19th century to subacute medical facilities. Unfortunately, due to lack of interest or to social stigma, the treatment of age-associated mental disorders has not kept pace. The high prevalence of psychiatric disturbances and high frequency of psychotropic medication prescriptions in nursing home populations demonstrates that nursing homes function as longterm psychiatric hospitals for the elderly. To provide comprehensive high-quality care, nursing homes need to develop programs designed to meet the psychiatric needs of their residents. In this way, they will come to increasingly resemble psychiatric hospitals of the present, rather than mental asylums of the past.
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