lntwmwtd Psychogeriatrics,Vol.4, No.2,1992 d 1992 Springer Publishing Company
Inappropriate Placement of Residents in Psychiatric Nursing Homes in Bergen, Norway Harald A. Nygaard, KBre J. Bakke, and Tor Jacob Moe ABSTRACT. The mental and physical capacitiesof all residentsin psychiatric nursing homes in Bergen were studied. It was found that 95% were moderately or severely mentally impaired and 53% received antipsychotic medication regularly. By objective criteria, 47.9% were considered improperly placed. These patients typically had had a long stay in the institution, were immobile, and were given antipsychoticdrugs infrequently.
The number of mentally impaired elderly, the majority of whom are demented, is increasing due to the rising number of elderly in the community. A substantial proportion of this part of the population is cared for in institutional settings, such as homes for aged people, somatic nursing homes (nursing homes for physical illness) and psychiatric nursing homes (Adolfsson et al.,1981; Dehlin & FranzCn, 1985; Mann et al.,1984; Nygaard et al.,1987). Anticipated growth in the number of persons with senile dementia led to a Parliament proposition in 1974 to extend psychiatric nursing home facilities in Norway by about 50%. rather than reducing psychiatric hospital capacity, as had been intended (Stortingsmelding, 1974). Thus, the need for psychiatric services in nursing homes was clearly indicated. Up to 1987, the actual increase in nursing home capacity was approximately 15% (Central Bureau of Statistics of Norway, 1989). Increasingly, demented patients have been referred to somatic nursing homes, where the proportion of demented residents has increased (Nygaard, 1991). Of all moderately to severely mentally impaired patients who were institutionalized, 9% had gone to live in psychiatric nursing homes, and 85% resided in somatic nursing homes or homes for the aged (Nygaard et al.,1987). From Bergen Kommune, Bergen-Fyllingsdden,Norway (H. A. Nygaard, MD, K. J. Bakke. M D and
T. J. Moe. MD). 26 1
262
H . A. Nygaard,K.J . B&,
and T. J . Moe
In general, in Norway no medical profession feels responsible for this group of demented patients. By definition, somatic nursing homes are not intended for any particular patient group. A need for nursing care is the main reason for admission to a somaticnursing home. Hence, mentally impaired persons are admitted because they require assistance and monitoring. A considerable number of these patients have a disturbing behavior, and approximately 5% were considered in need of psychiatric nursing care (Nygaard et al., 1987). Recently, efforts have been undertaken to define which problems associated with dementia should fall into the domain of psychiatric nursing homes in our county. It was decided that demented patients should meet the following criteria: “Continued deranged behavior disturbing others; demented patients who also develop psychotic symptoms; aggressive behavior which can be a danger to other patients; and patients who make intense efforts to leave the present place of living on hisher own without being able to take care of themselves.” Furthermore, a prerequisite is the inability to properly meet the patient’s needs in his or her present location (Fylkeshelsesjefen i Hordaland, 1988). The aim of this investigation, then, was to study and to evaluate characteristics related to improperplacement of patients living permanently in psychiatricnursing homes.
MATERIAL AND METHOD The city of Bergen, the second largest in Norway, has a population of approximately 207,000. Of this group, 10.7% are above 70 years of age. This study uses information taken from the results of a census performed during Week 6 in 1985 in Bergen. The census included all residents in long-term-care facilities, patients in a general hospital, awaiting placement in a nursing home, and persons over age 50 receiving home nursing (Nygaard et al., 1987). This report focuses on those patients permanently admitted to apsychiatric nursing home (n = 121.86 men and 34 women; and one patient whose gender is unknown). General demographicinformation was collected and the patients were assessed by the nurse in charge. A patient’s mental capacity was determined by means of the Clinical Dementia Rating scale (CDR) (Hughes et al., 1982; Nygaard et aL.1987). The CDR scale is a global rating scale consistingof six items: memory, orientation, judgment and problem solving, community affairs, home and hobbies, and personal care. Patients are assigned a rating of healthy (CDR = 0), “senescent forgetfulness” (CDR = OS), mild dementia (CDR = l), moderate dementia (CDR = 2). or severe dementia (CDR = 3). For estimating activities of daily living (ADL) and behavior, we used a workload scale (Adolfsson et al., 1981; Nygaard et al., 1987) consisting of seven items: bladder and bowel functions, ability to eat, motor function, hygiene, dressing, and behavior. Behavior was divided into the following groups: normal, apathetic, anxious, restrained, wandering/restless/aggressive. For the present purpose, all
Inappropriate Placemenls in Psychiatric Nursing Homes
263
items were dichotomized whether or not a patient was dependent. The item behavior was divided into patients who were wandenng/restless/aggressive and those who were not. All psychotropic drugs regularly prescribed were registered. The classification was performed according to the Anatomical Therapeutic Chemical Classification Code (ATC classification) Defined Daily Doses (DDD) (WHO Collaboration Centre for Drug Statistics MethodologylNordicCouncil on Medicines, 1990).The groups of psychotropic drugs were antipsychotics (NOSA), anxiolytics (N05B), hypnotics/sedatives (N05C), and antidepressants (N06A). Finally, the nurse in charge was asked to judge whether the patient was treated on an appropriate care level. The principles for proper placement of demented patients with disturbed behavior (Fylkeshelsesjefen i Hordaland, 1988) were determined after this study had been performed. Yet, we wanted to approximateour judgment to these criteria, which principally attempt to prevent the admission to a psychiatric nursing home unless a patient’s symptoms are constantly disturbing to others. This also applies to psychotic symptoms. Usually, demented patients with a wandering, aggressive, or restless behavior are most frequently the applicants for admission to a psychiatric nursing home. We considered patients with these traits to correspond to the given definition for inappropriate placement. Nonparametnc tests were used for statistics: a chi-square test with Yates’ correction, Fisher’s exact test when minimum estimated expected values were below 20, Cohen’s kappa test, and the Kruskal-Wallis test. Factors which in univariate analyses were significantly associated with inapproprate placement 0,c 0.05) were further analyzed in a stepwise logistic regression analysis. For this purpose, the duration of the patient’s stay was categorized. The median age of the patients was 82 years (range 47-96 years) and the median duration of stay was 26.8 months (range 0.03-155.2 months). Of the patients studied, 29 (24%) had stayed for less than one year. Two patients had been assigned a rating of CDR-0.5, four a rating of CDR-1, five a rating of CDR-2, and 110a rating of CDR-3. Twenty-two patients were continent for urine and 27 for feces, 61 were fed, 56 were independently mobile, 119 were dependent for hygiene and 104 were dependent for dressing. Regarding medications, 63 patients (52.1 Or,) used antipsychotic drugs, 10patients (8.3%)used antidepressants,eight patients (6.6%) used hypnoticlsedatives, and 5 patients (4.1 %) used anxiolytics.
RESULTS According to our definition, 58 patients (47.9%) were improperly placed. In the univariate analyses, inappropriately placed patients were significantly older and had stayed longer in the institutions than patients who were considered to be at an appropriate care level. Of the registered ADL functions, improper placement was associated only with impaired mobility; furthermore, it was inversely associated with the use of an antipsychotic drug (Table 1).
H.A . Nygaard, K.J . BaGke. and T. J . MIX
264
The results from the stepwise logistic regression analysis are shown in Table 2. The chance of being inappropriately placed increased with length of stay. In addition, the odds for improper placement were 3.4times higher for patients living four years or more in an institution than for patients who stayed less than two years. Further, immobile patients had odds for inappropriate placement that were 2.9 times those for mobile ones, while patients using antipsychotic drugs were 0.4 times more likely than nonusers to be placed improperly. Twenty-two patients (18.2%) were considered by the nurse in charge to be inappropriately placed. Of the 58 who by objective criteria were placed improperly, 20 were alsojudged by the nurse to be so. The agreement between the nurse and the objective criteria of being misplaced was poor (kappa = 0.32). Statistically there was no difference in any item registered between these 20 and the 38 patients not deemed inappropriately placed.
DISCUSSION Nearly half of all the patients were placed inappropriately when objective criteria for proper placement in a psychiatric nursing home were applied. We consider that the results correspond well with the standards set up for the function of a psychiatric nursing home. Deranged and aggressive behavior was used as the independent variable in our calculations. Compromised mobility prevented the patient from making efforts to leave his or her present living place, and the reduced usage of antipsychotic drugs must be regarded as an indication that neither psychotic symptoms nor the disturbing behavior are prominent any more. Psychiatric nursing homes are intended for psychiatric patients in need of specialized long-term care, but at a level lower than that provided in a mental hospital. It is further assumed that demented patients cannot be cared for in a general nursing home. The homes are apart of the general psychiatric services, with TABLE 1. Factors which in Univariate Analyses were Significantly Associated with Inappropriate Placement in a Psychiatric Nursing Home Appropriately . Inappropriately Placed Placed (n = 5 8 ) (n = 63) Age’ (median) (p = 0.02) Duration of stay’ (months, median) Mobility’ ( p = 0.0) Independent Dependent Antipsychotic drugs’ (p = 0.0004) No Yes
80.0 20.4
83.0 35.2
41 22
43
20 43
38 20
15
1) Kruskal-Wallis test. 2) Chi-square test with Yates’ correction.
InappropriatePlacemeas in Psychiatric Nursing Homes
265
a psychiatrist in charge of the medical services. The majority of the personnel has a nursing function and, until now, their task has been characterized by custodial care. The staffing has been poor (nursing personnel/patients = 0.37) (Ogar, 1983). although there has been some improvement in recent years. Usually patients move to a different facility when their physical dependency exceeds the level of care that can be given in a psychiatric nursing home. These factors may explain the poor agreement between the applied criteria for improper placement and the nurses’ judgment. In the present study, 95% of the residents in psychiatric nursing homes were moderately to severelymentally impaired. In anational survey, 22% of all residents in psychiatric nursing homes and 16% of those in psychiatric hospitals were demented (Ogar, 1983). On the other hand, only 5% of the patients in the local psychiatric university hospital were demented (Arsmelding Haukeland Sykehus, 1984). Our findings were later confirmed by an independent survey performed by the local health authorities (Fylkeshelsesjefen i Hordaland, 1988). One may speculate that the psychiatric nursing homes in this region have developed a complementary function, compensating for the small number of demented patients accepted in general psychiatry. The function in Norway of psychiatric nursing homes as a part of the psychiatric services seems quite unclear. To our knowledge, only Ogar (1983) has tried to describe their function, giving examples of different models that have been tried in various places. Their objectives are presented rather broadly, and a rational use of psychiatric nursing homes within the entire caring system for the demented is not discussed. The anticipated rise in the number of demented elderly as a justification for further increase of psychiatric nursing home facilities (Stortingsmelding, 1974) seems to be neglected. Somatic nursing homes are the main health care setting for serving persons with advanced physical and mental dependency. Their proper functioning assumes that patients who do not fit into this system are helped by adjacent care levels. Despite the current trend of establishing sheltered units within somatic nursing homes for demented patients with disturbed behavior, the need for more specialized psychiatric treatment and care still prevails. In this respect, patients with severely TABLE 2. Logistic Regression Analysis for Factors Associated with Inappropriate Placement in a Psychiatric Nursing Home Factor Duration of stay 2-4 years 2 4 years Diminished mobility Antipsychotic drug use *) p
< 0.05.
Beta
SE
0.604 1.231 1.076 -0.938
0.491 0.542 0.448 0.428
Odds Ratio
95% Confidence
1.8
0.7-4.8 1.2-9.9 1.2-7.1 0.2-0.9
3.4* 2.9* 0.4*
Interval
266
H . A , Nygaard, K.J . Bakk.e, and T. J . Moe
disturbed behavior are important. In most patients the symptoms will subside and specialized care can be terminated. One may object that moving from one place to another can have a negative impact on the elderly patient. However, careful planning of the move has been shown not to be associated with increased mortality (Gutman & Herbert, 1976). In London, the same experiences occurred when mentally infirm elderly were relocated in response to the closure of a mental hospital (L. Simpson, personal communication, 1988). Services to the elderly are organized differently in most countries, making a comparison across nations difficult. However, the care of elderly with disturbed behavior seems to be a general problem in several western countries. In Sweden, long-term care of the demented elderly has mainly become the field of geriatric medicine, yet 19.5% of institutionalized demented had been placed in psychiatric institutions (Pauseret al., 1989). In Denmark, Gulmann (1989) estimated a similar number to be in psychiatric care and the waiting time for transfer from a psychiatric hospital to somatic long-term care was almost one year (JBrgensen et al., 1990). In Great Britain, the mobility of the patient determines whether psychiatric care is justified (Godber, 1987). Also, there seems to be a general need for better transfer of patients among the various care levels. In an English study 90%of elderly patients in psychogeriatric hospitals were deemed inappropriately placed (Donaldson, 1983); their characteristics were similar to those in the present study. Kirk et al. (1989) defined criteria for the use of all institutional care levels in Ireland, finding that approximately 60% of the residents in psychogeriatric institutions were inappropriately placed. In Ogar’s study (1983) 18% were considered inappropriately placed, though criteria for determining this are not mentioned. Lack of agreement regarding where to treat demented with severely disturbed behavior may also reinforce the impression that patients who are admitted to psychiatric nursing homes are stigmatized as “psychiatric,” thus blocking further rational treatment, even if their initial behavioral disturbances abate. A more rational use of psychiatric nursing homes will probably also contribute to an improved environment in somatic nursing homes, where several patients are reported to be in need of psychiatric care (Brochmann, 1987;Nygaard et al., 1987).
CONCLUSION The care of demented persons demands a variety of alternatives. In Norway it is now accepted that most demented patients should be cared for in somatic long-temcare facilities when institutionalization becomes necessary. A small number of patients will need more specialized care in a psychiatric nursing home. To play an active role within the caring system for demented, these institutions should be properly equipped. Patients who have become mentally stabilized should subsequently be discharged home or to a lower caring level when continued stay in an institution is required. In this way it should be possible to utilize a limited number
Inappropriate Placements in Psychiatric Nwsing Homes
267
of specialized places in psychiatric nursing homes to benefit a greater number of patients. The present study shows that a considerable number of patients are cared for in psychiatric nursing homes despite the fact that their psychiatric symptoms have vanished and their basic needs are for general nursing care.
REFERENCES Adolfsson,R., Gottfries,C. G.,NystriSm,L., & Winblad, B. (1981).Prevalenceofdementia disorders in institutionalizedSwedishold people. Acta Psychiatrica Scandinavica,63, 225-244. hsmelding Haukeland Sykehus. Bergen (1984). Brochmann, A. (1987). Pasientvold i sykehjem. Tidsskrij?for Den Norskekgeforening, 107,2142-2143. Central Bureau of Statistics of Norway. (1989). Statistical yearbook, 75. Dehlin, O., & Franzgn, M. (1985). Prevalence of dementia syndromes in persons living in homes for the elderly and in nursing homes in southern Sweden. ScandinavianJournal of Primary Health Care, 3,215-222. Donaldson, L. J. (1983). Characteristics of elderly people misplaced in hospitals and homes. Public Health, London, 97,257-263. Fykeshelsesjefen i Hordaland. (1988). Aldersdemente. Hvem tar ansvaret? Rapport fra arbeidsgruppe for A utrede tilbudet ti1 aldersdemente. Bergen: Fy Ikeshelsesjefen i Hordaland. Godber, C. (1987). Psychogeriatricand social services for the demented. In B. Pitt (Ed.), Dementia. Edinburgh: Churchill Livingstone. Gulmann,N. C. (1989).Demens- Stromme.Report to the Danish Center for Human Rights, Aarhus. Gutman, G. M., & Herbert, C. P, (1976). Mortality rates among relocated extended-care patients. Journal of Gerontology,31,352-357. Hughes, C. P., Berg, L., Danziger, W. L., Coben, L. A., & Martin,R. L. (1982). A new clinical scale for staging of dementia. British Journal of Psychiatry, 140, 566-572. Jergensen, O., Petersen, P., & Glue, P. (1990). Indlaeggelse av demente pB psykiatrisk hospital. Ugeskrijifor Laeger, 152,232-235. Kirk, S., Compton, S. A., Devaney, N., Donnelly, C, M., & McGuigan, M. (1989). The elderly in long-term care: An estimate of misplacement using objective criteria. international Journal of Geriatric Psychiatry, 4,305-309. Mann, A. H., Graham,N., & Ashby, D. (1984). Psychiatricillness in residential homes for the elderly: A survey in one London borough. Age and Aging, 13,257-265. Nygaard, H. A. (1991). Permanenteopphold i sykehjem. Endringer i innleggelsesm%nster fra 1979 ti1 1989. Tidsskriftfor Den Norske Laegeforening, 111,1941-1943. Nygaard, H . A,, Breivik, K., BaWre, K., Brudvik, E., & Moe, T. J. (1987). Dementia and work load evaluation among the elderly. Comprehensive Gerontology[A], 1(2), 65-68. agar, B. (1983). Psykiatriske sykehjem idag. Morgendagens psykiatriske bo og behandlingssentra? Rapport Nr.7 1983. Trondheim: Norsk Institutt for Sykehusforskning,NIS. ksmelding Haukeland Sykehus. Bergen. (1984).
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and T.J . Moe
Pauser, H., Lundmark, J., & Lindgren, B. (1989). Ny geropsykiatriskvArdmodell mojliggor snabbt omhiindertagande av adre. En femksrappon. Ldkurtidningen, 86, 2600-2603. Stortingsmeldingnr. 9 (1974-75). (1974). Sykehusutbyggingm.v. i et regionalt helsevesen. Oslo: Sosialdepartementet. WHO Collaboration Centre for Drug Statistics Methodology/Nordic Council on Medicines, (1990). Guidelinesfor ATC clussificution.Oslo,WHO CollaborationCentrefor Drug Statistics Methodology/NordicCouncil on Medicines.
Acknowledgment. We thank Prof. R. Skjaerven, Section for Medical Informatics and Statistics, University of Bergen, for valuable advice on statistics.
Offprints.Requests for offprints should be directed to Overlege Harald A.Nygaard, FyUingsdalen Sykehjem, N-5033Bergen-Fyllingsdalen, Norway.
Inappropriate Placement of Residents in Psychiatric Nursing Homes in Bergen, Norway Harald A. Nygaard, KBre J. Bakke, and Tor Jacob Moe ABSTRACT. The mental and physical capacitiesof all residentsin psychiatric nursing homes in Bergen were studied. It was found that 95% were moderately or severely mentally impaired and 53% received antipsychotic medication regularly. By objective criteria, 47.9% were considered improperly placed. These patients typically had had a long stay in the institution, were immobile, and were given antipsychoticdrugs infrequently.
The number of mentally impaired elderly, the majority of whom are demented, is increasing due to the rising number of elderly in the community. A substantial proportion of this part of the population is cared for in institutional settings, such as homes for aged people, somatic nursing homes (nursing homes for physical illness) and psychiatric nursing homes (Adolfsson et al.,1981; Dehlin & FranzCn, 1985; Mann et al.,1984; Nygaard et al.,1987). Anticipated growth in the number of persons with senile dementia led to a Parliament proposition in 1974 to extend psychiatric nursing home facilities in Norway by about 50%. rather than reducing psychiatric hospital capacity, as had been intended (Stortingsmelding, 1974). Thus, the need for psychiatric services in nursing homes was clearly indicated. Up to 1987, the actual increase in nursing home capacity was approximately 15% (Central Bureau of Statistics of Norway, 1989). Increasingly, demented patients have been referred to somatic nursing homes, where the proportion of demented residents has increased (Nygaard, 1991). Of all moderately to severely mentally impaired patients who were institutionalized, 9% had gone to live in psychiatric nursing homes, and 85% resided in somatic nursing homes or homes for the aged (Nygaard et al.,1987). From Bergen Kommune, Bergen-Fyllingsdden,Norway (H. A. Nygaard, MD, K. J. Bakke. M D and
T. J. Moe. MD). 26 1
262
H . A. Nygaard,K.J . B&,
and T. J . Moe
In general, in Norway no medical profession feels responsible for this group of demented patients. By definition, somatic nursing homes are not intended for any particular patient group. A need for nursing care is the main reason for admission to a somaticnursing home. Hence, mentally impaired persons are admitted because they require assistance and monitoring. A considerable number of these patients have a disturbing behavior, and approximately 5% were considered in need of psychiatric nursing care (Nygaard et al., 1987). Recently, efforts have been undertaken to define which problems associated with dementia should fall into the domain of psychiatric nursing homes in our county. It was decided that demented patients should meet the following criteria: “Continued deranged behavior disturbing others; demented patients who also develop psychotic symptoms; aggressive behavior which can be a danger to other patients; and patients who make intense efforts to leave the present place of living on hisher own without being able to take care of themselves.” Furthermore, a prerequisite is the inability to properly meet the patient’s needs in his or her present location (Fylkeshelsesjefen i Hordaland, 1988). The aim of this investigation, then, was to study and to evaluate characteristics related to improperplacement of patients living permanently in psychiatricnursing homes.
MATERIAL AND METHOD The city of Bergen, the second largest in Norway, has a population of approximately 207,000. Of this group, 10.7% are above 70 years of age. This study uses information taken from the results of a census performed during Week 6 in 1985 in Bergen. The census included all residents in long-term-care facilities, patients in a general hospital, awaiting placement in a nursing home, and persons over age 50 receiving home nursing (Nygaard et al., 1987). This report focuses on those patients permanently admitted to apsychiatric nursing home (n = 121.86 men and 34 women; and one patient whose gender is unknown). General demographicinformation was collected and the patients were assessed by the nurse in charge. A patient’s mental capacity was determined by means of the Clinical Dementia Rating scale (CDR) (Hughes et al., 1982; Nygaard et aL.1987). The CDR scale is a global rating scale consistingof six items: memory, orientation, judgment and problem solving, community affairs, home and hobbies, and personal care. Patients are assigned a rating of healthy (CDR = 0), “senescent forgetfulness” (CDR = OS), mild dementia (CDR = l), moderate dementia (CDR = 2). or severe dementia (CDR = 3). For estimating activities of daily living (ADL) and behavior, we used a workload scale (Adolfsson et al., 1981; Nygaard et al., 1987) consisting of seven items: bladder and bowel functions, ability to eat, motor function, hygiene, dressing, and behavior. Behavior was divided into the following groups: normal, apathetic, anxious, restrained, wandering/restless/aggressive. For the present purpose, all
Inappropriate Placemenls in Psychiatric Nursing Homes
263
items were dichotomized whether or not a patient was dependent. The item behavior was divided into patients who were wandenng/restless/aggressive and those who were not. All psychotropic drugs regularly prescribed were registered. The classification was performed according to the Anatomical Therapeutic Chemical Classification Code (ATC classification) Defined Daily Doses (DDD) (WHO Collaboration Centre for Drug Statistics MethodologylNordicCouncil on Medicines, 1990).The groups of psychotropic drugs were antipsychotics (NOSA), anxiolytics (N05B), hypnotics/sedatives (N05C), and antidepressants (N06A). Finally, the nurse in charge was asked to judge whether the patient was treated on an appropriate care level. The principles for proper placement of demented patients with disturbed behavior (Fylkeshelsesjefen i Hordaland, 1988) were determined after this study had been performed. Yet, we wanted to approximateour judgment to these criteria, which principally attempt to prevent the admission to a psychiatric nursing home unless a patient’s symptoms are constantly disturbing to others. This also applies to psychotic symptoms. Usually, demented patients with a wandering, aggressive, or restless behavior are most frequently the applicants for admission to a psychiatric nursing home. We considered patients with these traits to correspond to the given definition for inappropriate placement. Nonparametnc tests were used for statistics: a chi-square test with Yates’ correction, Fisher’s exact test when minimum estimated expected values were below 20, Cohen’s kappa test, and the Kruskal-Wallis test. Factors which in univariate analyses were significantly associated with inapproprate placement 0,c 0.05) were further analyzed in a stepwise logistic regression analysis. For this purpose, the duration of the patient’s stay was categorized. The median age of the patients was 82 years (range 47-96 years) and the median duration of stay was 26.8 months (range 0.03-155.2 months). Of the patients studied, 29 (24%) had stayed for less than one year. Two patients had been assigned a rating of CDR-0.5, four a rating of CDR-1, five a rating of CDR-2, and 110a rating of CDR-3. Twenty-two patients were continent for urine and 27 for feces, 61 were fed, 56 were independently mobile, 119 were dependent for hygiene and 104 were dependent for dressing. Regarding medications, 63 patients (52.1 Or,) used antipsychotic drugs, 10patients (8.3%)used antidepressants,eight patients (6.6%) used hypnoticlsedatives, and 5 patients (4.1 %) used anxiolytics.
RESULTS According to our definition, 58 patients (47.9%) were improperly placed. In the univariate analyses, inappropriately placed patients were significantly older and had stayed longer in the institutions than patients who were considered to be at an appropriate care level. Of the registered ADL functions, improper placement was associated only with impaired mobility; furthermore, it was inversely associated with the use of an antipsychotic drug (Table 1).
H.A . Nygaard, K.J . BaGke. and T. J . MIX
264
The results from the stepwise logistic regression analysis are shown in Table 2. The chance of being inappropriately placed increased with length of stay. In addition, the odds for improper placement were 3.4times higher for patients living four years or more in an institution than for patients who stayed less than two years. Further, immobile patients had odds for inappropriate placement that were 2.9 times those for mobile ones, while patients using antipsychotic drugs were 0.4 times more likely than nonusers to be placed improperly. Twenty-two patients (18.2%) were considered by the nurse in charge to be inappropriately placed. Of the 58 who by objective criteria were placed improperly, 20 were alsojudged by the nurse to be so. The agreement between the nurse and the objective criteria of being misplaced was poor (kappa = 0.32). Statistically there was no difference in any item registered between these 20 and the 38 patients not deemed inappropriately placed.
DISCUSSION Nearly half of all the patients were placed inappropriately when objective criteria for proper placement in a psychiatric nursing home were applied. We consider that the results correspond well with the standards set up for the function of a psychiatric nursing home. Deranged and aggressive behavior was used as the independent variable in our calculations. Compromised mobility prevented the patient from making efforts to leave his or her present living place, and the reduced usage of antipsychotic drugs must be regarded as an indication that neither psychotic symptoms nor the disturbing behavior are prominent any more. Psychiatric nursing homes are intended for psychiatric patients in need of specialized long-term care, but at a level lower than that provided in a mental hospital. It is further assumed that demented patients cannot be cared for in a general nursing home. The homes are apart of the general psychiatric services, with TABLE 1. Factors which in Univariate Analyses were Significantly Associated with Inappropriate Placement in a Psychiatric Nursing Home Appropriately . Inappropriately Placed Placed (n = 5 8 ) (n = 63) Age’ (median) (p = 0.02) Duration of stay’ (months, median) Mobility’ ( p = 0.0) Independent Dependent Antipsychotic drugs’ (p = 0.0004) No Yes
80.0 20.4
83.0 35.2
41 22
43
20 43
38 20
15
1) Kruskal-Wallis test. 2) Chi-square test with Yates’ correction.
InappropriatePlacemeas in Psychiatric Nursing Homes
265
a psychiatrist in charge of the medical services. The majority of the personnel has a nursing function and, until now, their task has been characterized by custodial care. The staffing has been poor (nursing personnel/patients = 0.37) (Ogar, 1983). although there has been some improvement in recent years. Usually patients move to a different facility when their physical dependency exceeds the level of care that can be given in a psychiatric nursing home. These factors may explain the poor agreement between the applied criteria for improper placement and the nurses’ judgment. In the present study, 95% of the residents in psychiatric nursing homes were moderately to severelymentally impaired. In anational survey, 22% of all residents in psychiatric nursing homes and 16% of those in psychiatric hospitals were demented (Ogar, 1983). On the other hand, only 5% of the patients in the local psychiatric university hospital were demented (Arsmelding Haukeland Sykehus, 1984). Our findings were later confirmed by an independent survey performed by the local health authorities (Fylkeshelsesjefen i Hordaland, 1988). One may speculate that the psychiatric nursing homes in this region have developed a complementary function, compensating for the small number of demented patients accepted in general psychiatry. The function in Norway of psychiatric nursing homes as a part of the psychiatric services seems quite unclear. To our knowledge, only Ogar (1983) has tried to describe their function, giving examples of different models that have been tried in various places. Their objectives are presented rather broadly, and a rational use of psychiatric nursing homes within the entire caring system for the demented is not discussed. The anticipated rise in the number of demented elderly as a justification for further increase of psychiatric nursing home facilities (Stortingsmelding, 1974) seems to be neglected. Somatic nursing homes are the main health care setting for serving persons with advanced physical and mental dependency. Their proper functioning assumes that patients who do not fit into this system are helped by adjacent care levels. Despite the current trend of establishing sheltered units within somatic nursing homes for demented patients with disturbed behavior, the need for more specialized psychiatric treatment and care still prevails. In this respect, patients with severely TABLE 2. Logistic Regression Analysis for Factors Associated with Inappropriate Placement in a Psychiatric Nursing Home Factor Duration of stay 2-4 years 2 4 years Diminished mobility Antipsychotic drug use *) p
< 0.05.
Beta
SE
0.604 1.231 1.076 -0.938
0.491 0.542 0.448 0.428
Odds Ratio
95% Confidence
1.8
0.7-4.8 1.2-9.9 1.2-7.1 0.2-0.9
3.4* 2.9* 0.4*
Interval
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H . A , Nygaard, K.J . Bakk.e, and T. J . Moe
disturbed behavior are important. In most patients the symptoms will subside and specialized care can be terminated. One may object that moving from one place to another can have a negative impact on the elderly patient. However, careful planning of the move has been shown not to be associated with increased mortality (Gutman & Herbert, 1976). In London, the same experiences occurred when mentally infirm elderly were relocated in response to the closure of a mental hospital (L. Simpson, personal communication, 1988). Services to the elderly are organized differently in most countries, making a comparison across nations difficult. However, the care of elderly with disturbed behavior seems to be a general problem in several western countries. In Sweden, long-term care of the demented elderly has mainly become the field of geriatric medicine, yet 19.5% of institutionalized demented had been placed in psychiatric institutions (Pauseret al., 1989). In Denmark, Gulmann (1989) estimated a similar number to be in psychiatric care and the waiting time for transfer from a psychiatric hospital to somatic long-term care was almost one year (JBrgensen et al., 1990). In Great Britain, the mobility of the patient determines whether psychiatric care is justified (Godber, 1987). Also, there seems to be a general need for better transfer of patients among the various care levels. In an English study 90%of elderly patients in psychogeriatric hospitals were deemed inappropriately placed (Donaldson, 1983); their characteristics were similar to those in the present study. Kirk et al. (1989) defined criteria for the use of all institutional care levels in Ireland, finding that approximately 60% of the residents in psychogeriatric institutions were inappropriately placed. In Ogar’s study (1983) 18% were considered inappropriately placed, though criteria for determining this are not mentioned. Lack of agreement regarding where to treat demented with severely disturbed behavior may also reinforce the impression that patients who are admitted to psychiatric nursing homes are stigmatized as “psychiatric,” thus blocking further rational treatment, even if their initial behavioral disturbances abate. A more rational use of psychiatric nursing homes will probably also contribute to an improved environment in somatic nursing homes, where several patients are reported to be in need of psychiatric care (Brochmann, 1987;Nygaard et al., 1987).
CONCLUSION The care of demented persons demands a variety of alternatives. In Norway it is now accepted that most demented patients should be cared for in somatic long-temcare facilities when institutionalization becomes necessary. A small number of patients will need more specialized care in a psychiatric nursing home. To play an active role within the caring system for demented, these institutions should be properly equipped. Patients who have become mentally stabilized should subsequently be discharged home or to a lower caring level when continued stay in an institution is required. In this way it should be possible to utilize a limited number
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of specialized places in psychiatric nursing homes to benefit a greater number of patients. The present study shows that a considerable number of patients are cared for in psychiatric nursing homes despite the fact that their psychiatric symptoms have vanished and their basic needs are for general nursing care.
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Acknowledgment. We thank Prof. R. Skjaerven, Section for Medical Informatics and Statistics, University of Bergen, for valuable advice on statistics.
Offprints.Requests for offprints should be directed to Overlege Harald A.Nygaard, FyUingsdalen Sykehjem, N-5033Bergen-Fyllingsdalen, Norway.
