Perspectives in Psychiatric Care

ISSN 0031-5990

Multidisciplinary, Nurse-Led Psychiatric Consultation in Nursing Homes: A Pilot Study in Clinical Practice Bauke Koekkoek, RN, ANP, PhD, Carlijn van Baarsen, MSc, and Mirella Steenbeek, MD Bauke Koekkoek, RN, ANP, PhD, is an Associate Professor, Research Group Social Psychiatry & Mental Health Nursing, HAN University of Applied Sciences, Nijmegen, The Netherlands, Pro Persona Mental Health Care, ProCES, Wolfheze, The Netherlands; Carlijn van Baarsen, MSc, is a Research Psychologist, Department of Specialized Geriatric psychiatry, Senior Division, Altrecht Mental Health Care, Zeist, The Netherlands; and Mirella Steenbeek, MD, is a Psychiatrist, Geriatric Psychiatry, Molemann Mental Health Care, Zeist, The Netherlands

Search terms: Consultation, geriatric psychiatry, neuropsychiatric symptom, nursing, nursing home Author contact: [email protected], with a copy to the Editor: [email protected] Conflict of Interest Statement None for any author. First Received July 23, 2014; Final Revision received March 1, 2015; Accepted for publication March 26, 2015.

PURPOSE: To determine the effects of multidisciplinary, nurse-led psychiatric consultation on behavioral problems of nursing home residents. Residents often suffer from psychiatric symptoms, while staff psychiatric expertise varies. DESIGN AND METHODS: A pre-post study was conducted in seven homes using the Neuropsychiatric Inventory Nursing Home version (NPI-NH). FINDINGS: In 71 consultations during 18 months, 56–75% of residents suffered from agitation/aggression, depression, anxiety, and disinhibition. Post-intervention (n = 54), frequency, and severity of psychiatric symptoms were significantly and clinically meaningfully reduced. Also, staff suffered from less work stress. PRACTICE IMPLICATIONS: Nurse-led psychiatric consultation is valuable to both nursing home residents and staff.

doi: 10.1111/ppc.12120

For decades, it has been observed that behavioral problems occur frequently in nursing homes (Seitz, Purandare, & Conn, 2010; Zimmer, Watson, & Treat, 1984), and that psychiatric disorders are prevalent but often remain undetected (Rovner & Katz, 1993; Seitz et al., 2010). In spite of these consistent findings, training and skills of nursing home staff appear to be substandard to address this issue (Borson, Reichman, Coyne, Rovner, & Sakauye, 2000). While several service models for mental health problems in nursing home residents have been suggested (Bartels, Moak, & Dums, 2002), nursing staff is still poorly supported in struggling with challenging behaviors by nursing home residents (Zwijsen et al., 2014). Psychiatric symptoms occur in up to 70–80% of nursing home residents (Craig & Pham, 2006; Fenton et al., 2004; Seitz et al., 2010). Research shows that 10% of residents suffer from major depression and 24–29% have depressive symptoms (Jongenelis et al., 2003; Seitz et al., 2010). Anxiety disorders are found in approximately 10% of residents, and anxiety symptoms in almost 20% (Smalbrugge, Pot, Jongenelis, Beekman, & Eefsting, 2005). It is estimated that 35% of the Dutch nursing home population has behavioral Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.

problems. Cognitive disorders are most prevalent: about half of residents over 85 have some form of dementia (Meesters, 2002). Among these residents with evidence of cognitive impairment, the prevalence of one or more psychiatric symptoms is 85% (Heeren, Lagaay, & Rooijmans, 1992; Zuidema, Koopmans, & Verhey, 2007). Studies in other countries show about the same pattern: 78% of the elderly with dementia have psychiatric symptoms (Seitz et al., 2010). These problems are associated with increased prevalence of physical injury, poor health outcomes, increased rates of hospitalization, greater use of emergency services, and lower rates of retention of nursing home staff (International Psychogeriatric Association, 2010). Psychiatric expertise varies across nursing homes and staff members, but there is a frequent need for external support from specialist psychiatric services. Psychiatric consultation is often defined as either (a) liaison psychiatry or (b) individual consultation. Liaison refers to a structural contact between the consultation team (CT) and nursing home staff (nurses, psychologists, and doctors) in order to identify vulnerable residents and to coach staff in working with frequent 1

Multidisciplinary, Nurse-Led Psychiatric Consultation in Nursing Homes: A Pilot Study in Clinical Practice

psychiatric problems in residents. Individual consultation refers to the (single) meeting of CT and nursing home staff, aimed at discussing an ad hoc problematic situation or resident (Krul, 2001). Reasons for psychiatric consultations may vary. Staffperceived behavioral problems, such as agitation, verbal and physical aggression, wandering, and destructive acts, are the main reasons to apply for consultation, while residentperceived complaints of anxiety are another important reason (Brodaty, Draper, & Low, 2003; Brodaty et al., 2003; Callegari et al., 2006; Fenton et al., 2004; Leo, Sherry, DiMartino, & Karuza, 2002). Depressive symptoms in cognitively impaired residents, as well as psychotic symptoms in all residents, are less well detected, thus seldom resulting in a consultation request (Brodaty et al., 2003; Callegari et al., 2006; Fenton et al., 2004; Leo et al., 2002). Recent Dutch research confirms this international picture: aggression is an important reason for consultation, but apathy hardly is—and as such is often missed as a symptom of a possible psychiatric disorder (Kat et al., 2008). The usefulness of psychiatric consultation in nursing homes has been demonstrated previously (Bartels et al., 2002; Collet, de Vught, & Verhey, 2010; Fossey et al., 2006; Reichman, Coyne, Borson, Rovner, & Sakauye, 1998; Snowdon, 2010). As a result, more therapeutic interventions are carried out, less aggressive incidents occur, fewer antipsychotic medications are administered, and less physical restraint occurs (Opie, Doyle, & O’Connor, 2002; Ray et al., 1993; Rovner, Steele, Shmuely, & Folstein, 1996). Furthermore, psychiatric consultation results in fewer general hospital admissions and in an increase in the competence of staff working with psychiatric needs. Stress and burn out among staff is reduced (Craig & Pham, 2006). Content and application of psychiatric consultation may vary within and across countries and health care systems. In The Netherlands, it is usually multidisciplinary in nature, consisting of interventions by both an advanced practice nurse (psychiatric nurse practitioner or community psychiatric nurse) and a psychiatrist (Dorland, Pot, Veerbeek, & Depla, 2007; Snowdon, 2010). There is some evidence that nurse-led interventions may be effective, for instance, in community-dwelling elderly with mental health problems (Thompson, Lang, & Annells, 2008) or nursing homes (Markle-Reid et al., 2014). Research into the effectiveness of multidisciplinary, nurse-led psychiatric consultation in nursing homes however is virtually absent. The following questions therefore are stated: (a) for what nursing home residents a consultation is requested, (b) what advice is offered by the CT and to which extent is this advice followed up, (c) which changes can be detected in the psychiatric complaints and symptoms of nursing home residents, and (d) which changes can be detected in the experienced work stress or care burden among nursing home staff? 2

Methods Design This is a pre-post study into multidisciplinary, nurse-led psychiatric consultation in order to pilot study the effects before wider implementation. The effect of consultation on both nursing home residents and staff was established by using the Neuropsychiatric Inventory Nursing Home version (NPI-NH). Participants/Sample Participants were nursing staff and nursing home residents. The sample was recruited from seven nursing homes in a Dutch health region comprising approximately 1,250 beds. Of those, 47% was based in cities, 53% was based in smaller communities. This was a convenience sample of homes willing to participate in the study. Nursing homes participated in the study during 18 months and provided one consultation case on every visit of the multidisciplinary CT, every 6–8 weeks. Nurses were in general diploma-level or associate degree-level trained. No inclusion or exclusion criteria were used for this case—the nursing home decided which resident would be discussed. Intervention A specialized geriatric psychiatry department of a large mental health institute conducted a study of nurse-led multidisciplinary consultation, by three psychiatric advanced practice nurses (APNs) and one psychiatrist. The APNs all received training in supportive and psychotherapeutic interventions, but did—in accordance with national legislation at the time of the study—not have the right to prescribe medication. This CT was present in nursing homes according to a fixed schedule in order to support and advise the full nursing home staff. The CT offered psychiatric diagnostics and gave recommendations for treatment, management, and placement. Once every 6–8 weeks the full CT visited each nursing home. At that moment, a case was presented to the CT, often by a doctor or psychologist of the nursing home, supported by the nursing staff. A diagnosis and treatment advice were formulated by both the APN and the psychiatrist, based on this presentation, existing case notes, meetings with nursing staff, and the resident him/herself. This was verbally elucidated, written out, and sent by email or postal mail a few days later. Depending on the case, one to three follow-up consultations were carried out by the APN, within 6–8 weeks. During the following scheduled staff consultation, 6–8 weeks later, the case was evaluated. The type of psychiatric consultation used here is structural, multidisciplinary, nurse-led, and long-term. While the conPerspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.

Multidisciplinary, Nurse-Led Psychiatric Consultation in Nursing Homes: A Pilot Study in Clinical Practice

sultation process described here was multidisciplinary from the start, follow-up meetings were carried out by APNs alone. Thus, apart from the initial assessment and advice, the work with the nursing home staff was predominantly done by nurses: relating to and offering repeated hands-on support to their colleagues in the nursing homes. This procedure was based on the methods described as effective in national and international literature on psychiatric consultation in nursing homes. From these sources, it is evident that structural presence of a multidisciplinary team is most effective, while single consultations by a psychiatrist followed by written advice were least effective (Bartels et al., 2002; Collet et al., 2010). In this study, we aimed to give psychosocial or behavioral advice first, only then followed by advice on psychotropic medication since the latter has proven to be less effective (Kleijer et al., 2009; Smalbrugge et al., 2008)—unless there was a clear need of medication. Data Collection Demographic data and reasons for consultation were determined from the nursing home’s application forms. Briefly after the consultation took place, a CT member filled out a schedule on which planned care and treatment were recorded. After 6–8 weeks, the extent to which the advice was followed up was assessed through a brief interview by the APN with the nurse of the involved resident, resulting in a categorical score (yes/no/partial). Measurements took place during the fixed visits of the full CT, not during the individual APN visits, at the first consultation and the follow-up consultation (6–8 weeks later). The Dutch version of the NPI-NH (Lange, Hopp, & Kang, 2004) was filled out by the APN, in the presence of, and making use of the direct information of nursing home staff. All APNs were trained in the application of the NPI-NH by the Dutch Geriatric Psychiatric Centre of Expertise. The NPI-NH is a 12-item scale rating behavioral disturbances commonly occurring in residents with dementia, assessed on the basis of a structured interview with the professional caregiver. The items include delusions, hallucinations, agitation/aggression, depression/dysphoria, anxiety, elation/ euphoria, apathy/indifference, disinhibition, irritability/ lability, aberrant motor behavior, nighttime behaviors, and appetite and eating disorders. The NPI-NH also measures the perceived work stress of nursing personnel using the same scoring but a different question that inquires of the perceived stress these behaviors give to staff. Frequency (0–4) and severity (0–3) of each behavior are determined and multiplied, and all the items are summed for a total score of 0–144 (higher scores indicate more psychopathology). Psychometric properties of the NPI-NH are satisfactory to good for both the English (Lange et al., 2004) and—the original—the Dutch version (Kat et al., 2002). Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.

Inter-rater agreement is very high (kappa between .91 and .99 for subscales and total scale; Kat et al., 2002), internal consistency is sufficient (alpha .67; Lange et al., 2004), concurrent validity is sufficient (Spearman’s rank correlation .51–.69; Kat et al., 2002), and factor analyses yield between 55.1% (Kat et al., 2002) and 63.2% (Lange et al., 2004) explained variance. The NPI-NH is quite sensitive to change and measurement error, which is why Zuidema et al. (2011) recently concluded that a reliable change consists of at least an 11-point total increase. The NPI-NH was scored by the APN interviewing the nursing staff member.

Ethical Considerations The study was reviewed by the Institutional Review Board of the consultation service’s institution and permission was granted. Prior to the consultation, staff members and residents were informed about the study and informed consent forms were signed.

Data Analysis Demographic data were, after controlling for normality, analyzed using descriptive statistics in SPSS version 19. Paired t-tests were used for the analysis of pre-post differences. Effect size r in this study was calculated using the formula: r = √(t2/t2 + df) (Field, 2005). Before the start of the study, the developer of the Dutch NPI-NH version was consulted on the required sample size. To detect a small effect size (.3) with a statistical power of 80% (beta) and a p-level of .05 (alpha), and twosided t-tests, a sample size of 50 would be required.

Results Nature and Reasons of Consultations Between July 2008 and January 2010, 71 visits were paid to the total of 7 nursing homes, resulting in 71 consultations carried out and registered (Table 1). Women were slightly overrepresented (56.3%),and mean age was 74.3 years (SD 14.1).In 45% of cases,consultations concerned nursing home residents with a previously diagnosed cognitive disorder. In the entire group, aggression/agitation was the most frequent reason for consultation (32% of cases), while mood problems (26%) and psychotic symptoms (7%) came next. In the group without previously diagnosed cognitive disorders, mood problems were the most frequent reason (38% of cases). Upon baseline measurement, in over 75% of cases, aggression/agitation or irritability was found (although this was the reason for consultation in only 32% of cases). Symptoms of depression, anxiety, and mania were present in 65%, 63%, and 56% of residents, respectively. 3

In this paper, we described a pre-post observational study of multidisciplinary, nurse-led psychiatric consultation in 4

19) 10) 41) 36) 35) 14) 24) 32) 44) 22) 30) 24) 53) (3.008, (3.296, (5.517, (3.264, (3.826, (1.188, (2.059, (3.799, (4.657, (2.868, (3.500, (3.950, (4.622, .007 .008 .001 .002 .001 .255 .051 .001 .001 .009 .001 .001 .001 (1.15) (1.08) (1.37) (1.12) (1.40) (1.11) (1.27) (1.52) (1.18) (1.30) (1.28) (1.36) (7.31)

Post Mean (SD)

(4.13) (4.61) (3.67) (4.56) (4.35) (4.08) (4.06) (3.70) (3.30) (3.75) (4.11) (4.61) (22.52)

3.35 2.81 4.23 3.32 3.44 2.20 4.84 4.81 4.68 4.04 2.64 2.60 26.15

(3.29) (3.86) (3.38) (2.63) (3.12) (2.11) (4.74) (4.39) (3.19) (3.90) (3.19) (3.79) (16.07)

.001(4.558, .008(3.289, .001(5.582, .001(4.982, .001(5.695, .077(1.906, .001(3.687, .001(3.633, .001(6.105, .005(3.157, .001(5.088, .001(4.763, .001(7.222,

19) 10) 41) 36) 35) 14) 24) 32) 44) 22) 30) 24) 53)

.72 .72 .66 .64 .69 .45 .60 .54 .68 .59 .68 .70 .70

2.55 2.73 3.45 2.54 2.56 1.93 1.92 3.12 3.22 2.52 2.52 2.36 17.26

(1.85) (2.00) (1.48) (1.73) (1.63) (1.28) (1.58) (1.34) (1.31) (1.59) (1.61) (1.89) (10.74)

1.20 0.82 2.07 1.59 1.50 1.33 1.24 1.85 2.07 1.39 1.23 0.88 10.93 7.65 7.45 7.85 7.02 7.02 4.66 7.64 7.33 8.22 7.21 6.80 7.00 46.35


1 Delusions 2 Hallucinations 3 Agitation/Aggression 4 Depression/Dysphoria 5 Anxiety 6 Elation/Euphoria 7 Apathy/Indifference 8 Disinhibition 9 Irritability/Lability 10 Aberrant motor behavior 11 Nighttime behaviors 12 Appetite and eating disorders Total NPI-NH score

Of the 71 consultations, 54 (76%) could be followed up. This loss to follow-up was due to seven residents passing away, six residents having moved (two to another nursing home, one to a care home, one to own home, one to a psychiatric hospital, and one to a general hospital), two residents being evaluated for involuntary commitment and not followed up further, two unknown. After the consultation, frequency and severity of neuropsychiatric symptoms strongly decreased as well as the experienced work stress of nursing staff decreased. In Table 2, the effects of the intervention are shown using the usual frequency × severity NPI-NH notation. Neuropsychiatric symptoms decreased substantially (overall ES = 0.70). With the exception of the symptoms/subscales euphoria and apathy, all subscale differences were statistically significant. Similar results were found among nursing staff’s work stress, decreasing with an overall effect size of .54.

Pre Mean (SD)


Effect size

Various types of advice were given: in 85% of cases, it was psychosocial or behavioral in nature, concerning the staff– resident interaction (management), which was fully or partially followed up in 64% of cases. Additional medication advice (treatment) was given in 67% of cases and was followed up in 48%. In 21% of cases, a transfer to another ward (placement) was advised, of which ten cases concerned a transfer in the nursing home sector, three cases concerned a transfer to the mental health care sector, and one case a transfer elsewhere.

p value (t, df)


Post Mean (SD)

(32) (27) (7) (34)

Pre Mean (SD)

23 19 5 24

NPI-NH subscale

39 (55) 32 (45)

Staff-perceived work stress

40 (56.3) 74.3 (14.1)

p value (t, df)

n (%)

Frequency × Severity of symptoms

Demographics Woman Age (mean/SD) Type of nursing home ward Physical care Psychogeriatric care Consultation ground Aggression/agitation Mood problems Psychotic symptoms Other

Table 2. Neuropsychiatric Inventory Nursing Home (NPI-NH) Scores of Nursing Home Residents Pre-Consultation (n = 71) and Post-Consultation (n = 54) Using Paired t-Test Analyses


Effect size

Table 1. Socio-Demographic and Clinical Characteristics of Nursing Home Residents for Whom Psychiatric Consultation was Requested (n = 71)

.57 .72 .65 .48 .54 .30 .39 .56 .58 .52 .54 .63 .54

Multidisciplinary, Nurse-Led Psychiatric Consultation in Nursing Homes: A Pilot Study in Clinical Practice

Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.

Multidisciplinary, Nurse-Led Psychiatric Consultation in Nursing Homes: A Pilot Study in Clinical Practice

nursing homes. Most important reasons for consultation were aggression/agitation, followed by depression and anxiety complaints. Participants scored high on several subscales, indicating the complexity of this group through several severe neuropsychiatric symptoms. The effects of psychiatric consultation, as measured by the NPI-NH, proved to be medium to large, both for residents and for staff. Limitations This explorative study has a number of limitations. There was no control group so we could not assess whether comparable changes would have occurred with another group, or with a group who did not receive any intervention at all. Also, the group under study was quite heterogeneous: almost half (45%) suffered from cognitive disorders, while the other half did not. Participants came from different wards in different nursing homes. While a possible threat to the internal validity of the study, these are conditions likely to improve the study’s external validity since many psychiatric consultations takes place under comparable circumstances. Assessment of the degree of follow-up of advice was subjective, assessed through inquiry by the CT, and responded to by either “yes” or “no” by the nursing home staff. A quarter of initially assessed residents could not be followed up for a number of reasons. Additional inspection of case files showed that loss to the follow up was not selective. In our resident group, 10% of participants died during the intervention period, which is usual in a group of nursing home residents with severe (co)morbidity such as dementia, delirium, and depression (Koopmans et al., 1994; Matusik et al., 2012). Scoring of the NPI-NH was done by members of the CT, possibly introducing a bias toward positive outcomes. However, the NPI-NH leaves little space for subjective interpretations due to the nature of its data collection using other informants (here: nursing home staff). Comparison to Existing Research We compared our results to outcomes of untreated cohorts of nursing home residents with neuropsychiatric symptoms. In this recent review (Wetzels, Zuidema, de Jonghe, Verhey, & Koopmans, 2010), problematic behavior, depression, and anxiety decreased over time (3–12 months) without treatment. Agitation, irritability, and mania, however, increased over this period, while psychotic symptoms remained the same. In another study by Kleijer et al. (2009) on behavioral problems of nursing home residents, the use of antipsychotic medication resulted in improvement in only 18% of cases and in deterioration in almost half of all cases. Our resident group consisted not only of dementia patients, and follow-up was briefer, yet we conclude that intervening with psychiatric consultation offering psychosocial advice yields more positive results than no treatment or medication treatment alone. Perspectives in Psychiatric Care •• (2015) ••–•• © 2015 Wiley Periodicals, Inc.

The large effect sizes show that substantial progress can be made by means of a relatively simple intervention. It must be noted though that the NPI-NH is quite sensitive to change and measurement error, which is why Zuidema et al. (2011) recently concluded that a reliable change consists of at least an 11-point total increase. The absolute increase found in this study, somewhat over 20 points, and the matching effect sizes are larger than those in other studies. Implications for Nursing Practice A possible explanation for the effects found, apart from methodological shortcomings, may be the type of psychiatric consultation used here: structural, multidisciplinary, nurse-led, and long-term. While the consultation process described here was multidisciplinary from the start, follow-up meetings were carried out by advanced practice nurses alone. Although not the focus of this study, we believe that the hands-on support to colleagues in the nursing homes was crucial to the success of this consultation. However, this remains to be assessed empirically. Professionals in nursing homes in The Netherlands have repeatedly stated that they need more structural support from psychiatric services (Kat et al., 2008; Meesters, 2002). This study shows, apart from a reduction in symptoms on resident level, that experienced work stress in nursing staff decreases significantly and substantially without residents being transferred to psychiatric services. Multidisciplinary, nurse-led psychiatric consultation is potentially an effective (mental) health intervention to the nursing home sector. Controlled research, however, is required to further establish its effectiveness. Acknowledgment Altrecht Mental Health Care provided funding for this study. References Bartels, J. S., Moak, G. S., & Dums, A. R. (2002). Models of mental health services in nursing homes: A review of the literature. Psychiatric Services, 11, 1390–1396. Borson, S., Reichman, W. E., Coyne, A. C., Rovner, B., & Sakauye, K. (2000). Effectiveness of nursing home staff as managers of disruptive behavior: Perceptions of nursing directors. American Journal of Geriatric Psychiatry, 8, 251–253. Brodaty, H., Draper, B., & Low, L. F. (2003). Nursing home staff attitudes towards residents with dementia: Strain and satisfaction with work. Journal of Advanced Nursing, 44, 583–590. Brodaty, H., Draper, B. M., Millar, J., Low, L. F., Lie, D., Sharah, S., & Paton, H. (2003). Randomized controlled trail of different models of care for nursing home residents with dementia complicated by depression of psychosis. Journal of Clinical Psychiatry, 64, 63–72.


Multidisciplinary, Nurse-Led Psychiatric Consultation in Nursing Homes: A Pilot Study in Clinical Practice

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Multidisciplinary, Nurse-Led Psychiatric Consultation in Nursing Homes: A Pilot Study in Clinical Practice

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Multidisciplinary, Nurse-Led Psychiatric Consultation in Nursing Homes: A Pilot Study in Clinical Practice.

To determine the effects of multidisciplinary, nurse-led psychiatric consultation on behavioral problems of nursing home residents. Residents often su...
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