Psychiatric Consultation in a Teaching Nursing Home LARRY
S.
M.D. B.S.
GOLDMAN,
ADAM KLUGMAN,
The first 60 psychiatric consultations provided to a university-affiliated teachin8 nursin8 home are reviewed. All patients seen had a diagnosable mental disorder. and over 40% sufferedfrom major affective illness. Consultation resulted in a critical change in diagnosis and management in more than one-third ofpatients. The authors discuss the benefits and drawbacks ofpsychiatric consultation for nursing home patients, staffphysicians. and the psychiatrists themselves.
A bout one-half of 1% of the U.S. population, ..L\..the vast majority elderly, resides in nursing homes. It is estimated that about 5% of the elderly population currently live in such homes 1and that one-quarter will live in one at some time in their lives. 2 Nonetheless, although nursing homes are "a major health care resource for the older population," they have remained "largely outside the mainstream of traditional medical practice. ,,3 Since Goldfarb's 1962 study demonstrating that some 87% of the patients in the nursing homes he surveyed had psychiatric disorders,4 subsequent reports have confirmed a high incidence of serious psychopathology in this setting. The careful study by Teeter et aL in 1976 found a prevalence of 85%, with two-thirds of the disorders undiagnosed at the time of the study. 5 Two more recent studies, using more modem diagnostic nomenclature (DSM-III 6 ) revealed that 1% of newly admitted 2 and 94% of randomly sampled established7 nursing home patients had mental disorders. In spite ofthese findings, it is estimated that fewer than 1% of nursing home residents receive formal mental health treatments,3 and consultation is requested infrequently, even for problems identified as serious. In spite of the sizable numbers of patients and the extent of psychiatric illness in nursing VOLUME 31 • NUMBER 3 • SUMMER 1990
homes, we were unable to find any reports describing psychiatric consultation experience in this setting. Articles have reviewed mental health problems in such homes,2.3·8.9 the chronically mentally ill in nursing homes,JO nursing home consultation as part of a larger geriatric or consultation program, 11.12 a nursing home stafftraining project in mental health care,13 and a specialized psychiatric program within a nursing home. 14 The absence of a detailed review of the consultation process and its effects prompted this report. One of us (LSG) provided ongoing psychiatric consultation to a nursing home as part of the development of a teaching nursing home by the University of Illinois at Chicago. This preliminary report of the clinical problems and some of the treatment issues raised in such a setting is based on the first 60 consultations.
Received October 17. 1988; revised April 3. 1989; accepted April 26. 1989. From the Consultation-Liaison Service. University of Illinois College of Medicine.• Chicago. Address reprint requests to Dr. Goldman. Box 411. 5841 S. Maryland. Chicago. IL 60637. Copyright © 1990 The Academy of Psychosomatic Medicine. 277
Psychiatric Consultation in a Nursing Home
SETIING AND METHODS Westshire is a 450-bed. privately owned nursing home in Cicero, Illinois. a suburb just west of Chicago. For the past several years. the department of medicine of the University of Illinois at Chicago has been developing a model program of care there. Approximately 125 residents of Westshire are cared for by one of three geriatric internists from the full-time faculty of the university. The remaining patients are cared for by private physicians and, at times, by psychiatrists from the community. Consultations were accepted from university and private physicians. Patients with dementia were cared for in a special program. The most medically ill patients (those requiring feeding tubes. dressing changes, etc.) were cared for on the skilled-care floor. The remaining patients were divided evenly among the remaining four floors. The records of all patients seen in psychiatric consultation were reviewed. The consultation process consisted of a review of the residents' medical records (history, physical. laboratory data, medications, social history, and behavioral observations by nursing staff), discussion with the primary physician and nursing staff, and interviews with the patient and. where indicated, one or more family members. All patients and family members were asked specifically about alcohol or other drug use. A few patients were seen initially by psychiatric residents, but all charts were reviewed and all patients were interviewed and diagnosed by the senior author. Diagnoses were based on DSM-III criteria. No specific rating instruments were utilized for all patients. RESULTS Of the 60 patients. 34 (57%) were female. and 26 were male. Fifty patients were white; seven, black; two. Hispanic; and one, Oriental. The youngest patient was 37; the oldest, 92. The distribution was relatively normal and the mean age was 75. The age and racial distribution of the subjects were fairly comparable to those of the entire population of the nursing home (Prizant P, 278
personal communication. 1987). Two-thirds of the nursing home residents were women, so men were slightly over-represented in the consulting sample. Five patients were referred from the floor with the special dementia program; seven were from the skilled-care floor; and the remainder were evenly distributed from the four generalcare floors. Thus the dementia-floor residents were markedly under-represented and the skilled-care residents slightly so. Table I summarizes the reasons for consultation given by the primary care physician. (One woman with schizophrenia who felt she was overmedicated was self-referred). The figures add to more than 60 since at times there was more than one reason for consultation. Depression-related problems and behavioral disruptions accounted for well over half of the reasons for consultations. Few patients were referred for alcohol- or anxiety-related problems. Stroke was the most common significant medical problem noted by the consultant. occurring in 12 (20%) cases. Other medical problems noted were diabetes (six patients), hypertension (five). heart disease (five), Parkinson's disease (four), chronic obstructive pulmonary disease (four). epilepsy (three). and cancer (three). Table 2 shows the consultant's psychiatric diagnoses for the patients at the end of the study period. All 60 patients seen were felt to suffer from at least one mental disorder. Some patients received more than one diagnosis. Major affective illness (43% of the patients) and organic mental disorders (25%). mostly dementia. accounted for over two-thirds of the diagnoses. An additional one-fifth of the sample suffered from adjustment disorders, usually with depressed or mixed depressed and anxious mood. Adjustment disorders almost always were related to the onset of a medical illness. placement in the nursing home. or both. The small numbers of patients with any particular medical disorder made it difficult to connect specific medical illnesses and psychiatric disorders. Seven of the 12 stroke patients were felt to have a major depression, three adjustment disorders with depressed mood, and one each multi-infarct dementia and pathological weepPSYCHOSOMATICS
Goldman and Klugman
ing. There were no other correlations between particular medical conditions and psychiatric diagnoses. Also of some note was the discovery of eight patients with previously undiagnosed extrapyramidal disorders (Table 2). Although two patients had tardive dyskinesia, the remainder had acute treatable side effects of neuroleptic medications. Table 3 shows the 19 cases in which the consultant did not agree with the existing diagnosis. Each case resulted in major changes in patient management. Eight cases of "pseudodementia" were identified (13% of all cases), and cognitive impairment improved when the underlying depression, schizophrenia, and paraphrenia were treated. As expected from the diagnoses, therapeutic interventions were largely somatic. Five patients were hospitalized for psychiatric care during the 16-month study period. Three patients required electroconvulsive therapy. Further medical evaluation (neurologic consultation, dementia work-up, audiologic evaluation, etc.) was recommended for 22 patients. Psychopharmacologic treatment was initiated for 20 patients (13 for antidepressants) and discontinued in 10 patients, most of whom were on unneeded antipsychotics. Environmental manipulations were suggestTABLE I.
Reasons for consultation request for 60 geriatric residents of a teaching nursing home
Reason
Number
Depression. suicidal ideation
22
Behavioral disturbance agitation wandering irritability
20
ed as the predominant intervention for six patients, generally involving moving the patient to a floor that better matched their level of functioning, staff assignment changes, or providing a "buddy system" for socially isolated new patients. Brief psychotherapy as an exclusive treatment was recommended for six patients. Two patients required formal family treatments. DISCUSSION Referral bias limits the conclusions that can be drawn about the prevalence of psychopathology at this nursing home. Since the only patients evaluated were those specifically referred, inferences about the prevalence of psychopathology can yield only minimum figures. About 40% of the patients cared for by the university's geriatricians were seen in consultation in less than a year and a half, and all of these patients had a diagnosable mental disorder. TABLE 2.
Consultant's diagnoses for 60 geriatric residents of a teaching nursing home
Diagnosis
Number
Psychiatric diagnosis Affective disorder all major depression bipolar Organic brain syndromes all dementia pathologic weeping organic affective
26 17 9
15 12
2 I
12
8
Adjustment disorders Paranoid disorders
5
Schizophrenia. schizoaffective
4
Paranoia
4 2 7
Alcohol abuse
2
Psychiatric history
6
Anxiety disorders
Confusion. dementia
5
Personality disorders
2 2
Psychosis
3
Mental retardation
Personality change
All psychiatric diagnoses
Competency evaluation
3 2
Alcohol abuse
I
Pseudoparkinsonism
5
Anxiety
I
Tardive dyskinesia
2
Self-referral
I
Akathisia
I
All reasons
72
All
8
VOLUME 31' NUMBER 3· SUMMER 1990
I
69
Extrapyramidal disorders
279
Psychiatric Consultation in a Nursing Home
TABLE 3. Cases in which the consultant's diagnosis connicted with the existing diagnosis IN:19)
Existing Diagnosis
Consultant's Diagnosis
Number
Depression
Organic brain syndrome
Dementia
Major depression
4 4
Dementia
Schizophrenia
3
Dementia
Paranoid disorder
I
Schizophrenia
Bipolar disorder
2
None
Bipolar disorder
5
Infonnal discussions with these physicians revealed that additional patients were not referred in spite of known mental illness because they presented no particular diagnostic or management problems. Since the tendency of primary care physicians to underdiagnose mental disorders is well-documented,15 there is considerable indirect evidence suggesting that the prevalence of mental disorders at this nursing home must have been considerably higher than 40%, perhaps approaching the figures in the studies cited earlier. We currently are studying this issue. The distribution of specific mental disorders was notable as well. Of the 60 patients seen, 26 (42%) suffered from major affective illness. Even if in the unlikely event that these were the only patients in the nursing home with affective disorders, the prevalence (about 6%) well exceeds that of the geriatric population as a whole. 16 A few of these patients received nursing home care exclusively for their mental disorders, but, in general, the affective disorder represented serious comorbidity with their medical problems. In particular, the relationship between stroke and depression noted by Robinson et al. 17 was seen in this population as well. Most surveys suggest that 50% to 60% of nursing home residents suffer from dementia,lS yet only 25% of the referred patients were so diagnosed. This probably reflects several factors: some diagnoses were missed; some cases may be managed successfully by the primary care physician; some physicians are reluctant to refer demented patients to psychiatrists; the specialized program at Westshire may have obviated the need for some referrals; and the true incidence of 280
dementia at Westshire may have been lower due the limited number of beds available on the special floor (although some demented patients were cared for on other floors). The large number of adjustment disorders attests to the stress of transition to nursing home living 2 and coping with serious medical illness. 19 Major issues for these patients centered on loss of autonomy and independence, separation from family and friends, fear of mistreatment, lack of privacy, enforced proximity to others (a particular problem for those previously socially isolated by choice), and behavioral disruptions (screaming, theft, hostility) by other patients. Since so many ofthese concerns were realistic, supportive psychotherapy needed to be integrated with concrete environmental changes where possible, such as room or floor changes, special attention or care, altered family involvement, and development of behavior modification paradigms. The paucity of patients either referred for, or diagnosed by, the consultant as suffering from alcohol-related problems or personality disorders was unexpected. This may have resulted from limited recognition by the primary physicians, less disruption by the patients than by other patients, difficulty in establishing these diagnoses using the diagnostic methods employed, or a true lower prevalence in this population. Did consultation affect care? New or altered diagnoses led to critical changes in management in 19 patients alone (Table 3), largely in the direction of treating specific mental disorders that either were diagnosed incorrectly (eight patients) or missed (seven patients). Reversible neurologic side effects of medications were discovered and treated in six other patients. A number of other patients received psychotherapy; optimization of antidepressant, antipsychotic, or lithium therapy; or treatment of unusual symptoms such as pathological weeping. 20 Clarification of some symptoms as being beyond the patient's control (e.g., manic irritability) or related to stressors (e.g., increased neediness while the patient's family was away on vacation) also led to better staff understanding and more therapeutic care. The applicability of the conclusions reached PSYCHOSOMATICS
Goldman and Klugman
here, of course, must be tempered by the retrospective nature of the data collection and the special features of the setting (teaching nursing home, suburban location, psychiatrically sophisticated geriatricians, etc). Reports from other long-term care settings would clarify this matter. From the consultant's perspective the rewards of being a consultant in a nursing home are also clear: a varied and interesting array of psychopathology, often undiagnosed and frequently treatable, a group of patients who always appear for their appointments, and considerable appreciation at times (by patients, family, or staff) for amelioration in the patient's condition. On the other hand, such consultation at times also can
involve marked resistance from patients, families, physicians, and staff; inability to monitor outcomes and side effects carefully because of a psychiatrically naive staff; obstacles to behavior management because of low staff ratio and high turnover; and frustrations in working with chronically ill, frail patients who may be refractory to one's best efforts. The study of psychiatric needs and models of care in nursing homes remains in its relative infancy. With increased attention being paid to long-term care, geriatric medicine, and teaching nursing homes, we hope that the psychiatric needs of this population can be studied and met as well.
References I. Brody JA. Foley DJ: Epidemiologic considerations. in Schneider EL: The Teaching Nursing Home. New York. Raven. 1985. pp 4-25 2. Herst L. Moulton P: Psychiatry in the nursing home. Psychiatric Clin North Am 8:551-561. 1985 3. Borson S. Liptzin B. Nininger J. et al: Psychiatry and the nursing home. Am] Psychiatry 144: 1412-1418. 1987 4. Goldfarb AI: Prevalence of psychiatric disorders in metropolitan old age and nursing homes. ] Am Geriatr Soc 10:77-84.1962 5. Teeter RB. Goretz FK. Miller WR. et al: Psychiatric disturbances of aged patients in skilled nursing homes. Am] Psychiatry 133:1430-1434.1976 6. American Psychiatric Association: Diagnostic and Statistical Manual ofManual Disorders. 3rd Edition. Washington. DC. American Psychiatric Association. 1980 7. Rovner BW. Katonek S. Filipp L. et al: Prevalence of mental illness in a community nursing home. Am ] Psychiatry 143:1446-1449. 1986 8. Zimmer JG. Watson N. Treat A: Behavioral problems among patients in skilled nursing facilities. Am] Public Health 74:1118-1121.1984 9. Rovner BW. Rabins PV: Mental illness among nursing home patients. Hasp Community Psychiatry 36:119128. 1985 10. Stotsky BA: A controlled study of factors in the successful adjustment of mental patients in nursing homes. Am ] Psychiatry 124:1243-1251. 1967
VOLUME 31· NUMBER 3· SUMMER 1990
II. Liptzin B: The geriatric psychiatrist's role as consultant. ] Geriatr Psychiatry 16: 103-112.1983 12. Gurian BS. Scherl DJ: A community-focused model of nursing home services for the elderly. ] Geriatr Psychiatry 5:77-92.1972 13. Goldman EB. Woog P: Mental health in nursing homes training project. 1972-73. Gerontologist 15:119-124. 1975 14. Colthan SM: A mental health unit in a skilled nursing facility.] Am Geriatr Soc 22:453-456. 1971 15. Jencks SF: Recognition of mental distress and diagnosis of mental disorders in primary care. ]AMA 253:19031907.1985 16. Kramer M. German PRo Anthony JC. et al: Patterns of mental disorders among the elderly residents of eastern Baltimore.] Am Geriatr Soc 33:236-244. 1985 17. Robinson RG. Lipsey JR. Price TR: Diagnosis and clinical management of post-stroke depression. Psychosomatics 26:769-778.1985 18. Schneck MK. Reisberg B. Ferris SH: An overview of current concepts of Alzheimer's disease. Am] Psychiatry 139: 165-173. 1982 19. Moffic HS. Paykel ES: Depression in medical inpatients. Br] Psychiatry 126:346-353.1975 20. Schiffer RB. Herndon RM. Rudick RA: Treatment of pathologic laughing and weeping with amitriptyline. N EnglJ Med 312: 1480-1482. 1985
281
S.
M.D. B.S.
GOLDMAN,
ADAM KLUGMAN,
The first 60 psychiatric consultations provided to a university-affiliated teachin8 nursin8 home are reviewed. All patients seen had a diagnosable mental disorder. and over 40% sufferedfrom major affective illness. Consultation resulted in a critical change in diagnosis and management in more than one-third ofpatients. The authors discuss the benefits and drawbacks ofpsychiatric consultation for nursing home patients, staffphysicians. and the psychiatrists themselves.
A bout one-half of 1% of the U.S. population, ..L\..the vast majority elderly, resides in nursing homes. It is estimated that about 5% of the elderly population currently live in such homes 1and that one-quarter will live in one at some time in their lives. 2 Nonetheless, although nursing homes are "a major health care resource for the older population," they have remained "largely outside the mainstream of traditional medical practice. ,,3 Since Goldfarb's 1962 study demonstrating that some 87% of the patients in the nursing homes he surveyed had psychiatric disorders,4 subsequent reports have confirmed a high incidence of serious psychopathology in this setting. The careful study by Teeter et aL in 1976 found a prevalence of 85%, with two-thirds of the disorders undiagnosed at the time of the study. 5 Two more recent studies, using more modem diagnostic nomenclature (DSM-III 6 ) revealed that 1% of newly admitted 2 and 94% of randomly sampled established7 nursing home patients had mental disorders. In spite ofthese findings, it is estimated that fewer than 1% of nursing home residents receive formal mental health treatments,3 and consultation is requested infrequently, even for problems identified as serious. In spite of the sizable numbers of patients and the extent of psychiatric illness in nursing VOLUME 31 • NUMBER 3 • SUMMER 1990
homes, we were unable to find any reports describing psychiatric consultation experience in this setting. Articles have reviewed mental health problems in such homes,2.3·8.9 the chronically mentally ill in nursing homes,JO nursing home consultation as part of a larger geriatric or consultation program, 11.12 a nursing home stafftraining project in mental health care,13 and a specialized psychiatric program within a nursing home. 14 The absence of a detailed review of the consultation process and its effects prompted this report. One of us (LSG) provided ongoing psychiatric consultation to a nursing home as part of the development of a teaching nursing home by the University of Illinois at Chicago. This preliminary report of the clinical problems and some of the treatment issues raised in such a setting is based on the first 60 consultations.
Received October 17. 1988; revised April 3. 1989; accepted April 26. 1989. From the Consultation-Liaison Service. University of Illinois College of Medicine.• Chicago. Address reprint requests to Dr. Goldman. Box 411. 5841 S. Maryland. Chicago. IL 60637. Copyright © 1990 The Academy of Psychosomatic Medicine. 277
Psychiatric Consultation in a Nursing Home
SETIING AND METHODS Westshire is a 450-bed. privately owned nursing home in Cicero, Illinois. a suburb just west of Chicago. For the past several years. the department of medicine of the University of Illinois at Chicago has been developing a model program of care there. Approximately 125 residents of Westshire are cared for by one of three geriatric internists from the full-time faculty of the university. The remaining patients are cared for by private physicians and, at times, by psychiatrists from the community. Consultations were accepted from university and private physicians. Patients with dementia were cared for in a special program. The most medically ill patients (those requiring feeding tubes. dressing changes, etc.) were cared for on the skilled-care floor. The remaining patients were divided evenly among the remaining four floors. The records of all patients seen in psychiatric consultation were reviewed. The consultation process consisted of a review of the residents' medical records (history, physical. laboratory data, medications, social history, and behavioral observations by nursing staff), discussion with the primary physician and nursing staff, and interviews with the patient and. where indicated, one or more family members. All patients and family members were asked specifically about alcohol or other drug use. A few patients were seen initially by psychiatric residents, but all charts were reviewed and all patients were interviewed and diagnosed by the senior author. Diagnoses were based on DSM-III criteria. No specific rating instruments were utilized for all patients. RESULTS Of the 60 patients. 34 (57%) were female. and 26 were male. Fifty patients were white; seven, black; two. Hispanic; and one, Oriental. The youngest patient was 37; the oldest, 92. The distribution was relatively normal and the mean age was 75. The age and racial distribution of the subjects were fairly comparable to those of the entire population of the nursing home (Prizant P, 278
personal communication. 1987). Two-thirds of the nursing home residents were women, so men were slightly over-represented in the consulting sample. Five patients were referred from the floor with the special dementia program; seven were from the skilled-care floor; and the remainder were evenly distributed from the four generalcare floors. Thus the dementia-floor residents were markedly under-represented and the skilled-care residents slightly so. Table I summarizes the reasons for consultation given by the primary care physician. (One woman with schizophrenia who felt she was overmedicated was self-referred). The figures add to more than 60 since at times there was more than one reason for consultation. Depression-related problems and behavioral disruptions accounted for well over half of the reasons for consultations. Few patients were referred for alcohol- or anxiety-related problems. Stroke was the most common significant medical problem noted by the consultant. occurring in 12 (20%) cases. Other medical problems noted were diabetes (six patients), hypertension (five). heart disease (five), Parkinson's disease (four), chronic obstructive pulmonary disease (four). epilepsy (three). and cancer (three). Table 2 shows the consultant's psychiatric diagnoses for the patients at the end of the study period. All 60 patients seen were felt to suffer from at least one mental disorder. Some patients received more than one diagnosis. Major affective illness (43% of the patients) and organic mental disorders (25%). mostly dementia. accounted for over two-thirds of the diagnoses. An additional one-fifth of the sample suffered from adjustment disorders, usually with depressed or mixed depressed and anxious mood. Adjustment disorders almost always were related to the onset of a medical illness. placement in the nursing home. or both. The small numbers of patients with any particular medical disorder made it difficult to connect specific medical illnesses and psychiatric disorders. Seven of the 12 stroke patients were felt to have a major depression, three adjustment disorders with depressed mood, and one each multi-infarct dementia and pathological weepPSYCHOSOMATICS
Goldman and Klugman
ing. There were no other correlations between particular medical conditions and psychiatric diagnoses. Also of some note was the discovery of eight patients with previously undiagnosed extrapyramidal disorders (Table 2). Although two patients had tardive dyskinesia, the remainder had acute treatable side effects of neuroleptic medications. Table 3 shows the 19 cases in which the consultant did not agree with the existing diagnosis. Each case resulted in major changes in patient management. Eight cases of "pseudodementia" were identified (13% of all cases), and cognitive impairment improved when the underlying depression, schizophrenia, and paraphrenia were treated. As expected from the diagnoses, therapeutic interventions were largely somatic. Five patients were hospitalized for psychiatric care during the 16-month study period. Three patients required electroconvulsive therapy. Further medical evaluation (neurologic consultation, dementia work-up, audiologic evaluation, etc.) was recommended for 22 patients. Psychopharmacologic treatment was initiated for 20 patients (13 for antidepressants) and discontinued in 10 patients, most of whom were on unneeded antipsychotics. Environmental manipulations were suggestTABLE I.
Reasons for consultation request for 60 geriatric residents of a teaching nursing home
Reason
Number
Depression. suicidal ideation
22
Behavioral disturbance agitation wandering irritability
20
ed as the predominant intervention for six patients, generally involving moving the patient to a floor that better matched their level of functioning, staff assignment changes, or providing a "buddy system" for socially isolated new patients. Brief psychotherapy as an exclusive treatment was recommended for six patients. Two patients required formal family treatments. DISCUSSION Referral bias limits the conclusions that can be drawn about the prevalence of psychopathology at this nursing home. Since the only patients evaluated were those specifically referred, inferences about the prevalence of psychopathology can yield only minimum figures. About 40% of the patients cared for by the university's geriatricians were seen in consultation in less than a year and a half, and all of these patients had a diagnosable mental disorder. TABLE 2.
Consultant's diagnoses for 60 geriatric residents of a teaching nursing home
Diagnosis
Number
Psychiatric diagnosis Affective disorder all major depression bipolar Organic brain syndromes all dementia pathologic weeping organic affective
26 17 9
15 12
2 I
12
8
Adjustment disorders Paranoid disorders
5
Schizophrenia. schizoaffective
4
Paranoia
4 2 7
Alcohol abuse
2
Psychiatric history
6
Anxiety disorders
Confusion. dementia
5
Personality disorders
2 2
Psychosis
3
Mental retardation
Personality change
All psychiatric diagnoses
Competency evaluation
3 2
Alcohol abuse
I
Pseudoparkinsonism
5
Anxiety
I
Tardive dyskinesia
2
Self-referral
I
Akathisia
I
All reasons
72
All
8
VOLUME 31' NUMBER 3· SUMMER 1990
I
69
Extrapyramidal disorders
279
Psychiatric Consultation in a Nursing Home
TABLE 3. Cases in which the consultant's diagnosis connicted with the existing diagnosis IN:19)
Existing Diagnosis
Consultant's Diagnosis
Number
Depression
Organic brain syndrome
Dementia
Major depression
4 4
Dementia
Schizophrenia
3
Dementia
Paranoid disorder
I
Schizophrenia
Bipolar disorder
2
None
Bipolar disorder
5
Infonnal discussions with these physicians revealed that additional patients were not referred in spite of known mental illness because they presented no particular diagnostic or management problems. Since the tendency of primary care physicians to underdiagnose mental disorders is well-documented,15 there is considerable indirect evidence suggesting that the prevalence of mental disorders at this nursing home must have been considerably higher than 40%, perhaps approaching the figures in the studies cited earlier. We currently are studying this issue. The distribution of specific mental disorders was notable as well. Of the 60 patients seen, 26 (42%) suffered from major affective illness. Even if in the unlikely event that these were the only patients in the nursing home with affective disorders, the prevalence (about 6%) well exceeds that of the geriatric population as a whole. 16 A few of these patients received nursing home care exclusively for their mental disorders, but, in general, the affective disorder represented serious comorbidity with their medical problems. In particular, the relationship between stroke and depression noted by Robinson et al. 17 was seen in this population as well. Most surveys suggest that 50% to 60% of nursing home residents suffer from dementia,lS yet only 25% of the referred patients were so diagnosed. This probably reflects several factors: some diagnoses were missed; some cases may be managed successfully by the primary care physician; some physicians are reluctant to refer demented patients to psychiatrists; the specialized program at Westshire may have obviated the need for some referrals; and the true incidence of 280
dementia at Westshire may have been lower due the limited number of beds available on the special floor (although some demented patients were cared for on other floors). The large number of adjustment disorders attests to the stress of transition to nursing home living 2 and coping with serious medical illness. 19 Major issues for these patients centered on loss of autonomy and independence, separation from family and friends, fear of mistreatment, lack of privacy, enforced proximity to others (a particular problem for those previously socially isolated by choice), and behavioral disruptions (screaming, theft, hostility) by other patients. Since so many ofthese concerns were realistic, supportive psychotherapy needed to be integrated with concrete environmental changes where possible, such as room or floor changes, special attention or care, altered family involvement, and development of behavior modification paradigms. The paucity of patients either referred for, or diagnosed by, the consultant as suffering from alcohol-related problems or personality disorders was unexpected. This may have resulted from limited recognition by the primary physicians, less disruption by the patients than by other patients, difficulty in establishing these diagnoses using the diagnostic methods employed, or a true lower prevalence in this population. Did consultation affect care? New or altered diagnoses led to critical changes in management in 19 patients alone (Table 3), largely in the direction of treating specific mental disorders that either were diagnosed incorrectly (eight patients) or missed (seven patients). Reversible neurologic side effects of medications were discovered and treated in six other patients. A number of other patients received psychotherapy; optimization of antidepressant, antipsychotic, or lithium therapy; or treatment of unusual symptoms such as pathological weeping. 20 Clarification of some symptoms as being beyond the patient's control (e.g., manic irritability) or related to stressors (e.g., increased neediness while the patient's family was away on vacation) also led to better staff understanding and more therapeutic care. The applicability of the conclusions reached PSYCHOSOMATICS
Goldman and Klugman
here, of course, must be tempered by the retrospective nature of the data collection and the special features of the setting (teaching nursing home, suburban location, psychiatrically sophisticated geriatricians, etc). Reports from other long-term care settings would clarify this matter. From the consultant's perspective the rewards of being a consultant in a nursing home are also clear: a varied and interesting array of psychopathology, often undiagnosed and frequently treatable, a group of patients who always appear for their appointments, and considerable appreciation at times (by patients, family, or staff) for amelioration in the patient's condition. On the other hand, such consultation at times also can
involve marked resistance from patients, families, physicians, and staff; inability to monitor outcomes and side effects carefully because of a psychiatrically naive staff; obstacles to behavior management because of low staff ratio and high turnover; and frustrations in working with chronically ill, frail patients who may be refractory to one's best efforts. The study of psychiatric needs and models of care in nursing homes remains in its relative infancy. With increased attention being paid to long-term care, geriatric medicine, and teaching nursing homes, we hope that the psychiatric needs of this population can be studied and met as well.
References I. Brody JA. Foley DJ: Epidemiologic considerations. in Schneider EL: The Teaching Nursing Home. New York. Raven. 1985. pp 4-25 2. Herst L. Moulton P: Psychiatry in the nursing home. Psychiatric Clin North Am 8:551-561. 1985 3. Borson S. Liptzin B. Nininger J. et al: Psychiatry and the nursing home. Am] Psychiatry 144: 1412-1418. 1987 4. Goldfarb AI: Prevalence of psychiatric disorders in metropolitan old age and nursing homes. ] Am Geriatr Soc 10:77-84.1962 5. Teeter RB. Goretz FK. Miller WR. et al: Psychiatric disturbances of aged patients in skilled nursing homes. Am] Psychiatry 133:1430-1434.1976 6. American Psychiatric Association: Diagnostic and Statistical Manual ofManual Disorders. 3rd Edition. Washington. DC. American Psychiatric Association. 1980 7. Rovner BW. Katonek S. Filipp L. et al: Prevalence of mental illness in a community nursing home. Am ] Psychiatry 143:1446-1449. 1986 8. Zimmer JG. Watson N. Treat A: Behavioral problems among patients in skilled nursing facilities. Am] Public Health 74:1118-1121.1984 9. Rovner BW. Rabins PV: Mental illness among nursing home patients. Hasp Community Psychiatry 36:119128. 1985 10. Stotsky BA: A controlled study of factors in the successful adjustment of mental patients in nursing homes. Am ] Psychiatry 124:1243-1251. 1967
VOLUME 31· NUMBER 3· SUMMER 1990
II. Liptzin B: The geriatric psychiatrist's role as consultant. ] Geriatr Psychiatry 16: 103-112.1983 12. Gurian BS. Scherl DJ: A community-focused model of nursing home services for the elderly. ] Geriatr Psychiatry 5:77-92.1972 13. Goldman EB. Woog P: Mental health in nursing homes training project. 1972-73. Gerontologist 15:119-124. 1975 14. Colthan SM: A mental health unit in a skilled nursing facility.] Am Geriatr Soc 22:453-456. 1971 15. Jencks SF: Recognition of mental distress and diagnosis of mental disorders in primary care. ]AMA 253:19031907.1985 16. Kramer M. German PRo Anthony JC. et al: Patterns of mental disorders among the elderly residents of eastern Baltimore.] Am Geriatr Soc 33:236-244. 1985 17. Robinson RG. Lipsey JR. Price TR: Diagnosis and clinical management of post-stroke depression. Psychosomatics 26:769-778.1985 18. Schneck MK. Reisberg B. Ferris SH: An overview of current concepts of Alzheimer's disease. Am] Psychiatry 139: 165-173. 1982 19. Moffic HS. Paykel ES: Depression in medical inpatients. Br] Psychiatry 126:346-353.1975 20. Schiffer RB. Herndon RM. Rudick RA: Treatment of pathologic laughing and weeping with amitriptyline. N EnglJ Med 312: 1480-1482. 1985
281
