THE CANADIAN JOURNAL OF PSYCHIATRY Volume 37
Ottawa, Canada, October 1992
Psychiatric Services: A Survey of Nursing Homes and Homes for the Aged in Ontario* DAVID
CONN, M.B. I , VICTORIA LEE, M.D. 2, ALLAN STEINGART, M.D. 3 AND MICHEL SILBERFELD, M.D. 4
pression (1,2). Moreover, the incidence of psychotic disorders in individuals suffering from dementia is at least 30% to 40% (3). In the United States, the 1977 National Nursing Home Survey (4) reported that approximately 20% of all nursing home residents had a mental disorder as their primary source of disability and that nearly 70% (more than 900,000 residents) had a chronic mental disorder contributing to social dependency, functional impairment and the need for institutional care. The results of the 1984 pre-test of the National Nursing Home Survey (5) suggested that the overall prevalence of mental disorder was 68%. Of these patients, 39% had a diagnosis of organic brain syndrome and 29% had other mental disorders. Borson et al (6) note that no reliable data have been published on the availability of psychiatric care for patients in nursing homes and that the results of small surveys suggest that fewer than one percent of all patients with a diagnosable mental disorder receive specific mental health care. Recognition of the need for better care for the mentally ill in nursing homes has prompted a sweeping legislative reform in the United States, entitled OBRA 87 (7). Despite the distinct lack of psychiatric care for nursing home residents, several studies suggest that psychotropic drugs .are overused in nursing homes (6). According to a survey of 60 nursing homes, over one-half ofthe patients were receiving a psychotropic agent regularly, although less than ten percent had a recorded diagnosis justifying the use of such medication and psychiatric consultation was extremely rare (8). A review of previous studies found that 35% of patients received sedative/hypnotic medication and 20% received neuroleptics (9). Ray et al (10) surveyed the records of 173 nursing homes and found that 43% of almost 6,000 patients had been prescribed a neuroleptic. The average dose per patient appeared to be related to the size of the nursing home and the prescribing physician's caseload. It has also been demonstrated that health care professionals in long term care facilities require more information and skills related to mental disorders and their management (11).
A survey was conducted to determine perceptions and attitudes of psychiatric services available to nursing homes and homesfor the aged across Ontario. A questionnaire was sent by mail to medical and nursing directors separately. Thirty-six point eight percent of responders reported that the nursing home residents never receive psychiatric care, and 88.2% of responders estimated the total psychiatric care received by all oftheir residents per month was five hours or less. Almost three-quarters ofthe responders stated that they require more psychiatric services. Significantly more nursing directors than medical directors wanted more psychiatric services. Southwestern Ontario, followed by Northern Ontario, had the least perceived availability ofa visiting psychiatrist. Perceived availability was greatest in larger urban areas and least in rural areas. The mean percentage of residents perceived to have psychiatric or behavioural problems was 30.5%, while the mean percentage perceived to require psychotropic medication was 37.4%. Physical aggression, wandering and agitation were identified as the behavioural problems of greatest concern to staff. When a visiting psychiatrist is not available, residents sometimes have (0 travel long distancesfor psychiatric evaluation. Planning is required to facilitate and encourage the development of efficient and effective psychiatric services for long term care facilities for the elderly.
tudies suggest that at least 80% of elderly nursing home residents suffer from some form of mental disorder, most commonly dementia, another organic brain syndrome or de-
*Presented at the Annual Meeting of the Gerontological Society of America, Boston MA, November 1990. Manuscript received November 1990, revised September 1991. tAssistant Professor, Department of Psychiatry, University of Toronto; Head, Department of Psychiatry, Baycrest Centre for Geriatric Care, Toronto, Ontario. 2formerly, Lecturer, Department of Psychiatry, University of Toronto; Staff Psychiatrist, Department of Psychiatry, Baycrest Centre for Geriatric Care, Toronto, Ontario. 3Assistant Professor, Department of Psychiatry, University of Toronto; Coordinator, Psychiatric Day Hospital, Baycrest Centre for Geriatric Care, Toronto, Ontario. 4Assistant Professor, Department of Psychiatry, University of Toronto; Coordinator, Competency Clinic, Baycrest Centre for Geriatric Care, Toronto, Ontario. Address reprint requests to: Dr. David Conn, Baycrest Centre for Geriatric Care, 3560 Bathurst St., North York, Ontario M6A 2E 1
There is evidence, therefore, that the prevalence of mental disorders in nursing homes is very high but that few nursing home residents receive psychiatric care. The primary purpose of this survey was to ascertain the availability of and the perceived need for psychiatric services in long term care facilities for the elderly throughout Ontario. To our knowledge, there have been no studies of these services in Canada. We also wished to obtain information on the nature of psychiatric problems in these facilities.
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CANADIAN JOURNAL OF PSYCHIATRY
Table I Profile of the 589 Medical and Nursing Directors Who Responded to the Survey n
Medical directors Nursing directors Region
• North • Southwest • Central • Southeast • Unknown Population • Over 200,000 • 50,00 to 200,000 • Under 50,000 • Unknown Size of the home (number of beds) • Over300 • 150 to 300 • 50 to 150 • Less than 50 • Unknown Type of home • Nursing home (MOH) • Home for the aged (COMSOC) • Non ministry run or unknown
58 244 142 144 I 115 99 373 2
26 116 354 91
2 321 212 56
Methodology A questionnaire was constructed focusing on the perceived availability of a visiting psychiatrist, need for psychiatric services, and the nature of psychiatric problems in nursing homes. A total of 1,148 questionnaires were sent separately to the medical directors (n = 574) and nursing directors (n = 574) of all Ministry of Health (MOH) nursing homes and Ministry of Community and Social Services (COMSOC) homes for the aged in Ontario; a small number were sent to facilities not run by the ministry. (A computerized mailing list of long term care facilities for the elderly was obtained, compiled from Ministry of Health and COMSOC listings.) Because we wished to compare the responses of the nursing and medical directors, the accompanying letter requested that they not consult with each other. Ontario was divided into four regions (north, central, southeast and southwest), according to COMSOC divisions. The central region is the most densely populated and includes Metropolitan Toronto. Northern Ontario is the largest and most sparsely populated region and is recognized as being particularly underserviced by physicians, including psychiatrists. The southeast and southwest regions are both predominantly rural with a few large urban centres. The population of local towns was determined using the 1987 Census (12). The distance from nursing homes to mental health care facil-
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ities (including hospitals, mental health clinics and psychiatrists' offices) was measured using a standard provincial map. There were a few anonymous responders and incomplete questionnaires. In these cases, all supplied data were used. Six hundred and one responses were received, for an overall response rate of 52.3%. Twelve responses were not analyzed since the responders reported that their facilities were neither nursing homes nor homes for the aged. The remaining 589 responders were all from long term care facilities for the elderly; a profile ofthese responders is shown in Table I. There were 269 responses from medical directors and 320 responses fromnursing directors. Responses from both medical and nursing directors were received from 152 institutions. The response rates by region were as follows: north55.8%, southwest - 57.3%, central- 45.9% and southeast50.3%. The response rate (excluding anonymous responders) for the nursing homes was 44.8% and the rate for homes for the aged was 57.9%. The responses were classified according to type ofdirector (medical or nursing), region, population of local town, size of institution and classification of institution. The sample was of sufficient size to use the chi-square test to determine whether the distribution of responses varied from one class to another. In order to evaluate the validity of reporting total responses, we compared total responses and "institutional" responses. The use of "institutional" responses eliminates any effect of having two responses from some but not all institutions. "Institutional" responses were counted as follows: for any "yes/no" question, only one response per institution was counted; if the nursing and medical directors agreed, one response was counted; if they disagreed, the institution was not counted; for questions with a numerical answer, one average response was counted. We found no apparent differences between total responses and "institutional" responses. Therefore, in order to present all available data, the results are reported as total responses. We also found no apparent differences when comparing the responses of the medical and nursing directors based on total responses versus comparisons based on matched pairs alone. Therefore, any reported differences between medical and nursing responses are also based on total responses.
Results Availability of a Visiting Psychiatrist Do you have a psychiatrist who will do consultations in your nursing home? Two hundred and seventy-one of the responders (46.2%) responded "yes" and 316 (53.8%) responded "no" to this question. The responses to this question according to region, population of local town and size of institution are shown in Table II. In the southwest region, only 33.6% ofresponders said a psychiatrist was available to come to their nursing home, compared with 48.3%,56% and 57.3% respectively in the north, central and southeast regions. In the larger towns (with a population of more than 200,000), 67.8 % of the responders had a psychiatrist who would come to the
A SURVEY OF NURSING HOMES AND HOMES FOR THE AGED
Table II Availability of a Visiting Psychiatrist Psychiatrist Available n %
No Psychiatrist Available n
Region" • North • Southwest • Central • Southest Populariont • Over 200,000 • 50,00 to 200,000 • Under 50,000
28 82 79 82
48.30 33.60 56.00 57.30
30 162 62 61
78 45 148
67.80 45.90 39.80
37 53 224
Size of the home (number of beds)! • Over 300 • 150 to 300 • 50 to 150 • Less than 50
13 71 165 21
50.00 61.20 46.70 23.61
13 45 188 68
'region: southwest versus central significant at p < 0.001; southwest versus southeast significant at p < 0.00 I tpopulation: > 200,000 versus 50,000 to 200,000 significant at p < 0.01; >200,000 versus >50,000 significant at p < 0.001 §beds: >300 versus < 50 significant at P < 0.001
Table III Agreement Between Nursing Directors' and Medical Directors' Perceptions of the Need for More Psychiatric Services" Yes Medical Directors Yes No Total
96 33 129 (87.16%)
Nursing Directors No
7 12 (12.84%)
Total 103 (69.59%) 45 (30.41%) 148 (100.00%)
"data are included only for homes where both the nursing director and the medical director responded to the survey
nursing home, compared with 45.9% in towns of between 50,000 and 200,000, and 39.8% in towns of less than 50,000. In facilities with less than 50 beds, only 23.6% reported having a psychiatrist available, whereas in facilities with between 150 and 300 beds, 61.2% reported having a psychiatrist available. There was no significant difference between the responses of the medical and nursing directors or responses from nursing homes and homes for the aged in this regard. Estimate the number ofhours ofassessment and treatment that your residents receive from psychiatrists per month. Thirty-six point eight percent of the responders said that their residents never receive any psychiatric care; 88.2% of the responders estimated that the total psychiatric care received
by all of the residents in their institution per month was five hours or less (that is five hours or less of care in total for the whole institution.) Less than one percent of the homes received more than 20 hours of psychiatric care for all their residents per month. These low levels of psychiatric care were evident in all regions of the province.
Perceived Needfor Change in the Availability ofPsychiatric Services Do you believe that you have a need for increased psychiatric services to your nursing home? Seventy-three point eight percent of the responders said that they required more services, while 26.2% replied that they did not. There were no significant differences by region or size of the local population, although the greatest reported need for more services was in the northern region (83% of the responders). The greatest need for more services was reported in the nursing homes with more than 150 beds. There was no significant difference between responses from the nursing homes and the homes for the aged. There was a significant difference between the response of medical directors and nursing directors: 80.8% of the nursing directors believed that there was a need for more services, while only 66.8% of the medical directors did (p < 0.001). Since this is a particularly important question, we also present the matched pair data (see Table III). Of the 148 matched pairs who answered this question, 87.2% of the nursing directors and 69.6% of the medical directors report a need for more psychiatric services. In the ideal situation estimate the number of hours of assessment and treatment that your residents would receive from psychiatrists per month. Fifty-seven point nine percent of the responders felt that the ideal total amount of psychiatric care for all their residents was at least five hours per month (total hours of care for the whole institution), and 26.6% wanted at least ten hours of care per month. Only 7.8% of responders felt that their residents should receive a total of at least 20 hours of psychiatric care per month. How frequently do you have to transfer/discharge a resident because of psychiatric-behavioural problems? Eightythree point two percent of the responders said that they had to transfer or discharge residents to other facilities at least once per year, and 20.8% had to transfer or discharge residents at least three times per year. If a psychiatrist does not come to your nursing home, where do you send the residentforpsychiatric care? Fifty-one point two percent of the responders sent residents to general hospitals, 29.4% sent residents to psychiatric hospitals, and 13.4% transferred residents to a private practice or a mental health clinic. In 46.4% of the cases, a distance of greater than 20 km of travel was required, and in 29.4% of cases, a distance of more than 50 km travel was required. The Nature ofPsychiatric Problems Estimate the percentage of your residents who have psychiatric or behavioural problems. The mean estimated percentage of residents with psychiatric or behavioural prob-
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lems was 30.5%. There was no apparent difference between the responses of the medical directors (mean = 32.8%) and nursing directors (mean = 29%). The number of nursing homes where more than 40% of the residents had perceived problems significantly exceeded the number of homes for the aged where more than 40% of the residents had such problems. Estimate the percentage of your residents who require treatment with psychotropic medications (tranquilizers, antidepressants, hypnotics, etc.). The mean estimated percentage of residents requiring psychotropic medication was 37.4%. There was no significant difference between the response of the medical directors (mean = 39.8%) and the nursing directors (mean = 35.8%). The distribution of responses is shown in Figure I. The number of nursing homes where more than 40% of the residents were believed to require medication significantly exceeded the number of homes for the aged where this was the case. Choose three ofthe following problems which occur most frequently in residents at your nursing home (agitation, verbal aggression, physical aggression, depression, wandering, hallucinations, paranoia, suicidal ideation/behaviour). The most common problems identified were agitation (81.9% of all responders), wandering (61%) and depression (56.4%). The medical directors chose agitation, depression and wandering as the most common problems, in that order, whereas the nursing directors chose agitation, wandering and physical aggression. Which ofthese problems causes the most concern foryour staff? Both the medical and nursing directors stated that
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physical aggression, wandering and agitation were of greatest concern to their staff. Does your staffreceive any education regarding the management ofthese kinds ofproblems? If yes.from whom (which profession) and how often? Eighty-three point four percent of the directors suggested that some education was available for staff. However, of these, 58% failed to answer the question on the frequency of educational activities, and 19% reported that education was sporadic. Seventeen point four percent stated that the teachers were psychiatrists or members of a psychiatric or psychogeriatric team, 32.8% were from the nursing profession, and 16.5% were physicians who were not psychiatrists. Discussion The results of the survey suggest that the current availability of psychiatrists who actually perform consultations in nursing homes and homes for the aged varies by region. The perceived availability of service was found to be greatest in larger urban areas and least in rural areas. Southwestern and Northern Ontario appear to have the fewest services, probably reflecting a lower availability in rural and sparsely populated regions. It is difficult to explain the difference in perceived availability between Southwestern and Southeastern Ontario, although this finding might reflect the considerably larger number of facilities in the Southwestern region. The actual amount of time spent by psychiatrists in such facilities is reported to be extremely low. This suggests that in the vast majority of long term care institutions, very few residents receive any psychiatric care.
Figure 1. Percentage of nursing home residents believed to require psychotropic medication.
A SURVEY OF NURSING HOMES AND HOMES FOR THE AGED
Seventy-three point eight percent of the responders said that they required more psychiatric services. However, the number of hours of care required were modest: only 26.6% of the responders felt that their residents should receive ten hours or more of psychiatric care in total per month. This suggests that some responders may be content with a consultative model of psychiatric intervention, whereby only residents with more serious problems are referred to psychiatrists. More nursing directors than medical directors believe there is a need for more psychiatric services. This might reflect the nursing directors' better understanding of the difficulties experienced by frontline nursing staff in the management of these residents. This finding might also reflect ambivalence of some medical directors about the usefulness of psychiatric services, possibly based on their difficulties in obtaining such services in the past. Some medical directors may feel competent managing psychiatric disorders; indeed, a number of medical directors commented that this was the case. One factor which would have to be considered in any attempt to exp.and such services is that more than one-third of medical directors did not feel that there was a need for more psychiatric services. The need to transfer or discharge residents occasionally to other facilities because of psychiatric or behavioural problems was very common, and travel over long distances was sometimes required. The need to transport residents might be avoided if more psychiatric services were available. Several responders stated that local psychiatric inpatient units were extremely reluctant to admit residents from long term care facilities. . The nursing and medical directors differed in their view of which psychiatric or behavioural problems were most prevalent in their nursing homes. While they agreed that agitation and wandering were common problems, the medical directors included depression in the top three problems, in contrast to the nursing directors, who believed that physical aggression was one of the top three problems. Nurses tend to receive the brunt of physical aggression or threats of physical aggression and this might explain the nursing directors' greater awareness of this problem. The medical directors' choice of depression suggests an awareness of depression as a significant and treatable problem in this population. The wide range of responses from both medical and nursing directors regarding the percentage of residents believed to require psychotropic medication suggests that prescribing habits also vary considerably. More research is required to determine optimal criteria for the use of psychotropic medication to treat nursing home residents. The proportion of directors reporting that some education was available was surprising high. However, this response may be somewhat misleading, since the question itself was vague and referred to "any" education for psychiatric or behavioural problems. Indeed, the lack of response to the question on the frequency of available education suggests that educational activities are relatively infrequent. The need for more education was widely commented upon. One problem
for consulting psychiatrists is that education and other liaison activities are not funded in a fee-for-service system. Alternative means offunding educational activities, such as sessional fees, should be considered in any plan for the provision of more psychiatric services. We recognize that there are weaknesses inherent. in descriptive data obtained from a mail survey and suggest that a definitive survey be carried out. One possible bias is that those who responded to the survey may have a greater interest in psychiatric care than those who did not. Nevertheless, our survey appears to indicate a perceived need for more psychiatric services in long term care facilities for the elderly across Ontario. The current level of psychiatric services might be even lower in provinces which have fewer psychiatrists per capita than Ontario. A variety of models for the provision of psychiatric services could be employed. With the current development in geriatric psychiatry, there may be a greater number of trained psychiatrists available with a special interest in this area. Larger nursing homes could benefit greatly by employing a psychiatric nurse/clinician who could work with a consulting psychiatrist. The nurse/clinician could be responsible for a considerable degree of follow-up care and staff education. For smaller institutions, teams from community psychogeriatric services are becoming increasingly available to consult with the staff. The results of this survey suggest that there is an urgent need for representatives from institutions and governments, psychiatrists and other mental health professionals to coordinate an approach that facilitates the development of efficient and effective psychiatric services for the residents of these facilities. Acknowledgements We thank Peter Slasor for statistical analysis, Paula Ferreira and Marci Fromstein for secretarial assistance and Katherine Steirman for compiling the data.
References l. Teeter RB, Garetz FK, Miller WR, et al, Psychiatric disturbances of aged patients in skilled nursing homes. Am J Psychiatry 1976; 133: 1430-1434. 2. Rovner BW, Kafonek S, Filipp L, et al. Prevalence of mental illness in a community nursing home. Am J Psychiatry 1986; 143: 1446-1449. 3. Wragg R, Jeste DV. An overview of depression and psychosis in Alzheimer's disease. Am J.Psychiatry 1989; 146: 577-587. 4. National Center for Health Statistics. The National Nursing Home Survey: 1977 summary for the United States. Vital and Health Statistics, Serial 13, Number 43. Washington DC: US Government Printing Office, 1979. 5. Bums BJ, Larson DB, Goldstrom !D, et al. Mental disorder among nursing home patients: preliminary findings from the national nursing home survey pretest. International Journal of Geriatric Psychiatry 1988; 3: 27-35. 6. Borson S, Liptzin B, Nininger J, eta!. Psychiatry and the nursing home. Am J Psychiatry 1987; 144: 1412-1418. 7. Omnibus Budget Reconciliation Act of 1987. Washington DC: US Government Printing Office, 1987. 8. Glasscote RM, Beigel A, Butterfield A, et al, Old folks at homes: a field study of nursing and board-and-care homes.
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Washington DC: Joint Information Service of the American Psychiatric Association and the National Association for Mental Health, 1976. Prien RF. Problems and practices in geriatric psychopnarmacology. Psychosomatics 1980; 21: 213-223. Ray WA, Federspiel CF, Schaffner W. A study of antipsychotic drug use in nursing homes: epidemiologic evidence suggesting misuse. Am J Public Health 1980; 70: 485-491. Avorn J, Dreyer P, Connelly K, et al. Use of psychoactive medication and the quality of care in rest homes. N Engl J Med 1989; 320: 227-232. Statistics Canada. Census divisions and subdivisions: population and dwelling counts - Canada 1986. Ottawa ON: Canadian Government Publishing Centre, 1987.
Aux fins d' enquete sur les perceptions et les attitudes a l' egard des services psychiatriques dans les foyers de soins infirmiers et dans lesfoyers pourpersonnes agees en Ontario, un questionnaire a ere envoye par la poste aux directeurs medicaux et aux directrices des soins infirmiers. Ceux-ci ont renvoye 601 questionnaires dument remplis, soit un taux de reponse de 52,3 %. Trente-six virgule huit pour cent des personnes qui ont repondu au questionnaire indiquent que les residents de leur etablissement ne recoivent jamais de soins psychiatriques et 88,2 % estiment que les soins psy-
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chiatriques prodigues mensuellement a l' ensemble des residents se chiffrent a cinq heures ou moins. Pres des trois quarts des repondarus (73,8 %) declarent qu' it faudrait intensifier les services psychiatriques dans leur etablissement. Considerablement plus de directrices des soins infirmiers (80,8 %) que de directeurs medicaux (66,8 %) desirent qu' on etoffe les services psychiatriques. C' est dans le sud-ouest de l'Ontario, puis dans le nord de cette province, que les psychiatres visiteurs semblent les moins disponibles. Ces specialistes paraissentplus nombreux dans les grands centres urbains (population de plus de 100 000) et le sont moins dans les regions rurales. La proportion moyenne de residents presentant des troubles psychiques ou du comportement se chiffrerait a 30,5 %, tandis que la proportion moyenne de residents exigeant des medicaments psychotropiques serait de 37,4 %. L' agression physique, le vagabondage et l' agitation sont les problemes de comportement qui preoccupent le plus le personnel des etablissements de soins. Lorsqu'il est impossible d' obtenir les services d' un psychiatre visiteur, les residents doivent parfois faire de longs deplacements pour subir des examens psychiatriques. It faudrait faciliter et encourager l'intensification des services psychiatriques dans les etablissements de soins de longue duree pour personnes agees.