Mohammed T. Abou-Saleh

690 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYThrough the American Psychiatric Association’s PracticeResearch Network (PRN), we are just now able to describe anationally representative profile of patient characteristics andtreatments received from psychiatrists 11 . Similar practice-basedresearch for other mental health disciplines has yet to be launched,and only recently have data been reported that describes thedemographic and treatment characteristics of patients aged 65+treated by psychiatrists 12 . Generally speaking, PRN psychiatristsprovide a full array of diagnostic and treatment services for olderpatients. PRN provides descriptive baseline data. About 51% ofpatients aged 65+ in the PRN have a primary diagnosis of anaffective disorder, followed by cognitive disorders (20%) andschizophrenia (19%). Older adults have more medical comorbiditiesand lower initial global assessment of functioningscores. About 49% of older patients were seen in outpatientsettings, followed by hospital settings (32%) and nursing homesettings (16%). Over 50% of patients receive both pharmacotherapyand psychotherapy, and 40% of older patients receivepharmacotherapy alone. Only 2% receive psychotherapy alone.Of patients receiving medications, over 60% of older patientsreceived antidepressants, 40% antipsychotics and 48% benzodiazepinemedications.Data are lacking on how well psychiatrists or other mentalhealth clinicians employ best practices or adhere to existingtreatment guidelines for older adults. Future research will beneeded to answer these types of questions and establish theeffectiveness of treatments for subpopulations of elderly patients,such as minorities, those living in different environments andthose with significant medical–psychiatric co-morbidity.Community Mental Health CentersOlder patients with severe and persistent mental illness (SPMI)pose significant challenges for the US system of care. Theseindividuals have long-term care needs, have limited financialresources, and secular trends in managed care, home- andcommunity-based alternatives to institutional care are beingpromoted as the major venue for mental health services 13 .About 2% of persons aged 55+ in the USA have SPMI, whichis expected to double over the next 30 years 14 . The downsizing andclosure of state hospitals over the last few decades has resulted intrans-institutionalization of SPMI patients into nursing homesand other less restrictive environments, such as boarding carehomes, assisted living and other forms of community-based livingarrangements. Currently, over 89% of all institutionalized olderadults with SPMI reside in nursing homes 15 . It is unlikely thatnursing homes will be a principal resource for care of olderpatients with SPMI, as further effects of nursing home reform(OBRA-87) and managed Medicaid are reinforced by patientpreference 14 .Mental health services for the elderly SPMI population hasbeen provided largely through community mental health centers(CMHCs). The CMHCs have not been particularly attuned to, orcapable of, accommodating the unique and complex needs of theelderly, and they may not be capable of coordinating medical–psychiatric treatments 16 . Older persons with severe mental illnessalso receive services from home health agencies that providelimited mental health care and, to a lesser extent, from the generalmedical sector 14 . As with patients with less severe mental illness,older patients with SPMI require close collaboration amongproviders in the general and specialty mental health sectors.Promising models of integrated care include co-location ofmedical and mental health providers, multidisciplinary treatmentteams and cross-training of medical–psychiatric providers. Theseprograms must also include social support services to maintainfunction and improve quality of life, integrative case managementservices, home-based residential family support services, caregivertraining and psychosocial rehabilitation 14 . Managed care may bethe vehicle to promote such service integration because of thepossibility of pooling resources from federal, state and localfunding agencies. Appropriate risk adjustment mechanisms toaccount for the psychiatric medical and social service complexityof these patients will be required for programs to be successful.Nursing HomesIn 1997 almost 1.5 million elderly resided in nursing homes. Onehalfof these people were aged 85+ and three-quarters werewomen 17 . Nursing homes have supplanted state hospitals as themajor loci of institutionally-based long-term care for older adultswith psychiatric disorders. Surveys of nursing home residentsshow uniformly high prevalence rates of dementia (46–78%) 18–20 ,and clinically significant depression (20–40%) 21 . Early in thetrans-institutionalization movement, nursing homes became therepository of many SPMI patients. Current trends, however, findmany older SPMI patients live in community settings 14 .OBRA-87 legislation, also known as the Nursing Home ReformAct of 1987, was enacted in response to inappropriate andinadequate care for mental illnesses in nursing homes. Thelegislation restricted the inappropriate use of restraints, physicaland pharmacologic, and required pre-admission screening for allpersons suspected of having a serious mental illness. Screeningwas designed to improve treatment and psychosocial assessmentfor nursing home residents with mental disorders. In 1998, theInstitute of Medicine (IOM) convened a follow-up analysisexamining the effectiveness of the original legislation. From apsychiatric services perspective, the results have been mixed 22 .Pharmacoepidemiologic evidence has shown a downward trend inthe use of psychotropic medications, and interventional trialsdesigned to reduce physical–chemical restraints in nursing homesdemonstrated that educational efforts complementing consultationby skilled mental health professionals had the best results 23,24 .Physician prescribing practices have also changed. A newgeneration of psychotropic medications are now commonlybeing prescribed that have fewer side effects and are bettertolerated by frail nursing home residents 25 . Multidisciplinarytreatment guidelines have been developed to deal with difficultpsychiatric and behavioral problems, such as depression andagitation, in dementia patients. Less certain outcomes of OBRA-87 include unnecessary tensions between the legitimate use ofmedications and federal/state survey procedures; collection ofuniform information on nursing home residents that do not havesufficient flexibility to measure quality-of-life outcomes or qualityindicators; logistic barriers for medically necessary psychiatricservices; and the unintended effect of establishing incentives forthe inappropriate provision of some mental health services, e.g.psychotherapy services for severely demented patients 22 .Important components in state-of-the-art mental health servicesin nursing homes include ‘‘intrinsic’’ and ‘‘extrinsic’’ mentalhealth services 22 . Intrinsic services refer to the biopsychosocialelements of daily patient care activities and range from thenursing home environment to individual attitudes of professionalstaff, which are tied to respect, dignity and empathetic interpersonalexchanges. In addition, intrinsic services may includespecialized settings and discrete units that provide behaviorallyorientated services with highly trained staff. Dementia care units,‘‘special care units’’ and psychiatric nursing home units areexamples of specialized intrinsic services that are relevant to thetreatment of older persons with mental disorders. Extrinsicservices are linked to the ability of nursing home residents togain access to specialized psychiatric services in a timely, efficientand sensitive manner. Extrinsic services generally refer to