Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0130The Psychiatrist in the Nursing HomeWilliam E. ReichmanUniversity of Medicine and Dentistry, Piscataway, NJ, USAIn the USA, nursing homes and other related long-term carefacilities care for approximately 1.5 million persons annually.There are nearly 600 000 beds in these facilities across the country.While at any given time only 5% of the nation’s elderly reside inthese settings, up to 50% of citizens can expect to spend someportion of their lives there 1 . Over the past several years, manyauthors have described the impressive prevalence and vast arrayof psychiatric disorders complicating the care of nursing homeresidents. When dementia is included, rates of diagnosable mentalillnesses have exceeded 80% 2–9 . The widespread use of psychoactivemedications 10,11 and mechanical restraints 12,13 for thetreatment of disturbed behavior in this setting has been welldocumented 5 . The National Medical Expenditures Survey in 1987reported that 31% of nursing home residents had a non-dementiarelatedprimary or secondary diagnosis of mental illness 14 . Theprincipal psychiatric conditions that are especially noteworthy inthe nursing home include dementia-associated behavioral complications,such as agitation 15 , depression 16–18 , anxiety 19–21 , sleepimpairment 22,23,29–31 , psychosis 19,24–26 and substance abuse 27 . Whilethe prominence of mental disorders in long-term care settings isnow beyond dispute, in the USA, staffing patterns, staff expertise,environmental design and models of care delivery much moreclosely approximate subacute and chronic general medical carecapabilities than thoughtfully conceived mental health services 9 .As a result, there is a great need to redesign the accessibility,structure and quality of psychiatric care in American nursinghomes. Toward this end, this chapter will address the fundamentallyimportant functions that may appropriately be provided bythe psychiatrist in the nursing home setting.THE ROLE OF THE PSYCHIATRISTIn the USA, contemporary training in general psychiatryemphasizes application of the biopsychosocial model to theunderstanding and treatment of mental disorders and behavioralsymptomatology. This orientation is especially appropriate foraccurately diagnosing and successfully treating the elderly nursinghome resident, in whom there is often the co-morbid occurrenceof physical, neurological, psychological and social contributors todisturbances of behavior. By virtue of their medical training,psychiatrists are uniquely qualified to integrate biological,psychological and social factors into a multidimensional treatmentplan that reflects the full complexity of a given resident’sbehavioral symptomatology. Specifically, well-trained psychiatristsare potentially able to offer approaches to treatment thatinclude recommendations for the appropriate use of a wide varietyof psychoactive medications as well as psychological, behavioraland milieu-orientated therapies. Unfortunately, little is presentlyknown about the availability of psychiatrists to consult or manageresidents in nursing homes in the USA. Additionally, a paucity ofservices research has been done to assist healthcare planners tobetter understand the character, quality and quantity of thoseprofessional functions that are provided by psychiatrists workingwithin the nursing home milieu. In most settings, it appears thatpsychiatrists assume a purely consultative role, in which theprimary physician (internist or family medicine practitioner)orders medication and is responsible for the course of treatment.In other settings, full responsibility for the management of theresident’s psychiatric treatment resides more definitively with thepsychiatrist. The factors that determine the relative intensity andscope of the psychiatrist’s role vs. that of the primary physician inany given facility are largely unknown.In a recently published study, Reichman et al. 28 examined theavailability, characteristics and perceived adequacy of psychiatricconsultation in nearly 900 nursing homes throughout theUSA through a mailed survey to the directors of nursing ofthese facilities. Results indicated that 38% of nursing homeresidents were noted to be in need of a consultation by apsychiatrist. The frequency of these services was rated as‘‘adequate’’ by only half of these homes. Nursing homes inurban and suburban regions reported better availability ofpsychiatric services than those located in rural areas. Nursinghomes with larger bed capacities were also more likely to receivea higher frequency of services by a consulting psychiatrist. Inexamining the perceived adequacy of the psychiatrist’s functions,these specialists were noted by two-thirds of the facilities asadequately providing diagnostic and psychopharmacologicrecommendations. However, advice regarding non-medicationapproaches to treatment (e.g. psychotherapeutic, behavioral ormilieu interventions), staff support, staff education, and attendingto occasional conflict between the staff of the nursing homeand resident families were reported as inadequately provided byconsulting psychiatrists. Overall, the results of this study suggestthat, in nursing homes in the USA, the perceived need forservices provided by psychiatrists is significantly greater than thelevel actually provided. Additionally, it appears that the nursingdirectors of these settings would welcome an expanded treatmentrole for psychiatrists in the care of their residents with mentalillness and behavioral disturbances.While a substantial amount of research remains to be done toidentify best practices for the delivery of psychiatric services innursing homes, it is clear that the specialty of psychiatry has avital role. In many facilities, the template of consultation–liaisonpsychiatry is most appropriately applied. In this framework, thepsychiatrist attends to the specific mental health needs of anPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd