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 0-470-84641-0131Psychiatric Services in Long-term CareIra R. Katz 1,2 , Kimberly S. Van Haitsma 3 and Joel E. Streim 1,21 University of Pennsylvania, 2 Philadelphia VA Medical Center and 3 Philadelphia Geriatric Center, Philadelphia, PA, USAOlder people require long-term care when they have care needsthat go beyond what they and their families can provide. It canconsist of subacute, step-down or convalescent care for individualsdischarged from hospitals, rehabilitative services for thoserecovering from illness or injury, and hospice care for those withterminal illness, as well as life-long care for those with irreversibledisability. Increasingly, the landscape of settings for long-termcare is expanding to include home- and community-basedprograms. Even for those who require residential care, the optionsare expanding to include increasingly diverse forms of assistedliving or personal care facilities, as well as nursing homes.Nevertheless, nursing homes remain the most important settingsfor long-term care, especially for those individuals who are oldestand most disabled. However, nursing homes are also evolving,with increasing numbers of patients admitted for short stays forsubacute or rehabilitation care and a proliferation of special careunits designed for patients with dementia.According to recent government reports 1–4 , there are approximately1.6 million residents occupying 1.76 million beds in 16 840American nursing homes. For persons who turned 65 in 1990, anestimated 43% will enter a nursing home at some time. Of thisgroup, 55% will have a total lifetime use of at least 1 year, and21% will have total lifetime use of 5 years or more. Although boththe number of facilities and the number of beds increased almost20% from the mid-1980s to the mid-1990s, they did not keep pacewith the growth of the elderly population. The ratio of nursinghome beds to the size of the population aged 75 years and overdropped 17% from 1987 to 1996—127–117 beds/1000 people.However, the occupancy rate declined from 92.3% in 1987 to88.8% in 1996. Thus, the nursing home market is beginning toexperience the combined effects of healthier aging and theavailability of alternative approaches to long-term care.US nursing homes are heterogeneous: 65.5% are for-profit vs.27.9% non-profit, 6.6% are government-owned; 53.8% are ownedby chains; and 13.6% are hospital-based. In 1997, 67.4% ofnursing home costs were paid by Medicaid (approximately half ofthis paid by the federal government and half by the states), 9.4%by Medicare, and 23.3% from private funds or other payers.Federal payments account for the majority of expenditures fornursing home care and have been estimated in the late 1990s to beapproximately $40 billion/year.Among all US nursing home residents in 1996, the average agewas 84.6; 9% were under 65, 12% 65–74, 30% 75–84 and 49%85+; 71.6% of residents were women; 88.7% of residents wereWhite, and 8.9% African-American; 13.9% required assistancewith one or two activities of daily living tasks, and 83.3% withthree or more; 88.2% required assistance with dressing, 96.5%with bathing, 59.7% with eating, 73.6% with transferring into orout of bed, 66.4% with mobility and 79.7% with toileting.Compared to comparable findings from a decade earlier, theaverage age of residents increased by 0.9 years; the proportionaged 85+ increased from 49% to 56% for women and from 29%to 33% for men. Disability of residents also increased and theproportion of those requiring assistance in three or more activitiesof daily living was 15% higher in 1996 than 1987.The psychiatric needs of nursing home residents are thus thoseof a population characterized by extreme old age and high levelsof disability. Accordingly, the delivery of psychiatric services inthe nursing home must be informed by knowledge of the clinicalpsychiatry of this population. However, mental health providersmust also be aware of other factors that shape the delivery of care.These include the potential for use of the nursing homeenvironment as a therapeutic agent, either in Special Care Unitsfor dementia or in other programs, and the extensive federalregulations that govern clinical services in US nursing homes.CLINICAL PSYCHIATRY IN THE NURSING HOMEAccording to recent reports from the Nursing Home Componentof the Medical Expenditure Panel Survey (MEPS), approximately48% of US nursing home residents have a diagnosis of adementia 1 . However, this figure probably underestimates theactual prevalence. Other MEPS data demonstrate that approximately70% of residents have memory problems, 73%orientation problems, and 80% impairments in decision-makingcapacity. It also estimates that approximately 30% of residentshave behavioral problems; 11.8% are verbally abusive, 9.1% arephysically abusive, 14.5% are socially inappropriate, 12.5% areresistive to care, and 9.4% wander. In addition to this highprevalence of cognitive impairment, the MEPS reports thatapproximately 20% of residents have a diagnosis of a depressivedisorder. Comparing these figures with comparable data from adecade earlier suggests that the number of residents withdiagnoses of dementia or depression has increased. However,the number of individuals with schizophrenia has declined,especially among the younger residents 5 . Findings from thisnational representative sample confirm earlier research reportsabout the high prevalence of psychiatric disorders in nursinghome residents 6 . In particular, they support the validity andgeneralizability of estimates from research in a single facilitythat demonstrated that 80% of residents have a psychiatricdiagnosis. Findings from this earlier research provided insightinto the nature of the disorders; 67% of residents had dementia,with most having Alzheimer’s disease; approximately 40% ofthose with dementia had other psychiatric syndromes ascomplications (psychosis 13.5%, depression 6.3%, and delirium7.3%); and 12.8% had other psychiatric disorders, mostPrinciples 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