Mohammed T. Abou-Saleh

718 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYcommonly depression 7 . Among those with dementia, it wasthose with psychiatric complications who were most likely toexhibit behavioral problems.The available findings suggest that, in spite of significantchanges in American nursing homes over recent years, the highlevels of psychiatric morbidity and the distribution of disordershas remained the same. There has, however, been significantprogress in developing and validating treatments for psychiatricdisorders in nursing homes. One particularly promising interventionfor residents with dementia and behavioral problemscombined augmented activities, guidelines for use of psychotropicmedications, and educational rounds 8 . It was tested in arandomized clinical trial and found to be effective in reducingthe prevalence of behavioral disorders and the use of bothantipsychotic drugs and physical restraints. Another series ofstudies has shown that individualized consultations to staff nursesabout the management of patients with dementia can reduce theuse of physical restraints 9 . There has been little research on theeffectiveness of specific psychotherapies for nursing homeresidents with depression. Although available findings are highlypromising 10 , research on individualized behavioral interventionsfor patients with behavioral and psychological symptoms ofdementia have been limited to case series or small-scale controlledstudies.Psychotherapeutic medications are widely used in nursinghomes. The US Health Care Financing Administration estimatedthat use of these agents increased during the 1990s from 21.7% in1991 to 46.1% in 1997 3,4 . This reflected a 59.8% decrease in theuse of antipsychotic medications from 33.7% to 16.1%, but a97% increase in the use of antidepressants from 12.6% to 24.9%.These changes probably reflect a number of factors, includingscientific developments, accumulating effects of professionaleducation and specific federal regulations (as described below).Two randomized clinical trials have demonstrated the efficacyof the atypical antipsychotic agent risperidone for the treatmentof the psychotic and behavioral symptoms in residents withdementia 11,12 . The available findings suggest that it has bothantipsychotic effects and independent effects on aggression oragitation. Longer-term follow-up studies suggest that it may causeless tardive dyskinesia than typical neuroleptics 13 . A randomizedclinical trial of olanzepine vs. placebo has demonstrated similarefficacy 14 and additional findings on other atypical antipsychoticagents are expected in the near future. However, the controlledclinical trials on antipsychotic agents have evaluated only theiracute effects, typically for periods of 6–12 weeks, and little isknown about the effectiveness of antipsychotic drug treatmentover longer periods of time. In fact, recent double-blind, placebocontrolledstudies of neuroleptic discontinuation demonstrate thatthe majority of patients who have been receiving longer-termtreatment with these agents can be withdrawn from them withoutill-effects 15,16 . Two randomized clinical trials studies evaluated theefficacy of mood-stabilizing anticonvulsants for the treatment ofagitation and aggression. One studied carbamazepine and foundthat it was effective for agitation, hostility and aggression but notfor other symptoms, such as hallucinations or delusions 17 .Findings from staff reports demonstrated that treatment withactive medication led to decreases in the nursing time required forpatient care. Another recent study evaluated valproate vs. placeboand found evidence for efficacy 18 .There are now several acetylcholinesterase inhibitors approvedfor use in patients with mild to moderate Alzheimer’s disease, andthere have been questions about whether they are useful intreating nursing home residents with more advanced disease. Onerandomized clinical trial demonstrated that use of donepazil wasassociated with improvements in cognitive performance comparableto those observed in less impaired outpatients 19 . Althoughthere have been suggestions that cholinesterase inhibitors may beuseful in managing behavioral symptoms, this issue is unresolvedat this time.There have been two randomized clinical trials evaluating theeffects of antidepressants in nursing home residents, both usingthe classical tricyclic nortriptyline. One of the studies was placebocontrolled20 . Positive findings were used to confirm the validity ofthe diagnosis of major depression among nursing home residentsin spite of potential confounds from medical, environmental andexistential factors. Another finding from this study was thatpatients with major depression, low levels of serum albumin andhigh levels of self-care disability were less likely to respond totreatment; this led to the suggestion that patients with this clinicalprofile may benefit from early hospitalization and evaluation ofthe need for electroconvulsive therapy. The second studyrandomized patients to regular vs. low-dose nortriptyline andfound significant plasma level response relationships in thosepatients who were cognitively intact, again confirming the validityof the diagnosis of depression 21 . However, the plasma levelresponse relationship was significantly different in patients withdementia, suggesting that the depression of dementia may be adistinct disorder. There have been no randomized clinical trials ofselective serotonin reuptake inhibitors (SSRIs) or related medicationsin nursing home residents, and available open-label studieshave mixed results, especially with respect to the outcomes oftreatment in nursing home residents with dementia 22–26 . In arelated area, there is evidence from an older clinical trial that thestimulant medication methylphenidate may be useful in dementedpatients with symptoms of apathy and withdrawal 27 .The recent estimate that almost 25% of US nursing homeresidents are receiving an antidepressant medication reflects anextraordinary change in patterns for drug utilization, especially inlight of findings indicating that a generation ago only 15% ofresidents with a known diagnosis of depression were receivingantidepressants 28 . Although significant components of currentantidepressant usage may be for other putative indications, suchas agitation, sleep or pain, it is important to note that reportedutilization rates are comparable to estimates for the prevalence ofdepression. Research is needed to determine whether it is possibleto demonstrate an impact of prescribing on the mental health ofthe population as a whole.THE NURSING HOME AS A MENTAL HEALTHCARE ENVIRONMENTIn the past decade there has been a growing awareness of theimportance of the psychosocial and mental health aspects ofnursing home care and a number of conceptual models have beendeveloped to focus on the person–environment interaction as thetarget for care practices. These have included ‘‘progressivelylowered stress threshold’’ 29 , ‘‘stimulation-retreat’’ 30 , and ‘‘personcentered’’31–33 care. Other widely discussed concerns that reflectthe increased awareness of the psychosocial aspects of nursinghome care include quality of life 34 , individualization of care 35 , theimportance of the patient’s perspective 36,37 , and autonomy 38,39 .Many of these concepts have been applied in the design andoperation of special care units (SCUs) for residents with cognitiveimpairment. The popularity of these units has been phenomenal,with current estimates that 22% of nursing homes have designatedSCUs for patients with dementia. Outcome studies evaluatingspecial vs. traditional care have suggested positive effects in avariety of selected outcomes, such as the nature of the servicesprovided, depression, family perception of quality of life and therate of decline in mobility 40–43 . However, more rigorous randomizedclinical trials have reported positive outcomes only incircumscribed areas, such as catastrophic reactions 44 and observedpositive emotional responses 45 .