Mohammed T. Abou-Saleh

PSYCHIATRIC SERVICES IN LONG-TERM CARE 719While it is encouraging to find evidence that the outcomes ofcare in nursing homes may be modifiable, it is important torecognize that there are no effects that are consistent acrossstudies. However, these mixed findings are not unexpected, giventhe tremendous variability in the definitions, structure andprograms of SCUs as well as other methodological limitations,such as selection biases, attrition and measurement limitations.Therefore, many researchers have increasingly called for studiesfocused on the evaluation of specific interventions associated withimproved comfort, health status and quality of life, in attempts toidentify and evaluate the ‘‘active ingredients’’ of special care 37,46,47 .Many programs have been based upon modification of thephysical environment to decrease behavioral difficulties andenhance positive quality of life in the nursing home. Promisingprograms that incorporate natural elements into the environment,include a bathing intervention that uses bird songs, pictures ofnature and food during bathing to decrease agitated or aggressivebehavior 48 , and use of ‘‘white noise’’ machines emitting sounds ofocean waves or waterfalls 49 . The use of bright lights in the careenvironment has been shown to consolidate sleep and to reduceagitation, but only in those with disturbed sleep-wake cycles 50 .Anintervention that decreased noise and light in the night-timeenvironment did not, by itself, improve the quality of theresidents’ night-time sleep; however, when combined with adaytime program of increased physical activity, it did providebenefits 51,52 .Some programs have gained great popularity in the clinicalcommunity, but have not yet been evaluated in controlled studies.These include the ‘‘Eden Alternative’’, which attempts to increasebiological diversity in the institutional setting by incorporatingchildren, plants and animals into the day-to-day life of the nursinghome 53 , and horticultural interventions 54 . Another set of promisinginterventions are based upon spirituality or religiously-basedprogramming 55,56 . Music therapies, in particular, have beenstudied more intensively and may be effective in increasingpositive emotional and social engagement and decreasing problembehaviors 57 .Technological interventions have been used in the nursinghome, either to provide enhanced surveillance to increase safety orto use modalities such as audio or videotapes as therapeutic tools.Only one of these therapeutic interventions has shown positiveresults after testing under controlled conditions—simulatedpresence therapy 58 , in which residents with dementia are askedto listen to taped, simulated telephone conversations with familymembers, was superior to placebo in decreasing problembehaviors and increasing well-being.Several studies have demonstrated efficacy in programsdesigned to promote functional independence in persons withdementia residing in the nursing home. One focused on altering‘‘dependency support scripts’’ and found increased independentbehavior on the part of residents 59 . Other studies have focused onevaluating programs designed to target specific functionalcapabilities. Several groups have found positive effects fromprograms that modify usual routines for morning care anddressing. One analyzed videotapes of dressing behaviors todevelop care prescriptions, and found that these led to increasedindependence in dressing 60 . Another used a ‘‘skill elicitation’’intervention and found that it significantly increased the amountof time participants were engaged in dressing and other ADLs,while simultaneously decreasing the frequency of disruptivebehavior 61 . A third found that an ‘‘abilities-focused’’ program,teaching direct care staff to modify the moment-to-momentprocedures used in morning care on the basis of knowledge of theresidents’ specific cognitive deficits, led to improvement in calm/functional behaviors, agitation and social functioning 62 .Other important factors affecting the psychosocial environmentin nursing homes are those related to the caregiving staff. It iscertified nursing assistants (CNAs) who serve as primarycaregivers to a population characterized by ever-increasing levelsof dementia, dependency and mental health disorders. There is nodoubt that the increased demands on skills and time, togetherwith the physically and emotionally demanding labor, requireattention to selection, training, supervision, and a focus on therole of the CNA as a provider of psychosocial care. There aremultiple sources of stress for these paraprofessionals, includingindividual self-related needs, off-the-job stressors, patient contact,and administrative and organizational factors. One study demonstratedthat 57% of CNAs screen positive for clinically significantlevels of distress 63 . However, the paraprofessional staff do not, asa rule, receive adequate support from the psychological andpsychiatric community in addressing such issues as non-pharmacologicmanagement techniques, assisting with family conflictsand coping with job-related stress 64 .Fortunately, there is evidence that training programs for CNAscan have positive outcomes for the CNAs, including increasedinteraction and sensitivity to resident cues, provision of morechoice and praise, and increased behavioral management skills.Moreover, these can translate into improvements in residents’mood and functioning 65,66 . Another line of research has foundthat mental health outcomes can be affected by structural andorganizational elements of nursing homes, such as chain status,size, staffing levels, turnover, staff selection, job assignments, jobdesign and the adequacy of supplies; moreover, interventionsmodifying formal elements of staff management can have positiveeffects on staff behavior 67 .THE REGULATORY ENVIRONMENT IN USNURSING HOMESAlthough nursing homes have historically been designed to carefor patients with medical and surgical conditions, the vastmajority of their residents have psychiatric disorders. Themismatch between resident needs and facility characteristics inUS nursing homes has been associated with inadequate,inappropriate and even inhumane treatment 68 . During the1980s, concerns expressed by advocacy and professional groupswere reinforced by a report from the Institute of Medicine 69documenting major problems in the quality of care provided innursing homes. Specific issues included the undertreatment ofdepression and use of physical and chemical restraints to controlbehavioral symptoms in patients with dementia. Other concerns atthat time were that elderly patients with chronic and severepsychiatric conditions were discharged from state hospitals andinappropriately placed in nursing homes at Medicaid expense,thereby denying them access to the active psychiatric treatmentthey needed, and shifting a substantial portion of the costs of theircare from the states to the federal government.Recognition of problems in the quality of care in US nursinghomes, together with ongoing concerns about costs, promptedCongress to pass legislation, the Nursing Home Reform provisionsof the Omnibus Budget Reconciliation Act (OBRA) of1987 70 , which has transformed nursing homes into one of the mosthighly regulated environments for healthcare delivery in theUSA. To operationalize the laws enacted under OBRA ’87,Congress directed the Health Care Financing Administration(HCFA), the agency that administers Medicare and Medicaid, toissue specific regulations that govern nearly all aspects of nursinghome operations 71 , and charged the states with the responsibilityfor conducting surveys to determine whether nursing facilitieswere in compliance. In response, HCFA developed a set ofinterpretive guidelines for state surveyors 72 , which has beenrevised over the past 10 years to reflect changes in healthcarepractice and policy. Mental health screening, evaluation, care