Mohammed T. Abou-Saleh

NUTRITIONAL STATE 753By early 1999, 140 000 nursing home and hostel places wereavailable in Australia, with 2500 new places being established eachyear, mostly in hostels 1 . These places serve 2 154 000 Australiansaged 65+, of whom 129 600 were thought to have dementia in1995 5 .Few residential facilities offer specialized care for the elderlywith mental illness. In the State of Victoria a small number ofnursing homes subsidized by the State Government, called‘‘Psychogeriatric Nursing Homes’’, offer specialized care toelderly people with mental health problems (usually dementia),associated with behaviour too challenging to be managed inmainstream facilities. Long-term care in large mental hospitalsand state geriatric centres is virtually a thing of the past 6 .A small number of researchers have examined the prevalence ofpsychiatric disorders among elderly people in Australian nursinghomes and hostels. At least 50% and possibly 80% of nursinghome residents have dementia 5–7 . Around 40% of hostel residentshave cognitive impairment consistent with dementia 6,8 . Althoughthe more severely demented residents cannot be assessed, it isunusual for an assessable resident to have no symptoms ofdepression at all and at least 10% suffer a depressive disorder atany time 9,10 . No detailed statistics are available for the numbers ofindividuals with schizophrenia and related disorders living innursing homes in Australia. The four specialist psychogeriatricnursing homes in the author’s own catchment area, which serve apopulation of over 120 000 elderly, have 120 beds, of whicharound 30 are occupied by individuals with a primary diagnosis ofschizophrenia and related disorder. Most of these residents areformer long-term inmates of psychiatric facilities, so thispercentage is likely to fall in future as fewer individuals withschizophrenia will experience long-term incarceration. Thepercentage of individuals with schizophrenia and related disordersin ordinary nursing homes and hostels would be far lower thanthis.Despite high levels of depression and dementia, a recent studyby Reberger, Hall and Criddle 11 revealed that entering a hostelcan lead to an overall improvement in quality of life, although thesize of the study was small, assessing only 50 subjects.General practitioners are responsible for the medical care of thevast majority of individuals in nursing homes and hostels, as fewresidents see a psychiatrist once, let alone on a regular basis. Awell-conducted study of over 2000 residents in 46 Sydney nursinghomes revealed very high levels of psychotropic drug prescribingto this population 12 . Psychotropic drugs were taken regularly by58.9% of residents and another 7% were prescribed such drugs onan ‘‘as-required’’ basis. Antipsychotic drugs were taken regularlyby 27.4% and on an ‘‘as-required’’ basis by a further 1.4%. Thesedrugs were more likely to be given to residents with greatercognitive impairment and more disturbed behaviour. Benzodiazepineswere prescribed to 32.3%, hypnotics to 26.6% andantidepressants to 15.6%. At least half the antidepressant doseswere subtherapeutic.As in other countries, one major concern has been theunderdetection and undertreatment of depression in residentialcare. An innovative and painstaking series of studies were done inNorth Sydney by Llewellyn-Jones et al. 13 . This project included arandomized, controlled trial, with control and intervention groupsstudied sequentially and blind follow-up after 9.5 months of 220depressed residents in a large residential facility. The interventionsconsisted of multidisciplinary consultation and collaboration,training of general practitioners and carers in the detection andmanagement of depression, and depression-related health educationand activity programmes for residents. The control groupreceived routine care. There was significantly more movement toless depressed levels of depression, as measured by the GeriatricDepression Scale (GDS) at follow-up, in the intervention than thecontrol group. Multiple linear regression analysis found asignificant intervention effect after controlling for possibleconfounders, intervention groups showing an average improvementof 1.87 points on the GDS. Although the impact of thisstudy on total GDS scores was not huge, small movements indepressive symptomatology in populations are likely to beassociated with significant decrease in morbidity among someindividuals. In the past it has been hard to show that interventionprogrammes in these populations can be efficacious 10 , but thework of Llewellyn-Jones’ team suggests that the future may not beas bleak as some of us had feared.There is no doubt that mental illness is common amongindividuals who live in residential care in Australia. The challengefor our health professionals is to improve the detection andmanagement of these conditions. A multifaceted approach isrequired, with improved medical education for both undergraduatesand general practitioners, education for care staff andan overall improvement in the quality of residential provision forolder people. Slow, relative economic decline in Australia 6 , whichcontinues apace, will make this a difficult challenge to rise to, butAustralia’s track record in this area suggests that the goal is not anunachievable one.REFERENCES1. Howe A. Future directions for residential care. Australas J Ageing1999; 183(suppl): 12–18.2. Howe AL. From states of confusion to a national action plan fordementia care: the development of policies for dementia care inAustralia. Int J Geriat Psychiat 1997; 12: 165–71.3. Flynn E, Ames D, LoGiudice D. Dementia service provision inAustralia. In O’Brien J, Ames D, Burns A, eds, Dementia. London:Edward Arnold, 2000.4. Gibson D, Liu Z. Planning ratios and population growth: will therebe a shortfall in residential aged care by 2021? Aust J Ageing 1995; 14:57–62.5. Henderson AS, Jorm AF. Dementia in Australia, 4th edn. Canberra:Australian Government Publishing Service, 1998.6. Ames D, Flynn E. Dementia services: an Australian view. In Burns A,Levy R, eds, Dementia. London: Chapman and Hall, 1994.7. Phillips-Doyle CJP. Social interventions to manage mental disordersof the elderly in long term care. Aust Psychol 1993; 28: 25–30.8. Rosewarne R, Carter MG, Bruce A. Hostel Dementia Care: Survey ofPrograms and Participants (Victoria). Canberra: CommonwealthDepartment of Community Services and Health, 1991.9. Phillips CJ, Henderson AS. The prevalence of depression amongAustralian nursing home residents: results using draft ICD-10 andDSM-IIIR criteria. Psychol Med 1991; 21: 739–48.10. Ames D. Depressive disorders among elderly people in long-terminstitutional care. Aust N Z J Psychiat 1993; 27: 379–91.11. Reberger C, Hall SE, Criddle RA. Is hostel care good for you?Quality of life measures in older people moving into residential care.Aust J Ageing 1999; 18: 145–9.12. Snowdon J, Baughan R, Miller R et al. Psychotropic drug use inSydney nursing homes. Med J Aust 1995; 163: 70–2.13. Llewellyn-Jones RH, Baikie KA, Smithers H et al. Multi-facteted,shared care intervention for late life depression in residential care:randomised, controlled trial. Br Med J 1999; 319: 676–82.