Long-Term Care

The Long-Term Care Shared Interest Forum welcomes all members of IPA who express an interest in participating in the forum and/or attending meetings to discuss matters relating to Long-Term Care.

Background

There are considerable differences in long-term residential care arrangements between different parts of the world. Some countries have devoted considerable resources to provision of long-term accommodation and services for disabled older persons, but the World Health Organisation declared that developing countries would be unable to afford to provide institutional care and should therefore concentrate on community-based options. Some cultures are known for their pertinacity in supporting disabled persons at home in extended families, thus limiting the need for residential care.

Recognising these variations, what is said about the role of mental health services in one country or region at one point in time may not apply in other places or at other times. Historical factors, together with differences in staffing, funding, culture, ageing of the population, the size and structure of residential facilities and how they are run, the organization of health and welfare services and other factors affect whether mental health services are provided in long-term residential care settings, and if so, how.

Numerous surveys have revealed the high prevalence of mental disorders in nursing homes and residential care facilities. Rates vary, depending partly on admission policies, the number of long-term care places per unit of population, factors affecting quality of life and factors determining the availability of rehabilitation and treatment resources. Studies in the United States have reported the prevalence of psychiatric disorders in nursing homes to be 80% to 91% (Streim et al, 1997). Clinical studies have revealed rates of dementia above 80%, with 25% to 50% of dementia patients having psychotic symptoms. Significant depressive symptoms were reported in 30% to 50% of nursing home patients who could be assessed, and major depression was diagnosed in 6% to 25% of residents. In the United States, 10% t of nursing home residents and about 5% in Australian nursing homes are said to have schizophrenia. Studies in Europe have shown similarly high rates for psychiatric conditions.

During the 1980’s, there was mounting criticism of the care provided in nursing homes in the United States, particularly in regard to excessive use of neuroleptic and sedative medication. Most prescriptions were written without any input from a mental health professional. OBRA-87 established many new rules and regulations for nursing home care. Since 1990, when OBRA regulations were implemented, there has been a fall in the use of antipsychotic medication and hypnotics in nursing homes within the United States. What is astonishing is to read that, even now, “most of the residents who need mental health services do not receive them…Nursing home administrators have estimated that two-fifths of nursing home residents need psychiatric services, yet half of nursing homes do not have access to adequate psychiatric consultation, and three-quarters are unable to obtain consultation and educational services for behavioural interventions” (Bartels et al, 2002).

Psychiatric services in nursing homes within the United States, when available, are most commonly provided by a consultant psychiatrist who works alone and does not provide subsequent care unless called back to review a case (Bartels et al, 2002). Various authors have stressed that the role of psychiatrists should extend beyond providing a consultative service for referred patients. Liaison with staff in the form of case conferences and other educational activities has been recommended. Regular opportunities to discuss behavioural management options have been recommended. Multidisciplinary teams are said to be the preferred model for mental health service provision in nursing homes, but arrangements vary. There have been reports of effective interventions provided by multidisciplinary old age psychiatry teams. Elsewhere, such teams have been organised within nursing homes, sometimes with a particular nurse taking responsibility for coordinating interventions for residents with mental health problems. An innovative approach used in Hong Kong was the use of telepsychiatry to link hospital-based mental health clinicians to a ‘care and attention home’.

Accounts have been provided in the literature concerning residential units that provide special care for older people who manifest disturbed behaviour. Those who provide mental health services to long-term residential care facilities report that a minority of residents may need referral for care in specialised mental health care facilities because of persistent and severely disturbed behaviour. If referral is impossible, the alternative appears to be the use of inappropriate long-term chemical restraint.

Long-term care provision has been insufficiently discussed in old age psychiatry journals. Government funding for the long-term care sector has commonly been regarded as inadequate, with the consequence that staff as well as residents in residential care facilities have become demoralised. Attempts to conserve funds have sometimes been discriminatory. For example, even in some developed parts of the world, there has been a move to separate dementia services (including care for people in nursing homes) from mental health services, with the result that BPSD and psychiatric problems co-morbid with dementia do not receive attention from staff with psychiatric training.

Clearly, those people in nursing homes who suffer from mental disorders form a substantial proportion of the worldwide population of elderly people whose problems are the focus of the International Psychogeriatric Association. There is good reason to focus on their needs and the deficiencies in systems that should be helping them.

The main reasons why IPA formed the Long-Term Care Shared Interest Forum are:

1. To encourage people working in the residential care field (especially nurses) to join IPA, and thereby to gather their input on a cross-national basis when considering how best to ensure good mental health care in these facilities (nursing homes, residential homes, etc), and
2. To support and strengthen mental health services in the long term care sector.

Results of a survey of how mental health services are provided in residential care settings in our various countries revealed widespread dissatisfaction with current arrangements. Services are provided inappropriately (if at all) in the countries that were surveyed. Although examples of good and effective assessment and intervention in particular facilities were cited, there were calls for services to be much more readily accessible, with ongoing involvement by mental health professionals (usually with a team approach) rather than the more usual one-consultation model. Since then, in our various discussions, group members have expressed a strong need to develop guidelines on how to achieve optimal care, assessments and interventions for people in residential care who have mental health problems. It is desirable to define standards, but recognising that differences in organisational systems, culture, community attitudes, social circumstances, resources and funding will affect what’s regarded as appropriate. Nevertheless, we agreed that it would be good if members from diverse parts of the world and from varying health care disciplines exchange views, aiming to produce a discussion document on how best to deal with mental health problems in residential aged care facilities. This will lead on to development of guidelines that can be adapted according to local situations.

The Long-Term Care Shared Interest Forum was aware of David Conn’s expertise and understanding of mental health issues in residential care situations. He has recently co-edited a third edition of a book entitled ‘Practical Psychiatry in the Long-term Care Home’. He and colleagues in Canada have published guidelines relating to aged care in that country, and David has experience in consensus conferences. He is the ideal person to head an IPA group with the aims outlined above.

Our discussions have ranged over various issues, including the importance of education for staff working in aged care facilities. The needs of ‘special groups’ such as people with developmental disability have been highlighted. It has been recommended that we establish links with professional groups with special interest in nursing home care, including psychologists working in long-term care and nursing home physicians.

References

Bartels SJ, Moak GS, Dums AR (2002).  Models of mental health services in nursing homes: a review of the literature.  Psychiatric Services  53, 1390-6.

Streim JE, Oslin D. Katz IR, Parmelee PA (1997).  Lessons from geriatric psychiatry in the long term care setting.  Psychiatric Quarterly  68, 281-307.

Reifler BV (1997).  The practice of geriatric psychiatry in three countries: Observations of an American in the British Isles.  International Journal of Geriatric Psychiatry 12, 795-807

Reifler BV and Cohen W (1998).  Practice of geriatric psychiatry and mental health services for the elderly: results of an international survey.  International Psychogeriatrics 10, 351-357

Bibliography (Posted December 2007)