Psychiatric consultation in the nursing home: referral patterns and recognition of depression

Psychiatric consultation in the nursing home: reasons for referral and recognition of delirium

Objective

To describe the behavioural and psychiatric problems found in nursing home psychiatric referrals in the Dublin South city area.

Methods

We undertook two consecutive surveys of nursing home referrals to the St James’s Hospital psychiatry of old age service over a 2-year period. During the second survey a new clinical nurse specialist was specifically appointed to manage the seven nursing homes included in the study.

Results

The most common reason for referral during survey one was uncooperative/aggressive behaviour (22%). For survey two, patients were most commonly referred for low mood (31%) or agitation (29%). During survey one, the majority of patients assessed were diagnosed with behavioural and psychological symptoms of dementia (41%). This was also a prevalent diagnosis during survey two, affecting 27% of those referred. Only 7% of patients were considered to be delirious during survey one. This rose to 31% the following year making it the most common diagnosis during survey two. Over the 2-year study period, 7% of referred patients were diagnosed with depression. In terms of prescribing practices, the discontinuation rate of antipsychotic mediation following psychiatric input was 13% in survey one. By survey two, this had risen to 47%.

Conclusions

Delirium is often undetected and untreated in nursing homes. Residents presenting with psychiatric symptoms should undergo routine bloods and urinalysis prior to psychiatric referral. Dedicated input from trained psychiatric nursing staff can lead to both an improvement in the recognition of delirium and reduced prescribing rates of antipsychotic medication.

Multidisciplinary, Nurse-Led Psychiatric Consultation in Nursing Homes: A Pilot Study in Clinical Practice

PURPOSE

To determine the effects of multidisciplinary, nurse-led psychiatric consultation on behavioral problems of nursing home residents. Residents often suffer from psychiatric symptoms, while staff psychiatric expertise varies.

DESIGN AND METHODS

A pre-post study was conducted in seven homes using the Neuropsychiatric Inventory Nursing Home version (NPI-NH).

FINDINGS

In 71 consultations during 18 months, 56-75% of residents suffered from agitation/aggression, depression, anxiety, and disinhibition. Post-intervention (n = 54), frequency, and severity of psychiatric symptoms were significantly and clinically meaningfully reduced. Also, staff suffered from less work stress.

PRACTICE IMPLICATIONS

Nurse-led psychiatric consultation is valuable to both nursing home residents and staff.

More age-care staff report helping care recipients following a brief depression awareness raising intervention

Background

Those working with elderly care recipients require a good working knowledge of depression and appropriate help giving responses. While it is important for age-care staff to recognize depression in care recipients it is also critical that they know the appropriate course of action to assist a care recipient who may be depressed. This study aims to determine the knowledge of age-care staff of appropriate help giving responses, their confidence in knowing what kind of assistance to provide and their actual likelihood of providing help to potentially depressed care recipients and to examine if these measures improve following an intervention training program.

Methods

One hundred and two age-care staff were surveyed on their confidence in helping age-care recipients and on their knowledge of appropriate ways to provide assistance. Staff then participated in a two hour depression awareness raising intervention. The survey was repeated immediately following the training and again six months later.

Results

Staff confidence in knowing how to provide assistance increased significantly subsequent to training and remained significantly improved at the six month follow up. In addition, a significantly higher proportion of staff reported helping care recipients at the six month follow up.

Conclusions

This study highlights the potential of a brief staff training program to provide a cost effective means to improve staff self-confidence and increase the likelihood of staff providing assistance to depressed care recipients.

Ability of nurses to identify depression in primary care, secondary care and nursing homes--a meta-analysis of routine clinical accuracy

PURPOSE

To clarify the ability of nurses and nursing assistants working in primary care, secondary care and nursing homes to identify depressed individuals using their clinical skills using meta-analysis of published studies.

METHODS

Literature search, appraisal and meta-analysis. We located 22 studies reporting on the detection of depression, 4 involving primary care or community nurses; 7 involving hospital nurses and 11 from nursing homes.17 of 22 studies had specificity data.

RESULTS

Across all 22 studies involving 7061 individuals, and a prevalence of 28.1% (95% CI=22.6-33.9%), practice and community nurses correctly identified 26.3% (95% CI=16.2-37.8%) of people with depression. They also correctly identified 94.8% (95% CI=91.3-97.4%) of the non-depressed. Nurses working in hospital settings correctly identified 43.1% (95% CI=31.9-54.8%) of people with depression and 79.6% (95% CI=71.5-86.7%) of the non-depressed. Those working in nursing homes correctly identified 45.8% (95% CI=38.1-53.6%) of people with depression and 80.0% (95% CI=68.6-88.7%) of the non-depressed.

CONCLUSIONS

Nurses have considerable difficulty accurately identifying depression but are probably at least as accurate as medical staff.

Levels and rates of depression among Chinese people living in Chinese ethno-specific and mainstream residential care in Sydney

BACKGROUND

This study aimed to examine the levels and rates of depression in Chinese residents living in ethno-specific nursing homes (NHs), and Chinese residents living in mainstream NHs in Sydney. Australia has a growing aging migrant population and rates of depression in NHs are high, but the prevalence of depression in culturally and linguistically diverse residents has received little attention in the research literature.

METHODS

Older persons from a Chinese background residing in either Chinese-specific or mainstream NHs located in Sydney were invited to participate in a cross-sectional survey. Assessments included the Mini-mental State Examination, the Cornell Scale for Depression in Dementia (CSDD), and interviews with family carers and staff.

RESULTS

Fifty-eight Chinese residents were recruited from three Chinese-specific NHs (n = 31) and 13 mainstream NHs (n = 27). There were no significant differences in resident depression levels or rates between the facility types. Mean CSDD scores were 9.4 (SD = 6.0) and 11.2 (SD = 6.1) in Chinese-specific and mainstream NHs, respectively. Chinese-specific NH residents had lower prescription levels of antipsychotics and more of them received effective antidepressant therapy in comparison to those in mainstream NHs.

CONCLUSIONS

These findings suggest that in comparison to mainstream care Chinese ethno-specific care does not impact on levels or rates of depression but is associated with less antipsychotic use and higher numbers of residents treated effectively with antidepressant therapy. Longitudinal research with larger samples and a range of outcome measures including quality-of-life and social engagement is required to explore further the effects of ethno-specific care.

Reasons for psychiatric consultation referrals in Dutch nursing home patients with dementia: a comparison with normative data on prevalence of neuropsychiatric symptoms

OBJECTIVE

To study psychiatric consultation referrals of nursing home patients with dementia and to compare referral reasons with normative data on prevalence of neuropsychiatric symptoms.

METHODS

This is part of a cross-sectional study of 787 patients residing in 14 nursing homes in the Netherlands. Nursing home physicians (NHP) noted the primary reasons for psychiatric consultation according to the Neuropsychiatric Inventory items and two extra domains. Patients were subsequently assessed by an old-age psychiatrist. Eligible patients were those that had dementia. Reasons for referral were compared with independent data on prevalence of neuropsychiatric symptoms in nursing home patients with dementia.

RESULTS

A total of 325/787 (41.3%) patients had dementia. Agitation, disinhibition and aberrant motor behaviour were frequent reasons for referral (>25%). Psychotic symptoms, apathy and eating behaviour changes were infrequent reasons (<10%) for seeking consultation. Agitation and disinhibition were more often primary reasons for consultation than would have been expected based on normative prevalence estimates of these symptoms. In contrast, delusions, euphoria, apathy, irritability and eating behaviour changes were less often reasons for referral compared with prevalence estimates.

CONCLUSIONS

This study is the first to examine psychiatric consultation for dementia patients in Dutch nursing home. Large differences exist between referral reasons and normative data on symptom prevalence. Specialized mental health service was provided for the agitated and disinhibited patient in particular. Chances are that this is at the expense of the apathetic, retarded and quietly 'not causing any trouble' patient.

Psychiatric consultations for nursing home residents: a perspective from Turkey and the implications for comparable countries

BACKGROUND

No specialized geriatric psychiatry consultation services are available for elderly people in the institutional care system in Turkey. Our aim was to evaluate psychiatric consultations among the residents of three homes for the elderly in a country with a rapidly aging population, and to investigate possible problems regarding psychiatric consultations.

METHODS

The residents of three homes for the elderly, which served partially as "care and rehabilitation centers" (equivalent to nursing homes), were chosen for the study. Data on the use of psychiatric services (mainly patient consultations with a visiting psychiatrist) were collected and analyzed.

RESULTS

The percentage of patients in the three homes for the elderly who had psychiatric consultations between 2005 and 2007 was 31.8% (172/540). The main reasons for referral were forgetfulness (61%), depressive symptoms (37.7%), agitation and disruptive behavior (29.6%), and psychotic symptoms (27.9%). Of these patients, 46.5% were diagnosed with dementia, 20.9% with depression, 20.5% with behavioral and psychotic symptoms of dementia, and 18.6 % with primary psychotic disorders such as schizophrenia.

CONCLUSION

Homes for the elderly in Turkey are not adequate in terms of consultations for psychiatric problems. Integration of these institutions with hospitals and organizing routine consultation visits from the psychiatry units would enhance the mental health of the elderly. Supporting the staff, maintaining good cooperation between them, and organizing educational programs in the field of mental health of the elderly are also required.

Professional carers' knowledge and response to depression among their aged-care clients: the care recipients' perspective

Depression is an under-diagnosed disorder among the elderly, even in those who are in receipt of aged-care services. One factor associated with this under diagnosis has been identified as a reluctance amongst the elderly to discuss their mood and emotions with their medical practitioners. The current study focused on why depression is not recognised and acted on by those providing residential or home-based care to older people. We interviewed 15 elderly people residing in high-level or low-level aged-care facilities, and three elderly people who were receiving personal care in their homes. All participants had been identified by their care agencies as depressed. Participants reported their perceptions of their personal carers' knowledge and practices in managing the residents' depression. Although the participants described their carers in positive terms, they were critical of their knowledge and skills in recognising depression, and indicated that the communication between personal carers and care recipients about depressive symptomatology was seriously flawed. Training for personal carers in these areas, and efforts to change organisational culture are recommended.

Knowledge and skills of professional carers working with older people with depression

OBJECTIVES

The current study was designed to evaluate the knowledge, skills and self-efficacy of care providers from the perspective of professionals working in the aged-care industry.

METHOD

Participants were 21 professional carers, 10 General Practitioners and 7 aged-care managers. Focus groups, which involved the completion of a semi-structured interview related to knowledge, recognition, confidence, referral procedures and use of screening tools for the detection of depression, were conducted.

RESULTS

The results showed that all groups of respondents recognised significant gap in the knowledge and awareness of depression among professional care staff working with older people in both the community and residential care-settings. Skills in the detection and monitoring of depression and the self-efficacy of these care staff were also seen to be a problem.

DISCUSSION

The implications of these findings in terms of training programmes for professional carers working in the aged health care sector are discussed.

Detecting depression in the aged: Is there concordance between screening tools and the perceptions of nursing home staff and residents? A pilot study in a rural aged care facility

OBJECTIVE

Recognition of depression in the elderly is exacerbated in rural and remote regions by a lack of mental health specialists. In nursing homes, screening tools have been advocated to circumvent the variable reliability of both nursing staff and residents in recognising depression. Debate concerning the utility of screening tools abounds. Previous research has neglected concordance between screening tools, nursing staff and residents in recognising depression. The present study aimed to determine if there was a significant difference in the proportion of depressed residents identified by recognition sources, and assessed the level of chance corrected agreement between sources.

PARTICIPANTS

One hundred and two residents of aged care facilities in Wagga Wagga, Australia, mean age of 85.19 +/- 7.09 years.

SETTING

Residents were interviewed within their residential aged care facility.

DESIGN

Cross-sectional, between-subjects design.

MAIN OUTCOME MEASURES

Residents, nursing staff, Geriatric Depression Scale (GDS-12R) and Hamilton Depression Rating Scale.

RESULTS

Hamilton Depression Rating Scale and nursing staff professional opinion were not significantly different; however, both measures were significantly different to the resident measures (GDS-12R and resident opinion). Kappa statistic analysis of outcome measures revealed, at best, no more than a moderate level of chance corrected agreement between said sources.

CONCLUSION

It is tentatively argued that the different sources might correspond to qualitatively different 'depression' constructs, and that health professionals who are concerned with depression in the elderly be aware of the disparity between, and subsequently consider, a variety of recognition sources.

Two years of psychogeriatric consultations in a nursing home: reasons for referral compared to psychiatrists' assessment

Background

In spite of the high prevalence of psychiatric disorders among elderly residents in nursing homes, only a small number of patients in need of specialist care are referred to a psychiatric consultant. The aim of this research was to evaluate the consultation activity and the appropriateness of referral to psychiatric assessment.

Methods

Data were collected and analysed on consultation carried out over a two-year period in a RSA (Residenza Socio-Assistenziale) in Northern-Italy. Data were catalogued with reference to: patients, consultation, diagnosis and recommended medications. Statistical correlation analysis by means of Spearman test and signification test was carried out.

Results

Residents referred to psychiatric consultation at least once were 112 (14.5% of all residents). Reason for referral were: depression (17.2%), delusions and hallucinations (14%), agitation (34.8%), aggressive behaviour (23.5%) and disturbances of sleep (6.8%). Most frequent diagnoses were organic, including symptomatic, mental disorders (33.9%), mood disorders (22.3%) and schizophrenia, schizotypal and delusional syndromes (18.8%). No psychiatric diagnosis was found only in 1.8% of cases, thus confirming high sensibility of referring physicians.

A statistically significant correlation was found when comparing referrals for depression or delusions and allucinations or sleep disturbances and diagnostic confirmation of such symptoms by specialistic assessment (respectively 49.8%, 52.7% and 19.6%).

Correlation between psychotic symptoms and the consequent prescription of antipsychotic drugs had a significant if somewhat modest value (24%) while correlation between depression symptoms and prescription of antidepressant drugs was more noticeable (66.5%).

Conclusion

Main reason for referral to psychiatric consultation resulted to be the presence of agitation, a non-specific symptom often difficult to attribute. Data concerning depression confirm tendency to underestimating this diagnosis in the elderly. Furthermore, symptomatic reasons for referral did not always correspond to subsequent diagnostic definitions by psychiatric consultants, therefore demonstrating modest predictive power.

A randomized trial of early psychiatric intervention in residential care: impact on health outcomes

BACKGROUND

The prevalence of psychological and behavioral disturbances among older adults living in residential care facilities is high, and it has been shown previously that people with such symptoms have poorer health outcomes. This study was designed to assess the efficacy of an early psychiatric intervention on the 12-month health outcomes of older adults admitted to residential care facilities in Perth, Western Australia. We hypothesized that subjects in the intervention group would have better mental and physical health outcomes than controls.

METHODS

The study was designed as a randomized, single-blinded, controlled trial. All subjects aged 65 years or over admitted to one of the 22/26 participating residential care facilities of the Inner City area of Perth were approached to join the study and were allocated randomly to the intervention or usual care group. Demographic and clinical information (including medications and use of physical restraint) was gathered systematically from all participants at baseline, and at 6 and 12 months. At each assessment, the Geriatric Depression Scale (GDS), the Health of the Nation Outcome Scales for older adults (HoNOS 65+), the Mini-mental State Examination (MMSE) and the Neuropsychiatric Inventory (NPI) were administered. Subjects in the intervention group who screened positive at the baseline assessment for psychiatric morbidity were reviewed within a 2-week period by the Inner City Mental Health Service of Older Adults (ICMHSOA). If clinically appropriate, mental health services were introduced without the involvement of the research team.

RESULTS

One hundred and six subjects and their next of kin consented to participate in the study (53 in each group). Mental health screening and early referral to a psychogeriatric service did not significantly change the average number of medical contacts, self-rated health, use of psychotropic or PRN medication, use of physical restraint, 12-month mortality, or mental health outcomes, as measured by the GDS-15, HoNOS 65+ and NPI (p > 0.05 for all relevant outcomes).

CONCLUSION

Systematic mental health screening of older adults admitted to residential care facilities and early clinical intervention does not change 12-month health outcomes. More effective interventions to improve the health outcomes of older adults with psychological and behavioral disturbances admitted to residential care facilities are needed.

Factors Affecting the Relationship Between the Timing of Psychiatric Consultation and General Hospital Length of Stay

The purpose of this study was to examine the factors affecting the timing of psychiatric consultations and length of stay in the current managed care era. It also assessed the relationships between the timing of consultations and demographic/clinical characteristics. Medical records of 541 consecutive psychiatric consultation patients at a university teaching hospital in 2001 were reviewed for demographic characteristics, lengths of stay, number of days from admission to consultation, specialty services requesting consultations, reasons for the referral given by the referring physicians, and all five axes of DSM-IV. Earlier consultations independently predicted shorter lengths of stay. Delayed consultations were seen more often in women; surgical patients; those seen with a request to assess depression; and those seen with a diagnosis of adjustment disorder, delirium, or no psychiatric disorder. Delay in psychiatric consultations continues to be associated with longer lengths of stay in the current managed care environment. It is now possible that early detection strategies for high-risk patients with behavioral health problems in the medical setting, such as use of the INTERMED, may lead to reduction in delayed psychiatric consultations and thus shorter lengths of stay.

Komorbidität psychischer Störungen im G-DRG-System - Einfluss auf die Verweildauer und Erlössituation an einem deutschen Universitätsklinikum

OBJECTIVES

The effect of comorbid mental disorders on the length of stay and revenue in a DRG system was investigated.

METHODS

For 33,189 cases of an university hospital (year 2002) the revenue based on a fictitious base rate was calculated, at first with and then without inclusion of diagnosed comorbid mental disorders. Furthermore, the effect of the latter on the length of stay was examined.

RESULTS

Renunciation of diagnoses of mental disorders lead to an different DRG grouping in 7.9 % of cases and to a reduction in revenues of about 170.000. Minimal influence of comorbid mental disorders on the length of stay (R2 = 0.02) could be detected for single diagnostic groups.

CONCLUSIONS

The lacking influence of comorbid mental disorders on the length of stay in a university hospital is mainly determined by the limited period of inpatient treatment and by the low frequency of diagnosed mental disorders. Therefore, a psychosocial consultation-liaison service is of major importance to guarantee the diagnosis and treatment of a comorbid mental (process quality) disorder and to guarantee adequate revenues in the G-DRG system (quality of structure).