Psychiatric assessment of elderly patients in the home: a survey of 176 cases

Home-Delivered Mental Health Services for Aged Rural Home Health Care Recipients

Home health care programs are generally able to meet a wide variety of older persons’ medical care needs, but are often unable to provide for the specialized needs of those patients who are experiencing emotional problems. This situation is most problematic in rural communities where services to meet the mental health needs of homebound elders are often not available. This article reports the results of a study that tested the efficacy of providing home-delivered psychotherapy to 78 elderly patients of a rural home health care agency. Patients who completed the brief, task-centered psychotherapeutic intervention reported improvements in their emotional well-being and indicated significant reduction of the problems associated with the target complaints that were the focus of the interventive activities. These results suggest that home-delivered psychotherapeutic interventions may have an important role to play in treating the mental health problems of older, rural, home health care recipients.

Physical and mental health of homebound older adults: an overlooked population

There are currently more than 38.9 million people aged 65 an older in the United States. Up to 3.6 million of these people are considered housebound and in need of home-based care. Although homebound status is not defined specifically, with a broad range of disability levels, it is evident that people who are homebound suffer from a multitude of medical and psychiatric illnesses. This review examines the current literature to identify the specific physical and psychiatric factors most responsible for older adults becoming and remaining housebound. Homebound older adults suffer from metabolic, cardiovascular, cerebrovascular, and musculoskeletal diseases, as well as from cognitive impairment, dementia, and depression, at higher rates than the general elderly population. The information in this review will explain the specific types of care the homebound population needs and discuss the care that could help ease their suffering and delay their entry into a nursing home or hospital.

Executive Dysfunction in Homebound Older People with Diabetes Mellitus

OBJECTIVES

To describe patterns of cognitive deficits and activities of daily living (ADLs) in older people with diabetes mellitus.

DESIGN

Cross-sectional, population-based study.

SETTING

Three homecare agency areas in Boston, Massachusetts.

PARTICIPANTS

Two hundred ninety-one homebound people aged 60 and older; 40% with diabetes mellitus.

MEASUREMENTS

Demographic data; evidence of diabetes mellitus and other diseases; Mini-Mental State Examination and tests of memory and executive function; ADLs.

RESULTS

Executive and visuospatial functions were more impaired in individuals with diabetes mellitus than in those without, as assessed using Block Design (mean score+/-standard deviation 17.1+/-8.6 vs 20.5+/-9.6, P=.003) and Trails B (median seconds to accomplish the task: 255 vs 201, P=.03). For memory, word retention score was lower in those with diabetes mellitus than without (39.1+/-28.9 vs 48.0+/-29.7, P=.01), but the other memory tests did not show a difference between these two subgroups. More individuals with diabetes mellitus suffered from depressive symptoms than those without (55% vs 42%, P=.03). The ADL scores of those with diabetes mellitus were higher than those without.

CONCLUSION

The pattern of cognitive deficits in people with diabetes mellitus suggests frontal-subcortical dysfunction, as seen in microvascular disease of the brain. The impairment in ADLs may be associated with this executive dysfunction, which cerebral microvascular disease in diabetes mellitus may cause.

Homebound status in a community-dwelling elderly population in Japan

The present study investigated the association between sociodemoraphic profiles, health condition and functional disabilities of subjects with a homebound status in a rural community setting. The subjects were residents aged 65 years or over in a mountain village of Japan. A comprehensive questionnaire was used to obtain their data. Among the 1,002 residents, the information of 866 residents (85%), who voluntarily completed the entire survey, was obtained for this study. All the subjects were native Japanese. Of the 866 subjects investigated, 301 (34.8%) were homebound as defined by the parameters of this study. Univariate analysis revealed age, female gender, functional impairment (vision, hearing and memory), all the ADL impairments, and the use of a portable toilet were associated with homebound status. Multivariate analysis revealed that older age, female gender, visual and two ADL impairments (moving inside the home and bathing) and use of a portable toilet remained significantly related to homebound status. Homebound elderly people have more functional limitation and disability related factor than their nonhomebound counterparts. Functional impairment, particularly in the mobility domain and sensory disturbances, was associated with homebound status. These data indicate the importance of assessment in the provision of home care for elderly people.

Characteristics of rural homebound older adults: a community-based study

OBJECTIVE

To determine the frequency and characteristics of homebound older adults in a rural community.

DESIGN

An epidemiological survey of an age-stratified random community sample.

SETTING

The rural mid-Monongahela Valley in Southwestern Pennsylvania.

PARTICIPANTS

A total of 878 noninstitutionalized persons aged 68 years and older, fluent in English, and with at least grade 6 education.

MEASUREMENTS

The frequency with which subjects left their homes, the Mini-Mental State Examination (MMSE) score, and additional information on demographics, self-reported health problems, health services utilization, IADLs, depression, and social support were measured.

RESULTS

10.3% of the sample was classified as homebound. In univariate analyses, being homebound was found to be associated significantly (P < .001) with being older, female, and widowed and with MMSE and IADL impairment, with more depressive symptoms and worse social supports, fair to poor self-rated general health, weight loss, and histories of stroke, angina, arthritis of the spine, and falls. In a multiple regression model, variables associated independently with homebound status were gender (odds ratio = 9.4, 95% confidence interval = 3.6 - 24.9), weight loss (OR = 3.7, CI = 1.7 - 8.2), IADL impairment (OR = 2.6, CI = 2.1 - 3.1), and depressive symptoms (OR = 2.1, CI = 1.3 - 3.2). Being homebound was also associated with recent acute hospitalization and use of home health and social services.

CONCLUSIONS

These data provide evidence that homebound older adults have a disproportionate share of morbidity and disability and suggest a sociodemographic and clinical profile to help identify those older people at risk of being or becoming homebound. They also point to the need for home-based health services for the older adults, particularly in medically underserved communities such as rural areas.

Psychogeriatric Services at Certified Home Health Agencies: Case Reports and Guidelines for Psychiatric Consultants

Because of the unmet mental health needs of older persons in the community, Medicare-certified home health agencies are increasingly taking the role of health providers. Here the authors review their experience and argue that the pathology seen in home mental health care situations is similar to that seen by specialized mental health outreach teams. Also the relations between the home care team and the psychiatric consultant require skillful management even when the team are mental health specialists. The authors offer guidelines for psychiatric consultants, given the extent to which home care services survive in a volatile, cost-contained environment.

A critical review of research on cognitive function/impairment in older adults

Research on aspects of cognitive function and impairment in older adults is critically reviewed with the aim of evaluation and synthesis. The body of research on cognitive aging, mostly atheoretical, has not been placed within the larger context of cognitive sciences. Methodological concerns and lack of a unifying framework inhibit integration of previous studies and the development of a cohesive body of knowledge. Therefore, one paradigm of adult cognition, information processing, is recommended to further advance nursing theory and research.

Psychiatric status among the homebound elderly: an epidemiologic perspective

OBJECTIVE

To compare the prevalence of specific psychiatric disorders in the homebound elderly to other elders, controlling for demographic, physical health, and socio-economic factors.

DESIGN

Survey.

SETTING

Epidemiologic Catchment Area (ECA) project in New Haven, CT.

PARTICIPANTS

2,553 non-institutionalized elders representing the total elderly population of the greater New Haven area.

INTERVENTION

None

MAIN MEASURES

Homebound status determined by self-report; psychiatric status according to DSM III by the Diagnostic Interview Schedule (DIS); cognitive status by Mini-Mental Status Examination.

RESULTS

Cognitive impairment (21.8% vs 11.0%, P less than 0.001), depression (2.3% vs 0.7%, P less than 0.01), dysthymia (3.9% vs 1.7%, P less than 0.01), and anxiety disorders (2.2% vs 0.4%, P less than 0.001) were each at least twice as prevalent among elders confined to a bed or chair as among non-homebound elders. Most of this increase was consistent with the poorer physical health status of the homebound; after controlling for health status, only dysthymia (Odds ratio = 2.1, P less than 0.01) was significantly more prevalent among elders confined to a bed or chair.

CONCLUSIONS

The higher prevalence of disorders among the homebound support recommendations that psychiatric assessments become routine in primary care examinations of homebound elders and that the availability of preventive and therapeutic psychiatric services to the homebound increase.

Homebound aged: the dilemma of psychiatric intervention

This study reports the 12 month experience of a hospital-based, multidisciplinary psychogeriatric community team. The patients evaluated were unable to come to the hospital clinics because of a psychiatric and/or physical disability. The group included some patients rarely seen in psychiatric office practice and outpatient facilities, but who posed problems for their families and the community. Some required referral to a clinic, crisis management or emergency hospitalization. Others however, required only minimal intervention. A total of 151 patients (119 females and 32 males) whose average age was 78.2, were seen. Seventy percent were widowed, single, divorced or separated; 43% lived alone. The patients were grouped according to the method of intervention used: psychiatric and social intervention--55%; social and nursing intervention--28%; no follow-up--11% and; emergency hospitalization--6%. Seventeen patients were left "untreated". These patients usually had more adequate family or community support than was initially apparent. They were referred for a crisis which was resolved quickly. An attempt is made to explain our approach, and several case examples are given.

The effectiveness of services and treatment in psychogeriatrics

The future development of new psychogeriatric services in Australia may well depend upon the demonstration of their potential effectiveness and efficiency. Descriptive accounts of effective services provide ample guidelines, although formal evaluation is lacking. Examining the major psychiatric disorders of the elderly shows that most are functional. Effective acute psychiatric treatment is available for these. In dementia cases, effective therapies exist for the reduction of secondary behavioural disabilities in the sufferer and the stress on carers. Adequately resourced comprehensive psychogeriatric services would be best equipped to deliver such treatments.

The yield of a home visit in the assessment of geriatric patients

Elderly patients often have problems not easily detected during an office visit. We investigated the yield of a home visit by a geriatric nurse specialist as part of an interdisciplinary assessment process. Compared with the findings of an office-based assessment by a general internist, the home visit resulted in up to four new problems (median = 2, mean = 1.7, 95% confidence interval = 1.5-1.8) and one to eight new recommendations (median = 4, mean = 3.6, 95% confidence interval = 3.4-3.9). Twenty-three percent of the problems could have resulted in death or significant morbidity. The most frequent problems related to psychobehavioral difficulties (23.1% of problems involving 38.3% of patients), safety (21.6% of problems involving 35.7% of patients), and caregiver related problems (20.4% of problems involving 33.8% of patients). The most common recommendations related to safety (30.7% of recommendations involving 81.8% of patients), caregiver well-being (19.8% of recommendations involving 52.6% of patients), and social issues (12.7% involving 33.8% of patients). Baseline clinical information did not predict the yield of the home visit in this sample. We conclude that an in-home assessment contributes unique and meaningful information to the geriatric assessment process.

Psychiatric emergency consultations to elderly patients in a Canadian general hospital

The authors compared the demographic and clinical characteristics and treatment recommendations for elderly (greater than or equal to 60 years) and younger patients (17 to 59 years) seen for an emergency psychiatric consultation in a teaching general hospital. Findings revealed 11 distinctive characteristics that differentiated elderly from younger patients. Most notably, the elderly experienced their chief complaint for a longer time before referral to the emergency room by their primary care physician and had higher prevalence of affective disorders and psychologic factors affecting physical condition. Some of the implications of these results are discussed with the view to planning psychiatric services for the elderly and education programs.