Nursing homes

Old age psychiatric services

Nursing homesdavid ames

AbstractMost residents of nursing homes are female, aged more than 80 years, are

physically frail and are highly likely to be affected by moderate-to-severe

dementia. symptoms of depression are common among these residents

(20–50%), and it is likely that schizophrenia is more common in this

population than among elderly people in the community. the manage-

ment of behavioural and psychological symptoms of dementia, includ-

ing agitation, resistiveness, aggression and excessive motor behaviour

presents a major challenge in this population. antipsychotic medications

should not be used routinely for these symptoms because management

with skilled nursing care and activity programmes will often contain

such behaviours. When antipsychotics are needed they should be used

in low dose and for the shortest time possible. it is likely that most

antipsychotics raise the risk of cerebrovascular events in people with

dementia, especially those with multiple risk factors for such events, but

typical antipsychotics should be avoided in most cases because of their

tendency to cause troublesome movement disorders and extrapyramidal

side effects, which reduce mobility for many patients. regular review is

the key to good management of such patients.

Keywords antipsychotics; behavioural and psychological symptoms of

dementia; dementia; depression

What is a nursing home?

Facilities delivering residential care for elderly people can be divided into those that provide direct nursing care 24 hours a day, and those that offer supervision of medication and meals and some assistance with activities of daily living, but do not have nursing staff directly available all the time (usually a staff member will sleep over and will be available only for emergencies). In many countries, the former are called nursing homes; the latter some-times are called hostels or residential care homes, or are known by some other name. Distinctions are to a degree arbitrary.

In Australia, where nearly all residential aged care is gov-ernment funded and potential residents must be assessed by a multidisciplinary aged-care assessment team before the government will pay for such care, most individuals in high-level

David Ames BA MD MRCP MRCPsych is University of Melbourne Professor

of Ageing and Health and director of the National Ageing Research

Institute, in Melbourne, Australia. He is editor of the peer-reviewed

journal International Psychogeriatrics, and undertook research for his

doctoral thesis on the topic of depression among residents of homes

for the elderly.

psychiatry 7:2 5

nursing-home care are too dependent to be cared for in any less intensive setting. However, in aged-care systems that are less rigorously controlled it is likely that some aged but relatively fit individuals will reside in nursing homes. The size of facilities varies dramatically – from small units with 30 or fewer residents, to huge institutions with more than 1000 residents. Management structures are diverse. Some nursing homes in some countries are run as businesses for profit, some are administered by charitable institutions such as churches, and others may be run directly by national, provincial or local government agencies.

Who lives in nursing homes?

The residents of nursing homes tend to be: • elderly (with a mean age of more than 80 years) • female (because of differential survival, and because younger

wives sometimes care for their older husbands at home) • physically frail • cognitively impaired (50–80% will have dementia).Residents often have symptoms of depression (up to 50% in some studies). With the progressive closure of large, long-stay psychiat-ric hospitals in most developed countries, an increasing proportion of elderly individuals with schizophrenia and related illnesses now receive care in nursing and residential homes. A small number of nursing-home residents are drawn from the ranks of the young chronic sick (including individuals with multiple sclerosis, stroke and other neurodegenerative disorders), and those with learning disability or chronic disabling congenital physical disorders.

The proportion of the elderly population resident in nursing homes varies widely amongst countries. In developing countries, few elderly people live in institutions. In developed countries such as Britain and Australia up to 7% of those aged 65 and over dwell in some form of residential care facility, although rates are lower in southern Europe and Asia. Nursing homes may provide between one-third and two-thirds of all residential care places, depending on the care system of the country in question.

Psychiatric disorders among residents of nursing homes

EpidemiologyDementia: epidemiological studies in nursing homes have found dementia to be common, affecting up to 80% of all residents (Table 1). There are a few cases of mild dementia, but severe dementia is very common in this population. This is hardly sur-prising, as the prevalence of dementia rises exponentially with age, it markedly impairs the ability to live independently, and it is associated with a range of other conditions (e.g. stroke) that can also compromise independence and lead to nursing-home admission. Although late-onset Alzheimer’s disease (AD) is the commonest cause of dementia in nursing homes (as in the wider community), dementia associated with cerebrovascular disease, dementia with Lewy bodies, primary frontal dementias, demen-tia associated with excessive alcohol use and uncommon demen-tias such as Huntington’s disease, early-onset AD and other rare dementing disorders account for the cause of dementia in other nursing-home residents.

Delirium is common in hospitals and uncommon among old people who live independently at home. Many studies of cognitive

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impairment in nursing homes fail to differentiate between indi-viduals with dementia and those affected by delirium, but it is likely that between 1% and 5% of nursing-home residents will have delirium at any given time. Some of these people will expe-rience delirium as a component of a terminal decline, but others will have a delirium whose underlying cause (most often due to infection or intoxication with medications) could be treated (see also Psychiatry 2008; 7:1: 39).

Depression, however defined, is 2–20 times more common among those living in residential aged-care facilities than among those in their own homes. Depressed individuals include those with depressive disorders that meet international diagnostic criteria for major depression (DSM-IV) or depressive disorder (ICD-10). More than half of these people will have a past history of depressive dis-order, but some will be experiencing depression for the first time. Modal rates of such disorder are around 20% in nursing homes.

Other nursing-home residents have significant symptoms of depression that do not fulfil internationally agreed criteria for depressive disorder. Sometimes this is because of other condi-tions that are classed by diagnostic manuals as exclusion criteria for a diagnosis of a primary depressive disorder, such as recent bereavement, or comorbid physical illness(es) that may account for the depression, or because the symptoms are insufficient in number or severity to fulfil specific diagnostic criteria. Between one-third and three-quarters of all nursing-home residents are affected by these milder but non-trivial depressions. It is impor-tant to note that although these people with milder depressions rarely receive specific help for their mood symptoms, there is good evidence that they experience significant impairment and distress due to their depression and that multifaceted interven-tions often will lessen the degree of depression experienced.

Schizophrenia: little work has been done on the prevalence of schizophrenia and related psychotic disorders among nursing-home residents, but it is likely that such illnesses are far more common than in the wider community, because many people with schizo-phrenia are isolated with no family carers, or have been moved to a nursing home from a psychiatric hospital that has closed.

Psychiatric disorders among nursing-home residents

Dementia (up to 80%)

• alzheimer’s disease

• cerebrovascular dementia

• dementia with lewy bodies

• Frontotemporal dementia

• alcohol-related dementia

Delirium (1–5%)

Depression (around 20%)

• Major depression/depressive disorder

• Mild depression

Schizophrenia

Other psychiatric syndromes

• e.g. anxiety disorders, substance abuse, personality disorders

Table 1

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Other psychiatric syndromes, including anxiety disorders, past or current substance abuse, disorders of personality and (occa-sionally) mania, will be seen from time to time in the nursing-home population, but little is known about the prevalence of these conditions in such settings.

AetiologyThe most important aetiological risk factor for most late-onset dementing disorders is advancing age. The commonest modifiable risk factors for dementia in the nursing-home population are: • hypertension • atrial fibrillation • diabetes • hyperlipidaemia • falls (leading to head injury).Chronically depressed and socially isolated people are at above-average risk for entry to institutional care, and it is likely that these factors account for at least some of the depression encoun-tered in nursing homes. However, chronic physical illness and disability – especially pain, urinary incontinence and limitation of activity – are robust predictors of depression in elderly people living at home and it is likely that they account for a great deal of depression in nursing homes. In addition many nursing-home residents are widowed and bereavement is a potent cause of depression which sometimes becomes chronic.

Environment and depression: noting the impoverished under-active environments of long-term care facilities (one Sheffield study published in 1980 found that the average resident spent over 70% of her waking hours doing nothing at all), many researchers have postulated that environmental factors must be important in the aetiology of depression among residents. There-fore, it is surprising that repeated research attempts to demon-strate a link between nursing-home environments and depression have failed, but this may simply reflect the fact that measuring environmental variables is a difficult and inexact business, and that showing an association between higher levels of activity and fewer depressive symptoms is virtually impossible when nobody does anything meaningful all day long! An important study con-ducted in a north Sydney residential complex clearly showed that depression among residents became less common when the environment was modified by a programme aimed at educating visiting general practitioners, care staff and residents about the frequency and treatability of late-life depression.1

DetectionPsychiatric disorders among nursing-home residents are more often missed by doctors and care staff than they are detected. Knowledge of how common they are, and specific education of nursing and care staff (who usually have had little training in psychiatry) might improve detection rates. Not much can be done to help individuals affected by psychiatric disorders unless those disorders are recognized in the first place.

Dementia managementIt is the behavioural and psychological symptoms of dementia (BPSD), rather than the cognitive impairment, that cause the great-est challenge for care staff and the most distress to residents and their families. Simple management techniques such as approaching



demented residents from the front rather than the side, explaining what is to be done in a clear voice, and setting appropriate limits can prevent much avoidable resistiveness and some assaults (Table 2). Although research on psychosocial interventions for BPSD tends to be poorly planned and inconclusive, there is some evidence that simple measures, such as staff education and resident activity pro-grammes, are helpful in reducing levels of disturbance.2,3 Before prescribing powerful psychotropic drugs to residents of nursing homes, it is worthwhile analysing the factors that predispose to and precipitate any problematic behaviours, making a specific psy-chiatric diagnosis, and ensuring that staff understand the nature and aetiology of the behaviours in question.

Pharmacological management: where psychotropic drugs are to be prescribed for BPSD it is best to: • keep doses as low as possible • try one treatment at a time • use available evidence • review the patient regularly with a view to ceasing or reducing

the medication when possible.Antipsychotic medications seem to be helpful in reducing

aggression and ameliorating psychotic symptoms in patients with BPSD. Newer antipsychotic drugs have better side-effect profiles than older medications. Risperidone has the best evidence for efficacy in nursing-home populations with BPSD. Novel antipsy-chotic drugs are associated with a higher rate of cerebrovascular adverse events than placebo medications in this population, but there is no evidence that older drugs such as haloperidol are safer in this regard (indeed they may be less safe) and they are more likely to cause extrapyramidal side effects and falls than are the newer medications. For a full discussion of the complex issues surrounding the prescription of antipsychotics to elderly people with dementia see Ames et al.4 The rationale for the use of other medications to treat BPSD rests on a slender evidence base, but modest evidence supports the use of anti-epileptic drugs such as sodium valproate to treat intermittent aggression.

Antidepressants – there is a large body of evidence to indi-cate that antidepressant medications are twice as effective as placebo in the treatment of late-life depression, but few studies have addressed depression in residents of nursing homes. It is rational to treat the more severe cases of depression in nurs-ing-home residents with antidepressant drugs, although tricyclic antidepressants should be avoided where possible because of

Dealing with aggression in a residential setting

• intervene early

• Keep the person away from situations that provoke them

• speak in a reassuring, gentle voice

• approach from the front

• Use non-threatening posture

• Use touch judiciously

• distract the person from their aggressive behaviour

• don’t argue

• avoid physical restraint

• summon help if necessary

Table 2

psychiatry 7:2

their adverse event profile when given to old people. The ben-efits of dealing effectively with pain, boredom and the adverse effects of prescribed medications (e.g. hyponatraemia caused by diuretics) for depressed elderly nursing-home residents should not be underestimated. Table 3 lists some non-pharmacological approaches to managing depression.

The role of the psychiatrist in the nursing home

The routine medical care of nursing-home residents is delivered by general practitioners in most countries, although the Netherlands is unique in having specialist nursing-home physicians to care for elderly people in institutions. Too often the doctor is peripheral to the running of the home and is asked to prescribe for the control of behaviours that might respond better to environmental meas-ures than to drugs. Antipsychotic medications are prescribed to huge numbers of old people in nursing homes (up to 25%) and benzodiazepines are over-used as well. The use of antidepressant medications has risen in recent years from levels that were scan-dalously low, given the high prevalence of depressive symptoms, to rates that may reflect a better appreciation of the frequency and treatability of depression in these environments.

It is usual for a psychiatrist to be called in only when behav-ioural disturbance causes severe disruption, or functional psy-chiatric illness such as depression or schizophrenia is floridly manifest. In these circumstances, taking a good history, thor-oughly examining the mental state, assessing environmental influences on the presenting complaint, and ensuring that recom-mendations are acted on and reviewed is the best treatment that most can manage. In an ideal world more psychiatrists would be both interested and involved in improving the quality and delivery of long-term residential care, as more than 40% of us are going to need such services ourselves in later life. ◆

REfERENcES

1 llewellyn-Jones r, Baikie Ka, smithers h, et al. Multifaceted

shared care intervention for late life depression in residential care:

randomised controlled trial. Br Med J 1999; 319: 676–82.

2 Opie J, rosewarne r, O’connor dW. the efficacy of psychosocial

approaches to behaviour disorders in dementia: a systematic

literature review. Aust N Z J Psychiatry 1999; 33: 789–99.

3 Burns a, O’Brien Jt, ames d, eds. dementia, 3rd edn. london:

hodder arnold, 2005.

4 ames d, Ballard c, cream J, et al. For debate: should novel

antipsychotics ever be used to treat the behavioural and

psychological symptoms of dementia (Bpsd). Int Psychogeriatrics

2005; 17: 3–29.

Non-drug approaches to overcoming depression

• increase and encourage enjoyable activity

• promote sense of purpose, meaning, autonomy

• address isolation and loneliness

• Maintain a bright and cheerful environment

• individualize the approach to each patient

Table 3


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Nursing homes