IPA Task Force
Mental Health Service Provision in
Nursing Homes and Residential Care Facilities
At the IPA congress in Stockholm (2005),
a first meeting was held of IPA members and
congress attendees with an interest in the
way mental health services are provided in
residential care facilities. The rationale
for forming a Task Force is argued below.
Representatives from a number of developed
and developing countries, and from a range
of health disciplines, contributed to the
discussions in Stockholm, and it was agreed
that the first step we need to take is to
gather information from various countries
about how mental health services are
currently provided in their part of the
world. John Snowdon in Sydney agreed to
collect this information, and he will
welcome contributions from anyone, anywhere!
He sent out a brief questionnaire to those
nominated as initial representatives of
about 20 countries, and copies of this can
be sent out to anyone else who'd be willing
to contribute. It is planned that there will
be a symposium at the IPA regional meeting
in Lisbon to present a summary of
information received and to consider what
our next steps should be. Do please attend,
and in the mean time, do correspond with
John at:
jsnowdon@mail.usyd.edu.au.
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. Ten per cent of United States 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.
In the United States in the 1980s there was mounting criticism of the care provided in nursing homes, 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 US nursing homes. 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 US nursing homes, 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.
Conclusion
This short paper is to provoke discussion. I have suggested that the IPA create a Task Force to consider the availability and characteristics of mental health services in the residential care sector around the world. Evidence suggests that there are big issues in some of the developed countries regarding a paucity of such services. Whether the same applies in developing countries is uncertain. Whether residential care is appropriate in looking after older people with dementia or psychiatric disability may be questioned. Appointment of a Task Force will facilitate involvement of health professionals from a variety of disciplines in developing the policies and planning future activities of the IPA. I request discussion at a Board meeting.
Clinical Professor John Snowdon, A.M., M.D. (Board member, IPA)
Sydney, Australia, December 22, 2004.
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
If you wish to participate in this new Task Force, please contact us at info@ipa-online.org
BIBLIOGRAPHY
(Posted December 2007)
Return to previous page.
|
