For elders confronted with the necessity of living in a nursing home, the choice of facility is a decision with profound consequences-for their health, their quality of life and their family finances. Nursing home care may cost $50,000 a year or even more, and more than half of all elders begin their nursing home stays by paying the costs out of pocket. That imposing sum can purchase excellent care, or can pay the rent for a place that is literally "worse than death" for the unfortunates who live there.

Since many elders in need of nursing home care are cognitively impaired, their spouses, children and other relatives are involved in the decision. For them, feelings of responsibility and guilt add to the weight of the decision. Psychiatrists who treat elderly people, or who treat the adult children of elderly people, encounter the emotional reactions of people faced with the nursing home decision. While the emotional reactions of their patients to the nursing home choice may become themes of psychotherapy, a wise choice regarding nursing home care can mitigate these reactions by reducing the realistic basis for having them. If patients and their families can be sure that facilities will serve them well, they can relax. Specifically, their minds are eased if they know that a facility will provide:

• Compassionate and competent medical care
• Rehabilitation to the greatest feasible extent
• Prevention of new medical problems
• Prevention of functional decline
• Activities appropriate to the resident's capacities and interests
• Physical safety
• Pleasant physical and social environment
• Respectful, individualized treatment
• Autonomy for the resident
• Freedom from abuse and exploitation; and
• Timely availability of any needed medical or mental health services.

Unfortunately, no nursing home fully meets these criteria. So, the elder and the family may profit from the psychiatrist's guidance in determining when an imperfect nursing home can be acceptable for a particular individual.

Goals of Home Placement

A good place to start is with an analysis of the real reason for nursing home placement, which may be different from the reason first given by a doctor, hospital or even a family caregiver. For example, Alzheimer's disease is not a reason for nursing home placement, since the vast majority of people with Alzheimer's disease live in the community. The reason must be some combination of specific conditions, impairments or medical needs (e.g. agitation, incontinence, need for intensive physical therapy), together with a lack of the personal, community, and/or financial resources to manage those conditions and impairments elsewhere. Regardless of the specific problem, an elderly person living alone is more likely to be placed in a nursing home than one married to a relatively intact spouse.

Once the psychiatrist has a general grasp of the elder's unmet needs, he or she should ask whether any of the persons' disabilities are treatable in the community or in a brief hospital stay. Unless comprehensive geriatric assessment has shown otherwise, it is not unusual to uncover treatable causes of excess disability. For example, a major depression can severely limit the ability of the elderly to take care of themselves. Treating depression, even if it requires brief hospitalization, usually should be attempted before committing to nursing home placement. A number of other conditions may push elders and their families toward nursing home placement, but might yield to effective medical intervention. These conditions include paranoid psychosis, incontinence, chronic pain and poor nutrition.

Falling and wandering-two common problems of dementia patients-often can be treated at home by a combination of environmental modifications and scheduled, assisted activity. When these are combined with the use of adult day care and respite services, families can manage many dementia patients at home.

The second question for the psychiatrist is whether a move short of nursing home placement can bring elders into an environment that can meet their needs. The care continuum is expanding, and such options as assisted living, adult day care and intensive home care are becoming available. For dementia patients without major medical comorbidities, specialized group residences that offer specialized activities and environments in a less "clinical" setting than a nursing home are becoming more common. The continuum of care is richer in more sophisticated metropolitan areas. In rural areas, however, residence with a "foster family" may be an option for some elders no longer able to live alone. In almost every region, professional care planners who are familiar with the full range of these options are available.

Helping Families Evaluate

Even with treatment of geriatric syndromes and exploration of alternatives, some elders will require nursing home placement. At times, the family will be under pressure to decide quickly upon a specific facility, either because the elder is being pushed out of an acute care hospital, or because a behavioral problem has escalated to the point of danger. In either case, the psychiatrist should encourage the family to resist a rushed placement, and advocate for them if need be. The choice is too important to do otherwise. When patients are in acute care hospitals, their right to choose their own residences can be invoked. If patients are too ill to be discharged home, the hospital cannot discharge them precipitously. If behavioral issues are urgent, the patient can be admitted to a geriatric psychiatry inpatient unit until the behavior is stabilized or a suitable nursing home placement is found.

Once the process is slowed down, the elders and their families can be educated about nursing home care, and the huge variations in its quality. For background, the family can be referred to one of the excellent recent books on the subject. For example, The Inside Guide to America's Nursing Homes by Robert Bua (Warner Books, 1997) provides a 10-step system for evaluating the suitability of a facility. Bua's book also lists every nursing home in the country, along with the results of the most recent state inspections. Another useful reference is Nursing Homes: Getting Good Care There by the National Citizens Coalition for Nursing Home Reform (Impact Publishing, 1997). This enables the elder and family to rule out homes with gross problems, and focus on ones that may be suitable.

Carefully Evaluate Resources

Using some combination of reference books, the advice of professional care planners, physicians and clergy, and referrals from organizations like the Alzheimer's Association, the elder and family can generate a list of possible nursing homes. These should be facilities generally regarded as better than average, that are conveniently located and which offer whatever specialized services are needed.

To help the elder and family assess the homes on the list, the psychiatrist should elicit what is most important to the elder-personally as well as medically. A suitable nursing home doesn't have to be excellent in every area, but it should excel in areas of particular relevance to the patient. These areas can be organized in terms of problems, preferences and pleasures.

An elder entering a nursing home usually has a few conspicuous problems, such as depression, frequent falls, incontinence or agitation. For each facility under consideration, the family should ask the director of nursing, the medical director or a charge nurse how each of these problems is assessed and managed.

For example, how does the facility tell when a resident with dementia is depressed? Are cognitively intact residents offered psychotherapy to deal with adjustment to the nursing home? How aggressively is incontinence treated before the facility resorts to diapers or catheters? Are frequent fallers given physical therapy to improve their strength and balance, or are they restrained? When evaluating the answers, the family need only determine whether the answer makes sense and implies respectful treatment of both the elder and the family. Defensiveness, obfuscation or inflexibility in the answers should exclude the home from further consideration.

When disease and disability have limited a person's options in life, it becomes critically important that he or she exercise his or her preferences whenever possible. A well-known study of nursing home residents showed that they care more about choice in their food, their roommates and their television shows than about living wills and advance medical directives. If an elder has strong preferences about food, hours of waking and sleeping, privacy, and the like, these should be honored. An administrator, social worker or nurse should be able to tell the family whether each of the elder's important preferences can be accommodated.

Pleasant events and experiences can make life bearable and even enjoyable despite the limitations of an institution. The family should determine which of the elder's favorite activities will be possible within the facility. These activities must not only be offered, but they should be truly accessible. Pleasant activities need to be adapted to the physical, sensory and cognitive levels of the elder. The facility should have a visible program for promoting physical activity, which is associated with longer life, better cognitive function and fewer falls. It should have exercise programs suitable for cognitively impaired people.

Elders with a strong religious orientation should have regular access to religious services and holiday observances. Animal lovers should be able to interact with animals in some way. Those who like to go out to cultural events should have the chance to do so, with appropriate transportation and supervision. People with dementia can, before the end stage, take real pleasure in their favorite foods, music and physical activities. A good facility will find ways to ensure that every ambulatory resident has at least one pleasant experience every day.

Finally, the psychiatrist should talk with the elder and the family about accountability. Care is always better when specific people take personal responsibility. In a good nursing home, the family will know the name of a specific nursing assistant who regularly cares for their relative. They will know the physician in charge, and the physician will know the elder's problems and current state of treatment. They will know when care planning meetings are held, and the facility will make efforts to include them at those meetings.

By taking this approach to helping elders and families with the nursing home decision, the psychiatrist can mitigate some of the anxiety, guilt, grief and powerlessness felt at the time of placement. Psychiatrists have knowledge and skills that are especially helpful at this time. Their knowledge of late-life mental disorders is important because the majority of nursing home residents have diagnosable mental disorders, regardless of their given reason for admission. Equally important are the psychiatrist's skills in eliciting the problems, preferences and pleasures of the person facing nursing home placement.