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Quality Mental Health Care for Geriatric Patients
in Nursing Homes
| Today, Americans are living longer; unfortunately
these extra years are not always quality. For physicians who
recognize that a geriatric patient may have a comorbid psychological
disorder along with medical, physical, or cognitive problems,
there are services offered to help improve their patient’s
quality of life and medical treatment. What behaviors most frequently
form the basis for referrals for psychiatric evaluations in
nursing home residents? Very commonly, Interpersonal problems
with other residents, staff and visiting family members. There
is also non-compliance with daily routine and care including
refusal to shower or follow other hygiene requirements. A general
apathy such as disinterest in social interaction, non-participation
in activities, and lack of productive activity is all too common.
Depressed residents often retreat to their room or bed and do
nothing but watch television. It is simple to recognize that
even though these residents are not necessarily causing problems,
this type of behavior is evidence of other, subtle problems
with serious implications to their mental and physical health.
The optimum program teams are comprised of a licensed psychiatrist
and a support group of therapists. In many residents there
is a high incidence of comorbid psychological disorders. These
can be precipitated by a reaction to the onset of debilitating
physical problems, the anxiety and depression that often accompanies
the onset of dementia, or the difficulty adjusting for a generation
of independent adults for whom losing their independence is
devastating. Stress or trauma in these patients can sometimes
cause a relapse of a prior condition. There is little argument
about the deleterious effects of these problems on a patient’s
attitude, outlook, treatment compliance and even immune system.
It is imperative that caregivers recognize the psychological
factors affecting our patients and make an effort to best assure
that their emotional and physical needs are addressed. The first
step should be proactive. The attending physician should request
a brief psychiatric evaluation conducted upon admission to the
nursing home. It does not have to be extensive, but rather a
brief assessment of the patient’s mental status, a short
questionnaire addressing depressive symptoms, and a clinical
interview by a psychiatrist to detect possible psychological
or cognitive problems. Not only does it provide early detection,
it becomes a baseline of information that can be referenced
in the future. This can help to recognize, subtle yet significant
declines in a patients mental health that might have otherwise
been overlooked. These symptoms include but are not limited
to subtle changes in language or cognition, fairly rapid loss
of ability to concentrate or remember (markedly more pronounced
than the course of most common dementias), severe delusions
not typical of the individual, and evidence of delirium. With
immediate medical evaluation, usually including urinalysis or
blood work, most patients are found to have many of the common
infections frequently encountered in the elderly. The next step
should be following this initial screening; begin documenting
ongoing observation of the patient. Small changes can signal
the onset of medical conditions or indicate increasing psychological
distress. In addition to the gathering patient information,
having a role in the treatment team gratifies the staff therefore
providing a more effective working environment. Equally important
is the availability of the ongoing data collection to inform
the primary care physician when positive changes occur during
medical treatment. This includes adjustment of medications,
particularly with so many of the psychotropic medications having
anticholinergic effects, their resulting effect being dampening
cognitive functions. Given the natural decline in the elderly’s
ability to concentrate, access short and long term memory, and
to perform cognitive tasks necessary to daily life, this is
critical. This loss of memory and the ability to concentrate
is one of the most distressing aspects for patients. Patients
with dementia, it is very important that the minimum necessary
doses of the anticholinergic drugs are prescribed. In closing,
increased initial data collection, documented, ongoing observation
and assessment, and enhanced communication among treatment professionals
can result in less frustration in our respective jobs working
with geriatric patients. More importantly, we can optimize the
effective level of care for our patients and, consequently,
their quality of life. |
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