An Intensive, Extensive Comprehensive
Model of Psyhiatric Care in LTC
Leo J. Borrell
The best treatment is known as “The Integrated Model of Geriatric Psychiatric Care.”
This plan includes follow-up visits to ensure that prescribed medication or behavioral treatment is implemented appropriately and that the resident is responding without side effects or problems.
Six Components of Geriatric Psychiatric Services Consistent with Best Practices:
1. A multidisciplinary team approach
2. Specific geriatric expertise and competence
3. Individualized assessment and treatment planning with routine follow-up, ideally using standardized outcome measures
4. Collaborative treatment planning between the consultant and the nursing home staff and primary care physician
5. A strong educational component
6. Family involvement
The six components listed above are particularly important with the resident with dementia because the symptoms fluctuate and the medication effects can vary as the dementia progresses. Therefore, it is crucial to detect symptoms early, and increase, decrease or initiate a change of dose in the medication if needed.
CARE PLANNING AND BEHAVIORAL ROUNDS
Despite regulations making nursing care planning for residents of long-term care facilities a standard of practice (both as a written document and as part of the interdisciplinary team), its use has not always been valued.
Problems arise because nurses do not believe in its efficacy and facilities did little to encourage direct caregivers to become involved in the care-planning process.
However in 2005, the American Health Care Association listed specific federal regulations regarding care plans. Each resident must have a comprehensive assessment.
Based on issues identified in the assessment, each resident must have a care plan that has measurable objectives and timetables that meet a resident's medical, nursing, and mental and psychosocial needs.
The care plan is to be used as a communication tool for the interdisciplinary team and should be reviewed and changed periodically as the needs of the resident changes.
This process is seen as the basis for which care is received on an individual basis and ensures that quality care is not disrupted. The resident is assessed using resident assessment protocols (RAPs) and by using the Minimum Data Set (MDS). RAPs are used for guidance to address a limited number of clinical issues that are seen in residents of nursing homes.
The interdisciplinary care plan and the written care plan are very different. The interdisciplinary team involves clinicians, residents, and their significant others in the planning process and is continually updated. The written care plan is not updated as often and even though it is expected to, it cannot specify the many issues involved in psychosocial issues.
The written plan is limited due to nursing home having few resources, rigid routines, and seemingly endless regulations.
In response to these issues, SPC has developed behavioral rounds to be used as the structure to help synthesize interdisciplinary care planning into the nursing home's routine operations. Behavioral rounds are part of the information gathering, interpreting, and integration of information. The information process is needed in order to obtain goals relating to the quality of care and the quality of life for each resident.
Nursing home staff, residents, and the resident's significant others all benefit from the development of strategies that are effective in synthesizing interdisciplinary care planning into the nursing home's operations.
Diagnosis and Treatment of Mental Health Problems in Seniors
50% of patients with dementia and depression are undiagnosed. Thus, the proportion of older adults who received a depression diagnosis is at least doubled. Of those diagnosed, the proportion receiving antidepressants increased from 53.7% to 67.1%, whereas the proportion receiving psychotherapy declined from 26.1% to 14.8%.
These shifts are most pronounced in groups with less-severe depression, in whom evidence of efficacy of treatment with antidepressants alone is less clear.
Depressive symptoms predict a range of negative outcomes, including total mortality, suicide, hospitalization, and medical complications in long-term care, and have been estimated to reduce active life expectancy at age 70 by 6.5 years for men and 4.2 years for women.
Antidepressants have been shown to have clear efficacy for treatment of major depressive disorder (MDD), and psychotherapy has been demonstrated to be efficacious as well.
More uncertainty exists concerning their efficacy for other depressive disorders. There is consensus that combined treatment of psychotherapy and antidepressants resulted in fewer relapses than either treatment alone.
From 1991 to 2005 the total number of antidepressant prescriptions paid by Medicaid rose 380%.
Although studies suggest that psychotherapy and antidepressant treatment in combination may produce better outcomes for depression than either treatment alone, such treatment became increasingly rare by 2002 to 2005, declining by 39%.
PSYCHOTHERAPIES DIFFERENT STROKES FOR DIFFERENT FOLKS
Focus of Intervention Specific Techniques
Cognitive- Behavioral Therapy (CBT)
Maladaptive thoughts and behaviors
Self-monitoring, increasing participation in pleasant events, challenging negative thoughts and assumptions
Interpersonal Therapy (IPT)
Unresolved grief, interpersonal disputes, role transitions, skills deficits
Exploration of affect, behavior change techniques, reality testing of perceptions
Problem-Solving Therapy (PST)
Problem-solving skills Identifying specific problems; brainstorming, evaluating, implementing and reviewing solutions
Brief Psychodynamic Therapy
Lack of insight, relationship problems
Analyzing current problems in light of historical patterns, using the therapeutic relationship to identify issues and practice new ways of relating to others.
Life Review Integration of past and present experiences
Structures reminiscence, constructive reappraisal of the past, recollection of previously used coping strategies
Dialectical Behavior Therapy (DBT)
Negative affect, impulsivity, suicidal thoughts and gestures, interpersonal skills deficits
Increasing mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness skills
Past and current family issues Psychoeducation of patient and family, assessment of relationship difficulties, behavioral prescriptions
Stress and burden Emotional support, encouragement of helpseeking and self-care, information about community resources, may include CBT and PST elements
Psychosocial treatments for anxiety should be considered viable, safe alternatives to medications in patients with dementia although, again, research is limited. Outcome data on cognitive-behavioral therapy (CBT) for anxiety in dementia have shown promising results in several case studies.
Successful CBT in these patients relies on strategies to circumvent cognitive limitations in learning and applying new coping tools.
These include simplifying skill training, repetition, and recruiting collaterals (eg,caregivers) to act as coaches.
Other non-drug interventions that show promising results in case series or small pilot studies include milieu therapy, addressing patients' specific environmental needs, and caregiver psychoeducation
Quality Care for Dementia Makes Dollars and Sense
Annual Costs of Caring for Residents with and without AD
– 26.4% had documented dementia
– Average additional 229 hours of care per year
– Average additional $4700 per patient with dementia per year
• Problem behaviors add costs to LTC
• Cholinesterase inhibitors may reduce this cost
• Residents with this medication, $49.60 a day
• Residents who discontinued it, $55.16 a day
What research shows about treatment of mental health problems in nursing homes:
1) 51% of participants with dementia and depression did improve their quality of life.
2) 58% of those with depression alone, receiving the comprehensive intervention had recovered from their depression six months later and had a better quality of life.
3) Only 25% of those receiving unsupplemented general practitioner care decreased depression, but they did not have significantly better quality of life. Without psychotherapy, individuals with depression or dementia or both:
• 20% continued to exhibit behavioral symptoms.
• 40% exhibited physically and/or verbally aggressive behavior Early evaluation and accurate comprehensive diagnosis is necessary. Medications alone are not enough. A comprehensive plan of 6-24 months with counseling is necessary to maximize results, prevent relapse and improve the quality of life Reality of Disclosure and Individuals with Dementia
50% OF PRACTIONERS DO NOT DISCLOSE DEMENTIA DIAGNOSIS
Only 47% knew correct diagnosis
66% said no one ever spoke with them about their illness
92% wanted to know to plan for the future and enjoy present while they could
65% were told after family was told
51% “reacted poorly” per family