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 patients 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 patients 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 patients 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 elderlys 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.