Effectiveness of nursing home staff as managers of disruptive behavior: perceptions of nursing directors.

Nursing directors of 899 geographically diverse skilled nursing facilities reported substantial limitations in the competence of staff at all levels in managing behaviorally disturbed patients and a broad-based need for improvements in skills. The authors propose an interdisciplinary team training model as an appropriate design for improving competence and promoting collaborative care.

Schizophrenia and older adults. An overview: directions for research and policy.

The Group for the Advancement of Psychiatry, Committee on Aging, believes that a crisis has emerged with respect to the understanding of the nature and treatment of schizophrenia in older persons. Moreover, critical gaps exist in clinical services for this population. In this article, we examine the epidemiology of aging and schizophrenia; life-course changes in psychopathology, cognitive function, social functioning, and physical health; and various concerns regarding treatment, services, and financing. Finally, we propose six research and policy recommendations and suggest methods for addressing the research questions that we have posed.

The Louisiana Medicare Electro-Convulsive Therapy Quality Improvement Project.

The first collaborative statewide psychiatric quality improvement project, initiated by Louisiana Health Care Review, Inc, focused on the practice of inpatient electro-convulsive therapy (ECT) among Medicare patients. Data from the project indicated that the majority of Medicare patients receiving ECT were white females living at home, in good physical health, in their seventies, and with a diagnosis of major depression or major depression with psychotic features. The quality indicators for the project included: (documentation of) monitoring of cognitive side effects, monitoring of depressive target symptoms, ECT appropriateness, electrode placement, anesthesia evaluation, and dental examination. An additional indicator (administration of possibly detrimental medication during ECT) was developed based on the recommendation by the study group. At project conclusion, significant improvement occurred in all project indicators. ECT as practiced in the participating hospitals was effective and appropriate. Appropriateness was determined as depression refractory to two medication trails or an emergency due to severe suicidal ideation or physical deterioration secondary to malnutrition. Transient hypertension (13%) and cardiac dysrhythmia (3.5%) which resolved in the recovery period were the most frequent complications.

Psychiatric consultation in the nursing home. A survey of six states.

The authors examined availability, characteristics, and perceived adequacy of psychiatric consultation in nursing homes, as reported by directors of nursing, who returned 899 questionnaires. Thirty-eight percent of nursing home residents were judged to need a psychiatric evaluation; current frequency of consultation was rated as adequate by half of nursing directors. Nearly two-thirds reported that psychiatrists adequately provided diagnostic and medication recommendations; however, advice on nonpharmacologic management techniques, staff support, and dealing with staff stress and family conflicts was largely viewed as inadequate. Findings suggest that perceived need for psychiatric services is far greater than the level actually provided. Overall, more attention must be directed to identifying incentives for psychiatrists to practice in nursing homes, determining clinical effectiveness of mental health services, and examining effects of alternative payment mechanisms on level of care.

Introducing psychiatric care into nursing homes.

A consultation-liaison psychiatry program in a teaching nursing home helped implement six guiding principles including: make the patient human to the staff; assume no behavior is random; look for depression of psychosis as a source of problems; reduce medications and medication doses; create a more homelike environment; and use conditions in which learning still occurs in dementia.