The impact of antipsychotic drug regulations on psychotropic prescribing practices in nursing homes.

The authors prospectively studied psychotropic prescribing practices and quality assurance data in 17 nursing homes in the Baltimore area to assess the impact of federal antipsychotic drug regulations. There was a 36% reduction in prescriptions for neuroleptics over 6 months, no increase in prescriptions for sedative/hypnotics, and a small increase in prescriptions for antidepressants. The authors conclude that psychotropic drug prescribing practices and patient outcomes remain important areas of study in nursing homes.

Psychosis and physical aggression in probable Alzheimer's disease.

OBJECTIVE: The purpose of this study was to determine the frequency and type of psychotic symptoms in patients with probable Alzheimer's disease and to test whether there is a relationship between specific psychotic symptoms and episodes of physical aggression. METHOD: From 209 patients with possible or probable Alzheimer's disease who had been assessed in a research clinic every 6 months for up to 4.5 years, 181 subjects with probable Alzheimer's disease were selected for study. On the basis of the summary note for each visit in the patients' charts, the presence of delusions, hallucinations, misidentifications, and episodes of physical aggression was determined. Data regarding psychotic symptoms and aggression were available for 170 and 169 subjects, respectively. RESULTS: Delusions had been reported for 74 (43.5%) of the patients and were the most frequent psychotic symptom; persecutory delusions were the most common type. Physical aggression had been noted for 50 (29.6%) of the patients. Delusions and misidentifications frequently preceded and were significantly associated with episodes of physical aggression. The presence of delusions was a significant predictor of physical aggression but accounted for only 3.5% of the variance. CONCLUSIONS: This study suggests that delusions are a risk factor for physical aggression in patients with probable Alzheimer's disease who have moderate to severe cognitive impairment. As delusions accounted for only a small percentage of the variance, further research is needed to identify other variables that may be significant predictors of physical aggression in this population.

Prevalence of mental illness in a community nursing home.

A research psychiatrist using a standardized interview found that 94% of a random sample of residents at a large, intermediate-care nursing home had mental disorders according to DSM-III criteria. Primary degenerative dementia and multi-infarct dementia were the most common diagnoses. In addition, the majority of demented patients also had noncognitive symptoms such as delusions and hallucinations, and these residents were significantly more likely to have an associated behavioral disorder than were residents without delusions or hallucinations. Replications of these results would point out the need for major revisions in the funding and delivery of psychiatric care for nursing home residents.

Depression and Alzheimer's disease.

In his classic case, Alzheimer described cognitive symptoms such as amnesia, aphasia, and apraxia and noncognitive symptoms such as delusions and agitation. Recent studies have suggested that depression also occurs in Alzheimer's disease. In this study, 144 patients who met criteria for Alzheimer's disease were examined for depression on a modified version of the Present State Examination. The prevalence rate of major depression was 17%. The depressed Alzheimer's disease patients were more cognitively impaired and more disabled than the nondepressed patients. Studies are needed to clarify the etiology and treatment of depression in Alzheimer's disease.

Delusions in newly admitted residents of nursing homes.

Two psychiatrists, using standardized clinical examinations, found that 21% of 125 patients newly admitted to nursing homes had delusions. The psychiatric disorders associated with these delusions are described. Delusional patients were more behaviorally disturbed before admission than nondelusional patients. These behavior problems were often the reason for admission, and they persisted after admission. Nursing home staff members infrequently identified and often inappropriately treated delusional patients. Since delusions are an important potentially treatable cause of behavior problems in nursing home residents, the authors suggest ways to improve the recognition and management of delusions.

Self-care capacity and anticholinergic drug levels in nursing home patients.

The serum anticholinergic levels of 22 demented nursing home patients were related to their cognition and capacity for self-care. The patients with high anticholinergic levels had greater impairment in self-care capacity than patients with low levels.

Association between family history of affective disorder and the depressive syndrome of Alzheimer's disease.

For each of 41 index patients with probable Alzheimer's disease and a first episode of major depression and 71 nondepressed Alzheimer's disease patients, two first-degree relatives were interviewed by a rater blind to presence or absence of depression in the proband. The depressed patients had significantly more first- and second-degree relatives with depression than did control subjects. The lifetime risk for major depression, adjusted for differences in age distribution, was significantly greater in first-degree relatives of index patients, suggesting that depression in Alzheimer's disease is genetically related to primary affective disorder. Alzheimer's disease may be useful for studying aspects of depressive pathophysiology.

Depression and increased risk of mortality in the nursing home patient.

Depression is a common clinical syndrome in the elderly, often resulting in attempted and/or successful suicide. Within the community and in a wide range of medical care settings, including nursing homes, depression is often undiagnosed and untreated. In a 1-year investigation that included 454 new patient admissions to eight Baltimore area nursing home facilities, major depressive disorder occurred in 12.6% of patients; an additional 18.1% had depressive symptoms. Most cases of depression were unrecognized and therefore untreated by nursing home physicians. Major depressive disorder was found to be an independent risk factor for mortality that increased the likelihood of death by 59% in the first year after diagnosis. Because new federal regulations now mandate the assessment of depression in nursing home patients, improved diagnosis and therapy (and therefore reduced disability and mortality) may be expected in the future.

Neuroticism predicts depression and disability in age-related macular degeneration.

OBJECTIVES: Age-related macular degeneration (AMD) is a common, disabling disorder of older age that is associated with depression. We investigated the incidence rate of depression and its risk factors and consequences in this 6-month longitudinal study. DESIGN: A prospective cohort study in which subjects were interviewed 6 weeks after the onset of bilateral vision loss and 6 months later. SETTING: The sample was recruited from the retinovascular clinic of a specialty eye hospital. PARTICIPANTS: Subjects were 51 patients with new onset bilateral AMD. MEASUREMENTS: We assessed depressive symptoms, personality traits, visual acuity, and vision and physical functioning. Additionally, we interviewed informants to obtain independent assessments of subjects' personality traits. RESULTS: The baseline prevalence rate of syndromal depression was 23.5% and high levels of depressive symptoms persisted over time. The 6-month incidence rate of depression was 27.8%. The strongest risk factors for incident depression were self-rated and informant-rated neuroticism. Patients who developed syndromal depression were 8.3 times (95% confidence interval = 1.1-63.4) more likely than nondepressed patients to become disabled in vision function, independent of change in visual acuity. CONCLUSION: AMD is associated with high rates of depression and visual disability independent of severity of vision loss. The personality trait of neuroticism is highly predictive of incident depression and identifies patients at high risk for excess disability. Psychotherapeutic treatments targeted to this group may prevent depression and reduce disability.

Depression and disability associated with impaired vision: the MoVies Project.

OBJECTIVE: To assess how depression and impaired vision relate to disability in older people. DESIGN: An epidemiological survey of an age-stratified random community sample. SETTING: The rural mid-Monongahela Valley in South-western Pennsylvania. PARTICIPANTS: A total of 872 noninstitutionalized persons aged 68 and older, fluent in English, and with at least a grade 6 education. MEASUREMENTS: Demographics, self-reported vision impairment, OARS Instrumental Activities of Daily Living (IADL), and modified Center for Epidemiologic Studies-Depression scale to assess depression. RESULTS: Compared with subjects with intact vision, those with impaired vision were more likely to have five or more depressive symptoms (29.7% vs 8.5%; OR = 4.6, 95% CI = 2.2, 9.6) and to be more functionally impaired (OR = 9.7, 95% CI = 4.9, 19.2). The number of depressive symptoms (1-4: OR = 2.4, CI = 1.8, 3.4) and (5+: OR = 5.9, CI = 3.6, 9.8) was associated independently with IADL impairment after controlling for vision, age, and gender. CONCLUSIONS: Impaired vision and depression are both associated strongly with functional impairment in this community population of older adults. Depression, however, increases the odds of functional impairment independent of vision impairment. Treating depression may reduce excess disability associated with impaired vision.

Depression and disability in older people with impaired vision: a follow-up study.

OBJECTIVE: To determine the prevalence of depressive symptoms and their relationship to disability in older low vision patients. DESIGN: Panel study with 2-year follow-up. PARTICIPANTS: Community-residing older people (N = 31). MEASUREMENTS: Geriatric Depression Scale, Community Disability Scale, and Snellen visual acuity. RESULTS: Twelve of 31 patients (38.7%) had GDS scores > or = 11 at baseline. Two years later, 10 of these 12 patients remained depressed, and three of the 19 (15.8%) previously nondepressed patients had become depressed. Depressed patients tended to be more disabled functionally than nondepressed patients at follow-up. The correlation of disability with depression and with vision were examined for the entire sample and revealed a strong correlation between disability and depression (r = .40; P = .013) compared with that of disability and vision (r = .34; P = .032) at baseline and at follow-up: depression (r = .68; P = .001), vision (r = .45; P = .006). There was no significant correlation between depression and vision at baseline (r = .06; P = .383), but there was a trend toward correlation at follow-up (r = .28; P = .067). CONCLUSION: Depressive symptoms are prevalent and persistent among low vision patients and appear more highly related to disability than is vision. The frequent occurrence of depression and the availability of effective treatment argue for its recognition and treatment as possible ways to reduce disability in older persons with low vision.

A randomized trial of dementia care in nursing homes.

OBJECTIVE: To evaluate the efficacy of a dementia care program to reduce behavior disorders in nursing home patients with dementia. DESIGN: Randomized controlled clinical trial with 6-month follow-up. SETTING: A 250-bed community nursing home. PATIENTS: The nursing home was screened to identify patients with dementia and behavior disorders. A total of 118 patients were eligible for randomization. Of these, 89 (75.4%) were randomized, and 81 of these (91.0%) completed the trial. INTERVENTION: The A.G.E. dementia care program consisted of Activities, Guidelines for psychotropic medications, and Educational rounds. The control treatment was usual nursing home care. MEASUREMENTS: Behavior disorders, antipsychotic drug and physical restraint use, patient activity levels, and cognitive and functional status. RESULTS: After 6 months, 12 of 42 (28.6%) intervention patients exhibited behavior disorders compared with 20 of 39 (51.3%) controls (OR = 0.38; 95% CI [0.15, 0.95]; P = .037). Controls were more than twice as likely to receive antipsychotics (OR = 2.55, 95% CI [0.96, 6.76]; P < .056), to be restrained during activity times (OR = 2.98, 95% CI [1.10, 8.04]; P < .028), and to be restrained on nursing units (OR = 2.14, 95% CI [0.9, 5.3]; P < .10). Intervention patients were much more likely to participate in activities (OR = 13.71; 95% CI [4.51, 41.73]; P = .001). CONCLUSIONS: The A.G.E. program reduces the prevalence of behavior disorders and the use of antipsychotic drugs and restraints. It is practical, feasible, and appears to improve the lives of patients with dementia in nursing homes.

Urinary incontinence in nursing homes: incidence, remission and associated factors.

OBJECTIVE: To determine the incidence and remission rates of daytime urinary incontinence (UI) in a cohort of newly admitted nursing home (NH) residents. DESIGN: Prospective cohort study. SETTING: Eight proprietary NHs in Maryland. SUBJECTS: Four hundred thirty new admissions age 65 or older who were participants in a larger prospective study of mental morbidity and adjustment to the NH. MEASURES: Nurses aides' reports of continence status, psychiatric examinations, and nursing staff assessments of mobility at 2 weeks, 2 months, and 1 year after NH admission. RESULTS: The prevalence of daytime UI at admission was 39% in both females and males. Among the 293 members (68%) of the admission cohort remaining in the NHs 2 months after admission, the incidence of daytime UI was 27% (21% in females, 51% in males); daytime UI resolved in 23% (24% in females, 20% in males). Among the 178 members (41%) of the admission cohort remaining in the NHs 1 year after admission, the incidence of daytime UI between 2 months and 1 year after admission was 19% (16% in females, 46% in males); daytime UI resolved in 22% (23% in females, 14% in males). The continence status of about two-thirds of residents remaining in the NH at 1 year after admission was stable over time: 22% had daytime UI, and 42% were continent at all three data collection points. The development of daytime UI was associated with male sex, the diagnosis of dementia, fecal incontinence, and the inability to ambulate or transfer independently. Resolution of daytime UI was associated with the absence of these characteristics. CONCLUSIONS: Despite limitations attributable to the method of defining UI and potential biases related to the attrition of the admission cohort over time, this is the first large prospective study to examine the incidence and remission patterns of daytime UI among NH residents. The strong association between UI and dementia was validated for the first time by direct psychiatric examinations. Sex and mobility are also closely associated with the development and remission of UI in this setting. This study provides some valuable data that can be used to assess the impacts of the recently developed Resident Assessment Protocol for UI and Agency for Health Care Policy and Research Clinical Practice Guidelines.

Sedative-hypnotic use and increased hospital stay and costs in older people.

OBJECTIVE: To assess the relationship between sedative-hypnotic (S/H) utilization, severity of illness, length of stay, and hospital costs among older patients admitted to a tertiary care university hospital. DESIGN: Retrospective review of computerized hospital and pharmacy data bases. SUBJECTS: A total of 856 older consecutive medical and surgical admissions from November 1993 to March 1994. MEASUREMENTS: Sedative/hypnotic utilization in accord with the Health Care Financing Administration (HCFA) guidelines for S/H use in nursing homes. Jefferson Disease Staging to estimate severity of illness. Hospital records to obtain demographic characteristics, length of stay, and hospital costs. RESULTS: Patients whose S/H use exceeded HCFA guide lines, compared with those within the guidelines and those receiving no drugs, had longer lengths of stay (21.5 days vs 12.3 days vs 6.7 days, P < .001), increased hospital costs ($29,245 vs $15,219 vs $7,516, P < .001). and greater severity of illness (245.8 vs 189.5 vs 148.5, P < .001). S/H use exceeding and within HCFA guidelines were associated with increased length of stay (both P < .0001) and hospital costs (both P < .0001). CONCLUSIONS: Older hospitalized patients receiving S/H have greater severity of illness, longer lengths of stay, and higher hospital costs compared with other patients. S/H use, and, in particular, S/H use exceeding the HCFA guidelines, are associated with increased hospital stay and cost.

Physical restraint use and cognitive decline among nursing home residents.

OBJECTIVE: This study investigated the association between physical restraint use and decline in cognition. DESIGN: Cohort analytic study describing changes in resident characteristics. SETTING: Eight nursing homes, both urban and suburban, operated by a proprietary corporation in a large metropolitan area. PARTICIPANTS: 437 nursing home admissions, with 201 remaining at 1 year. MAIN OUTCOME MEASURES: Cognitive status was measured by geropsychiatrists, using the Folstein Mini-Mental State Exam, during a psychiatric evaluation of the resident. Daily restraint use was documented from nursing orders. Observations were made at 2 weeks, 10 weeks, and 1 year. RESULTS: Restraint use alone and in combination with neuroleptic use was associated with poor cognition. Other variables associated with poor cognitive scores were: ADL impairment, poor adaptive behavior, and longer time in the nursing home. The use of neuroleptics alone was not significant. Variables which were associated with good cognitive status were: being non-ambulatory but without dementia and having strong social support. CONCLUSIONS: These findings raise the possibility that restraint use may contribute to cognitive impairment, specifically among residents who have moderate to no cognitive impairment at admission; however, the findings do not exclude an alternative explanation that residents undergoing cognitive decline are more likely to be put in restraints. Further research is needed to understand whether factors which can be manipulated contribute to cognitive decline.

The use of mental health measures in nursing home research.

To examine the quality of mental health research in nursing homes, 130 articles published in six geriatric specialty and health care delivery journals were reviewed. Thirty-nine (30%) articles used a mental health measure. Measures of cognitive function were most common, being used in 32 (25%) of the articles reviewed. Twenty-three (18%) studies measured abnormal mental experiences and 17 (13%) articles measured behavioral disorder. Many articles used measures or determinations with no established reliability. Twenty-six of the articles which used a mental health measure also used a measure of activities of daily living or physical function. Retrospective and prospective studies were similar in number. A minority of articles used control groups, random samples, or prepost measures while a majority (64%) identified an outcome measure. We conclude that nursing home research can be improved by the increased use of reliable measures of cognition and abnormal mental experiences and by the development of reliable measures of behavioral disorder. Study design can be improved by identifying a priori hypotheses and by the increased use of random sampling and control/comparison groups.

Agitation and other noncognitive abnormalities in Alzheimer's disease.

Agitation and other noncognitive abnormalities in patients with Alzheimer's disease are present in at least 50% of patients and are a serious problem for caregivers. Agitation can be divided into aggressive agitation, physically nonaggressive agitation, and verbal agitation. Persecutory delusions of suspiciousness and stealing are the most common psychotic symptoms. Auditory and visual hallucinations are also associated with delusions. Similar to delusions are misidentifications, which are false beliefs probably secondary to agnosia. They occur in one third of patients with dementia of the Alzheimer type in the form of the belief that strangers are living in the home and misidentification of the patient's home and reflection in the mirror. Passive personality changes are present early in the disease, whereas agitation and psychotic symptoms occur with disease progression and predict a more rapid rate of cognitive decline. Agitation and wandering are related to more severe cognitive impairment and psychosocial variables, and neurochemical variables that may be related to behavior disturbance require further study. There are few systematic studies of behavioral or environmental interventions for behavioral symptoms in patients with Alzheimer's disease. Current treatment emphasizes education of families, the formation of Alzheimer units in the nursing home, and adjunctive psychotropic agents to treat well-defined target symptoms.

Depression and anxiety in an 85-year-old woman with a toxic nodular goiter.

Depression is commonly encountered in medical settings and often may be a symptom of an underlying medical illness. This case report illustrates the disabling symptoms of anxiety and depression that can accompany a toxic nodular goiter, and underscores the importance of both accurate psychiatric diagnosis and appropriate medical evaluation in the assessment of psychiatric disorders in the elderly.

Prevalence of advance directives and guardianship in nursing home patients.

The Patient Self-Determination Act (PSDA) now requires federally funded nursing homes to inform newly admitted patients of their right to determine their future medical care. Many nursing home patients may not be able to understand these rights, given the high prevalence of mental disorders, particularly dementia, in this population, and well need family members for assistance. Prior to the onset of the PSDA we surveyed the families of all residents of a large, proprietary nursing home to determine whether family members understood the concept of advance directives and guardianship. We also ascertained the rate of use of these instruments in the population studied. We found that the majority of family member respondents understood these concepts, but that substantial proportions of both competent and incompetent patients lacked surrogate decision-making authority, either in the form of a court-appointed guardian or a written advance-directive instrument. Informing newly admitted patients and their families about advance directives is warranted because many lack these plans. However, the high proportion of incompetent patients among nursing home patients indicates the need to encourage currently competent patients to formulate advance directives prior to nursing home placement.

Psychiatric diagnosis and uncooperative behavior in nursing homes.

The prevalence of psychiatric disorders and behavioral disturbances in nursing homes is high, but the relationship between the two is unknown. We studied 454 new admissions who were diagnosed by research psychiatrists using DSM-III-R criteria and compared patients who nursing staff designated as cooperative or uncooperative by psychiatric diagnosis and use of restraints and neuroleptics. Uncooperative patients (n = 79; 17.4%) had a variety of psychiatric disorders (total, 87.3%) but particularly had dementia syndromes complicated by delusions, depression, or delirium (44.3%). Uncooperative patients were more frequently restrained and prescribed neuroleptics. Determining the origins of behavior disorders in patients with psychiatric disorders in nursing homes may reduce behavior disturbances.