Kenneth M. Sakauye

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.

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.

AAGP position statement: disaster preparedness for older Americans: critical issues for the preservation of mental health.

The Disaster Preparedness Task Force of the American Association for Geriatric Psychiatry was formed after Hurricane Katrina devastated New Orleans to identify and address needs of the elderly after the disaster that led to excess health disability and markedly increased rates of hopelessness, suicidality, serious mental illness (reported to exceed 60% from baseline levels), and cognitive impairment. Substance Abuse and Mental Health Services Administration (SAMHSA) outlines risk groups which fail to address later effects from chronic stress and loss and disruption of social support networks. Range of interventions recommended for Preparation, Early Response, and Late Response reviewed in the report were not applied to elderly for a variety of reasons. It was evident that addressing the needs of elderly will not be made without a stronger mandate to do so from major governmental agencies (Federal Emergency Management Agency [FEMA] and SAMHSA). The recommendation to designate frail elderly and dementia patients as a particularly high-risk group and a list of specific recommendations for research and service and clinical reference list are provided.

Evolution of the Geriatric Curriculum in General Residency Training: Recommendations for the Coming Decade

As the number of older Americans increased in the twentieth century, training programs added geriatrics to their teaching and clinical experiences. The advent of added qualifications in geriatrics through board examination and the accreditation of geriatric residency (fellowship) programs brought further recognition of the geriatric imperative. Yet curricular requirements for experience with old age mental illness remain minimal. Reduced support for graduate medical education dictates that general—rather than geriatric—psychiatrists will continue to provide the majority of specialty mental health services to older adults. The authors review the emergence of geriatrics in general residency training and present recommendations for further evolution.

Cultural Psychiatry Considerations in Older Adults

C psychiatry or transcultural psychiatry is “the comparative study of mental health and mental illness among different societies, nations, and cultures and the interrelationships of mental disorders with cultural environments . . . . In the past decade there has been greatly enhanced interest in the field and rapprochement of psychiatry with cultural anthropology, sociology, and behavioral science generally.”1 Among its many facets, it questions whetherpsychiatric classifications ordisorders are the same across cultures or ethnic groups, cultural factors that pose unique risks or buffers against mental illness, and varied social constructs, values and norms that guide behaviors. Forminority populationswithin other dominant cultural groups, it is often concerned with the impact of trauma, social exclusion, disparities in care and education, and prejudice on development and behavior. Older adults represent a subpopulation where cultural issues seem to be especially important. What has often been surprising for minority populations embedded in different cultures is the resilience they show in having marginally different, instead of higher rates, of major psychiatric diagnoses despite higher rates of exposure to psychosocial pressures known to increase risk for mental illness. It is worth mentioning that consensus documents have been developed to help professionals understand the common issues in dealing with patients from different cultures. For example, professional organizations such as the American Counseling Association,2 the American Psychological Association,3 the National Association of Social Workers,4 and the American Psychiatric Association5–7 have issued guidelines on Cultural Competence. In 2001, the Surgeon General’s Office issued a major report on mental health, race, and ethnicity.8 In 1994, the American Psychiatric Association developed an Outline for Cultural Formulation in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition9 (DSM-IV). The Association of American Medical Colleges now mandates medical schools to provide instruction on culturally competent assessment and treatment; and the Office of Minority Health, under the Substance Abuse and Mental Health Services Administration, developed standards for culturally and linguistically appropriate healthcare.10 This issue of the American Journal of Geriatric Psychiatry brings together six research articles showing some of the diversity in cultural psychiatry. In the first article, Boorsma et al.11 present data on incidence and risk factors of depression in Dutch nursing homes and residential care homes. Like the United States, about 10% of older adults older than 75 live in residential care homes and nursing homes. The InterRAI–Long-Term Care Facility instrument is applied every 3 months. This is an updated version of the Minimum Data Set. Incident depression was defined as the emergence of depression on followup either when there was an absence of a clinical diagnosis of depression or at first observation. The

Cultural influences on pain management in the elderly

Cultural influences are often more important in the elderly and help explain the influence of nonbiological factors underlying pain appraisal, expression, and folk treatments. Five main psychological theories that underlie these cultural influences help direct supportive interventions.

Psychiatric Care in the Nursing Home

This new edited volume by Drs. Reichman and Katz is especially timely and relevant in this era of managed care. Attention to care in the nursing home was initially stirred in 1986 by the Institute of Medicine Report on Improving the Quality of Care in Nursing Homes. This was followed by the Nursing Home Reform bill known as OBRA ’87, which emphasized the possible overuse of psychotropic medications and strengthened the need for psychosocial care. The reforms have met countercurrents of proponents and opponents of psychiatric involvement. From a psychiatrist’s vantage point, the need for psychiatric care in the nursing home is still not widely accepted, and in a few states, proposals have even been raised by Medicare intermediaries to eliminate Part B payments for psychiatrists in nursing homes altogether. As a collected volume, the 18 chapters cover a wide variety of issues and are written by some of the best-known psychiatrists in the field. Chapters cover clinical disorders like dementia, delirium, mood disorders, psychotic disorders, mental retardation, substance abuse, and sleep disorders; and special treatments like the role of psychotherapy and family involvement. Also, the provision of consultation–liaison in nursing homes, administrative issues, and ethical and medico-legal problems are addressed in separate chapters. The clinical discussions also pertain to patients outside of the nursing home setting, which makes the book a useful text for geriatric psychiatry in general. However, the chapters uniquely provide specific recommendations for implementation within nursing homes to address anticipated limitations or barriers. The chapters are well written and referenced, and they provide excellent reviews of current thinking in the field.

The Empty Chair Appointment

The objective was to test an intervention to reduce failed rates for psychiatric appointments. We collected data for this study of the characteristics of patients who missed appointments from March 2011 through September 2012. A phone triage assessment intervention was implemented to address chronic first-time failed attendance appointments (N = 78). The main reason for failed appointments was transportation difficulties. The first-time appointment show rate increased after implementing an assessment intervention. Phone assessment intervention was practical and may improve nonattendance for psychiatric appointments. The discussion reflects speculations about causes and possible measures to make services more accessible.