Pearl S. German

The prevalence and management of dementia and other psychiatric disorders in nursing homes.

The prevalence of psychiatric disorders among new admissions to nursing homes is unknown. Such data are needed to estimate the psychiatric needs of this population. We report the prevalence of specific psychiatric disorders in 454 consecutive new nursing home admissions who were evaluated by psychiatrists and diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised. Eighty percent had a psychiatric disorder. The commonest were dementia syndromes (67.4%) and affective disorders (10%). Also, 40% of demented patients had additional psychiatric syndromes such as delusions or depression, and these patients constituted a distinct subgroup that predicted frequent use of restraints and neuroleptics, and the greatest consumption of nursing time. These data demonstrate that the majority of nursing home residents have psychiatric disorders on admission, and that their management is often quite restrictive. Research is now needed to determine the best methods of treatment for nursing home patients with mental disorders.

Instruments for Screening for Depression and Dementia in a Long-Term Care Facility

The high prevalence of mental disorders such as depression and dementia in institutionalized elderly patients warrants screening for psychiatric diagnosis in patients newly admitted to long‐term care facilities. The diagnostic accuracy of the Mini‐Mental State Examination (MMSE) and the Geriatric Depression Scale (GDS) was evaluated against a standardized psychiatric interview. The MMSE was found to be 81% sensitive and 83% specific in screening for dementia using a previously established cutpoint of less than 24/30 points. Adjusting MMSE scores for physical disabilities precluding completion of specific tasks on the MMSE did not significantly change the diagnostic accuracy of the test. The GDS was 47% sensitive and 75% specific in screening for depression using the suggested cutpoint of greater than 13/30 points. The MMSE was significantly correlated with functional status (r = 0.48, P = .0001), but not with the scores on the GDS or the clinical diagnosis of depression. The GDS did not correlate with functional status. In summary, the MMSE is a good screening test for dementia in institutionalized elderly, but the GDS is not sensitive for depression in this population.

Patterns of mental disorders among the elderly residents of Eastern Baltimore

An extensive analysis of prevalence rates of cognitive impairment and other mental morbidities was carried out as part of a five‐site national study on the health and mental health of an ambulatory population. This study reports on prevalence rates contrasted by age across the 18 and over population for cognitive impairment and other diagnoses in the Baltimore, Maryland, site of this study. Differences in prevalence rates by age are striking. Eight conditions have rates above 1 per cent among those 64 and younger: phobia (13.8 per cent), alcohol use disorder (6.5 per cent), obsessive compulsive disorder (2.2 per cent), schizophrenia (1.4 per cent), and panic disorder (1.2 per cent). For the older group, 65 to 74 years, five conditions have such prevalence rates: phobic disorder (12.1 per cent), severe cognitive impairment (3.0 per cent), alcohol use disorder (2.1 per cent), obsessive compulsive disorder (2.2 per cent), and dysthymia (1.0 per cent). For the oldest group, those 75 and over, only four conditions have rates of 1 per cent or more. These are: phobic disorders (10.1 per cent), severe cognitive impairment (9.3 per cent), major depression (1.3 per cent), and dysthymia (1.1 per cent). Rates of cognitive impairment increase markedly with age and high rates of this disorder were found among those never married, separated, divorced, or widowed. Implications of these findings for understanding mental morbidity among the elderly and issues for future planning are discussed.

Mental Health of the Elderly: Use of Health and Mental Health Services

The utilization of services by older patients with mental morbidity is examined in this paper. The population is drawn from a large, multi‐site study, the Epidemiological Catchment Area studies, and reports on the findings from the Baltimore, Maryland, site, The Eastern Baltimore Mental Health Survey. The fact that older individuals with mental disorders are less likely to be seen and treated for these disorders than are younger individuals was substantiated by data from this study. Of those under age 65, 8.7 per cent have made a visit to a specialty or primary care provider for mental health care; for those age 65 to 74, the rate is 4.2 per cent, and of those 75 and over, only 1.4 per cent have had such care. In this last group, 75 and over, not a single person saw a specialty mental health provider. The likeliest source of care for older individuals for emotional or psychiatric problems is their primary care providers within the context of a visit made for physical medical problems. Past work and these data suggest that the factors that influence this low level of care can be found in the characteristics of the population as well as in the characteristics of the health care system. The implications of these findings are discussed.

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.

An experiment to change detection and management of mental morbidity in primary care.

A randomized clinical trial was conducted in a group practice for the primary care of adult patients to address the effect of feedback to providers of information from a psychiatric screening questionnaire, the General Health Questionnaire (GHQ). The practice is staffed by faculty, residents, and health care extenders of The Johns Hopkins University School of Medicines Division of Internal Medicine. The patient population was drawn mainly from the inner city community in Baltimore that surrounds the hospital, where the practice is physically based. The GHQ was administered at the time of a regular visit to the practice and results made available to the clinicians for randomly allocated subsamples of their patients. The study results showed that feedback of GHQ information led to only marginal effects on overall detection of mental health problems among the patients in general. However, marked increases in detection occurred among the elderly, blacks, and men, subgroups that ordinarily have relatively low rates of detection of mental morbidity by primary care practitioners. Feedback of GHQ information did not affect management.

A longitudinal examination of functional recovery among older people with subcapital hip fractures

OBJECTIVE: Few studies have examined the time‐dependent change in functional recovery along with the factors that affect the change among older hip fracture patients. The focus of this study is to examine the predictors of functional recovery in community‐dwelling older people with subcapital fractures using longitudinal data analysis methods.

Physical Restraint Use and Cognitive Decline among Nursing Home Residents

This study investigated the association between physical restraint use and decline in cognition.

Relationship between aggressive behaviors and depression among nursing home residents with dementia

Verbal and physical aggression are common behavior problems among nursing home residents with dementia. Depression among nursing home residents is also a common but underdiagnosed disorder.

Extended coverage for preventive services for the elderly: response and results in a demonstration population.

OBJECTIVES This study was undertaken to test the acceptability of preventive services under Medicare waivers to a community-dwelling population aged 65 and over and to examine the effect of such services on health. METHODS Medicare beneficiaries and designated primary care providers were sampled, and beneficiaries were screened and surveyed. A total of 4195 individuals were then randomized into intervention or control groups. Those in the intervention group were offered free preventive visits (under waivers) to their physicians. A follow-up survey of the entire group was administered after completion of the intervention. RESULTS Sixty-three percent of the intervention group made a preventive clinical visit, and about half of them a counseling visit. For men, being married and having a solo practitioner were positively associated with accepting the intervention services, while for women, having had a mammogram, having a confidant, having a high school education, and having a female practitioner were so associated. The intervention group showed a greater health benefit than did the control group and had a significantly lower death rate: 8.3% vs 11.1%. CONCLUSIONS Older individuals will respond to preventive programs, and such services will result in modest health gains.