The elderly are at high risk for mental disorders according to all epidemiological studies, with most citing a prevalence rate of 30% . The frail elderly group has a greatly increased risk of debilitating mental illness. Depression , leading to functional impairment, plagues up to 35% of this population. Cognitive disturbances of dementing illnesses such as Alzheimer's Disease and multi-infarct states leads to marked psychotic and behavioral disturbances in 40% of the over 80 population. Caretakers of these victims of dementia are themselves a high risk group for depression anxiety and other stress- related disorders. Alcoholism continues to be a rampant undetected treatable disorder in the elderly. Anxiety states, phobic behavior, and delirium are common and increase with aging.
Despite the increasing number of mentally disturbed elderly, mental health professionals have had limited track record of community outreach , . Psychiatric home care nurses have had the most hands on experience and report success in maintaining the elderly in their communities. The elderly are averse to seek mental health treatment. Stigma of mental illness, being labeled crazy, memories and media representations of state hospitals as snake pits are common barriers. Inaccurate information and lack of awareness of the value of psychotherapy and medication for depression, anxiety and other mental disorders are deterrants in many cases. Physical immobility impairs treatment at community clinics or office practices. Those homebound aged often go untreated and deteriorate remaining untreated until crises occur. Neighbors, family and overworked social service staff report their concerns severe malnutrition, medication noncompliance and other sequelaie of disorganized thoughts, cognitive impairment or debilitating mood disturbance are present.
This report summarizes 8 years of experience by the author (MN) in providing and establishing a psychiatric consultation service to the Penn South Cooperative in New York, a model urban Naturally Occurring Retirement Community. The model employs the consulting psychiatrist as a team member with expertise required in assessment, diagnosis, treatment and education of other professional staff, patients and families. At Penn South patients are screened initially by social workers or RNs. The psychiatrist is called for acute or subacute situations.
Patients were seen in their homes by the psychiatrist and one of the staff. 53 patient referrals were made during an 8 month period starting in July 1994. The average age of males was 82.7 and females 84.5 The majority were physically impaired and essentially homebound. 76% had home aides in place prior to the psychiatry intervention.
The referrals were called by neighbours, family members, the individuals themselves or by Penn South staff of social workers or nurses. 80% were female, all widowed or single and 20% were males. Of the males, 1/3 were married, the remainder single or widowers. 60% of consultations requests regarded dementia and its behavioral manifestations including: paranoid ideation, wandering, agitation, confusion, violence, and inability to care safely for themselves. 30% of consultation requests were for depressive spectrum disorders. 13% of the patients required acute psychiatric hospitalization. Of those hospitalized half were able to return home for at least 6 months; the remainder required skilled nursing home placement.
The psychiatric interventions were closely linked to team case management This was due to identification of confusional states, medication toxicity or noncompliance, treatable psychiatric conditions and overwhelming psychosocial stressors. Of those not immediately hospitalized, within the proceeding 6 months an additional seven per cent were hospitalized on a psychiatric unit. 73% of all patients were given psychotropic medication to treat symptoms of agitation, insomnia, anxiety and depression. 98% were taking two or more medications prescribed by their doctor prior to the psychiatric intervention.
We plan to develop a curriculum for staff education and training in detecting, diagnosing and treating mental disorders in this population to educate the residents, family members and informal network of supports of the NORCS about signs and symptoms of mental disorder and a guide to available services. Funding is needed for a pilot project to Identify at risk cases earlier.
Crisis intervention through team collaboration, and ongoing treatment are some of the many needs for psychiatry. This was effective in maintaining the majority of the referred cases in the community thus avoiding costly inpatient and nursing home placement.
References
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