SAN JUAN, P.R. – Consulting psychiatrists can help improve the lives of nursing home residents by establishing psychiatric diagnoses, coordinating medications, and educating staff, Dr. Olivera Bogunovic said at the annual meeting of the American Association for Geriatric Psychiatry.
An estimated 91%–94% of nursing home residents have some form of psychiatric disorder, said Dr. Bogunovic, professor of psychiatry at the State University of New York at Buffalo. Despite that high prevalence, though, only 2.3% of nursing home residents receive psychiatric consultations.
Consulting psychiatrists, therefore, play an important role in caring for nursing home residents–who are usually managed by internal medicine physicians. Most important, psychiatrists establish a diagnosis, said Dr. Bogunovic, who has also worked as a psychiatric consultant in nursing homes for several years.
Psychiatrists also can assess the interaction between patients with psychiatric disorders and nursing home staff. By educating staff about a patient's condition, psychiatrists can improve general patient care.
In addition, nursing home patients are often taking several medications. “The role of the psychiatrist is to optimize medications and simplify drug routines,” Dr. Bogunovic said. Make sure to discuss the rationale for medications with staff and provide some information about possible drug-drug interactions.
Consulting psychiatrists should also arrange for brief psychiatric hospitalization when necessary. Psychiatrists are often called upon to make competency assessments.
Consulting psychiatrists also have an important role to play in helping nursing homes conform to requirements of the Omnibus Budget Reconciliation Act (OBRA). These regulations require that individuals admitted for the first time to a nursing home be prescreened for major psychiatric disorders.
In addition, every 3 months, nursing homes are required to complete a minimum data set. This tool addresses patient mood, cognition, communication and behavioral patterns, psychosocial well-being, comorbid conditions, and medications.
The OBRA regulations also require clear documentation of the need for psychotropic medication use.
Once a patient is prescribed psychotropic medication, psychiatrists should attempt to reduce the dosage at regular intervals.
“The requirement is that nursing home residents should be maintained on minimal effective dosages,” Dr. Bogunovic said.
Sometimes nursing home residents must be hospitalized in a psychiatric ward, especially if they are assaultive or suicidal. “But the patient should be initially screened, because a lot of medical conditions may present with psychiatric symptoms,” Dr. Bogunovic said.
Psychiatrists can be instrumental in arranging the acceptance of temporarily hospitalized patients back into the nursing home.
Educating nursing home staff is one of the key roles for a psychiatrist. Nursing home staff are often poorly trained, and turnover rates are high. “I personally have experienced that these staff were really not aware and were not educated about psychiatric symptoms of dementia,” Dr. Bogunovic said.
Psychiatrists should consider giving in-service training on signs and symptoms of psychiatric disorders, stages of dementia, drug-drug interactions, pharmacologic and nonpharmacologic management, injury prevention, and minimizing restraint use, he suggested.
It might also be worthwhile to train staff in the administration of assessment tools, such as the Mini Mental State Examination or the Global Deterioration Scale, Dr. Bogunovic said.