Prof. Dr. med. Gabriela Stoppe

U N I

B A S E L

Mental Health in Nursing Homes

ProMenPol Conference Berlin 11.-12. October 2007

Mental Health in Nursing HomesIntroductory remarks

� During lifetime everyone wants /will go to school and work . However, this does not apply to the retirement and nursinghomes.

� The majority does not want to go to an institution and only up to 30% „must“ go.

� The delay of institutionalisation is even discussed as ou tcomevariable in antidementia drug trials.

� Nowadays especially nursing home admission symbolizes theend of a career of increasing impairment and frailty.

� The notion that „positive mental health does not mean theabsence of mental disorders“ is especially important for thisclientele.

� The elderly population residing in retirement and nursing homesis rapidly changing in the last decades. This must be taken intoaccount for future plannings. E.g. the growing mobility and singularisation as well as migration may have a major impa ct.

Mental Health in Nursing HomesTopics:

Risks� Dementia� Depression� Delirium� Drugs� Restraints

Positive � Environment� Nutrition� Fall prevention� Competent staff� Legal structures and

surveillance

Prevalence of disorders in nursing homesSÄVIP-Study (representative, 782 German nursing homes);

Hallauer et al. 2005

72,20%

45,40%53,40%

74,50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

urine incontinence fecal incontinence dementia immobil ity

Dementia as major mental healthproblem in institutions

Prevalence of dementia in nursing homes(Scandinavia, North America, UK since 1980)

Residential homes 27% (17-36%)

Nursing homes 66% (51-72%)

overall 59% (35-69%)

Behavioural problems in dementiaare frequent and have many reasons:

Example Agitation

Akathisia

Bladder function

wandering

anxietypain

Delirium:

� Frequent Problem in institutions and hospitals

� High risk of complications: falls, pneumonia� Increased risk in dementia, sensoric deficits,

impaired health, multimorbidity, polypharmacy� Prevention possible:

� Balanced sensoric input

� Identification of health problems and pain� Continuous personal company

� …….

Depression� Reason for as well as consequence of

nursing home admission� Main reason for high suicide rates in old

age� Well treatable� Ethical topic: right to die, refusal of food

and life sustaining treatment� Frequent comorbidity with physical

disorder: interaction with prognosis

Specialist Care in Nursing Homes(SÄVIP-Study, Hallauer et al. 2005)

� Only 20% of the clientele had contacts to private practice physicians

� Mostly specialists were called by thenursing staff

� Nearly no care provided in thespecialisations: ENT, ophthalmology, dentist, gynecology, urology, orthopedics

� About a third gets neuropsychiatricconsultations

Legal and Ethical Problems

PEG:� Often applied in

dementia� No risk reduction for

aspiration

� Mortality evenincreased

Restraints:� Often applied in

dementia� Risk of harm

� No reduced risk of falls

If structures help the dementedpeople and do not cause harm

or suffering to the non-demented population, thenthose structures should be

obligatory for all institutionsand settings providing care for

the elderly.

Example: light exposure in residential and nursing homes

Architecture for dementia, e.g. Iris Murdoch Building Sterling UK

Oblicht

Du./WC5.5m2

Du./WC5.5m2

Du./WC5.5m2

Therapie 14.5m2

Zimmer 11.5m2

Zimmer 11.5m2

Zimmer 11.5m2

Zimmer 17.5m2

K�che 13m2

Zimmer 11.5m2

Zimmer 11.5m2

Zimmer 11.5m2

Zimmer 17.5m2

Waschen 14.5m2

Wohnen 100m2

Abstell 8.5m2

Stationszimmer 16.5m2

sep. Raum 16m2Du./WC5.5m2

Du./WC4m2

Aussenbereich

Example: Bombach-project (CH):

� Cosy sitting rooms

� Furniture regardingbiographical contexts

� orientation

� optic stimulation

� Aroma (therapy)

Nutrition:

� Preparation togetherwith the patients

� No food, with which theelderly are notaccustomed to

� Nutrition as part of day-structure

� Detecting under- and malnutrition

� Vitamin supplementation� Care for the dental

situation

Care for the interaction with demented patients……

Drug safety

� Inadequate drug medication is the rule in manynursing homes

� This poses the elderly at greater risk for falls, delirium etc.

� About 15% of nursing home patients receive an acute and intermittend treatment on an ongoingbasis

� E.g. the OBRA-data from the US show thatcontrol systems might change the situation to the better

Drugs and elderly patients: data from a retrospective survey of insurance data

M:917; F:2680 >60y(Pittrow et al. 2002)

28,3%44%61%Psychoactive drugs

6,4%23,5%Pflegestufe III

35,7%49,1%Pflegestufe II

57,8%27,4%Pflegestufe I

539 €1126 €714 €Drug costs per year

5%10%4%>7 drugs parallel

3,04,63,6mean DDD (defined daily dosage)

controls(n=993)

outpatients(n=1603)

inpatients(n=996)

Lowcompetence

Few success

Low externalestimation Low self esteem

Exhaustion/burnout

More staff competence could help…..

Importance of mental health educationWish for education of nursing home staff

(0=low to 3= high)(SÄVIP-Study; Hallauer et al. 2005)

1,38 1,30

2,48 2,39

1,681,95 2,09 2,24

1,47

0

1

2

3ur

ine

inco

ntin

ence

feca

l inc

ont in

ence

dem

entia

depr

essi

onde

cubi

tal u

lcer

nutri

tion

fal l

prev

entio

n

pain

vacc

inat

ion

Do we neednursinghomes?