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EDITORIAL

Unique Tools of the Trade

Nursing Homes and Research in Geriatric Psychiatry

Joel E. Streim, M.D.

From the Section on Geriatric Psychiatry, Dept. of Psychiatry, Univ. of Pennsylvania; and the VISN 4 Mental Illness Research Education and ClinicalCenter, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA. Send correspondence and reprint requests to Joel E. Streim, M.D., Sectionon Geriatric Psychiatry, 3535 Market Street, Room 3055, Philadelphia PA 19104-3309. e-mail: jstreim@mail.med.upenn.edu

� 2005 American Association for Geriatric Psychiatry

“Today, a greater number of individuals withpsychiatric disorders reside in nursing homesthan reside in psychiatric hospitals.” — Amer-ican Psychiatric Association Task Force Reporton Nursing Homes and the Mentally Ill Elderly,19891

Since the 1980s, renewed attention to the highprevalence of psychiatric disorders among resi-

dents of nursing homes is helping to define a uniqueset of research needs and opportunities, as well as asubstantial public health problem. This month’s issueof The American Journal of Geriatric Psychiatry featuresseveral studies related to geriatric psychiatry in thenursing home setting. These studies, considered to-gether, highlight both the importance of nursinghomes as sites for delivery of mental health servicesto older adults, and the usefulness of nursing homesas laboratories for research in geriatric psychiatry.These are not new notions. However, this fertileground for research was cultivated by only a few pi-oneers during the two decades after Goldfarb pub-lished his landmark epidemiological study of long-term care facilities in 1962, revealing that 87% ofindividuals residing in nursing homes had a psychi-atric disorder.2 Since the mid-1980s, the high preva-lence of mental illness—especially dementia and de-pression—among nursing home residents has beenreconfirmed by several investigators,3–7 making itclear that nursing homes are de facto institutions forthe care of older adults with mental disorders. It isnot surprising then, that nursing homes have cometo be regarded as important sites for studying mentaldisorders in late life. The articles published in this

month’s issue of the Journal demonstrate that nursinghomes are more than a geriatric healthcare settingwhere epidemiology, disease phenomenology, clini-cal course, or treatment response can be studied inolder adults. Studies in this issue show how nursinghome placement as a milestone event can also be auseful clinical endpoint in studying the course of ill-ness, the response to treatment, or factors that con-tribute to morbidity and disability. Nursing homesmay also serve as laboratories for studying care pro-cesses and measuring outcomes of quality-improve-ment initiatives; and national nursing home data setsare important tools for health services research.

Nursing Homes and Special-Care Unitsas Research Laboratories

In this issue of the Journal, Pomara and colleagues8

report findings from a study of the relationship be-tween verbal agitation (screaming) and physical ag-gression in nursing home residents with dementia.They describe both linear and quadratic associationsof screaming and physical aggression, and suggestthe possibility that grabbing might represent com-pensatory behavior in patients with impaired abilityto communicate verbally. Based on this study, onecannot deduce specific attributions for different ag-gressive behaviors. However, it is worth noting thatthis study was conducted in a special-care unit (SCU)of a nursing home. Proliferation and aggressive mar-keting of SCUs during the 1990s prompted severalstudies of the effectiveness of such units, especiallythose designed to care for patients with dementia. Al-

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though clinical benefits have not been convincinglydemonstrated,9 the Pomara study suggests the re-search value of SCUs for accruing samples of subjectswith a high frequency of target symptoms and forconducting behavioral studies that require multipleobservations over time.

Nursing Home Admission as a StudyEnd-Point or Outcome Variable

Nursing home placement is generally associated withdisability and loss of independence and is a markerfor the end of “aging in place” in the community. Itis therefore not surprising that nursing home admis-sion has come to be identified as an important end-point in naturalistic studies as well as being used asan outcome measure in treatment studies. In thestudy by Kales and colleagues10 in this issue of theJournal, patients with coexisting dementia and de-pression were found to have significantly higher ratesof nursing home placement than patients with eitherdementia or depression alone. More noteworthy isthe finding that depression was detected less often—and treated less adequately—by physicians caring forpatients with coexisting dementia and depression.Recent work by Datto and others in our group11 high-lights the need to study care processes to guide qual-ity improvement efforts related to treatment of de-pression in older adults who already reside in nursinghomes. The study by Kales points to the need for re-search that examines processes of care for commu-nity-dwelling older adults with dementia and de-pression who are at risk for nursing home admission.This could inform the development of strategies thatmight prevent or delay institutionalization.

It has long been recognized that nursing home res-idents have high levels of disability, which makesnursing home populations suitable for the study offactors that contribute to disability. In this month’sissue of the Journal, Rapp and colleagues12 reportfindings from a study of neuropsychological perfor-mance of older adults, showing that executive func-tioning is related to functional disability even aftercontrolling for memory and cognitive speed, demen-tia diagnosis, and residential status. The finding of astrong relationship between executive functioningand functional deficits in elderly nursing home resi-

dents suggests, as the authors note, that measurementof executive functioning may be useful in interven-tion studies aimed at delaying nursing home place-ment. Considered in light of the study by Kales et.al.10 and the emerging literature on executive dys-function associated with late-life depression, mea-surement of affective status also appears to be crucialfor future studies that seek to elucidate the relation-ships between executive function, disability, andnursing home placement.

Research on Caregivers: Does the SettingMake a Difference?

To date, much of the research on caregiver burdenand quality of life has focused on caregiving at home.In studies of caregivers, it is common for nursinghome admission to be either the endpoint to beaverted or delayed, or a vehicle for reducing care-giver distress. It is often assumed that when nursinghomes provide short-stay respite services or long-term care, they alleviate caregiver burden at home.Craig and coworkers’ study13 of neuropsychiatricsymptoms in patients with Alzheimer disease exam-ines the distress experienced by caregivers in associ-ation with individual and aggregated symptomsacross an array of community and institutional set-tings, including home and nursing facilities. Meancaregiver distress scores were significantly related toneuropsychiatric symptoms, but not cognitive level,functional stage, or place of residence. Despite thefact that caregiver distress was uninfluenced by cur-rent place of residence in these analyses, we must becareful not to infer that the relationship of neuropsy-chiatric symptoms and caregiver distress found inone residential setting is readily generalizable toother settings for dementia care.

Limits of generalizability can be appreciated whenconsidering another study of the relationship of care-giver distress and quality of life to neuropsychiatricsymptoms in Alzheimer disease, reported in thismonth’s Journal by Shin and colleagues.14 Eighty-fivepercent of the caregivers in the sample were familymembers who lived with the patients or spent everyday with them. Caregiver quality of life was nega-tively correlated with patient neuropsychiatric symp-toms and their associated caregiver distress. Both pa-

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tient and caregiver ratings of patient quality of lifewere negatively correlated with depression. Thesefindings support and extend previous work on theimpact of depression and behavioral disturbances oncaregivers, especially family caregivers, in commu-nity settings; however, this does not obviate the needfor caregiver research specifically designed for andconducted in nursing homes. It cannot be presumedthat measures of distress or quality of life will be simi-lar for professional caregivers working in a nursinghome, given the differences in emotional attachmentto the patient, incentives for caregiving, extent of di-rect contact time (due to shift work, availability ofmultiple caregivers), and other individual and sys-tems variables. Distress and job satisfaction may be amore relevant combination of variables to measure innursing home caregivers. Thus, the unique character-istics of the nursing home as a residential-care settingrequire modifications in study design to answer simi-lar research questions.

What’s Ahead for Geriatric Mental HealthServices Research?

Opportunities for mental health services researchabound in the nursing home setting, especially be-cause of the existence of large public and proprietarydata sets. Brennan’s exemplary study15 in this issueof the Journal used resident data from the 1995 and1997 National Nursing Home Surveys to identify fac-tors that contribute to risk of nursing home admis-sion, and to compare mental health services useamong older nursing home residents with and with-out alcohol use disorders. Her work confirms and ex-tends previous findings of Oslin and our group16 thatnursing home residents with alcohol use disordersfunction better than other residents in performanceof basic activities of daily living. However, Brennanfound that those with alcohol use disorders were notyounger and that, despite their higher functional lev-els, they used more mental health and social servicesin the nursing home. This study illustrates what canbe accomplished by utilizing available national datasets from the nursing home setting; but this is onlythe tip of the database iceberg.

On the public side, the Centers for Medicare andMedicaid Services (CMS) have mandated the use ofthe Minimum Data Set (MDS)17 for periodic assess-ment of nursing home residents in virtually all com-munity nursing homes in the United States. CMS re-quires these facilities to transmit MDS data—including ratings of individual patients’ mood,cognition, behavior, and function—to a centralizeddatabase. Similarly, data from regulatory surveys aretransmitted to the Online Survey, Certification, andReporting (OSCAR) system, and some items corre-spond to quality indicators that are benchmarked foreach state and posted on the CMS website. AlthoughOSCAR is primarily an administrative, rather than aresearch database, and the current version of theMDS (2.0) was designed, in part, to compute case-mixfor reimbursement purposes and to identify facility-level noncompliance with federal requirements forquality of care, these tools have the potential to beadapted as powerful tools to help answer a widerange of clinical and health services research ques-tions. In a recent issue of the Journal, Ruckdescheland others in our group18 suggested improvementsin the MDS measurement of depression. The next ver-sion of the MDS, (3.0), is now undergoing field-test-ing and validation, and it is hoped that this will beuseful for research on depression, cognitive disor-ders, and behavioral disturbances in nursing homeresidents.

Large proprietary nursing home chains have alsocreated and maintained administrative databases,which could be adapted for research objectives. Thisis an intriguing possibility for facilitating observa-tional studies of care processes, the design and testingof disease-management models, validation of qualityindicators, and research on interventions to improvethe quality of mental health care in nursing homes.Possible funding mechanisms include NIH researchinfrastructure grants to develop public/private part-nerships for clinical and health services research.

Indeed, there is a public health need for expandedgeriatric mental health research in residential-caresettings. The good news, evident in this month’s issueof the Journal, is that investigators are making betteruse of the unique tools—nursing facilities, specialcare units, and databases—that are available for re-search in geriatric psychiatry.

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1. Borson S, Liptzin B, Nininger J, et al: Nursing Homes and theMentally Ill Elderly: A Report of the Task Force on Nursing Homesand the Mentally Ill Elderly. Washington, DC, American Psychi-atric Association, 1989, p 1

2. Goldfarb AI: Prevalence of psychiatric disorders in metropolitanold age and nursing homes. J Am Geriatr Soc 1962; 10:77–82

3. Rovner BW, Kafonek S, Filipp L, et al: Prevalence of mental illnessin a community nursing home. Am J Psychiatry 1986; 143:1446–1449

4. German PS, Shapiro S, Kramer M: Nursing home study of theEastern Baltimore Epidemiologic Catchment Area study, in Men-tal Illness in Nursing Homes: Agenda for Research. Edited byHarper MS, Lebowitz BD. Rockville, MD, National Institute ofMental Health, 1986

5. Chandler JD, Chandler JE: The prevalence of neuropsychiatricdisorders in a nursing home population. J Geriatr Psychiatry Neu-rol 1988; 1:71–76

6. Parmelee PA, Katz IR, Lawton MP: Depression among institution-alized aged: assessment and prevalence estimation. J Gerontol1989; 44:M22–M29

7. Tariot PN, Podgorske CA, Blazina L, et al: Mental disorders in thenursing home: another perspective. Am J Psychiatry 1993;150:1063–1069

8. Pomara N, Volavka J, Czobor P, et al: Screaming and physicalaggression in nursing homes. Am J Geriatr Psychiatry 2005;13:539–540

9. Phillips CD, Sloane PD, Hawes C, et al: Effects of residence inAlzheimer’s disease special care units on functional outcomes.JAMA 1997; 278:1340–1344

10. Kales HC, Chen P, Blow FC, et al: Rates of clinical depression

diagnosis, functional impairment, and nursing home placementin coexisting dementia and depression. Am J Geriatr Psychiatry2005; 13;441–449

11. Datto CJ, Oslin DW, Streim JE, et al: Pharmacologic treatment ofdepression in nursing home residents: a mental health servicesperspective. J Geriatr Psychiatry Neurol 2002; 15:141–146

12. Rapp MA, Schnaider-Beeri M, Schmeidler J, et al: The relationshipof neuropsychological performance to functional status in nurs-ing home residents and community-dwelling older adults. Am JGeriatr Psychiatry 2005; 13:450–459

13. Craig D, Mirakhur A, Hart DJ, et al: A cross-sectional study ofneuropsychiatric symptoms in 435 patients with Alzheimer dis-ease. Am J Geriatr Psychiatry 2005; 13:460–468

14. Shin I-S, Carter M, Masterman D, et al: Neuropsychiatric symp-toms and quality of life in Alzheimer disease. Am J Geriatr Psy-chiatry 2005; 13:469–474

15. Brennan PL: Functioning and health service use among elderlynursing home residents with alcohol use disorders: findings fromthe National Nursing Home Survey. Am J Geriatr Psychiatry 2005;13:475–483

16. Oslin DW, Streim JE, Parmelee P, et al: Alcohol abuse: a sourceof reversible functional disability among residents of a VA nursinghome. Int J Geriatr Psychiatry 1997; 12:825–832

17. Health Care Financing Administration: Medicare and Medicaid:Resident Assessment in Long-Term Care Facilities. 57 FederalRegister, 1992, pp 61614–61733

18. Ruckdeschel K, Thompson R, Datto CJ, Streim JE, Katz IR: Usingthe minimum data set 2.0 mood disturbance items as a self-reportscreening instrument for depression in nursing home residents.Am J Geriatr Psychiatry 2004; 12:43–49

References