ROLES

The main role of the geriatric-trained psychiatrist in any LTC setting is to provide psychiatric consultations and follow-up care for residents. These consultations are warranted by the presence of psychiatric illness, by regulations that stipulate routine psychiatric surveillance of residents and monitoring of psychotropic medications, and by the need for risk management for situations in which potentially dangerous behaviours present. In addition, the psychiatrist may play roles in administration, education, clinical oversight and research. A summary of all potential roles can be found in Table 127.1.

Although it is rare for a psychiatrist to serve as the actual medical director of a facility, it should be clear from Table 127.1 that his or

Table 127.1 The roles of the psychiatrist in LTC settings

her multifaceted roles go well beyond being merely a consultant. In fact, the psychiatrist’s deep immersion in the LTC milieu is critical to his or her understanding of the day-to-day dynamics of institutional care that impinge upon the well-being of residents.

The psychiatric consultant is also a key player in risk management. From the perspective of any facility, many situations that involve potential threats of harm to residents or that have the potential to incur substantial liability inevitably involve psychiatric conditions or the effects of psychotropic medications. Several of these circumstances are listed in Table 127.2.

One of the most critical roles of the consultant is to provide oversight for the use of psychotropic medications. As will be discussed

Table 127.2 Psychiatric issues that increase the risk of harm and liability

later in the chapter, the use of nearly all psychotropic medications requires clear documentation of the diagnostic indication, implementation of concomitant behavioural strategies, judicious dosing and mandatory attempts at dose reductions for conditions that naturally have symptomatic remission.

Another important role for the psychiatrist is to educate LTC staff about common psychiatric symptoms and diagnoses, and how to initiate referrals and provide clinical data, recognize medication side effects and deal with behavioural disturbances. Any employee of an LTC facility has the potential to recognize psychiatric illness, ranging from nurses, aides, dieticians, therapists and social workers who provide hands-on care, to administrators who deal with complaints and crises, to kitchen and custodial staff who may form bonds with residents and notice early changes in behaviour. Thus, all of these individuals need access to the psychiatrist as well as training in the recognition and management of common psychiatric symptoms.

Communication with family members and other caregivers is one of the most critical and yet often neglected roles of the psychiatric consultant. Not only can these caregivers provide some of the most detailed and accurate clinical information, but they often aide the implementation of treatment plans, from encouraging residents to take medications and participate in activities, to simply providing essential care and companionship⁴. Working in partnership with care-givers helps to reduce caregiver burden that otherwise takes a toll in terms of their mental and physical health⁵, and makes the LTC facility feel more like a community and less like an institution⁶. Ideal doctor–caregiver communication also serves a primary role in risk management for the facility, since it can mitigate feelings of anger, alienation and confusion when unfortunate events such as injuries occur – ultimately reducing litigiousness. In fact, such communication can engender realistic expectations of care in the LTC setting and even anticipate certain problems before they erupt. Several ways to optimize education and communication between the psychiatrist, staff and caregivers are listed in Table 127.3.

CLINICAL ISSUES

Table 127.3 Optimizing education and communication

Table 127.4 Epidemiology of major psychiatric conditions in nursing homes^a

^aNote: these figures are rounded off and based on approximate ranges from four sources^8–11.

acute delirium or chronic dementia – or both. There is also a greater concentration of psychiatric disorders including depression, dementia, anxiety disorders and schizophrenia compared to the community (see Table 127.4). Many of the same stigmas that limit adequate psychiatric care for elderly in the community will also apply in LTC, such as viewing depression or cognitive impairment as ‘normal’ in late life, or assuming that older personalities are more rigid, stubborn and treatment resistant⁷. All of these assumptions are incorrect and can prove discriminatory. Complicating the effects of these ageist views is the shortage of geriatric psychiatrists to consult in LTC settings, and the discriminatory reimbursement rates that have historically penalized psychiatric diagnosis (now being reversed by recent US federal legislation).

On the other hand, individuals with psychiatric impairment living in LTC settings have a much greater chance of being evaluated in a timely manner due to mandated regulations. Medication adherence can be better monitored, and supportive staff and therapeutic activities are all on site. Thus, many of the barriers to treatment in the community, such as lack of transportation or timely access to mental health clinicians, do not exist in LTC settings.

The first and most fundamental trigger of psychiatric decompensation in LTC is the transfer to the facility itself. Whether they are coming from a long-standing home or an inpatient ward at a hospital, most new admissions have faced a recent medical or psychiatric stress or crisis and are no longer able to live alone. The psychological impact of the reason for admission and the unfamiliarity of the setting and its rules can be upsetting, especially for individuals who do not like living with others or have set routines that are now being disrupted. The psychiatric consultant must be attuned to the symptomatic manifestations of this stress, found in anxious and depressed moods, anger, agitation, resistance to care, disruptions in sleep and appetite, exaggerated somatic complaints, poor rehabilitation, and even failure to thrive. Although previous psychiatric history may be a key guide to diagnosis and treatment, the adjustment reaction itself must be addressed. Several ways to recognize and ameliorate this adjustment are listed in Table 127.5.

Table 127.5 Recognition and treatment of adjustment reactions to LTC placement

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The Care Home Experience Alisoun Milne The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) Nicolas Cherbuin andAnthony Francis Jorm The Lundby Study Mats Bogren, Cecilia Mattisson and Per Nettelbladt Environmental Factors, Life Events and Coping Abilities Toni C. Antonucci and James S. Jackson The Multidisciplinary Team and Day Care Provision Martin Orrell and Kunle Ashaye Training Requirements for Old Age Psychiatrists in the UK Susan Mary Benbow and Aparna Prasanna

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