Two years of psychogeriatric consultations in a nursing home: reasons for referral compared to psychiatrists' assessment
© Callegari et al; licensee BioMed Central Ltd. 2006
Received: 16 December 2005
Accepted: 13 June 2006
Published: 13 June 2006
In spite of the high prevalence of psychiatric disorders among elderly residents in nursing homes, only a small number of patients in need of specialist care are referred to a psychiatric consultant. The aim of this research was to evaluate the consultation activity and the appropriateness of referral to psychiatric assessment.
Data were collected and analysed on consultation carried out over a two-year period in a RSA (Residenza Socio-Assistenziale) in Northern-Italy. Data were catalogued with reference to: patients, consultation, diagnosis and recommended medications. Statistical correlation analysis by means of Spearman test and signification test was carried out.
Residents referred to psychiatric consultation at least once were 112 (14.5% of all residents). Reason for referral were: depression (17.2%), delusions and hallucinations (14%), agitation (34.8%), aggressive behaviour (23.5%) and disturbances of sleep (6.8%). Most frequent diagnoses were organic, including symptomatic, mental disorders (33.9%), mood disorders (22.3%) and schizophrenia, schizotypal and delusional syndromes (18.8%). No psychiatric diagnosis was found only in 1.8% of cases, thus confirming high sensibility of referring physicians.
A statistically significant correlation was found when comparing referrals for depression or delusions and allucinations or sleep disturbances and diagnostic confirmation of such symptoms by specialistic assessment (respectively 49.8%, 52.7% and 19.6%).
Correlation between psychotic symptoms and the consequent prescription of antipsychotic drugs had a significant if somewhat modest value (24%) while correlation between depression symptoms and prescription of antidepressant drugs was more noticeable (66.5%).
Main reason for referral to psychiatric consultation resulted to be the presence of agitation, a non-specific symptom often difficult to attribute. Data concerning depression confirm tendency to underestimating this diagnosis in the elderly. Furthermore, symptomatic reasons for referral did not always correspond to subsequent diagnostic definitions by psychiatric consultants, therefore demonstrating modest predictive power.
A number of epidemiological studies have demonstrated a high prevalence of psychiatric disorders among elderly residents in nursing homes: almost half, in fact, present symptoms of depression which are clinically significant [1–3] and an extremely high percentage of these, varying between 14 – 26%, come into the category of major depression disorders [2, 4]. Psychotic symptoms, such as delusions and hallucinations, behavioural disturbances and agitation are presented with the same frequency [2, 5]. Furthermore, most of these disturbances are associated with the presence of cognitive deterioration or dementia  and chronic medical pathologies which increase the level of disability, thus making the psychiatric diagnosis and the correct treatment of the patient extremely difficult. In fact, if hyperactive delirium is often recognized among patients referred for agitation and behavioural disturbances, hypoactive delirium is, on the contrary, undetected  because its symptoms are less disturbing and do not represent a reason for psychiatric referral.
Psychiatric disorders represent an important part of the workload for the personnel working in these structures, however only a small number of patients who are in need of specialist care are referred to a psychiatric consultant [8–10]. It has, in fact, been noted that symptoms of depression are often not correctly recognised  as they may merely be interpreted as inevitable signs of old age or cognitive deterioration, or as they are less disturbing within the community environment are considered irrelevant and are therefore underestimated.
Considering the high prevalence of psychiatric disorders among elderly residents in nursing homes and the difficulty of treating them, psychiatric referral in these structures would appear to be crucial in order to improve both the assistance and the quality of the last remaining years of life.
The aim of this research was to evaluate the consultation which takes place in a residential nursing home for the elderly in Lombardy and to verify the pertinence of the request for psychiatric evaluation by comparing the reason for the request and the diagnosis made by the specialist. The characteristics of the consultation carried out were evaluated both in terms of motivation and urgency for the required intervention, and also in relation to diagnosis and recommended medications.
The study was carried out in the 'Residenza Sanitaria Assistenziale (RSA) Fondazione Molina' in Varese, a state funded home providing assistance and rehabilitation for the elderly who for the most part are no longer self-sufficient. It is composed of four large units and has 430 beds. There is also an integrated Day Care Centre.
The personnel consists of doctors specialized in internal medicine and geriatrics, professional nurses, physiotherapists, psychomotor therapists, welfare assistants, social workers, occupational therapists and social service care officers. National Health specialists are called in by the ward doctor to conduct any necessary consultations.
Since March 2000 psychiatric consultations have been in the hands of the Psychiatric Unit of the Department of Clinical Medicine of the Università degli Studi dell'Insubria.
A request for psychogeriatric referral is made by the internal medical staff, by filling out a special form giving: patient's name, location, date of the request, type of specialist examination, level of urgency and reason for the request. The examinations are carried out by the psychiatric specialist accompanied by post-graduate students in psychiatry.
Data were collected and analysed for examinations carried out over a two year period, between 27th March 2000 and 27th March 2002.
The collection of data was done manually both from the request forms and the patients' notes kept in the departments, for the in-patients and in the archives for those discharged or deceased. Data were catalogued according to:
patients: age, sex and level of disability classified in the patient's notes as Totally Non Self-Sufficient (NAT), Partially Self-Sufficient (NAP) and Self-Sufficient (AUTO);
referral: reason for psychiatric referral given by the ward doctor; type (urgent, ordinary, not specified)
symptomatology: symptoms collected by consulting psychiatrist.
formal diagnosis: made according to the ICD-10 classification by the consultant specialist in psychiatry;
recommended therapy: psychopharmacological, psycho-rehabilitative, psychological support.
delusions and hallucinations
Any reasons different from the above, being only sporadic (e.g. anxiety, control, therapy re-evaluation, etc.) were put into a category named 'other' (they were not, however, included in the data study). In some cases the reason for the request was only one, in others more than one.
During the 2 year period of the study there were no psychiatric requests for dementia. This was probabilly caused by the fact that in the nursing home Fondazione Molina patients with diagnosis of dementia were mainly referred to the neurologist. Furthermore most of the residents with this diagnosis reside in a specific Alzheimer unit.
symptoms of depression
For the statistical analysis of correlations we used sintomatology ascertained by the consultant instead of formal diagnosis classified according to the ICD-10, because symptoms gave a wider spectrum of elderly psychiatric clinical conditions and behaviours.
The correlation study was carried out using the Spearman test (ρ), binominal correlation test for nominal/categorical variables and the signification test.
The software SPSS was used for the elaboration of data.
Results and discussion
Characteristics of the sample
The total number of residents in the Fondazione Molina during the period under consideration was 775 – 564 female (72.8%) and 211 male (27.2%). Residents referred to psychiatric consultation at least once were 112 (14.5% of the reference population). This percentage is the same as that which emerges from publication data [9, 12, 13], and appears to confirm the tendency to underestimate the real prevalence of psychiatric pathology among the elderly in residential care homes.
sample distribution and nursing home residents distribution according to gender and age.
Age ≤ 64
Age ≥ 85
84 (100%) (75%)
28 (100%) (25%)
112 (100%) (100%)
Nursing home residents
564 (100%) (72.8%)
211 (100%) (27.2%)
775 (100%) (100%)
Type of referral requested
During the 2 year period, 224 consultations were carried out, 176 were for women (78%) and the remaining 48 for men (22%). The average age of the patients requiring consultation resulted as being 79.69 years (SD ± 9.231) for women and 77.13 years (SD ± 10.441) for men.
distribution of consultations according to gender and age.
N of consultations
Age ≤ 64
Age ≥ 85
176 (100%) (78%)
48 (100%) (22%)
224 (100%) (100%)
Thus for the latter age group we can resume that 37 female patients (12% of the female residents) required 66 consultations (1,78 pro capite) while 9 male patients (12% of the male residents) required 13 consultations (1,44 pro capite).
patients receiving only one consultation: 69 (61.6%)
patients receiving 2 consultations: 20 (17.9%)
patients receiving 3 or more consultations (up to a maximum of 11): 23 (20.5%).
The type of consultation was divided as follows:
Urgent: 51 (22.8%)
Ordinary: 161 (71.9%)
Not specified: 12 (5.3%).
Reasons for requests for consultation from the residential home are distributed as follows: depression (17.2%), delusions and hallucinations (14%), agitation (34.8%), aggressive behaviour (23.5%) and sleep disturbances (6.8%). Can be noted a greater frequency of agitation and aggressive behaviours that represent both operational and relational problems within the residential units.
Organic, including symptomatic, mental disorders (F00-09): 33.9%,
Mental and behavioural disorders due to psychoactive substance use (F10-19): 0.9%,
Schizophrenia, schizotypal and delusionals disorders (F20-29): 18.8%,
Mood [affective] disorders (F30-39): 22.3%,
Neurotic, stress-related and somatoform disorders (F40-49): 7.1%,
Behavioural syndromes associated with physiological disturbances and physical factors (F50-59): 1.8%
Disorders of adult personality and behavioural (F60-69): 5.8%,
Mental retardation (F70-79): 5.8%.
Only in 1.8% was no psychiatric diagnosis made, thus confirming a good capability of discerning when a psychiatric examination was in fact necessary.
As shown in Figure 3, in women there was a more frequent diagnosis for organic, including symptomatic, mental disorders (36.6% vs. 27.1% in men) and mood disorders (25% vs. 12.5%). The frequency of diagnosis in the schizophrenia and delusional syndrome category resulted much higher in males (29.2% vs. 16.3% in females), as also the diagnosis of personality and behavioural disorders (18.7% against 2.9%). In the older age groups there is a larger number of psychic disorders of an organic nature and syndromes and behavioural syndromes associated with physiological disturbances and physical factors (Figure 4). For the age ≤ 64 these pathological conditions are absent while there is a clear prevalence for the diagnosis of mental retardation, probably due to a premature institutionalization of these patients.
Correlations between reason for the request and diagnoses
The slight, even though statistically significant (ρ = 0.411; ρ < 0.001) correlation of data concerning agitation may likewise be attributed to the scarce specificity of this condition.
A strong correlation has also emerged between the request concerning agitation and that for aggressive behaviour (ρ = 0.445; p < 0.001) confirming the fact that a state of agitation may be a prelude to aggressive attitudes.
This data are in line with those in literature which indicate agitation as one of the most common behavioural complications of dementia which worsens with the advancement of cognitive impairment. .
During the two year period in question psychopharmacological therapy was indicated in 92.4% of the consultations carried out. These were: 79.2% antipsychotics (NL typical and atypical), in 52.7% anxiolytics and sleep inducers (BDZ), in 45.4% antidepressants (TCA, SSRI, SNRI), in 26.1% anti-Parkinson (anticholinergics) and in 10.6% mood stabilizers (carbamazepine, gabapentin). In 7.6% no therapy was administered.
In most cases a combination of drugs was prescribed belonging either to the same or different categories. Furthermore, the non medical indications, although not strictly quantifiable, represent an invaluable tool in the therapeutic approach to the patient. Patients were frequently referred to the psychomotor therapists and/or physiotherapists and talks with relatives, support psychologists, social assistants were customary. Discussion groups were periodically organized with members of staff from the different professions taking part.
comparing depression symptoms ascertained by the specialist and the prescription of antidepressant drugs (ρ = 0.665;p.< 0.001) and/or benzodiazepines (ρ = 0.222;p < 0.002);
comparing depression as reason for the referral on the consultation request form and the prescription by the psychiatrist of antidepressant drugs (ρ = 0.336; p < 0.001).
A statistically significant correlation also exists, but in the negative, between the presence of depression symptoms and the use of antipsychotic drugs (ρ = -0.327; p < 0.001).
The correlation between psychotic symptoms and subsequent use of antipsychotic drugs has a significant value (ρ = 0.240; p < 0.001) as also that between reasons for delusions and hallucinations on the consultation request and the use of this same pharmacological category (ρ = 0.149; p < 0.03). Furthermore, the consultant, due to the advanced age of many patients and the frequent co-morbidity with somatic pathology, takes great care when selecting cases to be treated with neuroleptics. Moreover, some psychotic symptoms, if they are an expression of a general medical condition, tend to regress as the basic illness itself improves.
From the therapeutic indications supplied by the psychiatrist during consultations it was also noted that:
a positive correlation exists between the use of antidepressants and anxiolytics (ρ = 0.231; p < 0.002) and a negative correlation between the use of antidepressants and antipsychotics (ρ = -0246; p < 0.001).
a statistically significant correlation exists between the use of anti-Parkinson and antipsychotics (ρ = 0.335; p < 0.001), and between anti-Parkinson and anxiolytics (ρ = 0.239); p.0.001), while the correlation between anticholinergics and mood stabilizers is statistically significant but in the negative (ρ = -0159; p < 0.02).
From the results obtained it has emerged that the main reason for psychiatric consultation requests for the elderly in nursing homes is the presence of agitation, associated or not with aggressive behaviours. The fact that this symptom is absolutely aspecific makes it even more difficult to interpret. Agitation can, in fact, masque somatic problems, which are even life-threatening (cardiac disturbances, neoplasia), likewise it may be the only symptom of a depression syndrome such as melancholy. It is also important to consider that behavioural correlations of agitation in the elderly are often expressions of the difficulty to adapt to life in an institution. A change of environment, in these cases, can represent a traumatic element in the life of an elderly person, worsened by feelings of uselessness and frustration that come to light over a period of time spent in residential care. Because clinical signs are not always immediately diagnosed and the necessity for immediate therapeutic intervention, agitation can often provoke reactions of alarm and destabilization. This problem is accentuated even further by the difficulties which arise when managing the patient. Furthermore this disturbing behaviour generates intolerance among the nursing staff, the other residents and relatives who have difficulty in understanding the cause of such a condition. Agitation, consequently, is seen by the nursing staff, more of a hindrance to normal activities rather than the symptom of a possible illness and therefore a request for psychiatric intervention for the patient also includes a request concerning back-up for the medical team that has to cope with the case.
Data concerning depression pathology underline how too often it can be underestimated in the elderly patient. In fact, the patients with symptoms of depression do not provide a disturbing element within the residential community, consequently the attention of the nursing staff is not drawn towards them, and cases often remain undiagnosed. Not infrequently the medical staff do not recognize or underestimate these symptoms because they are considered an inevitable expression of the ageing process or cognitive deterioration. The elderly suffering from depression thereby disappear into the routine of health care often continuing with antidepressants prescribed by their doctors before entering the nursing home with no further therapeutic revaluation being requested. These cases frequently only emerge on extreme occasions: the patient refuses to eat, threatens suicide, is agitated or delirious. It is also true that a somatic illness or accompanying cerebral damage make diagnosis more difficult, especially when observing that in many cases elderly patients suffering from depression masque mood swings with somatic complaints or clinically evident manifestations.
In conclusion this study underlines how the real necessity for nursing home residents to receive psychiatric consultation must be evaluated in a pertinent way by the doctors during ward rounds.
Nevertheless, symptoms indicated as the reason for consultation do not always correspond to those found by the specialist and therefore give only a modest predictive indication of the final diagnosis formulated. According to our findings, the complexity of problems encountered in the environment of the nursing home can not be totally captured by diagnostic categories, but is better conveyed by the description of symptoms both reported from staff and found during specialistic assessment. Diagnoses 'per se' can allow to segregate patients into defined categories but do not seem to be an adequate basis for understand real needs of patients and for planning a clinically helpful therapeutic program.
In this context psychogeriatric consultation aims to improve the integration of somatic and psychological aspects, in order to provide a global and personalized approach for each individual patient.
The authors thank Laura Greco MD and Cristiano Colli of the Fondazione Molina nursing home and Professor Simone Vender involved in revisig the manuscript critically for important intellettual content.
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