American Association for Geriatric Psychiatry (AAGP) 2011 Annual Meeting
March 18-21, 2011 San Antonio, TX
New Models of Mental Health Service Delivery Needed in Nursing Homes
San Antonio, TX—Among adults with mental illness newly admitted to nursing homes, most with schizophrenia are under age 65 years, and most with depression are age 65 years or older. Persons under age 65 years with depression have the highest rates of chronic medical comorbidity, and all adults age 65 years or older with schizophrenia, depression, or biopolar disorder have complex medical conditions. These findings point to the need for integrated and appropriate psychiatric and medical care for nursing home residents with a major mental illness, according to a study presented during a poster session at the recent AAGP annual meeting. “New models of mental health service delivery are needed in nursing homes that accommodate a range of ages and psychiatric needs, while also promoting appropriate community-based alternatives,” said Kelly A. Aschbrenner, PhD, Dartmouth Medical School, Concord, NH, lead author of the study, in an interview with Annals of Long-Term Care.
In the study, which was undertaken to better understand the prevalence of comorbid medical conditions and functional impairment in the growing number of persons with a major mental illness who were newly admitted to nursing homes, Aschbrenner and colleagues used national nursing home Minimum Data Set (MDS) assessments from 2008 to obtain data on thesed individuals and stratified the data by psychiatric diagnosis (schizophrenia, depression, and bipolar disorder) and age (<65 years and >65 years). One of the most important findings of the study, according to Aschbrenner, was the finding that the majority of persons with schizophrenia newly admitted to nursing homes were younger than age 65. Of the 16,179 persons with schizophrenia newly admitted to nursing homes, 9755 (60.3%) were under age 65 compared with 6424 age 65 and older. Compared with newly admitted persons 65 years of age or older with schizophrenia, the persons younger than age 65 had a lower rate of cognitive impairment (16.50% vs 9.23%), were more likely to be classified as low-care status (7.98% vs 22.54%), and had lower rates of chronic comorbid medical illnesses, including lower rates of congestive heart impairment (12.17% vs 6.46%), stroke (9.72 vs 6.39), Parkinson’s disease (5.41 vs 1.82), chronic obstructive pulmonary disease (23.65 vs 19.52), and arteriosclerotic heart disease (8.07 vs 3.15). According to Aschbrenner, these results highlight that “the majority of older adults with schizophrenia admitted to nursing homes are under age 65 and lack clinical indications for skilled nursing home level of care.” In contrast, the study found that patients under age 65 with depression and all patients age 65 and older with schizophrenia, depression, or bipolar disability had complex chronic comorbid medical illness that suggested “a pressing need for integrated psychiatric and medical care.” The study found that most of the people with depression newly admitted to nursing homes were older than age 65. Of the 255,282 people with depression, 206,780 (81%) were 65 years of age or older. Similar numbers of patients under age 65 and 65 or older with bipolar disorder were admitted (7585 and 7365, respectively).
Among the patients age 65 or older, the rates of chronic comorbid medical illnesses were similar across all 3 types of mental illness. The highest rates of chronic comorbid medical illnesses were found among the 48,402 new admissions under age 65 with depression. For example, the rate of congestive heart failure in these persons was 10.43 compared with 7.08 in persons under age 65 with bipolar disorder and 6.46 in persons under age 65 with schizophrenia. Limitations of the study include basing the study on the validity of the MDS data and using first-time admissions as the sample rather than a single cross section of residents at a given point in time.
Adult Day Healthcare Centers Can Be a Vital Resource for Older Adults After a Natural Disaster
San Antonio, TX—Adult day healthcare centers can be an important resource in a multidisciplinary team approach to minimizing the disruption to and impact on older adults displaced by a natural disaster, as demonstrated by a retrospective study presented at the recent AAGP annual meeting that evaluated steps taken by the adult healthcare center (ADHC), Alegria, following a 7.2 magnitude earthquake in Baja California on April 4, 2010. The study, which was led by Alegria’s founder, Bernardo Ng, MD, Sun Valley Research Center, Imperial, CA, found that steps taken by Alegria following the earthquake prevented mental illness exacerbation and new-onset mental illness among its participants. In addition, the aid that Alegria provided to displaced residents of a nearby assisted-living facility resulted in Alegria’s participation rates increasing. Following the earthquake, the center’s plan, which was implemented in collaboration with several municipal decision-makers, focused on relief efforts, including provision of food, shelter, hygiene, and medications to its participants. Steps were also taken to prevent the exacerbation of preexisting mental illness and onset of new mental illness. Immediately after the earthquake, the administrator and property landlord of Alegria inspected the facility and determined that it could open the next day. Alegria’s daily average census was 82 participants, but during the first week after the earthquake, the census dropped 50% to 70%, and steps were taken to locate missing participants. While these efforts were underway, the center staff learned that seniors from a nearby assisted-living facility had been displaced due to structural damage to their building, leaving it uninhabitable. Alegria staff provided various services to help these individuals: clothing was provided from staff donations; certified nursing assistants administered baths and shaves; nurses conducted blood pressure and glucose checks, contacted doctors’ offices to get new prescriptions, and worked to reschedule any current doctors’ appointments; and psychotherapists offered counseling, as needed. Simultaneously, Alegria’s administrator and assistants worked with established vendors and other city officials to secure meals and transportation for seniors and drafted a memorandum of understanding to provide services to uninsured displaced seniors. While patients were found to be more anxious, no hospitalizations or medication changes were required, demonstrating no exacerbation of preexisting mental illness and no new-onset mental illness.
As a direct result of Alegria’s active participation in the earthquake relief effort, the proportion of its participants from the assisted-living facility increased to 25% from 10% at 1 month after the disaster. Ng and colleagues conclude that, at the community level, an ADHC can be an effective partner in disaster management plans, and that organizations can look to Alegria’s experience when developing their own disaster preparedness plans. Although the Alegria sample was relatively small, this organization’s experience suggests that with adequate support and monitoring, it is possible to minimize the impact of disasters on the vulnerable elderly population. However, in an interview with Annals of Long-Term Care, Ng observed that while ADHCs can play a “vital” role in disaster plans, this role is threatened by budget cuts. “There are over 350 such centers [in California, a seismic area] and, with the budget crisis in the last few years, we are constantly under the threat that the state will no longer devote funds for such services,” he said. He also noted that the recent earthquake and tsunami in Japan underscores the importance of the topic since “nature can outdo any civilization, poor or rich.”
Caution Encouraged for Use of Antipsychotics to Treat Bipolar Disorder in Older Adults Due to Mortality Risk
San Antonio, TX—Use of atypical antipsychotics to treat older persons with bipolar disorder is associated with an increased mortality risk compared with standard anticonvulsant treatment, indicating the need for caution when prescribing these increasingly used medications in this population, according to the results of a study presented during a poster session at the recent AAGP annual meeting. “Even in nondemented geriatric populations, several commonly used antipsychotics showed an increased risk of mortality compared to standard anticonvulsant treatment when used for primary treatment of bipolar disorder,” said Sachin J. Bhalerao, DO, University of Michigan, Ann Arbor, in an interview with Annals of Long-Term Care. Despite increased concerns in recent years over the use of antipsychotics in older persons, particularly those with dementia, many older patients with bipolar disorder are receiving these medications, as shown in a recent review of national data from Veterans Affairs (VA) that found nearly 35% of patients older than 60 years with bipolar disorder received antipsychotics as part of their treatment.
To assess the mortality risk associated with the use of the most commonly used antipsychotics compared with the nonantipsychotic drug valproate to treat bipolar disorder in older patients, data were collected on 4854 older patients with bipolar disorder obtained from the national Department of VA registries maintained by the VA Serious Mental Illness Treatment Resource and Evaluation Center at the Ann Arbor VA Medical Center. Of the 4854 patients, 137 (2.8%) received haloperidol, 868 (17.9%) olanzapine, 1027 (21.2%) risperidone, 1119 (23.0%) quetiapine, and 1703 (35.1%) valproate. All patients in the study were at least 65 years of age, began treatment with one of the studied medications between 2001 and 2008, had a “clean period” of 12 months without any use of antipscyhotics or anticonvulsants prior to a new start, and were only taking either the antipsychotic or valproate during the 180-day follow-up. Patients treated with valproate who had a concurrent seizure disorder were not eligible. Significant differences were noted between the patients treated with haloperidol compared with the other treatment cohorts, including a greater likelihood of being unmarried and black, higher medical comorbidity, greater use of medical and nursing home services, and less likely to have depression or to be taking antidepressants. The study found that patients treated with haloperidol had the highest crude mortality rate, with a 180-day mortality rate of 15.3% compared with 2.6% found with quetiapine, which had the lowest mortality rate. Exposure analyses and propensity models adjusted for covariates also showed the highest mortality among patients treated with haloperidol, with a relative risk (RR; 95% confidence interval [CI]) of 1.31 (0.45-3.77) compared with risperidone (reference), olanzapine (RR, 0.75; 95% CI, 0.40-1.43), valproate (RR, 0.42; 95% CI, 0.19-0.96), and quetiapine (RR, 0.28; 95% CI, 0.13-0.62).
“The use of haloperidol, a conventional antipsychotic, showed significantly higher risk of mortality compared to other treatment groups, which is a striking finding and one that is consistent with other recent literature,” said Bhalerao. Emphasizing that antipsychotics are typically used to treat bipolar disorder and are approved by the Food and Drug Administration for such use, Bhalerao said that the results of their study suggest the need for caution in the use of these agents. “Our message is not to stop using these medicines but for clinicians to consider the mortality risks associated with this group of medications and to use them judiciously,” he said. “In addition, consideration should be given to alternative treatment options such as psychosocial interventions and psychotherapeutic strategies.”
Frailty May Be a Good Indicator of Quality of Life in Patients With Alzheimer’s Disease
San Antonio, TX—Frailty and neuropsychiatric symptoms in the early stages of Alzheimer’s dementia may be better indicators of quality of life in patients with Alzheimer’s dementia than more commonly used cognitive assessments, noted researchers at the recent AAGP annual meeting. “We have known for some time the influence of neuropsychiatric symptoms on the quality of life for both dementia patients and their families,” said Aine M. Ni Mhaoláin, MRCPsych, Mercer’s Institute for Research in Ageing, Dublin, Ireland, and lead researcher on the study, in an interview with Annals of Long-Term Care. “This is an important area to address in terms of intervention to help support and improve outcomes for our patients and their families.” The finding that frailty at the earlier stages of cognitive impairment could be a factor in quality of life is important because “this may be a new area for intervention given that frailty is suspected to be reversible at its early stages,” said Ni Mhaoláin. Both frailty and neuropsychiatric symptoms were found to be independent predictors of quality of life for subjects with a Mini-Mental State Examination (MMSE) score of ≥20 in a stepwise linear regression analysis.
The sole independent predictor of quality of life in those with an MMSE of ≤20 was functional limitations as measured by the Disability in Dementia score. An MMSE score of ≥20 indicates mild impairment, such that formal assessment may be helpful to better determine pattern and extent of deficits. The study applied a cross-sectional design of 115 patients with a clinical diagnosis of possible Alzheimer’s dementia. Patients were recruited through the Memory Clinic in St. James’s Hospital, Dublin. The Biological Syndrome Model was used to measure frailty, the 31-question DEMQOL-Proxy measured quality of life, and stepwise regression models were constructed to establish the predictors of quality of life and included measures of illness severity, functional limitations, neuropsychiatric symptoms, and frailty. Based on the study data, researchers concluded that frailty and behavioral and psychological symptoms are more strongly associated with quality of life than cognition or functional limitation in the earlier stages of Alzheimer’s dementia, an important finding given the potential reversibility of frailty at an early stage. “The surprising aspect of this finding,” said Ni Mhaoláin, “was that frailty had a greater association with quality of life in those with milder cognitive impairment. This suggests to us that there may be a window of opportunity at an early point to address frailty in those with dementia that may influence patient outcomes for the better. This work needs to be validated longitudinally but helps provide direction for future research in the important area of quality of life for dementia patients.”
