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Characteristics of double care demanding patients in a mental health care setting and a nursing home setting: results from the SpeCIMeN study

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Background: Older patients suffering from a combination of psychiatric disorders and physical illnesses and/or dementia are called Double Care Demanding patients (DCDs). Special wards for DCDs within Dutch nursing homes (NHs) and mental health care institutions (MHCIs) offer a unique opportunity to obtain insight into the characteristics and needs of this challenging population. Methods: This observational cross-sectional study collected data from 163 DCDs admitted to either a NH or a MHCI providing specialized care for DCDs. Similarities and differences between both DCD groups are described. Results: Neuropsychiatric symptoms were highly prevalent in all DCDs but significantly more in MHCI-DCDs. Cognitive disorders were far more present in NH-DCDs, while MHCI-DCDs often suffered from multiple psychiatric disorders. The severity of comorbidities and care dependency were equally high among all DCDs. NH-DCDs expressed more satisfaction in overall quality of life. Conclusions: The institutionalized elderly DCD population is very heterogeneous. Specific care arrangements are necessary because the severity of a patient's physical illness and the level of functional impairment seem to be equally important as the patient's behavioural, psychiatric and social problems. Further research should assess the adequacy of the setting assignment and the professional skills needed to provide adequate care for elderly DCDs.
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Aging & Mental Health
ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: http://www.tandfonline.com/loi/camh20
Characteristics of double care demanding patients
in a mental health care setting and a nursing
home setting: results from the SpeCIMeN study
Janine Collet, Marjolein E. de Vugt, Frans R. J. Verhey, Noud J. J. A. Engelen &
Jos M. G. A. Schols
To cite this article: Janine Collet, Marjolein E. de Vugt, Frans R. J. Verhey, Noud J. J. A. Engelen
& Jos M. G. A. Schols (2016): Characteristics of double care demanding patients in a mental
health care setting and a nursing home setting: results from the SpeCIMeN study, Aging &
Mental Health, DOI: 10.1080/13607863.2016.1202891
To link to this article: http://dx.doi.org/10.1080/13607863.2016.1202891
Published online: 01 Jul 2016.
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Characteristics of double care demanding patients in a mental health care setting
and a nursing home setting: results from the SpeCIMeN study
Janine Collet
a
,
c
, Marjolein E. de Vugt
b
, Frans R. J. Verhey
b
, Noud J. J. A. Engelen
c
and Jos M. G. A. Schols
a
a
Department of Family Medicine/Elderly Care Medicine and Department Health Services Research, School for Public Health and Primary Care
(CAPHRI), Maastricht University, Maastricht, The Netherlands;
b
Department of Psychiatry and Psychology, School of Mental Health and
Neuroscience, Maastricht University Medical CentreC, Alzheimer Centre Limburg, Maastricht, The Netherlands;
c
Department of Elderly, Mondriaan
Mental Health Care, Heerlen, The Netherlands
ARTICLE HISTORY
Received 14 January 2016
Accepted 14 June 2016
ABSTRACT
Background: Older patients suffering from a combination of psychiatric disorders and physical
illnesses and/or dementia are called Double Care Demanding patients (DCDs). Special wards for DCDs
within Dutch nursing homes (NHs) and mental health care institutions (MHCIs) offer a unique
opportunity to obtain insight into the characteristics and needs of this challenging population.
Methods: This observational cross-sectional study collected data from 163 DCDs admitted to either a
NH or a MHCI providing specialized care for DCDs. Similarities and differences between both DCD
groups are described.
Results: Neuropsychiatric symptoms were highly prevalent in all DCDs but signicantly more in MHCI-
DCDs. Cognitive disorders were far more present in NH-DCDs, while MHCI-DCDs often suffered from
multiple psychiatric disorders. The severity of comorbidities and care dependency were equally high
among all DCDs. NH-DCDs expressed more satisfaction in overall quality of life.
Conclusions: The institutionalized elderly DCD population is very heterogeneous. Specic care
arrangements are necessary because the severity of a patients physical illness and the level of
functional impairment seem to be equally important as the patients behavioural, psychiatric and
social problems. Further research should assess the adequacy of the setting assignment and the
professional skills needed to provide adequate care for elderly DCDs.
KEYWORDS
Geriatric psychiatry; nursing
home; double care
demanding patients;
integrated care
Introduction
Due to the ongoing process of deinstitutionalization of
psychiatric care services, problems may arise for the most
disabled chronic psychiatric patients, who are in need of
physical care or even nursing. These patients suffer from
multiple disorders and have combined mental (psychiatric
and/or psychogeriatric) and physical conditions and are
mostly older people. (Grabowski, Aschbrenner, Rome, &
Bartels, 2010; Health Council of the Netherlands, 2008;van
den Brink, Gerritsen, Oude Voshaar, & Koopmans, 2013).
Among them are chronic psychiatric patients with demen-
tia, but also dementia patients with or without a psychiat-
ric history who were admitted to a psychiatric hospital
due to behavioural disturbances that could not be dealt
with in a nursing home (NH). Another subgroup consists
of younger patients with chronic alcohol abuse, post-trau-
matic encephalopathies and degenerative diseases of the
central nervous system (Bleeker, De Reus, & Duurkoop,
1991). These double care demanding patients (DCDs) need
a combination of physical, psychogeriatric and psychiatric
care (Bartels, 2004;Snowdon,2010). Up till now, different
types of long-term care (LTC) are provided to older people
with advanced dementia, disabling psychiatric illnesses
and physical disabilities. In the Netherlands, tight networks
of regional NHs and regional integrated mental health
care institutions (MHCIs) exist. Traditionally, NHs provide
LTC for either psychogeriatric or physically disabled
patients and MHCIs provide LTC for patients with chronic
mental illnesses.
EarlierstudieshaveshownthatDCDsbenetfromcollabo-
rative psychiatric and physical medicine approaches, e.g. from
multidisciplinary care teams that deliver integrated mental and
physical health care (Bartels, 2004; Collet, de Vugt, Verhey, &
Schols, 2010;Inventoretal.,2005). The absolute categorization
of psychiatric treatment on the one hand and NH care (com-
posed of either physical care or psychogeriatric care) on the
other hand creates both regulatory and funding restrictions.
Health care insurance companies may not reimburse the costs
for physical care within a MHCI and vice versa the costs for psy-
chiatric treatment in a NH. Consequently, both NH-residents
with comorbid psychiatric disorders and psychiatric patients
with comorbid dementia and/or physical disabilities will not
always receive the type of care that they need (Health Council
of the Netherlands, 2008; NSW Department of Health, 2006;
Snowdon, 2010; van den Brink, Gerritsen, Oude Voshaar, &
Koopmans, 2014). Not receiving the most appropriate care can
have a negative inuence on neuropsychiatric symptoms (NPS)
and quality of life (Bakker et al., 2014; Slade, Leese, Cahill,
Thornicroft, & Kuipers, 2005;Whiteetal.,1997).
Although the traditional asylum function for older adults
with severe mental illness (SMI) has largely been taken
over by NHs (Bartels, Miles, Dums, & Levine, 2003), a study by
the Dutch Trimbos Institute found that according to NH-
personnel, 8.6% of the Dutch NH-residents were DCDs who
CONTACT Janine Collet j.collet@mondriaan.eu
© 2016 Informa UK Limited, trading as Taylor & Francis Group
AGING & MENTAL HEALTH, 2016
http://dx.doi.org/10.1080/13607863.2016.1202891
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surpassed the capabilities for psychiatric treatment available
in their own NH department (Dorland, 2007). Properly trained
nurses who are qualied to provide psychiatric care for elderly
people are rarely employed within NHs, and specic psychiat-
ric training for personnel is limited (Dutch Health Care Inspec-
torate, 2007; Grabowski et al., 2010; Molinari et al., 2008).
Patients diagnosed with SMI have a high prevalence of physi-
cal disorders, are less competent in interpreting physical
symptoms and have a reduced life expectancy (Collard, Boter,
Schoevers, & Oude Voshaar, 2012; De Hert et al., 2011; Scott &
Happell, 2011). The Dutch Inspectorate of Healthcare has
stated that Dutch MHCIs continue to display insufcient atten-
tion to the somatic needs of DCDs, and ofcial guidelines for
how to identify and treat somatic complications are still lack-
ing (Cahn et al., 2008; Dutch Health Care Inspectorate, 2004).
DCDs, thus, present a particular challenge to LTC services
within both NHs and MHCIs. Some Dutch NHs and MHCIs are
already operating special care units for DCDs (DCD-units),
offering a unique opportunity to study this population.
Knowledge of the characteristics and care needs of DCDs in
both settings is essential to improve care services to better
meet the specic needs of these DCDs. Although the term
DCD-units is used for both settings, it is very likely that DCDs
in NHs and MHCIs will differ in psychopathology, physical
comorbidity and activities of daily living (ADL) decits. The
present study will explore the similarities and differences of
DCDs who are admitted to either NH or MHCI, and addresses
the following research questions: what are the physical (in
terms of medical problems and care dependency) and mental
health-related characteristics (in terms of mental problems
and NPS) of these DCDs, and what is their perceived quality
of life.
The ndings of this study are relevant for planning of serv-
ices that should take into account different patterns of needs
among elderly DCDs.
Methods
Design
This study is a part of an explorative observational cross-
sectional study on the Specic Care in the Interface of Mental
health and Nursing homes (SpeCIMeN). Residents from two
types of care settings for DCDs were included in the study:
the mental health care setting and the NH setting. Data were
collected from November 2013 through April 2015.
Participants
The study was performed in the southernmost part of Limburg,
a province of the Netherlands. NH organizations and MHCIs in
the region were approached to identify specialized DCD-units
based on our denition: specialized units for patients with a
combination of psychiatric, physical and/or psychogeriatric care
needs. All of these by the organization identied DCD-wards
were included in the study with the ward as the unit of interest.
Four specialized DCD-units within a Dutch MHCI
(Mondriaan) with a total of 76 beds and seven specialized
DCD-units within two Dutch NH organizations (Envida and
Meander) with a total of 110 beds were identied and
included in the study. All of the specialized NH-DCD-units
were situated within psychogeriatric NHs.
The DCD-units within the MHCI varied from 14 to 20
patients, while the DCD-units within the NHs varied from 8 to
20 patients. DCD patients had to be admitted to the special-
ized care unit at least six weeks prior to the study before they
could be included. Patients who were temporarily admitted
to the specic DCD-unit because of admission problems else-
where in the NH or MHCI were excluded from the study.
Procedure
The local Medical Ethics Committee approved the study
(number 134049) and considered it not to be subject to the
Medical Research Involving Human Subjects Act. The study
was also approved by the Board of Directors and the Client
Advisory Councils of the participating institutions. Patient par-
ticipation was voluntary, and data collection was conducted
condentially and anonymously. Eligible patients were
included in the study after informed consent from the
patients or their legal representatives was obtained.
Data were collected through various methods. Medical
les were intensively studied to collect information on psychi-
atric and somatic morbidity. Direct patient measurements of
cognition, mood disturbances and perceived quality of life
were obtained. Finally, the vocational nurses who acted as
the primary responsible caretakers of the DCDs provided data
on care dependency, current behaviour and personality traits.
Measurements
Data collection from medical les
Baseline characteristics (such as age, sex, marital status, time
of institutionalization, level of education and representation)
and somatic illnesses were retrieved from the patients record.
All current physical disorders were collected from data on
both the medical diagnosis, the available laboratory results
(e.g. in conrming kidney failure) and medication use, as
stated within the patientsmedical record. The severity of all
conrmed somatic diagnoses was scored using the 14-item
version of the Cumulative Illness Rating Scale (CIRS) 14-item
version (Miller et al., 1992). This scale measures multimorbid-
ity in light of all medical problems encountered in a geriatric
population. The theoretical scores range from 0 to 56 based
on scoring the severity of co-occurring medical conditions
from 0 (no problem) to 4 (extremely severe problem). In this
study, the severity of co-occurring medical conditions was
scored excluding the psychiatryCIRS-subscale.
Psychiatric illnesses were retrieved from the medical
records and classied according to the Diagnostic and Statisti-
cal Manual of Mental Disorders. Both axis I and axis II classi-
cations were noted (DSM-IV-TR. Vol. 4th edition, Text Revision.
2000).
Data collection on patient level
Direct measurements. Patient cognition was measured using
the Dutch standardized version of the Mini Mental State
Examination (MMSE) (Folstein, Folstein, & McHugh, 1975).
Feelings of anxiety and depression were assessed using
the Dutch translation of the original Hamilton Anxiety and
Depression Scale (HADS) (Spinhoven et al., 1997; Zigmond &
Snaith, 1983). The HADS contains a 7-item subscale for
depression and for anxiety. Each item has a severity score
range from 0 (no problem) to 3 (severe problem). A trained
2 J. COLLET ET AL.
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research assistant interviewed the patients. Items were read
out loud, and patients were asked to choose one of the four
possible severity scores for each item.
Overall experienced quality of life was assessed using the
Manchester Short Assessment of Quality of Life (MANSA). This
is an abbreviated 6-item version of the original 16-item scale,
as used in the Dutch cumulative needs for care monitor (Druk-
ker et al., 2010; Priebe, Huxley, Knigh, & Evans, 1999). These
items address patientssatisfaction with general quality of life,
living situation, social relationships, physical health, psychologi-
cal health and quality of care. Items are scored on a 7-point Lik-
ert scale ranging from 1 (not satised) to 7 (very satised).
Data provided by vocational nurses
To measure patientsneeds and care dependency, we used
the Care Dependency Scale (CDS) (Dijkstra, Buist, & Dassen,
1998; Dijkstra, Tiesinga, Plantinga, Veltman, & Dassen, 2005).
The CDS measures to what extent the patient is able to per-
form activities independently. It consists of 15 categories, all
of which are scored using a 5-point Likert-type scale.
Responses range from 1Dcompletely dependentto
5Dalmost independent. Patients with a total CDS score of
68 are classied as care dependent.
NPS were assessed using the Dutch version of the Neuro-
psychiatric Inventory (NPI) (Cummings et al., 1994; Kat et al.,
2002). The NPI includes 12 NPS. The frequency and severity of
each symptom are rated on a 5-point (04) and 4-point (03)
Likert scale, respectively. The frequency and severity scores are
then multiplied. NPI symptoms were considered relevant when
the multiplied scores were 4. Agitation and aggression were
further specied with the Dutch version of the Cohen-Mans-
eld Agitation Inventory (CMAI-D) (Cohen-Manseld, 1986;de
Jonghe & Kat, 1996). The CMAI is a 29-item nurse-based rating
scale. All of the items are rated on a 7-point scale (17) rang-
ing from neverto several times an hour.
Based on previous factor analyses of both NH and MHCI
populations (de Jonghe & Kat, 1996; Zuidema, de Jonghe, Ver-
hey, & Koopmans, 2007), the agitation items were clustered
into three factors: non-aggressive physical behaviour (pacing,
hiding, hoarding, general restlessness, inappropriate dressing
or disrobing, handling things inappropriately and trying to
get to different places), aggressive physical behaviour (hitting,
pushing, scratching, grabbing, cursing or verbal aggression,
spitting and strange noises) and agitated verbal behaviour
(constant unwarranted requests for attention/help, complain-
ing, repetitive sentences or questions and negativism). CMAI
symptoms were considered relevant if they occurred at least
once a week (a score of 3).
Statistical analysis
The Statistical Package for Social Sciences (SPSS), version 21
was used for the statistical analysis. The analysis consisted of
conducting descriptive statistics of basic patient characteris-
tics, psychiatric illnesses, NPS, somatic illnesses, care depen-
dency and perceived quality of life. Explorative bivariate
comparisons between patient groups on the prevalence of
medical conditions, psychiatric diagnoses and NPS were per-
formed using Chi-square tests for nominal or ordinal varia-
bles and independent-samples t-tests for scale variables. For
variables that had an abnormal parametric distribution, anal-
yses were performed using the MannWhitney Utest. P-val-
ues of 0.05 or less were considered to be statistically
signicant.
Results
A total of 163 patients were included, 83 from special DCD-
wards of NHs (maximum 110 beds) and 80 from special DCD-
wards of a MHCI (maximum 76 beds; four patients were trans-
ferred to NHs during the inclusion period and then four newly
admitted patients were included in the study during the inclu-
sion period). All of the specialized care units had somewhat
different criteria for admission. Some units included patients
with a specic psychiatric history in combination with cogni-
tive decline or physical disability; others included patients
with very severe NPS due to specic types of dementia in
combination with physical disability and/or a history of psy-
chiatric treatment. Data collection from patient records was
complete. Proxy information about patients was collected in
70 out of 80 MHCI-DCDs (87.5%) and in 71 out of 83 NH-DCDs
(85.5%). Reasons for non-response were (severe) illness or
internal transfer of primary responsible vocational nurses.
Direct information from patients was collected in 50 out of 80
MHCI-DCDs (62.5%) and 57 out of 83 NH-DCDs (68.7%).
Refusal and serious hearing or vision impairment were rea-
sons for the non-participation of patients.
Demographic characteristics
Demographic characteristics of all of the included individuals
are shown in Table 1. The mean age of the DCDs was 68 years,
Table 1. Demographic characteristics of double care demanding patients (DCDs) in MHCI and NH.
Characteristics All DCDs (nD163) MHCI
a
(nD80) NH
b
(nD83) P
e
Age (years) Mean (SD) 68.2 (8.9) 71.6 (8.1) 64.9 (8.5) <0.001
Range 4794 4994 4787
Gender (n,%) Male 88 (54.0) 36 (45.0) 52 (62.7) 0.024
Representation (n,%) Family 56 (34.4) 13 (16.5) 43 (52.4) <0.001
Ap. trustee
c
: family 50 (30.7) 27 (34.2) 23 (28.0)
Ap. trustee
c
: law rm 55 (33.7) 39 (49.4) 16 (19.5)
Marital status (n,%) Married 38 (23.3) 8 (10.3) 30 (36.6) <0.001
Unmarried 46 (28.2) 32 (41.0) 14 (17.1)
Divorced 58 (35.6) 29 (37.2) 29 (35.4)
Widowed 18 (11.0) 9 (11.5) 9 (11.0)
Education
d
(n,%) Low 104 (63.8) 63 (78.8) 41 (49.4) <0.001
Middle 50 (30.7) 15 (18.8) 35 (42.2)
High 9 (5.5) 2 (2.5) 7 (8.4)
Length of stay (n,%) >1 year 132 (81) 61 (76.2) 71 (85.5) 0.131
Note:
a
MHCI Dmental health care institution.
b
NH Dnursing home.
c
Appointed trustee.
d
Low Dprimary school, middle Dsecondary school and lower vocational education, high Dupper vocational education and university.
e
Chi-square ( except age DMannWhitney Utest), signicance level is 0.05.
AGING & MENTAL HEALTH 3
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with younger DCDs in the NH group. Within the NH-DCDs,
there were almost two times more men than women. Many
of the MHCI-DCDs had never been married. Participantsedu-
cational level was low for most of the DCDs, with a distinct
higher percentage of lower education within the MHCI group.
Most of the DCDs had been institutionalized for longer than
one year. The MHCI-DCDs were mostly represented by
appointed trustees, while NH-DCDs usually had family mem-
bers serving as representatives.
Physical health-related characteristics
Multimorbidity and care dependency are shown in Table 2.
Overall, the DCDs had a mean of seven comorbid condi-
tions, with a mean disease severity score of 15.2 and a high
prevalence of cardiovascular, pulmonary, neurological and
gastrointestinal problems. All of the DCDs showed a clear
nursing care dependency, with a mean care dependency
score of 45 (range 1774; cut-off score 68).
Mental health-related characteristics
In Table 3, both axis I and axis II diagnoses are represented.
Over one-third of the MHCI-DCDs had a psychotic disorder
and the presence of multiple diagnosis on Axis I was two
times higher among the MHCI group. Cognitive disorders
were four times more often present among the NH group. A
personality disorder was diagnosed in almost one-quarter of
all of the DCDs. More than one-fth of the MHCI-DCDs were
intellectually disabled. The mean cognitive functioning of the
participants did not differ between groups (Table 4), with a
large range of MMSE-scores among all of the DCDs. The mean
depression score was higher for NH-DCDs. A high percentage
of clinically relevant NPS was reported in all of the DCDs
(Table 5). The mean total NPI-score was higher in MHCI-DCDs,
with a signicantly higher prevalence of the NPI symptoms
delusions, hallucinations and anxiety. The mean total CMAI-
score was similar for all of the DCDs, but the CMAI factor-
scores showed a greater prevalence of both verbally agitated
and physically non-aggressive behaviour in MHCI-DCDs.
Quality of life related characteristics
The majority of the patients expressed satisfaction with their
quality of life, with higher satisfaction rates in the NH-DCD
Table 2. Somatic and care characteristics.
All DCDs
(nD163)
MHCI
a
(nD80)
NH
a
(nD83) P
g
CDS
c
Mean (SD) 45 43.9 (13.8) 46.1 (17.1) 0.38
Range 1774 1871 1774
CIRS total
d
Mean (SD) 15.2 (5.0) 15.4 (4.7) 14.9 (5.3) 0.97
Range 231 731 227
Cardiac N(%) 57 (35.0) 34 (42.5) 23 (27.7) 0.05
Vascular 80 (49.1) 41 (51.2) 39 (47.0) 0.59
Haematological 34 (20.9) 24 (30.0) 10 (12.0) 0.01
Respiratory 134 (82.2) 65 (81.2) 69 (83.1) 0.75
Ophthalmological and ORL
f
113 (69.3) 54 (67.5) 59 (71.1) 0.62
Upper gastrointestinal 94 (57.7) 41 (51.2) 53 (63.9) 0.10
Lower gastrointestinal 120 (73.6) 58 (72.5) 62 (74.7) 0.75
Hepatic and pancreatic 63 (38.7) 19 (23.8) 44 (53.0) <0.001
Renal 31 (19.0) 17 (21.2) 14 (16.9) 0.48
Genitourinary 140 (85.9) 76 (95.0) 64 (77.1) 0.001
Musculoskeletal 123 (75.5) 60 (75.0) 63 (75.9) 0.89
Neurological 105 (64.4) 49 (61.3) 56 (67.5) 0.41
Endocrine, metabolic 48 (29.4) 28 (35.0) 20 (24.1) 0.13
Multimorbidity
e
Mean (SD) 7.0 (2.2) 7.1 (2.1) 6.9 (2.3) 0.95
Range 112 312 112
Note:
a
MHCI Dmental health care institution.
b
NH Dnursing home.
c
Care Dependency Scale.
d
Cumulative illness rate except psychiatric illness.
e
Amount of medical conditions.
f
ORL DOtorhinolaryngology.
g
MannWhitney Utest, signicance level is 0.05.
Table 3. Psychiatric diagnoses.
All DCDs
(nD163)
MHCI
a
(nD80)
NH
b
(nD83) P
e
DSM-IV axis I diagnosis
(A) Psychotic disorders total 30 (18.4%) 29 (36.2%) 1 (1.2%) <0.001
Schizophrenia (n)21201
Schizo-affective 6 6
Psychosis NOS
c
33
(B) Cognitive disorders total 79 (48.5%) 13 (16.2%) 66 (79.5%)
Dementia
d
NOS (n)29524
Korsakoff/alcohol related 32 1 31
Alzheimer and/or vascular 9 1 8
Cognitive problems 9 6 3
(C) Affective disorders total 5 (3.1%) 4 (5.0%) 1 (1.2%)
Depression (n) 431
Bipolar 1 1
(D) >1 axis I diagnosis total ABC 49 (30.1%) 34 (42.5%) 15 (18.1%)
Psychotic and cognitive (n)24 17 7
DSM-IV axis II diagnosis
Personality disorder Diagnosed (n,%) 38 (23.3) 18 (22.5) 20 (24.1) 0.048
Personality disorder probable 34 (20.9) 12 (15.0) 22 (26.5)
No personality disorder 66 (40.5) 32 (40.0) 34 (41.0)
Intellectually disabled 25 (15.3) 18 (22.5) 7 (8.4)
Note:
a
MHCI Dmental health care institution.
b
NH Dnursing home.
c
NOS Dnot otherwise specied.
d
Lewy body dementia and frontal-temporal lobe dementia and young onset
dementia.
e
Chi-square, signicance level is 0.05.
Table 4. Cognitive functioning, anxiety and depression.
All DCDs
(nD107)
MHCI
a
(nD50)
NH
b
(nD57)
P
e
MMSE
c
Mean (SD) 18.2 (7.4) 17.4 (7.4) 18.8 (7.5) 0.253
Range 230 430 230
HADS
d
anxiety Mean (SD) 6.2 (3.8) 6.9 (4.2) 5.7 (3.4) 0.111
Range 118 118 116
HADS
d
depression Mean (SD) 11.7 (3.7) 10.3 (3.7) 12.8 (3.3) 0.001
Range 318 315 418
Note:
a
MHCI Dmental health care institution.
b
NH Dnursing home.
c
Mini Mental State Examination.
d
Hospital Anxiety and Depression Scale.
e
MannWhitney Utest, signicance level is 0.05.
4 J. COLLET ET AL.
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group for given care, treatment and psychological well-being
(Table 6).
Discussion
To our knowledge, this is the rst study to report and com-
pare data on DCDs who are institutionalized in specialized
units in either MHCI or NH settings.
The elderly DCD population was a rather heterogeneous
group in terms of mental and physical health. As expected,
mental health problems were clearly more prominent in the
MHCI group. However, although we expected them to be
more prominent in the NH group, physical health problems
were equally divided between the groups. In both groups,
nursing care dependency was clearly present. While more
than half of all of the DCDs were satised with their perceived
quality of life, the NH-DCDs expressed an overall higher satis-
faction rate.
In the present study, no differences between DCD groups
were found regarding the severity of physical comorbidity (as
expressed in the CIRS total score) or care dependency scores.
As stated before, NHs are supposed to be more specialized in
clinical conditions, meaning that MHCI-DCDs that also have
important clinical problems might be in disadvantage.
The high prevalence of cardiovascular, pulmonary, neuro-
logical and gastrointestinal problems was consistent with ear-
lier studies on psychiatric inpatients in both MHCI and NH
(Lemke & Schaefer, 2010; Lyketsos, Dunn, Kaminsky, & Breaky,
2002; Robson & Gray, 2007; Scott & Happell, 2011). Compared
to a group of NH-residents with comorbid anxiety and depres-
sion, our study found a higher comorbidity rate (7.1 versus
3.7) (Smalbrugge et al., 2006).
Contradictory ndings on care dependency exist within the
literature. Compared with our study, Aschbrenner found lower
rates of care dependency in newly admitted NH-DCDs, while
Fullerton found that NH-residents with schizophrenia had com-
parable care dependency scores (Aschbrenner, Grabowski, Cai,
Bartels, & Mor, 2011; Fullerton, McGuire, Feng, Mor, & Grabow-
ski, 2009). Although cognitive disorders were far more preva-
lent among NH-DCDs than MHCI-DCDs, it was striking that the
MMSE-scoresdidnotdifferbetweenthegroups.Thismightbe
explained by the natural decline in cognitive functioning with
ongoing schizophrenia and the proven signicantly lower cog-
nition rates in older patients with schizophrenia compared to
older adults without schizophrenia and is consistent with the
ndings in earlier studies (Fullerton et al., 2009;Harvey,Reich-
enberg, Bowie, Patterson, & Heaton, 2010; Hendrie et al., 2014).
It could, however, also point to the fact that cognitive prob-
lems in MHCI settings are overlooked.
The mean total NPI-score in NH-DCDs in our study was
higher compared to both a non-DCD NH dementia population
(25.9 versus 16.9) and a group of young onset dementia
patients (25.9 versus 24.9) (Mulders, Zuidema, Verhey, &
Koopmans, 2014; Zuidema, Derksen, Verhey, & Koopmans,
2007). The nding that MHCI-DCDs had high levels of NPS
with even more verbal disruption is consistent with the nd-
ings of McCarthy, Blow, and Kales (2004). A higher prevalence
of delusions in the MHCI-DCDs could be explained by the
high percentage of diagnosed psychotic disorders. White
et al. (1997) found that a more severe level of delusions was
an important characteristic of elderly psychiatric patients who
could not be discharged to a NH from a psychiatric hospital.
This could indicate that accommodation within a MHCI-DCD-
unit would be preferable for DCDs who present with a more
severe level of delusions. The MHCI-DCDs in this study were
less satised with their overall experienced quality of life. This
could be due to the known social withdrawal, at affect and
lack of motivation that occur in the general SMI population
(Harvey et al., 1998).
Our study showed interesting demographical differences.
Compared to the usual NH-population, there were twice as
many men and the mean age was approximately 20 years
younger in the NH-DCDs (Ribbe, Frijters, & van Mens, 1993).
Thiscouldbeexplainedbythefactthatalargeproportionof
the NH-DCDs suffered from ARD or frontal-temporal lobe
dementia (FTD). ARD and FTD are more prevalent among peo-
ple who are younger than 65 years old, and ARD is also more
prevalent among men (Harvey, Skelton-Robinson, & Rossor,
2003; Ridley, Draper, & Withall, 2013). Consistent with earlier
ndings, relatively many MHCI-DCDs were not married or
divorced and had no family representation (Bartels, Mueser, &
Miles, 1997). Lower educational levels in MHCI-DCDs have also
been reported by Fullerton (Fullerton et al., 2009). The high
prevalence of intellectually impaired MHCI-DCD patients could
also explain the lower educational level within these DCDs.
Methodological considerations
The primary strength of this study is that various sources of
information such as medical records, patient reports and
Table 5. Neuropsychiatric symptoms.
All DCDs
(nD141)
MHCI
c
(nD70)
NH
d
(nD71) P
e
NPI
a
Total mean (SD) 29.5 (21.1) 32.6 (19.5) 25.9 (22.5) 0.009
Clinical relevant items (%)
Agitation/aggression 46.2 54.2 38.4 0.056
Anxiety 21.4 33.3 9.6 <0.001
Apathy 37.2 37.5 37.5 0.949
Restlessness 16.6 20.8 12.3 0.168
Depression 24.8 25.0 24.7 0.962
Eating disorder 15.2 20.8 9.6 0.059
Hallucinations 22.8 33.3 12.3 0.003
Disinhibition 35.9 38.9 32.9 0.450
Irritability 46.9 54.2 39.7 0.081
Sleep disturbance 17.2 15.3 19.2 0.534
Euphoria 15.9 15.3 16.4 0.848
Delusions 42.8 59.7 26.0 <0.001
CMAI
b
Total mean (SD) 48.6 (17.3) 50.9 (19.7) 46.1 (14.5) 0.241
Clinical relevant items (%)
Fact. physical aggression 54.9 59.7 50.0 0.241
Fact. aggression, not physical 60.8 69.0 52.8 0.047
Fact. verbally agitated behaviour 64.5 76.1 52.9 0.004
Note:
a
NPI DNeuropsychiatric Inventory, clinical relevant score 4.
b
CMAI DCohen-Manseld Agitation Inventory, clinical relevant score 3.
c
MHCI Dmental health care institution.
d
NH Dnursing home.
e
Chi-square, signicance level is 0.05.
Table 6. Patients perceived quality of life.
MANSA
c
(percentage (%)
of satised DCDs)
All DCDs
(nD108)
MHCI
a
(nD50)
NH
b
(nD58) P
d
Life as a whole 56.0 45.8 58.6 0.213
Living arrangements 65.0 55.1 65.5 0.337
Social relationships 69.0 54.0 72.4 0.060
Psychological well-being 64.0 52.1 67.2 0.027
Physical well-being 61.0 52.1 62.1 0.191
Care and treatment 74.0 55.1 81.0 0.006
Note:
a
MHCI Dmental health care institution.
b
NH Dnursing home.
c
Manchester Short Assessment of Quality of Life, adapted version.
d
Chi-square, signicance level is 0.05.
AGING & MENTAL HEALTH 5
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proxy information were combined during data collection. Fur-
thermore, a comprehensive study of patients medical records
could be accomplished for all of the included patients. This
study may be limited in its power to demonstrate representa-
tive characteristics of the DCD population because of the use
of a selected cohort of patients in the south of Limburg with-
out a direct comparison to a non-DCD-population in either
NH or MHCI.
Another possible limitation is the choice to use bivariate
analysis to compare the characteristics between the two set-
tings, because we included subjects on DCD-ward level. On
individual patient level, however, bivariate analysis may not
be sufcient from a statistical point of view. Despite these lim-
itations, this study was a rst important explorative step in
gaining deeper insight into the specic characteristics of
DCDs in both the NH and MHCI settings.
Conclusions and possible implications
The elderly DCD population in both settings was heteroge-
neous in many regards. The MHCI-DCDs had a similar level of
considerable care dependency and comorbidity as the NH-
DCDs. This stresses the importance of giving enough atten-
tion to physical care within a MHCI by allotting of personnel
capable of supervising clinical diseases in the MHCI setting.
There could be a mismatch between the type of patients and
the type of care offered. The MHCI-DCDs clearly differed from
the NH-DCDs as evidenced by a higher prevalence of psy-
chotic symptoms and psychiatric morbidity.
The heterogeneity of DCDs and the resulting care com-
plexities challenge the skills of professional caregivers in both
settings, as they must be able to address both somatic care
needs as well as psychiatric and psychogeriatric care needs.
Given the high amount of NPS and the variation in psychiatric
diagnoses and in dementia subtypes, professional caregivers
are required to constantly switch between different
approaches of care; sometimes a more restrictive or structur-
ing approach is needed, and sometimes a more supportive or
validating approach is more appropriate. Further knowledge
is needed on the professional competencies required to
deliver the most effective care for DCDs.
In light of the heterogeneity of the group and the parti-
tions in providing care, the question of which type of care is
most appropriate for which type of DCD patient remains to
be answered.
This suggests that not only the criteria for admission to
specialized MHCI- or NH-DCD-units and the transfer to a regu-
lar care unit need to be addressed, but the regulatory or fund-
ing barriers and reimbursement policies need to be
considered as well. The heterogeneity of the group raises the
question, what the usefulness is of the concept DCD. We think
the relevance of the concept is the way it can be used to
inform policies of organizing beds in a health care system
inasmuch one does not overlook the needs and clinical super-
vision of patients in the MHCI setting, nor the needs of the
patients and psychiatric training of nurses in the NH setting.
Further research is needed to investigate these topics in more
detail, using both qualitative and quantitative data.
Disclosure statement
No potential conict of interest was reported by the authors.
Funding
CZ-Health Insurance Company [award number 20120010].
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The use of schema therapy to treat personality disorders in older adults is gaining scientific attention. Personality disorders are prevalent in one out of ten older adults and have a detrimental effect on quality of life. Although 24% or more of nursing home residents may have personality disorders, psychotherapeutic treatment options in the case of comorbid cognitive impairment have not yet been studied. This study concerns a 63-year-old care-dependent male nursing home resident with a personality disorder, a substance use disorder, and several cognitive impairments due to cerebrovascular disease, who presented with complaints of loneliness, low self-esteem, sleeping problems and anger outbursts. Schema therapy was delivered based on the schema mode model for a period of 27 months. Post-treatment assessment demonstrated a decrease in early maladaptive schemas and dysfunctional schema modes and improved personality functioning overall. Although situational psychological distress fluctuated throughout treatment, quality of life improved after 7 months and remained stable onwards. Presented complaints either remitted or strongly diminished. Substance use was also addressed and was in remission for the last 20 months of therapy. This case study suggests that schema therapy is a viable treatment for older adults with personality disorders who present with cognitive impairments in nursing homes.
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Despite growing clinical attention to personality disorders in older adults (≥ 55 yrs.), empirical research addressing personality pathology in late life is scarce. Given the ageing of the population globally, scientific knowledge in this area is of vital importance. This article gives an overview of the epidemiological aspects of personality disorders in older adults, such as prevalence, the course and the impact on various domains of functioning.
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Thesis
The project focused on patients suffering from a mental health disorder and also in need of nursing home care (because of dementia and/or physical disorders). They present a particular challenge to LTC wards within both nursing homes (NHs) and mental healthcare institutions (MHs). They often surpass the level of mental healthcare that can be offered in NHs, and, vice versa, the level of physical care that can be offered in MHs. As these patients have a combined need for both mental health care and nursing home care, we refer to them as double care demanding patients (DCD-patients) in this thesis. The aim of this study was threefold: 1. to explore the characteristics and the care needs of DCD-patients; 2. to explore the characteristics and work-related wellbeing of nursing staff caring for DCD-patients; 3. to define the necessary elements for adequate care to DCD-patients, by combining expertise from both psychiatric care and nursing home care and taking into account barriers and facilitators. Several study designs were applied including a systematic literature search, observational cohort studies, a focus group study and a case study.
Full-text available
Thesis
The project focused on patients suffering from a mental health disorder and also in need of nursing home care (because of dementia and/or physical disorders). They present a particular challenge to LTC wards within both nursing homes (NHs) and mental healthcare institutions (MHs). They often surpass the level of mental healthcare that can be offered in NHs, and, vice versa, the level of physical care that can be offered in MHs. As these patients have a combined need for both mental health care and nursing home care, we refer to them as double care demanding patients (DCD-patients) in this thesis. The aim of this study was threefold: 1. to explore the characteristics and the care needs of DCD-patients; 2. to explore the characteristics and work-related wellbeing of nursing staff caring for DCD-patients; 3. to define the necessary elements for adequate care to DCD-patients, by combining expertise from both psychiatric care and nursing home care and taking into account barriers and facilitators. Several study designs were applied including a systematic literature search, observational cohort studies, a focus group study and a case study.
Full-text available
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Background: Little is known about care needs in young-onset dementia (YOD) patients, even though this information is essential for service provision and future care planning. We explored: (1) care needs of people with YOD, (2) the level of agreement within patient-caregiver dyads on care needs, and (3) the longitudinal relationship between unmet needs and neuropsychiatric symptoms. Methods: A community-based prospective study of 215 YOD patients-caregiver dyads. Care needs were assessed with the Camberwell Assessment of Need for the Elderly. The level of agreement between patient and caregivers' report on care needs was calculated using κ coefficients. The relationship between unmet needs and neuropsychiatric symptoms over time, assessed with the Neuropsychiatric Inventory, was explored using linear mixed models. Results: Patients and caregivers generally agreed on the areas in which needs occurred. Only modest agreement existed within patient-caregiver dyads regarding whether needs could be met. Patients experienced high levels of unmet needs in areas such as daytime activities, social company, intimate relationships, and information, leading to an increase in neuropsychiatric symptoms. Conclusions: Our findings indicate that in YOD, there are specific areas of life in which unmet needs are more likely to occur. The high proportions of unmet needs and their relationship with neuropsychiatric symptoms warrant interventions that target neuropsychiatric symptoms as well as the prevention of unmet needs. This underlines the importance of the periodic investigation of care needs, in which patient and caregiver perspectives are considered complementary.
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The characteristics of dementia relating to excessive alcohol use have received increased research interest in recent times. In this paper, the neuropathology, nosology, epidemiology, clinical features, and neuropsychology of alcohol-related dementia (ARD) and alcohol-induced persisting amnestic syndrome (Wernicke-Korsakoff syndrome, or WKS) are reviewed. Neuropathological and imaging studies suggest that excessive and prolonged use of alcohol may lead to structural and functional damage that is permanent in nature; however, there is debate about the relative contributions of the direct toxic effect of alcohol (neurotoxicity hypothesis), and the impact of thiamine deficiency, to lasting damage. Investigation of alcohol-related cognitive impairment has been further complicated by differing definitions of patterns of alcohol use and associated lifestyle factors related to the abuse of alcohol. Present diagnostic systems identify two main syndromes of alcohol-related cognitive impairment: ARD and WKS. However, 'alcohol-related brain damage' is increasingly used as an umbrella term to encompass the heterogeneity of these disorders. It is unclear what level of drinking may pose a risk for the development of brain damage or, in fact, whether lower levels of alcohol may protect against other forms of dementia. Epidemiological studies suggest that individuals with ARD typically have a younger age of onset than those with other forms of dementia, are more likely to be male, and often are socially isolated. The cognitive profile of ARD appears to involve both cortical and subcortical pathology, and deficits are most frequently observed on tasks of visuospatial function as well as memory and higher-order (executive) tasks. The WKS appears more heterogeneous in nature than originally documented, and deficits on executive tasks commonly are reported in conjunction with characteristic memory deficits. Individuals with alcohol-related disorders have the potential to at least partially recover - both structurally and functionally - if abstinence is maintained. In this review, considerations in a clinical setting and recommendations for diagnosis and management are discussed.
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In the Netherlands a tight network of mainly intramural psychogeriatric nursing facilities exists. A discussion is going on whether these beds may substitute beds for elderly infirm inpatients of psychiatric hospitals, which are more expensive. The move towards community psychiatry may lead to insufficient planning of services for patients with combined chronic mental and somatic conditions. Elderly patients in psychiatric hospitals and nursing homes show significant differences in psychopathology as well as ADL deficits. It is argued that in both types of facilities at present different categories of patient are taken care of. Planning of services should take into account different patterns of needs among elderly infirm mental patients. Dementia is in itself not a decisive factor in the allocation of patients to primary nursing homes or psychiatric facilities.
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Although exact figures are lacking, many studies show that mental–physical multimorbidity is common in older people (van den Brink et al. , 2013). Particularly, older patients with a chronic disease often have psychiatric disorders (Verdurmen et al. , 2006). Conversely, medical comorbidity is common in psychiatric patients, especially cardiovascular, pulmonary, and neurological disorders and diabetes (Lyketsos et al. , 2002).
Article
Background: People with Young Onset Dementia (YOD) have specific needs for care. These people eventually require institutional care, usually delivered by institutions designed for the elderly. The Dutch network of care organizations delivering specialized YOD care offers a unique opportunity to obtain more knowledge of this special population. Methods: Our cross-sectional study collected data from 230 people with YOD in eight care homes providing YOD specialized care. Data collected: demographic data, disease duration, dementia subtype, comorbidity, dementia severity (Global Deterioration Scale - GDS), neuropsychiatric symptoms (NPS; Neuropsychiatric Inventory - NPI, Cohen Mansfield Agitation Inventory - CMAI), disease awareness (Guidelines for the Rating of Awareness Deficits - GRAD), need for assistance (hierarchic Activities of Daily Living (ADL) scale - Resident Assessment Instrument - Minimum Data Set (RAI-MDS)). Results: The mean age of the residents with YOD in care homes was 60 years and 53% of them were men. There is a large variety of etiologic diagnoses underlying the dementia. Dementia severity was very mild to mild in 18%, moderate in 25%, and severe or very severe in 58% of the participants. The prevalence of NPS was high with 90% exhibiting one or more clinically relevant NPS. Comorbidity was present in more than three quarters of the participants, most frequently psychiatric disorders. Conclusions: The institutionalized YOD population is heterogeneous. NPS occur in almost all institutionalized people with YOD, and frequency and severity of NPS are higher than in late onset dementia (LOD) and community-dwelling YOD patients. Care should be delivered in settings accommodating a mixed male and female population, with appropriate, meaningful activities for all individuals. Further research is needed on NPS in YOD, to enhance quality of life and work in specialized YOD-care.
Article
The population of older patients with schizophrenia is increasing. This study describes health outcomes, utilization, and costs over 10 years in a sample of older patients with schizophrenia compared with older patients without schizophrenia. An observational cohort study of 31,588 older adults (mean age: 70.44 years) receiving care from an urban public health system, including a community mental health center, during 1999-2008. Of these, 1,635 (5.2%) were diagnosed with schizophrenia and 757 (2.4%) had this diagnosis confirmed in the community mental health center. Patients' electronic medical records were merged with Medicare claims, Medicaid claims, the Minimum Dataset, and the Outcome and Assessment Information Set. Information on medication use was not available. Rates of comorbid conditions, healthcare utilization, costs, and mortality. Patients with schizophrenia had significantly higher rates of congestive heart failure (45.05% versus 38.84%), chronic obstructive pulmonary disease (52.71% versus 41.41%), and hypothyroidism (36.72% versus 26.73%) than the patients without schizophrenia (p <0.001). They had significantly lower rates of cancer (30.78% versus 43.18%) and significantly higher rates of dementia (64.46% versus 32.13%). The patients with schizophrenia had significantly higher mortality risk (hazard ratio: 1.25, 95% confidence interval: 1.07-1.47) than the patients without schizophrenia. They also had significantly higher rates of healthcare utilization. The mean costs for Medicare and Medicaid were significantly higher for the patients with schizophrenia than for the patients without schizophrenia. The management of older adult patients with schizophrenia is creating a serious burden for our healthcare system, requiring the development of integrated models of healthcare.
Article
Background: Aging societies will be confronted with increased numbers of long-term care (LTC) residents with multimorbidity of physical and mental disorders other than dementia. Knowledge about the prevalence rates, medical and psychosocial characteristics, and care needs of this particular group of residents is mandatory for providing high-quality and evidence-based care. The purpose of this paper was to review the literature regarding these features. Methods: A systematic literature search was conducted in PubMed, EMBASE, PsycINFO, and CINAHL from January 1, 1988 to August 16, 2011. Two reviewers independently assessed eligibility of studies on pre-established inclusion criteria as well as methodological quality using standardized checklists. Results: Seventeen articles were included. Only one small study describes multimorbidity of a wide range of chronic psychiatric and somatic conditions in LTC residents and suggests that physical–mental multimorbidity is rather rule than exception. All other studies show prevalence rates of comorbid physical and mental illnesses (range, 0.5%–64.7%), roughly in line with reported prevalence rates among community-dwelling older people. LTC residents with mental–physical multimorbidity were younger than other LTC residents and had more cognitive impairment, no dementia, and problem behaviors. Care needs of these residents were not described. Conclusions: Although exact figures are lacking, mental–physical multimorbidity is common in LTC residents. Given the specific characteristics of the pertaining residents, more knowledge of their specific care needs is essential. The first step now should be to perform research on symptoms and behavior, which seem more informative than diagnostic labels as well as care needs of LTC residents with mental–physical multimorbidity.
Article
To systematically compare and pool the prevalence of frailty, including prefrailty, reported in community-dwelling older people overall and according to sex, age, and definition of frailty used. Systematic review of the literature using the key words elderly, aged, frailty, prevalence, and epidemiology. Cross-sectional data from community-based cohorts. Community-dwelling adults aged 65 and older. In the studies that were found, frailty and prefrailty were measured according to physical phenotype and broad phenotype, the first defining frailty as a purely physical condition and the second also including psychosocial aspects. Reported prevalence in the community varies enormously (range 4.0-59.1%). The overall weighted prevalence of frailty was 10.7% (95% confidence interval (CI) = 10.5-10.9; 21 studies; 61,500 participants). The weighted prevalence was 9.9% for physical frailty (95% CI = 9.6-10.2; 15 studies; 44,894 participants) and 13.6% for the broad phenotype of frailty (95% CI = 13.2-14.0; 8 studies; 24,072 participants) (chi-square (χ(2) ) = 217.7, degrees of freedom (df)=1, P < .001). Prevalence increased with age (χ(2) = 6067, df = 1, P < .001) and was higher in women (9.6%, 95% CI = 9.2-10.0%) than in men (5.2%, 95% CI = 4.9-5.5%; χ(2) = 298.9 df = 1, P < .001). Frailty is common in later life, but different operationalization of frailty status results in widely differing prevalence between studies. Improving the comparability of epidemiological and clinical studies constitutes an important step forward.