Modification of sampling-exposure procedures for increasing facilities utilization by chronic psychiatric patients

Sampling-exposure procedures (Curran et al., 1973) increased the use of off-unit facilities and services, with generalization to contiguous announce-only conditions in a milieu group of chronic mental patients but not in a social-learning group. However, the social-learning group showed comparable increases when ineligibility due to standing fines and possible token shortages was removed and when eligibility for off-unit facilities and services could be obtained by an additional payment on standing fines. Results for the social-learning group demonstrate that modifying treatment programs is preferable to concluding prematurely that patients are “unresponsive to treatment”. Practical suggestions are offered for treatment of chronic patients by: treating heterogeneous groups to maximize the value of good modeling; occasionally reinstating sampling-exposure procedures to “boost” performance; and using the “purchase eligibility” procedure in combination with response-costs to maintain exposure to backup reinforcers in token programs.     

Analyses of the minimum data set: comparisons of nursing home residents with multiple sclerosis to other nursing home residents

This research compares nursing home residents with multiple sclerosis (MS) at admission to other nursing home residents using the minimum data set (MDS). These comparisons include sociodemographic characteristics and health status measures, as well as treatments and procedures received. We analysed 14,009 admission assessments in the MDS for residents with MS between June 22, 1998 and December 31, 2000. We also analysed 440,642 MDS admission assessments for all residents admitted to nursing homes during the year 2000, with any admission assessments for residents with MS excluded from this comparison group. Residents with MS were significantly younger at admission than other recently admitted residents. In addition, residents with MS tended to be significantly more physically disabled and also less cognitively impaired than other residents at admission, based on analyses of several measures of physical disability and cognitive performance. Nursing homes caring for residents with MS should provide services and programs, including mental health care, that address the needs of these younger, more physically disabled, and more cognitvely intact residents.     

Assessment and treatment units for people with intellectual disabilities and challenging behaviour in England: an exploratory survey

Background Evaluative studies have shown that special units for people with intellectual disabilities (ID) who have challenging behaviour have advantages and disadvantages. There has been no survey of their number or characteristics for nearly 20 years. Methods A questionnaire was sent to all National Health Service trusts that had ID inpatient beds, and all private or voluntary healthcare establishments providing services for people with mental health problems or ID. This asked for information about the unit, its residents and the views of the unit manager. Results Forty‐four agencies confirmed that they provided assessment and treatment units, of which 38 returned questionnaires. These units served 333 people, of whom 75% had mild or moderate ID. A quarter had been there for more than 2 years. Forty per cent of residents had a discharge plan, and 20% had this and the type of placement considered ideal for them in their home area. The main strengths of the units were identified as the knowledge and experience of the staff and having sufficient staff; the main problems as inappropriate admissions, bed‐blocking and the relationship with other services; difficulties with recruiting and retaining staff; the location and environment of the unit; and the mix of residents. Conclusions There has been an increasing rate of provision of special units, which now predominantly serve people with moderate or mild ID. This model of service provision is becoming more widespread, but the potential problems identified 20 years ago are still present. Areas are identified for further research.     

Costs of occupational therapy in residential homes and its impact on service use

The Care Home Activity Project was a feasibility study examining the effect of occupational therapy on levels of depression and quality of life of residents in care homes. This paper describes the costs of the one year occupational therapy intervention, the use and cost of services received by the residents both before and after the intervention and compares these with the services received by a control group over the same period. Eight homes in northern England were included in the study with four homes receiving the services of a full-time occupational therapist, the remaining four acting as the control group. Services received by residents in both groups were recorded at the beginning and end of the one year study. The cost of the occupational therapy intervention was computed from published unit costs with adjustments for travel, equipment costs and methods of working. There was a significant increase in the likelihood of using social services in the intervention homes. This could be explained by previously unrecognised needs being revealed by the therapists. There may have been a reduction in health costs in the intervention group. At 2005 levels, the net cost of providing the occupational therapy service was pounds 16 (E 23) per resident per week. This study demonstrates that occupational therapy is feasible in residential homes at modest cost. It may uncover unmet needs for some services. Future studies should match groups for hospital use at baseline.     

Social climate within secure inpatient services for people with intellectual disabilities

Background The social climate of inpatient facilities is thought to be an important contributor to treatment outcome. However, little research has focused on this construct within secure forensic services for people with intellectual disabilities (ID). Therefore, the objective of this study was to investigate the social climate of two different types of secure units (‘low’ secure vs. ‘medium’ secure) contained within the same facility for offenders with ID. Two hypotheses were generated: (1) residents would rate the social climate of the whole facility in a more negative direction than staff, and (2) residents and staff would rate the social climate of the ‘low’ secure unit in a more positive direction than that of the ‘medium’ secure unit. Method Using a 2 (factor ‘Participant’ = Staff or Resident) × 2 (factor ‘Unit’ = ‘Low’ or ‘Medium’ Secure Unit) between‐subjects design, 18 residents and 37 staff members were recruited and completed the Correctional Institutions Environment Scale (CIES), a measure of social climate. Results Residents tended to rate the units in a more positive direction than staff on some sub‐scales. Participants rated the ‘low’ secure unit in a more positive direction than the ‘medium’ secure unit on two sub‐scales of the CIES. However, on selected sub‐scales there were differences. The findings of this study suggest that the CIES may be a valid instrument for use within forensic services for people with ID, and further suggests that residents and staff have different perceptions of the shared social climate, which may have implications for service development.     

Effects of a Recovery-Oriented Cognitive Therapy Training Program on Inpatient Staff Attitudes and Incidents of Seclusion and Restraint

We investigated the feasibility of implementing a recovery-oriented cognitive therapy (CT-R) milieu training program in an urban acute psychiatric inpatient unit. Over a 1-month period, 29 staff members learned short-term CT-R strategies and techniques in an 8-h workshop. Trainees’ perceptions of CT-R, beliefs about the therapeutic milieu, and attitudes about working with individuals with psychosis were evaluated both before the workshop and 6 months after the workshop had been completed. Incidents of seclusion and restraint on the unit were also tallied prior to and after the training. Results indicate that staff perceptions of CT-R and their beliefs about the therapeutic environment significantly improved, whereas staff attitudes towards individuals with psychosis remained the same. Incidents of seclusion and restraint also decreased after the training. These findings provide evidence that CT-R training is feasible and can improve the therapeutic milieu of an acute psychiatric inpatient unit.     

Alcohol abuse: a source of reversible functional disability among residents of a VA nursing home

The prevalence of psychiatric disorders was determined in a sample of 196 VA nursing home residents who were interviewed using the modified Schedule for Affective Disorders and Schizophrenia (mSADS). Of the 160 subjects for whom data were available, 86% had a diagnosis of at least one psychiatric disorder. The prevalence of clinically significant cognitive impairment was 60.6% and of major depression 13.8%. Of 110 residents for whom alcohol histories were obtained, 32 (29%) had a lifetime diagnosis of alcohol abuse. The degree of impairment in activities of daily living improved significantly from the time of admission to the time of the evaluation (average 1.4 years) among those who were recently abusing alcohol compared to those who formerly abused alcohol and those who never abused alcohol. The effect is clinically as well as statistically significant and has the potential benefit of reducing caregiver burden and health care costs for the elderly. © 1997 John Wiley & Sons, Ltd.     

Functioning and health service use among elderly nursing home residents with alcohol use disorders: findings from the National Nursing Home Survey.

OBJECTIVE: The author asked whether older nursing home residents with alcohol use disorders differ from demographically-matched residents without alcohol use disorders on functioning, admission characteristics, and health services use. METHOD: National Nursing Home Survey data were used to compare nursing home residents with alcohol use disorders (N=216) with demographically-matched residents without alcohol use disorders (N=216) on functioning, admission characteristics, and health services use. RESULTS: Residents with alcohol use disorders functioned somewhat better than did residents in the demographically-matched sample group, as indicated by performance of basic activities of daily living. However, they were significantly more likely to have lived alone before admission and to have obtained mental health and social services. There was a significant group x gender interaction on length of stay: men with alcohol use disorders had shorter lengths of stay than did men without alcohol use disorders; women with alcohol use disorders had longer lengths of stay than did women without such disorders. CONCLUSIONS: Having fewer social resources may contribute to elevated admission risk and need for mental health and social services among older nursing home residents who have alcohol use disorders. Duration and severity of alcohol problems may help explain gender differences in length of stay among these residents.     

Clinical characteristics and service use of persons with mental illness living in an intermediate care facility.

OBJECTIVE: The study examined the characteristics of residents living in a 450-bed intermediate care facility for persons with severe mental illness in Illinois and sought to determine the factors predicting their utilization of mental health services. METHODS: Data on 100 randomly selected residents with a chart diagnosis of schizophrenia were collected using chart review and interviews. Data for 78 residents whose diagnosis of schizophrenia or schizoaffective disorder was confirmed using the Structured Clinical Interview for DSM-IV were included in the analyses. RESULTS: Fifty-three percent of the residents used facility-based specialty mental health services beyond medication management, such as group therapy or a day program. Persons with the least severe psychiatric illnesses and with higher levels of motivation for overall care used the most mental health services. Thirty-five percent of the residents had been discharged to an inpatient psychiatric unit during the previous year. Residents most likely to be discharged to those settings were young men with a history of homelessness who refused facility-based health services. CONCLUSIONS: Despite recent policy-driven efforts to improve care in this intermediate care facility for persons with mental illness, the facility continues to have problems addressing the mental health needs of the residents.     

Psychosis, depression and behavioural disturbances in Sydney nursing home residents: prevalence and predictors

BACKGROUND: There is wide variation in the rates of behavioural and psychological symptoms of dementia (BPSD) reported in nursing homes. AIMS: This study aimed to investigate: (1) the prevalence of BPSD in nursing home residents using the BEHAVE-AD; (2) the relationships of BPSD with (a) demographic, (b) dementia, (c) diurnal and (d) nursing home variables; and (3) the inter-relationships between different types of BPSD, as measured by subscales of the BEHAVE-AD. RESULTS: Over 90% of residents exhibited at least one behavioural disturbance. Specifically, there was evidence of psychosis in 60%, depressed mood in 42% and activity disturbances or aggression in 82% of residents. Younger, more functionally impaired residents with a chart diagnosis of psychosis had higher BPSD rates, as did those residing in larger nursing homes. Individual BPSD were significantly intercorrelated. CONCLUSIONS: BPSD are ubiquitous in nursing home residents. Behavioural disturbances are frequently associated with psychosis and/or depression. The findings suggest the need for psychogeriatric services to nursing homes and smaller facilities.     

Characteristics and outcomes of dementia residents in an assisted living facility

BACKGROUND: Assisted living (AL) is the fastest growing segment of residential long-term care in the US. At least half of the estimated 1 million AL residents have dementia or cognitive impairment, with many AL facilities offering specialized dementia services. Little research has been done on the demographics, outcomes, or clinical variables of this population.METHODS: Participants were a cohort of 144 residents admitted to the AL unit of Copper Ridge, a specialized dementia-care facility. Comparison samples included 737 patients with dementia residing in other locations (home, nursing home, and other assisted living facilities). Selected measures of cognition, behavior, medical health, and function were taken at admission to AL and at 6-month intervals.RESULTS: When compared with residents of the dementia-specialized AL facility, dementia patients at home were younger, less cognitively impaired, and less likely to exhibit wandering, delusions, or aggression. Residents of a dementia-specialized nursing home had more cognitive impairment, greater medical comorbidity, and were more dependent on caregivers. The 2-year mortality rate in the dementia-specialized AL was 23%, significantly lower than rates reported for nursing homes. Primarily due to increasing care needs, most residents in the specialized AL relocated to a nursing home after a median stay of 10.9 months. Depression, falling, and wandering were significant predictors of the transition.CONCLUSION: Dementia-specialized AL facilities occupy a unique position in the long-term care continuum that is distinct from home-care and nursing home facilities. This research is the first step toward understanding the significant dementia population residing in assisted living.     

Does Closing Inpatient Beds in One Public Mental Health System Result in Increased Use of Hospital Services in Other Systems?

This study of users of Department of Veterans Affairs (VA) behavioral health services examines changes in their use of non-VA inpatient services from 1994 to 1997, a period of extensive VA bed closures. Data on service use were obtained on New York State residents who used VA behavioral health services and on residents who were hospitalized for behavioral health care at community general hospitals and state mental hospitals. Probabilistic population estimation, a novel statistical technique, was employed to evaluate the degree of overlap between VA mental health and non-VA inpatient populations without relying on person-specific identifiers. Annually, on average, 6% of VA behavioral health service users were hospitalized in either general hospitals in New York State or state mental hospitals: 4% of psychiatric patients, 10% of substance abuse patients, and 11% of dually diagnosed patients. Overall rates of cross system use did not change significantly from 1994 to 1997. Cross-system use of inpatient services is limited and was not affected by the closure of one-third of all VA mental health beds, most likely because of an increased supply of VA outpatient services.     

A 16-year follow-up of a child inpatient population

The purpose of this study was to evaluate long-term outcomes of children who had been inpatients in a child psychiatry unit. Fifty children, who were consecutive admissions to a Dublin inpatient child psychiatry unit between November 1978 and July 1980, were followed up 16 years later. We obtained some direct information on 33 subjects; of these, 4 subjects had died and 11 subjects (33%) were living abroad. A poor outcome as defined by death, imprisonment, adult psychiatric disorder or unemployment was present in 18 of the 24 subjects (79%) on whom this information was available. We conclude that more support and increased availability of services post discharge are needed. Accepted: 23 August 1999     

Impact of dining room environment on nutritional intake of Alzheimer's residents: a case study

This case study, in a Veterans Affairs Alzheimer's unit, was conducted to evaluate noise and lighting conditions at mealtimes and to assess the food intake of ambulatory dementia residents. The case study compared the noise, lighting, and nutritional intake of 16 Alzheimer's residents eating the same cycle menu in the extended-care (EC) dining room and the Alzheimer's unit (AU) dining room five weeks later. Noise was significantly lower in the EC (p < or = .02). Lighting was significantly higher in the EC (p < or = .001). Intake of calories and protein was slightly higher, with some days significantly higher, in the AU. Total five-day fluid intake at breakfast was significantly higher in the AU (p < or = .02). Although residents' total food and fluid intake was higher in the AU, the project identified a need to decrease noise and increase lighting in the AU. Lighting enhancement and noise reduction may further improve intake, which, in turn, may promote improved nutritional status.     

Improved seizure control by alternating therapy of levetiracetam and valproate in epileptic rats

Purpose: Tolerance to drug treatment is a serious problem in the treatment of epilepsy. We previously showed that tolerance to levetiracetam (LEV) developed within 4 days after the start of the treatment in a rat model for spontaneous seizures after electrically induced status epilepticus. In the current study we tested whether the development of tolerance to LEV could be prevented by alternating between LEV and valproate (VPA) treatment. Methods: Before starting the alternating therapy with LEV and VPA (3 day LEV–3 day VPA, two cycles), we assessed the efficacy of VPA monotherapy by administering VPA to chronic epileptic rats via osmotic minipumps during 7 days. The anticonvulsive effects were determined by continuous video‐EEG (electroencephalography) monitoring, and the concentration of VPA and LEV was measured in plasma using gas chromatography. Results: VPA significantly suppressed spontaneous seizures in chronic epileptic rats for 5 days. Hereafter, seizure frequency increased to pretreatment values despite adequate VPA blood levels. Seizure duration was reduced for 6 days during treatment. Seizure severity was reduced throughout the 7‐day treatment period. Alternating treatment of LEV and VPA did not prevent development of tolerance; however, seizures were suppressed significantly longer compared to VPA and LEV monotherapy. Conclusions: Because alternating treatment with LEV and VPA led to a prolonged effective seizure control in the animal model, it would be worthwhile to explore the possibilities of using an alternating treatment protocol in pharmacoresistant patients in whom an effective treatment is hampered by tolerance to antiepileptic drugs.     

Engaging life in two Irish nursing home units for people with dementia: Quantitative comparisons before and after implementing household environments

Objectives: This study compares the Social Engagement and Interactive Occupation of residents with dementia in two Irish nursing homes, before and after conversion to a household model environment. The changes were an open plan design and a functioning unit kitchen, supported by a homemaker role and operational policies which reduced task-based work in favour of person-centred care offering choice.

Method: A snapshot observation method was used to obtain quantitative data of resident activity using the Assessment Tool for Occupation and Social Engagement (ATOSE). Residents were assessed for four hours, on seven different weekdays, over a six-week period both pre- and post-renovation. The exception to this was the assessment of the traditional model unit (TMU) for Nursing Home 1 which was reduced to four days due to the early start of the building work.

Results: The results were consistent for both nursing homes and data were aggregated. Residents spent more time in the communal living spaces and were more likely to be active and engaged in the household model units (HMUs) compared to the TMUs. Using the independent t-test, these changes were found to be highly significant (p? Conclusion: Creating an HMU increased the Interactive Occupation and Social Engagement of residents in the communal areas of the two nursing homes. The physical environment change, in conjunction with supportive staff procedures and organizational initiatives, improved the well-being of residents with dementia. The outcomes must be viewed in context with financial implications.     

Responses of human limbic neurons to induced changes in blood gases.

Fine wires were stereotaxically placed in the temporal lobes of psychomotor epileptics for diagnostic purposes. The single and multiple units detected by these chronic electrodes were recorded during olfaction and changes in ventilation. No unit responsive to odorous stimuli was found in the amygdala (n = 116), hippocampus (n = 90), or hippocampal gyrus (n = 173). However, approximately 20% of the units in all 3 structures showed definite changes in firing rate during sniffing from an empty or odorous flask for varying periods of time or during hyperventilation with the nose or mouth plugged. These units did not respond to a variety of control tasks, including passive olfactory and trigeminal stimulation. In all structures, patients, and tasks, the unit response had a latency of 10–15 sec and persisted for about 20 sec after the hyperventilation or sniffing terminated. No relationship was found between the location of responsive units and localized abnormal epileptiform slow waves or EEG spikes. In two patients, the unit responses to hyperventilating a CO₂O₂ mixture were opposite to the responses obtained when hyperventilating air. These tasks were identical in their sensory and motor components, but produced opposite effects on cerebral vasculature. Therefore, those units responsive to changes in ventilation appear to be directly sensitive to changes in their physiological milieu. Information from previously published studies suggests that the critical stimulus for the unit response is the decrease in cerebral O₂ availability caused by hyperventilation. It is further hypothesized that the responsive neurons lie in areas of relatively deficient O₂ supply equidistant between adjacent capillaries.     

Evaluation of psychiatric training in the emergency room

Records of 233 patients evaluated by psychiatric residents in the Emergency Room and subsequently reevaluated by senior psychiatrists in the Acute Treatment Clinic were examined for gross discrepancies in diagnosis, mental status, prescribed medication, and appropriate disposition of outpatients to a crisis clinic. The work in the Emergency Room was rated satisfactory in 90% of the cases. Length of training heightened the agreement between residents and senior staff on the mental status examination, the diagnosis and, to a lesser extent, the medication. There was no relationship between length of training and the agreement about the disposition. This was probably due to the lack of follow-up of the patients by the residents who had seen them in the Emergency Room. It was concluded that for optimal training purposes the Emergency Room experience should be combined with work in a crisis clinic where residents continue to treat patients whom they have referred from the Emergency Room.     

Does a hostel's managing agency determine the access to psychiatric services of its residents?

This study examines the effect of managing agency (local authority, private or voluntary) on the use of other health and social care services by residents in mental health hostels and group homes with different levels of staffing in England and Wales. The sample comprised 1323 residents in 275 facilities in eight districts. The measures of service use were number of days in hospital and number of other service contacts. There were highly significant differences between facilities with similar levels of staffing managed by different agencies. Residents in the voluntary sector used fewer community services overall; residents in low-staffed local authority facilities used more services than those in similar facilities managed by other agencies. These differences were not easily explained by differences in the social or clinical characteristics of residents. This suggests that there may be organisational factors, e.g. hostel staff knowledge of services, which influence access to and use of community services. Accepted: 2 March 1998     

Analyses of nursing home residents with multiple sclerosis and depression using the Minimum Data Set

Depression is the most common psychiatric condition among people with multiple sclerosis (MS). A total of 14009 people with MS at admission to a nursing facility were analyzed using the Minimum Data Set and 36% also had depression. This study developed profiles of nursing home residents with MS who also had depression and compared them with other residents with MS. MS residents with depression were significantly more likely to be female and younger than other MS residents, with significant racial differences as well. MS residents with depression were significantly more likely than other MS residents to have a history of mental health conditions, exhibit mood indicators, and have unsettled relationships. Both groups of MS residents had high levels of physical disability, although MS residents with depression tended to be slightly less disabled. MS residents with depression were more likely than other MS residents to experience daily pain and more likely to have the diseases common to all residents with MS. This research found that most MS residents with depression did not receive mental health services, demonstrating that nursing facilities must improve the mental healthcare provided to residents with MS with depression.