The high prevalence of mental disorders among residents of long-term care (LTC) homes is highlighted in the paper by Seitz et al. in this special issue of International Psychogeriatrics. The International Psychogeriatric Association's Task Force on Mental Health Services in LTC Homes was formed in 2005 with two goals: (1) to gather information and share views from diverse countries and settings about how best to restore or ensure good mental health in LTC settings; and (2) to support and strengthen mental health services in the LTC sector. Since its formation, groups of members of the Task Force have visited residential facilities in Stockholm, Lisbon, Istanbul, Osaka, Dublin, Montreal and the Netherlands. Members have also reported on visits to LTC homes in the U.S.A., U.K., Korea, Thailand, South Africa and Nigeria. Further visits have been arranged during the IPA's meeting in Spain in September 2010. Information has also been provided by members in discussion groups and in response to a Task Force survey about facilities in various other countries.

Background: The population of older adults in long-term care (LTC) is expected to increase considerably in the near future. An understanding of the prevalence of psychiatric disorders in LTC will help in planning mental health services for this population. This study reviews the prevalence of common psychiatric disorders in LTC populations.

Methods: We searched electronic databases for studies on the prevalence of major psychiatric disorders in LTC using medical subject headings and key words. We only included studies using validated measures for diagnosing psychiatric disorders or psychiatric symptoms. Our review focused on the following psychiatric disorders: dementia, behavioral and psychological symptoms of dementia (BPSD), major depression, depressive symptoms, bipolar disorder, anxiety disorders, schizophrenia, and alcohol use disorders. We also determined the prevalence of psychiatric disorders in the U.S. LTC population using data from the 2004 National Nursing Home Survey (NNHS).

Results: A total of 74 studies examining the prevalence of psychiatric disorders and psychological symptoms in LTC populations were identified including 30 studies on the prevalence of dementia, 9 studies on behavioral symptoms in dementia, and 26 studies on depression. Most studies involved few LTC facilities and were conducted in developed countries. Dementia had a median prevalence (58%) in studies while the prevalence of BPSD was 78% among individuals with dementia. The median prevalence of major depressive disorder was 10% while the median prevalence of depressive symptoms was 29% among LTC residents. There were few studies on other psychiatric disorders. Results from the 2004 NNHS were consistent with those in the published literature.

Conclusions: Dementia, depression and anxiety disorders are the most common psychiatric disorders among older adults in LTC. Many psychiatric disorders appear to be more prevalent in LTC settings when compared to those observed in community-dwelling older adults. Policy-makers and clinicians should be aware of the common psychiatric disorders in LTC and further research into effective prevention and treatments are required for this growing population.

Background: Neuropsychiatric symptoms (NPS) occur frequently in residents of long-term care institutions. The aim of this study was to review the literature systematically on the course of NPS in residents with dementia in long-term care institutions.

Methods: A systematic literature search was conducted using Medline, PsychInfo, Embase and Cinahl. Search terms included “dementia”, “long-term care institutions”, “NPS”, “longitudinal”, and additional related terms. All titles and abstracts were independently assessed for inclusion and for methodological quality by two researchers, and the full texts of relevant papers were retrieved. Inclusion criteria were: dementia diagnosis, long-term care institutions, NPS, and longitudinal design.

Results: The literature search revealed 1982 papers of which 18 met the inclusion criteria. The patients were predominately female and aged 75 years and over. The follow-up period ranged from three months to one year. The number of assessments ranged from two to five, and 12 different assessment instruments were used to study NPS. Aberrant motor behavior, depression, anxiety, and euphoria showed decline over time, and psychosis remained constant whereas apathy, agitation, irritability, and disinhibition increased over time. All symptoms showed specific intermittent courses. The methodological quality of the literature was limited by the small sample sizes, short follow-up periods, and lack of comprehensive neuropsychiatric assessment instruments.

Conclusions: In the reviewed studies, NPS in institutionalized residents with dementia showed a heterogeneous course, although methodological limitations and the diversity of the studies call for caution in interpretation. Future research should focus on large prospective cohort studies with institutionalized residents with dementia, examining a wide range of NPS.

Background: The IPA Taskforce on Mental Health Issues in Long-Term Care Homes seeks to improve mental health care in long-term care (LTC) homes. The aim of this paper is to provide recommendations on comprehensive assessment of depression and behavioral problems in order to further stimulate countries and professionals to enhance their quality of care.

Methods: Existing guidelines on comprehensive assessment of depression or behavioral problems in nursing home (NH) patients or patients residing in LTC homes were collected and a literature review was carried out to search for recent evidence.

Results: Five guidelines from several countries all over the world and two additional papers were included in this paper as a starting point for the recommendations. Comprehensive assessment of depression in LTC homes consists of a two-step screening procedure: an investigation to identify factors that influence the symptoms, followed by a formal diagnosis of depression according to DSM-IV-TR or the Provisional Diagnostic Criteria for Depression in Alzheimer Disease in cases of dementia. Comprehensive assessment of behavioral problems encompasses three steps: description and clarification of the behavior, additional investigation, and assessment of probable causes of the behavior. The procedure starts in the case of moderate behavioral problems.

Conclusion: The recommendations given in this paper provide a useful guide to professional workers in the LTC sector, but clinical judgment and the consideration of the unique aspects of individual residents and their situations is necessary for an optimal assessment of depression and behavioral problems. The recommendations should not be rigidly applied and implementation will differ from country to country.

Background: The prevalence of mental disorders in long-term care (LTC) homes is high, but quality and availability of mental health services to assess and help in management of cases have been criticized.

Method: Literature concerning mental health problems in LTC homes was reviewed, especially regarding models of mental health service delivery and factors that affect development, persistence and reduction of symptoms and distress.

Results: The advantages of consultation-liaison arrangements and of telepsychiatry were noted. Discussions led to development of recommendations aimed at improving mental health expertise and provision of assessment and intervention services in LTC homes in diverse countries. Prompt recognition of mental health problems among residents is required, with availability of a team working within the facility to deal with these problems. Commonly such multidisciplinary teams are formed by facility staff linking with visiting mental health professionals or services. Quality of care is also affected by the organization, attitudes and education within LTC facilities.

Conclusion: Provision of optimal mental health care in LTC settings is dependent on adequate funding, availability of expertise and education, positive and caring attitudes, recognition of needs, and supportive teamwork. The latter should include cooperative links between well-resourced and under-resourced regions.

Background: The International Psychogeriatric Association Task Force on Mental Health Services in Long-Term Care Facilities aims to support and strengthen mental health services in the long-term care sector. The purpose of this paper is to identify broad principles that may underpin the drive towards meeting the mental health needs of residents of long-term care facilities and their families, as well as to enhance the overall delivery of residential care services.

Methods: Principles of good care are extrapolated from an analysis of international consensus documents and existing guidelines and discussed in relation to the research and practice literature.

Results: Although the attention to principles is limited, this review reveals an emerging consensus that: (1) residential care should be situated within a continuum of services which are accessible on the basis of need; (2) there should be an explicit focus on quality of care in long-term care facilities; and (3) quality of life for the residents of these facilities should be a primary objective. We take a broad perspective on the challenges associated with actualizing each of these principles, taking into consideration key issues for families, facilities, systems and societies.

Conclusions: Recommendations for practice, policy and advocacy to establish an internationally endorsed principles-based framework for the evolution and development of good mental health care within long-term care facilities are provided.

Background: A large and growing number of people with dementia are being cared for in long-term care. The empirical literature on the design of environments for people with dementia contains findings that can be helpful in the design of these environments. A schema developed by Marshall in 2001 provides a means of reviewing the literature against a set of recommendations. The aims of this paper are to assess the strength of the evidence for these recommendations and to identify those recommendations that could be used as the basis for guidelines to assist in the design of long term care facilities for people with dementia.

Methods: The literature was searched for articles published after 1980, evaluating an intervention utilizing the physical environment, focused on the care of people with dementia and incorporating a control group, pre-test-post-test, cross sectional or survey design. A total of 156 articles were identified as relevant and subjected to an evaluation of their methodological strength. Of these, 57 articles were identified as being sufficiently strong to be reviewed.

Results: Designers may confidently use unobtrusive safety measures; vary ambience, size and shape of spaces; provide single rooms; maximize visual access; and control levels of stimulation. There is less agreement on the usefulness of signage, homelikeness, provision for engagement in ordinary activities, small size and the provision of outside space.

Conclusions: There is sufficient evidence available to come to a consensus on guiding principles for the design of long term environments for people with dementia.

Background: This paper was written as a result of the International Psychogeriatric Association Task Force on Mental Health Services in Long-Term Care. The appraisal presented here aims to (1) identify the best available evidence that underpins best practice for geriatric mental health education and training of staff working in long-term care, and (2) summarize the appraisal of the literature to provide recommendations for practice.

Methods: An initial search of databases found 138 papers related to the search strategy. Selected papers were summarized and compared against set inclusion criteria. This resulted in 17 papers suitable for review.

Results: The majority of papers focused on behavior skills training. A number of key factors were identified that determine the success of geriatric mental health education and training and recommendations are outlined.

Conclusions: Methodological weaknesses are common and highlight the need for further replication studies using strong research designs.

Introduction: The International Psychogeriatric Association Task Force on Mental Health Services in Long-Term Care Facilities seeks to improve care of persons in residential aged care facilities (RACFs). As part of that effort the current authors have contributed an overview and discussion of the uses of brief screening instruments in RACFs.

Methods: While no current guidelines on the use of screening instruments in nursing homes were found, relevant extant guidelines were consulted. The literature on measurement development, testing standards, psychometric considerations and the nursing home environment were consulted.

Results: Cognitive, psychiatric, behavioral, functional and omnibus screening instruments are described at a category level, along with specifics about their use in a RACF environment. Issues surrounding the selection, administration, interpretation and uses of screening instruments in RACFs are discussed. Issues of international interest (such as translation of measures) or clinical concern (e.g. impact of severe cognitive decline on assessment) are addressed. Practical points surrounding who can administer, score and interpret such screens, as well as their psychometric and clinical strengths more broadly, are articulated.

Conclusions: Guidelines for use of screening instruments in the RACF environment are offered, together with broad recommendations concerning the appropriate use of brief screening instruments in RACFs. Directions for future research and policy directions are outlined, with particular reference to the international context.

Background: Psychosocial interventions in long-term care have the potential to improve the quality of care and quality of life of persons with dementia. Our aim is to explore the evidence and consensus on psychosocial interventions for persons with dementia in long-term care.

Methods: This study comprises an appraisal of research reviews and of European, U.S. and Canadian dementia guidelines.

Results: Twenty-eight reviews related to long-term care psychosocial interventions were selected. Behavioral management techniques (such as behavior therapy), cognitive stimulation, and physical activities (such as walking) were shown positively to affect behavior or physical condition, or to reduce depression. There are many other promising interventions, but methodological weaknesses did not allow conclusions to be drawn. The consensus presented in the guidelines emphasized the importance of care tailored to the needs and capabilities of persons with dementia and consideration of the individual's life context.

Conclusions: Long-term care offers the possibility for planned care through individualized care plans, and consideration of the needs of persons with dementia and the individual life context. While using recommendations based on evidence and consensus is important to shape future long-term care, further well-designed research is needed on psychosocial interventions in long-term care to strengthen the evidence base for such care.

Background: Technology has emerged as a potential solution to alleviate some of the pressures on an already overburdened care system, thereby meeting the growing needs of an expanding population of seriously cognitively impaired people. However, questions arise as to what extent technologies are already being used in residential care and how ethically and practically acceptable this use would be.

Methods: A systematic literature review was conducted to explore what is known on the moral and practical acceptability of surveillance technologies in residential care for people with dementia or intellectual disabilities, and to set forth the state of the debate.

Results: A total of 79 papers met the inclusion criteria. The findings show that application and use of surveillance technologies in residential care for vulnerable people generates considerable ethical debate. This ethical debate centers not so much around the effects of technology, but rather around the moral acceptability of those effects, especially when a conflict arises between the interests of the institution and the interests of the resident. However, the majority of articles lack in depth analysis.

Furthermore, there are notable cultural differences between the European literature and American literature whereby in Britain there seems to be more ethical debate than in America. Overall however, there is little attention for the resident perspective.

Conclusion: No ethical consensus has yet been reached, underlining the need for clear(er) policies. More research is thus recommended to determine ethical and practical viability of surveillance technologies whereby research should be specifically focused on the resident perspective.

Background: Although studies have shown the prevalence of depression in nursing homes to be high, under-recognition of depression in these facilities is widespread. Use of screening tests to enhance detection of depressive symptoms has been recommended.

Methods: This paper aims to provoke discussion about optimal management of depression in nursing homes. The utility of the Cornell Scale for Depression in Dementia (CSDD) is considered. CSDD data relating to residents assessed in 2008–2009 were collected from three Sydney nursing homes.

Results: CSDD scores were available from 162 residents, though raters stated they were unable to score participants on at least one item in 47 cases. Scores of 13 or more were recorded for 23% of residents in these facilities, but in most of these cases little was documented in case files to show that the results had been discussed by staff, or that they led to interventions, or that follow-up testing was arranged.

Conclusions: Results of CSDD testing should prompt care staff (including doctors) to consider causation of depression in cases where residents are identified as possibly depressed. In particular, there needs to be discussion of how to help residents to cope with disability, losses, and feelings of powerlessness. Research is needed, examining factors that might predict response to antidepressants, and what else helps. Accreditation of nursing homes could be made to depend partly on evidence that staff regularly search for, and (if found) ensure appropriate responses to, depression.

Background: Nursing home residents are often prescribed large numbers of psychotropic medications. Previous studies suggest that antipsychotic medications are often unnecessary and can be withdrawn without ill effects. Depression, in contrast, is believed to be under-recognized and under-treated.

Method: A six-month audit was carried out of the antipsychotic, antidepressant, anxiolytic and hypnotic medications prescribed to 166 newly admitted residents of a convenience sample of seven nursing homes in Melbourne, Australia.

Results: Over the six-month period, antidepressants were started in 6% of all cases and stopped in 2% of treated cases. Antipsychotics were added in 5% of all cases and stopped in 15% of treated cases. Residents were switched from one antidepressant to another in 5% of treated cases and from one antipsychotic to another in 4%. Benzodiazepine use was relatively modest.

Conclusions: Judging from epidemiological data, treatment revisions were almost certainly insufficient to address residents’ mental health needs. We discuss ways of harnessing existing nursing and pharmacy resources to ensure better care for aged residents.

Background: Dementia and depression are common in advanced age, and often co-exist. There are indications of a decreased prevalence of depressive symptoms among old people in recent years, supposedly because of the manifold increase in antidepressant treatment. Whether the prevalence of depressive symptoms has decreased among people in different stages of dementia disorders has not yet been investigated.

Methods: A comparison was undertaken of two cross-sectional studies, conducted in 1982 and 2000, comprising 6864 participants living in geriatric care units in the county of Västerbotten, Sweden. Depressive symptoms were measured using the Multi-Dimensional Dementia Assessment Scale (MDDAS), and the cognitive score was measured with Gottfries’ cognitive scale. Drug data were obtained from prescription records.

Results: There was a significant decrease in depressive symptom score between 1982 and 2000 in all cognitive function groups except for the group with moderate cognitive impairment. Antidepressant drug use increased in all cognitive function groups.

Conclusion: The prevalence of depressive symptoms decreased between 1982 and 2000, in all levels of cognitive impairment except moderate cognitive impairment. This might possibly be explained by the depressive symptoms having different etiologies in different stages of a dementia disorder, which in turn might not be equally susceptible to antidepressant treatment.

Background: Understanding the prevalence, incidence and cofactors of depression among long-term elderly nursing home (LTNH) residents domiciled for eight months or more may help optimize depression treatment in this vulnerable group. We quantified first year depression in American LTNH residents and the associations between depression and resident/facility characteristics.

Methods: Data were obtained from the Minimum Data Set and Online Survey Certification and Reporting for 634,060 LTNH residents admitted from 1999 to 2005 in 4,216 facilities. Depression first diagnosed at admission and at subsequent quarterly intervals through the first year of stay was examined. Logistic regressions modeled correlates of newly identified depression in each time-period.

Results: Recorded depression at admission and during the first year increased from 1999 to 2005. By 2005, 54.4% of LTNH residents had depression diagnosed over the first year; 32.8% at admission and a further 21.6% later during the first year. Antidepressant use was reported prior to depression diagnosis for 48% of those first identified depressed after admission. Men, non-Hispanic blacks, never married, and severely-cognitively impaired LTNH residents were less often identified with depression, particularly at admission. Pain and physical comorbidity were positively associated with depression identified throughout the first year. Prior institutionalization was associated with depression at admission, but not new depression after admission. Facility characteristics had weaker associations with depression.

Conclusions: High depression rates at admission and during the first year indicate a need to monitor and treat large numbers of American LTNH residents for depression. Reduced associations between demographics and depression as stays progress suggest other factors have increased roles in depression etiology.

Background: Screaming is common among older persons living with dementia in nursing homes. Research on this population has not provided a useful basis for understanding such behavior that could help determine appropriate interventions. The purpose of this study was to explore the meanings of screams in older people living with dementia and their influencing factors.

Methods: Critical ethnography was selected as the research design. Seven triads, each composed of an older person living with dementia who screamed, a primary family caregiver, and one or two formal caregivers, were recruited in a nursing home. Various data collection methods and Spradley's (1979) ethnographic analysis were used.

Results: Screaming is related to vulnerability, suffering, and loss of meaning experienced by older persons. This singular behavior also expresses various final outcomes that can be differentiated through modulation criteria. The meanings of screams are influenced by stability and flexibility in the nursing care organization and reciprocal effects between older persons who scream and others in the nursing home environment. Each person's screams constitute a unique language that can be learned. Other influencing factors include respect for the older person's wishes, needs, and personality, shifts in power relations within the triad, and feelings of powerlessness and guilt in family and formal caregivers.

Conclusions: This study advances knowledge of the meanings of screams in older persons living with dementia. It has implications for and offers insight on culturally congruent care for older persons living with dementia and the people around them.

Background: This study sought to investigate the extent to which structural and functional social support promotes psychological well-being among nursing home residents in a Chinese society.

Methods: 71 nursing home residents (57 women, 14 men) provided ratings on contact frequency and emotional and instrumental support exchanges with network members. Psychological well-being was measured using depression, loneliness, positive affect, and life satisfaction.

Results: Network size was associated with well-being, but was largely nonsignificant after controlling for frequency of contact or functional support. Contact and support from staff and fellow residents were consistently related to all well-being variables, whereas interactions with family were associated with life satisfaction and positive affect only. Being able to reciprocate support was also related to well-being in this sample of frail elderly, controlling for other factors.

Conclusion: Interactions with staff and residents in the institution are more protective of well-being than interactions with family members. Even in a society where familism is strongly valued, assimilation into the institution facilitates support exchange when needed.

Social isolation is an important determinant of elderly suicides (Shah and De, 1998). If elderly people have telephones then social isolation can be reduced as they can contact friends and relatives and vice versa. Also, the elderly can use the telephone to seek help from telephone helplines, general practitioners, social workers, psychiatric services and friends and relatives. Additionally, general practitioners, social workers, psychiatric services and friends and relatives can contact elderly people to check on them and support them. However, a major criticism of such interventions is that those determined to kill themselves are unlikely to use a helpline. There are several studies looking at the relationship between suicide and telephone help lines. These studies showed evidence that the helpline reduced suicidality during the course of the telephone consultation or immediately afterwards and reduced the number of re-attempted suicides (De Leo et al., 1995; Mishara and Daigle, 1997; Vaiva et al., 2006; Gould et al., 2007). A study of elderly participants reported an association between lower suicide rates and availability of a telephone help and telephone check service (De Leo et al., 1995). This service provided elderly people with home assistance by allowing them to call for help and to receive weekly assessments of needs and emotional support. However, there are only a limited number of studies in this area. Therefore, a cross-national study examining the relationship between elderly suicide rates and the prevalence of societal use of telephone was undertaken.