Psychiatric consultation in the nursing home. An inquiry among Amsterdam nursing home physicians

Psychiatric disorders are common among nursing home residents. However, little is known about psychiatric consultation in Dutch nursing homes. As an exploration of the topic, Amsterdam-based nursing home physicians were asked to rate a number of aspects of psychiatric consultation as performed in their nursing home. Striking differences are reported between 14 participating nursing homes with regard to the intensity of psychiatric consultation and the number of consultation requests, which seems low compared with the perceived psychiatric problems. Somatically ill and psychogeriatric residents are estimated to generate an equal number of consultation requests. Psychiatric consultation appears to be characterized by diagnostic clarification, medication recommendations and behavioral management advice whereas staff-directed activities are scarce. Physicians report shortcomings in psychiatric skills among care staff. Research is necessary concerning the psychiatric care delivered to nursing home residents, as well as with regard to the optimal model for psychiatric consultation services. Integration of psychiatric care in nursing homes with mental health care services appears to be desirable.     

New structures in geriatric care: the geriatric home consultation by a nurse practitioner

The growing number of elderly and chronically ill people causes an increasing demand for care. New patterns in care for geriatric patients are required, to guarantee geriatric care in the future. In the Transmural Model for Geriatric Care, the geriatric nurse practitioner participates in geriatric home consultation. The geriatric nurse practitioner makes the home visits of the geriatrician. First experiences with home consultation by geriatric nurse practitioner are positive. The input of the geriatric nurse practitioner in home consultation has two goals: care substitution and improvement of quality of care. Substitution of care enlarges the possibilities of the geriatrician, which are limited now, because of the enormous demand for geriatric care. The specific tasks of the geriatric nurse practitioner are functional assessment and care coordination.     

Changing patterns of home visiting in the north of England.

The visiting habits of general practitioners in the north of England in 1969 and in 1980 have been compared. During this period overall visiting was reduced by 41%. The reduction was most pronounced in repeat visits, particularly to children. There was a greater reduction in visits to patients with respiratory disease than to those with other illness. The reduction was least in visits to patients over the age of 65. New visits requested by patients were reduced by 31%, but the general practitioner still considered that about the same percentage of patients could have attended the surgery as in 1969. The reasons for these differences include flexible appointment systems, improved efficiency, better organisation of the surgery, and more flexible arrangements for certification of absence from work. Though total workload (as measured by the number of consultations with patients) has diminished, general practice has changed, being more concerned with prevention, chronic disease, and vocational training.     

Whether or not to treat pneumonia curatively in (demented) psychogeriatric patients: evaluation of a guideline for nursing home physicians

A guideline was developed to support decision-making about whether or not to treat pneumonia curatively in psychogeriatric (demented) nursing home patients. This guideline was developed as a 'checklist of considerations', primarily of the ethical and legal aspects of decision-making. Nursing home physicians used and evaluated the list. The list's acceptance was assessed by measuring the frequency of the list's use, and judgements of the list's contents and 'usefulness'. The list was used in 50 out of 58 participating nursing homes, in 47% of the 489 psychogeriatric patients in whom pneumonia occurred. The list was found somewhat to very useful to support decision-making in 47% of 107 individual patients. For the targeted patient category as a whole, 85% of 48 physicians who were asked retrospectively (one physician per home) found the list somewhat to very useful. The content of the list was judged favourably. In conclusion, the nursing home physicians accepted the considerations of the checklist as a basis for decision-making on whether or not to treat pneumonia curatively in psychogeriatric patients. In the future, the format of the list can be adapted for use in diverse clinical situations. Suggestions are provided to increase user friendliness and usefulness.     

Patterns of goal attainment among young mothers in a home visiting program

This paper examined heterogeneity in parents’ patterns of goal attainment following home visiting. Young mothers (n = 696) participating in a randomized controlled trial (RCT) evaluation of a statewide home visiting program were classified, using latent class analysis (LCA), according to their pattern of goal attainment (i.e., educational attainment, employment, parenting, personal functioning) two years postpartum. We explored direct and indirect (via social connectedness) associations between program participation and goal attainment. LCA revealed four classes: (a) High Education & Employment/High Parenting & Personal Functioning (n = 286, 41%); (b) High Education & Employment/Low Parenting & Personal Functioning (n = 212, 30%); (c) Low Education & Employment/Low Parenting & Personal Functioning (n = 71, 10%); and (d) Low Education & Employment/High Parenting & Personal Functioning (n = 127, 18%). Home visiting was not directly associated with class membership, but indirectly through social connectedness. This paper contributes to understanding home visiting impacts.     

Male Corncrakes Crex crex extend their home ranges by visiting the territories of neighbouring males

Capsule Radiotracked male Corncrake often intruded on the territories of neighbouring males.

Aims To test that intruders' visits are goal-directed, not just a by-product of extended spatial activity during daylight hours.

Methods Using radiotelemetry, we sampled a total of 20 three-day home ranges from 11 tagged males. We recorded daily vocal activity and used a permutation test to see if the movements of tracked males were independent of the position of neighbouring males.

Results The majority of males who had a neighbouring male, up to approximately 600 m from their night calling site, undertook goal-directed visits to the neighbour's territory. Males undertook these visits every day, or every other day, when the neighbours were close. Males undertook visits approximately once every three days when they were more distant. The time spent in the neighbour's territory was longest where the distance between night calling sites was about 200 m. Males tended to be silent in neighbour's territory, apparently to prevent confrontation. Otherwise the distance of neighbouring males did not significantly affect daytime vocal activity. Visiting males tended to sing more often in their home territories.

Conclusions Daily movement of the majority of males was towards the neighbouring male's calling site. We suggest that the purpose of these visits was to seek females. These males may try to drive a female into their territory or gain extra-pair copulation.     

Factors associated with home visiting in an inner London general practice.

We decided to examine the services provided by doctors in an inner London practice for domiciliary care. It was expected that the study would highlight the most relevant questions and variables related to access and uptake of this service; it would thus contribute to the design of an accurate procedure for auditing the pattern of delivery of home care to be conducted in the practice in the future. During the study period, 1976-81, there were 90 500 doctor-patient contacts. For patients up to the age of 10 years the proportion of home visits was 9.2%, falling to 2.2% in the age group 20 to 29; then there is a quasi plateau till the age of 60. After 60 the proportion of home visits doubles in each of the following 10 year age groups, reaching 54% in the over 80s. The proportion of home visits (standardised by age) rises from social class II (8.0%) to social class V (10.0%), but is higher in social class I (11.7%). The proportion of home visits according to distance from the practice rises from 8.2% near the health centre to 9.6% at a distance of 0.25 to 0.50 mile, and drops to 8.8% beyond 0.75 mile. The distance effect is not consistent when the social class dimension is added: social classes I and II have higher proportions of home visits in certain age and distance groups. Single people have the lowest proportion of home visits (6.8%); there are large differences between men and women among widowed (14.1% and 8.6% respectively) and divorced or separated (7.0% and 10.7% respectively) patients. There are important variations in the proportions of home visits made by the doctors in the practice, the trainees carrying out proportionally many more home visits. Data collected in the practice can be used to define specific issues for future audit exercises. Furthermore, sociodemographic characteristics of patients have been shown to be associated with use and access to medical services.     

Sister chromatid exchanges in lymphocytes of nuclear medicine physicians

OBJECTIVE: The aim of this study was to assess whether occupational exposure to chronic, low doses of Iodine 131 (I-131) and Technetium 99m (Tc-99m) may lead to genotoxicity. Medical personnel occupied in nuclear medicine departments are occupationally exposed to low doses of I-131 and Tc-99m. The determination of the frequency of sister chromatid exchanges (SCEs) and of cells with a high frequency of SCEs (HFC) is considered to be a sensitive indicator for detecting genotoxic potential of mutagenic and carcinogenic agents. Therefore, we examined peripheral lymphocytes from nuclear medicine physicians for the presence of both SCE and HFC. METHODS: Sixteen exposed nuclear medicine physicians (non-smokers) were compared to 16 physicians (non-smokers) who had not been exposed to chemical or physical mutagens in their usual working environment at the same hospital. RESULTS: A statistically significant difference was found between SCE frequencies and HFC percentages measured in lymphocytes from the exposed and control groups. CONCLUSIONS: The present observation on the effect of chronic low doses of I-131 and Tc-99m indicates the possibility of genotoxic implications of this type of occupational exposure. Hence, the personnel who work in nuclear medicine departments should carefully apply the radiation protection procedures and should minimize, as low as possible, radiation exposure to avoid possible genotoxic effects.     

Teaching and training in geriatric medicine in the European Union

In 1993 about 20% of the population in the 15 'old' member countries of the European Union (EU) was over 60 years of age and this percentage will increase to more than 25% in 2020. These developments play a key role for the investments in education and training to meet societies needs for health care services. In 2002 about 25% of the medical students in the 'old' EU did not receive any education in geriatric medicine. A question is who will provide the services for older people in related areas, like social care, community care, acute care in the hospitals, long-term care, permanent care and care for psychiatric patients? Geriatric medicine has been recognized as an independent specialty in 8 of the 15 member countries of the 'old' EU. In all EU member states the governments are autonomous regarding all aspects of health care services, including the recognition of specialties and specialist training programmes. A two years training in internal medicine has been recommended in the EU, followed by another four years of training in geriatric medicine. The specialist training has a hospital oriented character, however, it includes also community care and other institutionalised care like nursing homes. The curriculum should contain: biological, social, psychological and medical aspects of common diseases and disturbances in older people. A problem in many EU countries is the shortage of well trained researchers and leading persons for academic positions for geriatric medicine. In a number of countries chairs at the universities remain vacant for long periods of time or even disappear. Good services in the health care for older people need a high quality curriculum and training programme.