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.
The visits and discussions have revealed an extraordinary diversity in the way LTC is provided. Many countries have few or no LTC facilities, and families or local communities are expected to make provision for care of people with severe physical and/or cognitive disabilities. The burden on carers must be very high in many cases, just as it is for numerous families in countries that do have LTC homes available, when they struggle to avoid having to admit their loved ones to nursing homes. Nevertheless, concerns about availability of appropriate services and care in nursing homes have prompted some (including Task Force members) to ask if the funds used in building and running LTC homes are being used appropriately. Would the home-care model be preferable if all those funds could support visiting services? Or is it possible to adapt nursing homes to provide a more home-like environment?
There has been much criticism of nursing home care in general. As Eliopoulos (Reference Eliopoulos2010) recently noted: “Instead of arising from the biopsychosocialspiritual needs of the population served, the nursing home model evolved from practices utilized in other institutional settings and regulatory standards that were responses to substandard practices”. A variety of models designed to humanize LTC homes with the creation of a home-like environment have been developed. The goals include optimizing the residents’ quality of life at the same time as raising the quality of care. These models include the Eden Alternative (http://edenalt.com), the Green House program (http://ncbcapitalimpact.org) and the Wellspring program (http://WellspringProgram.org). A number of countries such as the Netherlands, Japan and Sweden have developed alternative living arrangements for seniors with dementia, such as small group homes. Philosophy of care, culture and funding possibilities differ among LTC facilities around the world. The way services are provided partly depends on what funds are made available by governments. Staffing ratios and training vary, and this affects the time and expertise available for helping people with mental health problems. Where mental health professionals are unavailable, it may be appropriate for primary care doctors and/or nurses to take on roles in recognizing and managing mental health conditions. However, in countries where there are adequate numbers of psychiatrists and others trained to assess and treat mental disorders, the main demand from LTC homes in response to the Task Force's survey was for mental health services to be much more readily accessible and for ongoing involvement by mental health professionals rather than the usual one-consultation visit.
A one-day expert meeting with a focus on mental health issues in LTC was organized by the Task Force and took place during the IPA congress in Montreal in September 2009. The aim was not so much to reach consensus but to provide material for discussion, with the aim of holding a full consensus conference in due course. Presenters were invited to summarize the existing literature and guidelines and to provide recommendations. Most of the papers presented in Montreal appear in this special issue of International Psychogeriatrics. They were required to go through the full peer review process of the Journal. The papers highlight principles of good care, creating an optimal environment, adequate screening, comprehensive assessment, an evidence-based approach to psychosocial interventions and models of mental health service delivery. Additional papers were presented by Zuidema (on pharmacological interventions) and Luxemberg (system and organizational issues). Several other papers related to LTC have also been included in this special issue.
Task Force members have called for:
(1) Guidelines (adaptable according to local situations) on how to achieve optimal care, assessment and interventions for residents in LTC facilities who have mental health problems. Canadian guidelines on mental health issues in LTC homes could form a basis for further discussion (Canadian Coalition for Seniors’ Mental Health, 2006). Attention should be given to special groups, including those in LTC homes with developmental disability, younger residents, those with frontotemporal dementia and other frontal lobe syndromes, and people with Huntington's disease.
(2) Standards regarding mental health service provision in nursing homes, but recognizing that differences in organizational systems, community attitudes, culture, resources and funding affect what is regarded as appropriate.
(3) Advocacy in seeking appropriate levels of mental health service provision in LTC settings around the world. Even (or maybe especially) in economically developed countries, improvements are needed in the way services are financed, organized and delivered.
The Task Force's residential care meeting in Spain will have taken place by the time this editorial is published, and it is hoped that it will have left the Task Force in a position to organize a full consensus conference at the next IPA biennial congress (possibly with the World Psychiatric Association and/or other international bodies). We should be aiming to ensure equitable access to optimal LTC.
Finally, to foster debate, we would suggest that the ideal LTC home is one where residents retain self-esteem, with opportunities for choice and (as far as possible) for controlling their own lives in a home-like environment, where staff show respect for residents, and vice versa. The ideal LTC home ensures there is ongoing education of staff, residents and families concerning matters affecting mental health and ensures staff (including doctors) work as a team, coordinating and communicating – and involving relatives and residents in discussions. To make this possible they need time and adequate funding. In the ideal LTC home, staff and residents and visitors feel confident and content – and, if they don't, someone is taking remedial action.
We would like to thank all of our colleagues on the Task Force for their important contributions; in particular, we thank those who contributed to the Expert Meeting in Montreal. We would also like to thank Professor David Ames and the editorial staff of International Psychogeriatrics for their support and encouragement regarding the publication of this special issue.
