Borson S, Loebel J P, Kitchell M, Domoto S, Hyde T
Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA.
J Am Geriatr Soc. 1997 Oct;45(10):1173-81. doi: 10.1111/j.1532-5415.1997.tb03766.x.
As part of nursing home practice reforms, OBRA-87 mandates formal psychiatric assessments (PASARR) of nursing home residents suspected of having mental disorders, a responsibility it delegates individually to states. We describe the initial year of implementation of the PASARR process in King County, Washington, and characterize the mental disorders and mental health services needs of nursing home residents referred for psychiatric screening.
Cross-sectional study.
The 54 Medicare-certified King County nursing homes (total beds = 7013).
All patients referred for psychiatric evaluation under PASARR (n = 510).
A systematic, multidimensional evaluation including a semistructured psychiatric diagnostic examination, validated measures of cognitive dysfunction, depression, and global psychopathology, functional variables relevant to need for nursing home care, and selected mental health services indicators.
Fewer than 10% of all nursing home residents were referred for psychiatric evaluation. A primary mental illness, evenly divided between psychoses and mood disorders, was found in 60% of the sample, and a psychiatric disorder associated with dementia or mental retardation was found in 25%. Six percent had complex neuropsychiatric features defying classification, and 4% had no mental disorder. Other disorders, such as substance abuse, were rare. Cognitive impairment and global psychopathology were prevalent in all diagnostic groups, and depressive symptoms were common even in patients without affective diagnoses. Eighty-eight percent of the sample were appropriately placed, based on their needs for daily care. Fifty-five percent had unmet mental health services needs.
The PASARR referral process detected a group of seriously mentally ill, functionally disabled patients, most of whom required the level of care that nursing homes provide. Depressed and psychiatrically impaired dementia patients were underrepresented in the referral pool as measured against widely accepted prevalence figures for mental disorders in nursing home populations. The PASARR process as currently configured appears to be most efficient in identifying schizophrenic patients, who represent a small minority of nursing home residents, and the skewed sample it generates fails to provide an adequate basis for estimating overall mental health services needed in nursing homes. The PASARR process should be altered to improve referral rates for depressed and behaviorally disturbed dementia patients.
作为疗养院实践改革的一部分，《1987年综合预算调节法案》（OBRA - 87）要求对疑似患有精神障碍的疗养院居民进行正式的精神病学评估（PASARR），并将此责任分别委托给各州。我们描述了华盛顿州金县PASARR程序实施的第一年情况，并对被转介进行精神病学筛查的疗养院居民的精神障碍和心理健康服务需求进行了特征描述。
横断面研究。
金县54家获得医疗保险认证的疗养院（总床位 = 7013张）。
所有根据PASARR被转介进行精神病学评估的患者（n = 510）。
进行系统的多维度评估，包括半结构化的精神病学诊断检查、经过验证的认知功能障碍、抑郁和整体精神病理学测量、与疗养院护理需求相关的功能变量以及选定的心理健康服务指标。
所有疗养院居民中被转介进行精神病学评估的不到10%。在样本中，60%的人被发现患有原发性精神疾病，精神疾病和情绪障碍各占一半，25%的人被发现患有与痴呆或智力障碍相关的精神疾病。6%的人具有难以分类的复杂神经精神特征，4%的人没有精神障碍。其他疾病，如药物滥用，很罕见。认知障碍和整体精神病理学在所有诊断组中都很普遍，即使在没有情感诊断的患者中，抑郁症状也很常见。根据他们的日常护理需求，88%的样本被安置得当。55%的人有未满足的心理健康服务需求。
PASARR转介程序检测出了一群严重精神疾病、功能残疾的患者，他们中的大多数需要疗养院提供的护理水平。与疗养院人群中广泛接受的精神障碍患病率数据相比，转诊人群中抑郁和患有精神障碍的痴呆患者比例较低。目前配置的PASARR程序在识别精神分裂症患者方面似乎最有效，而精神分裂症患者在疗养院居民中只占少数，并且该程序产生的样本偏差无法为估计疗养院所需的整体心理健康服务提供充分依据。应改变PASARR程序，以提高抑郁和行为紊乱的痴呆患者的转诊率。
