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C H A P T E R 1 Introduction and Epidemiology Long-term care (LTC) is one of the fastest-growing segments of health care in the United States and is an important setting in which to prevent , identify, and treat behavioral and psychological symptoms the residents experience. LTC facilities include both nursing homes and alternatives to nursing homes (primarily assisted living facilities). The spectrum of LTC also may include people living in subacute care, special care units, and hospice, as well as people in retirement communities who receive assistance with activities of daily living (ADLs) or whose medications are monitored. Psychiatric disorders are prevalent in elderly people, and this prevalence (especially of dementia, delirium, and depression) increases considerably with age (Martens et al. 2007). The presence of dementia, delirium, depressive disorders, anxiety disorders, psychotic disorders, and sleep disorders in LTC is so high (40%–100%) that many consider LTC facilities to be psychiatric institutions. The relative rates of these disorders depend on a person’s age and the severity of coexisting medical illnesses. Although psychiatric disorders have a major impact on disability, mortality, care needs, and care costs, they are underrecognized and undertreated. There is growing evidence that mental health care is efficacious for residents in LTC facilities, and data is accumulating from both randomized clinical trials and the outcomes of real-life care that treatment can improve daily functioning. Psychiatric morbidity and the prevalence of dementia are increasing in LTC facilities. In fact, LTC facilities are becoming places primarily for individuals who have advanced dementia. Of those with dementia, 30 percent are cared for in an LTC facility and 70 percent reside in the community, either in their own homes or in retirement communities (also called residential care 2 P S y C H I AT R I C C O N S U L TAT I O N I N L O N G - T E R M C A R E communities) (Caselli et al. 2006). Between 70 and 90 percent of all people with dementia eventually develop one or more behavioral symptoms. yet the intensity of the services required for residents of LTC facilities is significantly greater than that for community-dwelling older adults, with the former using twice the number of prescriptions and accounting for four times the total overall amount of health care spending (Stefanacci 2006). These numbers underscore the urgency of improving the psychosocial well-being and quality of life for all residents in LTC facilities, as well as for their families and professional caregivers. The residents’ characteristics (acuity, prevalence of dementia, etc.) and the services provided to them vary considerably from one LTC facility to another and from one state to another. Although the regulation of assisted living facilities also differs greatly from one state to another, all nursing homes are regulated by the federal government. Nonetheless, the differences between some assisted living facilities and nursing homes are vague and ill defined, with a certain number of assisted living facilities providing a mix of services once reserved for nursing home residents. On the whole, LTC facilities are more different than similar. Thus, across all community and facility settings, more consistency is needed in the information collected on the characteristics of the settings and the services offered, as well as on the characteristics of residents, so that analyses can identify factors associated with the choice of setting, transitions between settings, and outcomes. Demographics of Residents in Long-Term Care Facilities In term of demographics, residents of LTC facilities are becoming older and increasingly female (table 1.1), with the women older than the men (mean age 83 versus 76). According to a recent American Community Survey, 1,834,880 people were living in LTC facilities (U.S. Census Bureau 2007). The majority were women (69.2%), and 42.8 percent of all residents were 85 years of age or older. The median age was 83.2 years. Additionally, 83.9 percent were white, 12.8 percent were black, 3.8 percent were Hispanic or Latino, 1.2 percent were Asian, and 0.5 percent were American Indian or Alaskan native. All of those surveyed reported not living with a marital partner . About 17.9 percent said they were married but living separately from the spouse, 1.4 percent were separated, 10.7 percent were divorced, 54.1 percent were widowed, and 15.8 percent had never married. The average per capita income of those surveyed was $12,251. Some 58.8 percent...

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