Homebound Aged: The Dilemma of Psychiatric Intervention

Abstract

This study reports the 12 month experience of a hospital-based, multidisciplinary psychogeriatric community team. The patients evaluated were unable to come to the hospital clinics because of a psychiatric and/or physical disability. The group included some patients rarely seen in psychiatric office practice and outpatient facilities, but who posed problems for their families and the community. Some required referral to a clinic, crisis management or emergency hospitalization. Others however, required only minimal intervention. A total of 151 patients (119 females and 32 males) whose average age was 78.2, were seen. Seventy percent were widowed, single, divorced or separated; 43% lived alone. The patients were grouped according to the method of intervention used: psychiatric and social intervention—55%; social and nursing intervention — 28%; no follow-up —11% and; emergency hospitalization — 6%. Seventeen patients were left “untreated”. These patients usually had more adequate family or community support than was initially apparent. They were referred for a crisis which was resolved quickly. An attempt is made to explain our approach, and several case examples are given.

Characteristics of Rural Homebound Older Adults: A Community‐Based Study

“…All community‐based studies that made age comparisons found the home‐bound significantly older than the non‐homebound. In the reports restricted to beneficiaries of various outreach programs 1–4,6,7,9,10 , in which there was no non‐homebound group for comparison, the mean age of the homebound ranged from 75 to 85 years. The socioeconomic status of the homebound was also relatively low: in the New Haven 16 and Chicago 13 samples, as in the Monongahela Valley, the home‐bound were less educated than the non‐homebound, and in New Haven 16 and Kentucky, 14 they had lower household incomes.…”

“…Relatively high rates of cognitive dysfunction and/or psychiatric problems (dementia, depression, paranoia) were found among patients served by outreach programs for homebound older adults 1–4,6–10,13 . Such rates appear to reflect the basis upon which these individuals were referred to the outreach services, although Reifler et al 9 found that reasons for referral often did not predict subsequent diagnoses.…”

“…Various authors 34–36 have appealed to physicians to recognize the importance of making housecalls to older people and have discussed strategies for dealing with primary care physicians' negative attitudes toward home care 37 . We have reviewed several articles 1–4,6,8,10,38,39 that describe innovative primary care and psychiatric outreach programs to homebound older adults in various parts of the United States and Canada. Our own experience (ARF, unpublished observations) of medical home‐care practices in two urban areas suggests strongly that home care should be multidisciplinary and should provide ongoing, coordinated, medical and psychiatric services to homebound older adults.…”

“…The larger group of papers 1–10 reports on health and human service programs for the homebound; some of these outreach programs focus on psychiatric disorders, 6–9 whereas others provide primary medical care. Some of these papers also describe the demographics and burden of illness among the recipients.…”

In-Home Mental Health Services for the Elderly

“…Despite its potential advantages, implementation of a quality home psychiatric treatment program is not feasible in many states because of: It is to be hoped that further research demonstrating the efficacy of psychiatric home care programs will support a reconsideration of these policies. A number of demonstration projects (Levy, 1985;Ratina, 1982;Parish & Landsberg, 1984;Morgan & Wieman, 1990;Sherr, Eskridge, & Lewis, 1976;Selan & Gold, 1980;Currie, Moore, Friedman, & Warshaw, 1981;Reifler, Raskind, & Kethley, 1982;Brown & Lieff, 1982;Wasson, Ripeckyj, Lazarus, Kupferer, Barry, & Force, 1984;Raschko, 1988;Roca, Storer, Robbins, Tlasek, & Rabins, 1990;DeRenzo, Byer, Grady, Matricardi, Lehmann, & Gradet, 1991;Grauer, Kravitz, Davis, & Rodrigue, 1991;Holroyd, Baukhages-Smith, & Rabins, 1991;Kohn, Goldsmith, & Sedgwick, in press) have touted the benefits of in-home psychiatric treatment for geriatric patients. Unfortunately, no research has been conducted in the United States to demonstrate whether such a treatment approach is more effective and economical than traditional models.…”