S. Borson et al., PSYCHIATRIC ASSESSMENTS OF NURSING-HOME RESIDENTS UNDER OBRA-87 - SHOULD PASARR BE REFORMED, Journal of the American Geriatrics Society, 45(10), 1997, pp. 1173-1181
OBJECTIVE: As part of nursing home practice reforms, OBRA-87 mandates
formal psychiatric assessments (PASARR) of nursing home residents susp
ected of having mental disorders, a responsibility it delegates indivi
dually to states. We describe the initial year of implementation of th
e PASARR process in King County, Washington, and characterize the ment
al disorders and mental health services needs of nursing home resident
s referred for psychiatric screening. DESIGN: Cross-sectional study. S
ETTING: The 54 Medicare-certified King County nursing homes (total bed
s = 7013). PARTICIPANTS: All patients referred for psychiatric evaluat
ion under PASARR (n = 510). MEASUREMENTS: A systematic, multidimension
al evaluation including a semistructured psychiatric diagnostic examin
ation, validated measures of cognitive dysfunction, depression, and gl
obal psychopathology, functional variables relevant to need for nursin
g home care, and selected mental health services indicators.RESULTS: F
ewer than 10% of all nursing home residents were referred for psychiat
ric evaluation. A primary mental illness, evenly divided between psych
oses and mood disorders, was found in 60% of the sample, and a psychia
tric disorder associated with dementia or mental retardation was found
in 25%. Six percent had complex neuropsychiatric features defying cla
ssification, and 4% had no mental disorder. Other disorders, such as s
ubstance abuse, were rare. Cognitive impairment and global psychopatho
logy 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 n
eeds. CONCLUSIONS: The PASARR referral process detected a group of ser
iously mentally ill, functionally disabled patients, most of whom requ
ired the level of care that nursing homes provide. Depressed and psych
iatrically impaired dementia patients were underrepresented in the ref
erral pool as measured against widely accepted prevalence figures for
mental disorders in nursing home populations. The PASARR process as cu
rrently configured appears to be most efficient in identifying schizop
hrenic patients, who represent a small minority of nursing home reside
nts, and the skewed sample it generates fails to provide an adequate b
asis for estimating overall mental health services needed in nursing h
omes. The PASARR process should be altered to improve referral rates f
or depressed and behaviorally disturbed dementia patients.