House calls for the psyche.

How did your weekly visits to the nursing homes come about?

Anderson: After moving to the Cambridge area, the medical community, recognizing my skills and knowledge, referred their elderly patients to me. Over time, I was able to schedule nursing home visits. Studies have shown 80 percent of geriatric patients have some form of psychiatric problem, dementia with behavior problems, or suffer from depression. A nursing home is in some way a psychiatric hospital because of the nature of the mental problems its residents may have.

What type of care does a forensic psychiatrist provide?

Anderson: Forensic psychology deals with determining if residents have the capacity to make decisions for themselves. Are they able to give informed consent or make medical-care decisions? Is the resident able to author a will or have the capacity to enter a contract such as marriage?

On average, how often do you visit a nursing home resident?

Anderson: This is extremely variable. Some residents may only require a one-time consultation. And some residents may need quarterly follow-up visits. If a behavior episode initiated the consultation, the follow-up visits may be weekly and then weaned down to a simple regimen and the resident handed back to the care of his or her primary-care doctor. I prefer to continue having some visits with the resident, though.

What are the most common mental problems in the elderly?

Anderson: Depression, psychotic symptoms such as paranoid thinking or hallucinations, and dementia syndrome with psychotic behavior problems are common. Residents who exhibit serious aggression (physically striking out at other residents or staff) could become the victim themselves if their victim strikes back. Non-demented residents may suffer from depression.

Some states may transfer psychiatric hospital patients to a nursing home because of a medical condition. Those residents have more serious psychiatric illnesses such as schizophrenia, bipolar disorder (also known as manic depressive disorder), panic attacks, obsessive/compulsive disorders, and other anxiety disorders.

What are the warning signs that a resident is becoming agitated or may become violent?

Anderson: Minor changes in behavior such as a resident who is normally cooperative and friendly becomes irritable and snappy, the resident's sleep pattern changes, or he or she starts walking uninvited into other residents' rooms. Signs of depression are an active resident suddenly stops participating in activities, no longer eats all of his or her meal, is no longer as social, or begins refusing therapy.

This is where another component of going to the nursing home comes in. I get to see the residents' interactions with the staff. Often, staff members don't know how to manage behavioral problems or extensive mental illness. I can teach the staff. I have developed a relationship with the staff as well, so I can advise a nurse or CNA on how to handle a resident.

What can be done to calm an agitated resident?

Anderson: An effective tool is the distraction technique. In a resident with significant memory relapse, the CNA can redirect that resident. As human beings we crave attention, it's nice to know someone else cares about us. One of the first things to do is give the resident attention. Saying to a resident, "I'd really like to spend a few minutes with you. I'd like to talk with you," will draw his attention away from the cause of his agitation.

If the resident is more cognitively intact, the technique works a little differently. The staff member needs to jump in, verify the resident's feelings of anger, and then draw her to another area (her room is a good place) and talk about the situation there. The conversation should continue to address the resident's feelings and possibly come up with a solution.

Are nursing home residents medicated too quickly?

Anderson: Yes, I think that happens very frequently. I would hope that it happens much less frequently in nursing homes that employ geriatric psychiatrists. We have to be careful to look for unrecognized pain when addressing behavior problems. Ten years ago, there wasn't much thought that behavior problems are aggravated by something like a urinary tract infection. A geriatric psychiatrist's medical background enables him or her to identify physical problems that could be the cause of the behavior problem.

Allan Anderson, MD, medical director of Shore Behavioral Health Services in Cambridge, Md., provides a rare service to his community. He makes weekly house calls to two local nursing homes, Chesapeake Woods Center in Cambridge and William Hill Manor in Easton, Md. Anderson is board certified in general psychology and subspecialties geriatric psychiatry and forensic psychiatry and has served as the chair of the Communications and Marketing Committee of the American Association for Geriatric Psychology. Anderson, whose current practice is 80 percent geriatrics, treats memory disorders, Alzheimer's, and other geriatric psychiatric disorders. He also provides forensic psychiatry consultations to determine the mental competency of elderly patients admitted to Dorchester General Hospital, Cambridge.