The July 2009 report, Trends in Mental Health Admissions to Nursing Homes, 1999 – 2005 notes that “the proportion of nursing home residents with mental illness, in particular depression, has overtaken the proportion of those with dementia”. According to a July 1, 2009 article by Liza Berger in McKnights.com, “younger mentally ill people now account for nearly 10% of the nation’s nearly 1.4 million nursing home residents”. While there is discussion of more preferable housing options for these residents, here are some suggestions to help those currently in long term care. As always, if there’s something I’ve missed, please add it to the Comments section.
1. Collect as much information as possible prior to admission about the psychiatric history and the medications which stabilize the individual.
2. Upon admission, refer the resident to the psychiatrist to assess mental status, review medications, and to establish a relationship. Mentally ill residents need to feel there are people in the nursing home looking after their mental health care as well as their physical care.
3. Upon admission, refer the resident to the psychologist, who can offer additional mental health support and monitoring. It’s better to refer someone before problems arise than to wait until negative behaviors and conflicts have been established. For more on this, see my earlier post, The Critical Period in Nursing Home Placement.
4. The social worker, as the most consistently available member of the mental health part of the treatment team, can act as the liaison between the psychiatrist, psychologist, resident, family, and the rest of the nursing home team, helping to share information.
5. Train the staff, especially the CNAs and nurses, to be familiar with the signs and symptoms of mental health problems.
6. Add the element of “behavioral rounds” to the change of shift report, noting any changes in behavior. In the psychiatric hospital, we did it very quickly, running down the names of the patients on the unit, speaking up if any unusual behavior occurred. For example, when the CNA-equivalent on the psychiatric team reported she’d seen a man with Bipolar Disorder laughing by himself in the hallway, the psychiatrist immediately increased his meds, recognizing the early signs of a manic episode. Early detection is particularly important because the lag time between referral for and completion of a psychiatric consult can be substantial.
7. Refer unstable or aggressive residents out to the psychiatric hospital as soon as possible. Doing so sends the message to other residents, staff, and visitors that their emotional and physical health are important, and relieves them of the anxiety of living or working with a resident who might be dangerous to themselves or someone else. It also provides the limit-setting such a resident requires for their own well-being.
8. Establish a relationship with a psychiatric hospital that’s familiar with the needs of older adults and provides adequate stabilization. For example, one nursing home changed the psych hospital they used after a paranoid schizophrenic resident in her 80s returned from a hospitalization still actively psychotic, with a baby doll, reflecting the hospital’s view of the elderly.
9. If possible, use the resident and family as resources. Knowledgeable residents and family members will be able to tell the team what medications have been successful in the past, and what proved troublesome.
10. When the right combination of medications is found, post this prominently in the chart and educate the resident and family so they have the information for future use.
11. If there are a group of residents with a psychiatric history who are functioning relatively well physically, it can be beneficial to provide them with a well-monitored space for group activities such as dominoes and card games which they can initiate without staff intervention. Training the staff monitors to work with groups of mentally ill residents will make such programs more successful.
12. Consider providing access to support groups such as Alcoholics Anonymous, either on-campus or in the community. Many mentally ill residents have a comorbid substance abuse history due to attempts at self-medicating. Such groups will provide emotional support and skills for living.
13. The social worker and psychologist can prepare appropriate residents for living in the community in a less restrictive, but still supportive, environment such as an adult home.
Hey Eleanor, you made a reference to "the rest of the nursing home team," but I feel you should recognize the importance of the invovlement of the recreation staff. We, often see residents from a different perspective than the Psychiatrist, who sees the resident only on occasion, the Psychologist who sees the resident for a brief weekly visit, or the nursing staff whose relationship may be strained due to various care issues. Of course, the helpfulness of the staff will vary from facility to facility, resident to resident, and staff member to staff member, however, we may be more likely to see the resident as a whole, his/her strengths as well as weaknesses and since we have more time to observe them in group situations, we may have more insight regarding behaviors, their needs etc.
I also find it amazing that more nursing home staff, Nurses and C.N.A.s are not better trained to deal with issues revolving around mental health.
Good point, Sue. The recreation staff do have the opportunity to see the residents in situations other team members aren't able to observe and have important information to contribute to the discussion of how the resident is behaving.
The challenge in teamwork is communication, and it's essential for all staff members feel their observations are valuable and welcome, whether this means attending the team meetings or informing the nurse or another team member who is able to initiate action to address concerns.
One of the reasons I got into nursing home work is that it is so similar to my beloved psych hospital days. Another tip to add to the list is for nursing homes to bring in nurses with psychiatric experience. it's an invaluable perspective.
I agree wholeheartedly with your comments, article submissions except of course the use of Social Workers. Particularly if they are LCSW’s they are recognized by Medicare to provide mental health services and can be invaluable if utilized staff to provide direct counseling and mental health assessments not just as a liaison in a facility.
I agree, Heather. Well-trained social workers can work wonders in the nursing home environment, particularly when they’re given the time and opportunity to provide counseling and education. What I’ve seen all too often, though, are social workers that are so busy with the day to day intakes, discharges, and emergencies that they have no time for the type of counseling that would reduce the number of emergencies and elevate the nursing home in terms of mental health services.