Category: Depression/Mental illness/Substance Abuse
Posted by Dr. El - July 14, 2009 - Business Strategies, Common Nursing Home Problems and How Psychologists Can Solve Them, Communication, Depression/Mental illness/Substance Abuse, Resident care, Role of psychologists
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.
Posted by Dr. El - January 23, 2009 - Business Strategies, Common Nursing Home Problems and How Psychologists Can Solve Them, Customer service, Depression/Mental illness/Substance Abuse, Resident care, Role of psychologists, Transitions in care
I couldn’t wait to go to college. I was ready to shake off the old me, and begin a brand new self. No one would know who I’d been, and I could therefore be whomever I wanted to be.
In my Psych 101 textbook, there was a picture of animal behaviorist Conrad Lorenz, followed by a row of baby geese. The goslings had found Dr. Lorenz during their critical period of imprinting, when they bonded to the first suitable stimulus they saw. Conrad Lorenz became the goslings’ mama.
When residents enter nursing homes, they have the opportunity to create new identities. They are surrounded by strangers and novel social situations, with as limited a pull from family and friends to be their old selves as they are likely to have experienced in decades. While most residents aren’t necessarily looking to become new people, their early nursing home contacts can affect how they settle into their environment.
Mrs. Leibowitz arrived at the nursing home depressed, but wasn’t referred for psychological services until months after her arrival. She’d already established the pattern of spending days alone in her room, watching television for hours at a time. She was irritable with staff members, often refusing care, or chasing them out of her room with her foul language. “There’s nobody to talk to here,” she told me. I had my work cut out for me. The critical period had been lost.
Mr. O’Conner, on the other, was lucky enough to be placed in a room with Mr. Chu, the President of the Resident Council. Mr. Chu took Mr. O’Conner under his wing (so to speak), and together they played cards with some of the other gentlemen, and attended activities which appealed to them both. Our new resident integrated nicely into the community and never needed psychological treatment.
I’d like to see every nursing home form a welcoming committee, by residents, for residents, to help aid the transition to the nursing home. And I’d like to get my referrals early, during the critical period, instead of after the conflicts, isolation, and other problems have become entrenched. That way I can more easily help people take advantage of the best that nursing homes have to offer.
Posted by Dr. El - November 30, 2008 - Business Strategies, Depression/Mental illness/Substance Abuse, McKnight's Long-Term Care News, Younger residents
http://www.mcknights.com/Young-adults-in-long-term-care-the-canaries-in-the-%20coal-mine/article/112345/
Young adults in long-term care
Eleanor Feldman Barbera, Ph.D.
July 3, 2008
Anne Marie Barnett, in her June 10, 2008 guest column, wrote about the disruptive effects of younger residents on long-term care facilities. As a psychologist who has worked with many younger residents over the years, I’d like to offer my perspective and some suggestions about how to create an environment in which younger residents can flourish and staff time can be devoted to care rather than to behavior problems. Today’s young residents are pointing out flaws in our system we need to address now before the baby boomers arrive. The generation of older adults who believe that “doctor knows best” will be gone, replaced by a cohort of residents who know and are ready to fight for their rights, just like our young people now. Setting up systems and programs for today’s young residents will prepare you for tomorrow’s boomers.
I find it helpful to differentiate between four general types of younger residents, as they require different approaches from the staff.
- Some of our younger residents arrive with illnesses with which they’ve been coping for years, such as MS or ALS. These residents need assistance adjusting to the facility, but are likely to be able to integrate into the existing programming with only modest changes.
- Many younger (and older) residents with serious mental illnesses have found their way into our system. They need regular psychiatric monitoring, but can often attend existing activities.
- Young adults who have been ill from birth are sometimes behavioral problems because they have been institutionalized from a very young age and know how to work the system. Other times they were exempted from the discipline of their able-bodied siblings. Placement in the nursing home is the first time they are expected to behave, and experience consequences, like everyone else. Intensive initial work will help them integrate into the environment.
- Young residents who have sudden onset of physical problems related to their lifestyle choices are generally the most difficult and time-consuming residents to work with. They require special programs and assistance with prior mental health and substance abuse issues, in addition to adjustment to their physical illnesses and loss of control over their lives.
Recommendations:
1. Strong psychology and psychiatry teams: Mental health staff should be considered a part of the treatment team rather than adjunct services. Efforts to increase visibility, understanding, and utilization of mental health services will ease the burden on nursing staff.
2. Early mental health referral: There is a critical period following the arrival of a new resident where they can be redirected onto a new, positive path or can be left to repeat the same negative patterns over again. Residents identified upon admission as having potential problems should be referred immediately, before resident/staff conflicts become entrenched.
3. Psychiatric nurses: The nursing home environment is remarkably similar to that of a psychiatric hospital, except that virtually all full time staff members aside from the social workers have no mental health training. Adding nurses, especially nursing supervisors, with psychiatric experience will improve use of techniques to reduce agitation and conflict.
4. Distinct recreational activities: Younger residents need activities geared toward their interests and without older adults. The most successful activities are likely to be ones chosen by the residents themselves and lead by the “coolest” member of recreation team. When your young residents have developed to the point of trustworthiness, they can run their own groups with staff as helpers. Activities which provide a showcase for the talents/expertise of various residents are likely to be successful among all age groups and provide an excellent forum for increasing connections among peers.
5. On campus support groups: Many of our young people would benefit from attendance at 12-Step meetings such as Alcoholics Anonymous or Nicotine Anonymous. If you have a large population of residents with a particular illness, an illness-specific support group can also be helpful. Providing space for such community groups allows the residents the opportunity to connect with positive peers in the community, reduces isolation, and increases the visibility of the nursing home. Most hospitals have 12-step meetings and other support groups on premises; nursing homes should too.
6. Peer-to-Peer Support: Residents who are successfully addressing their disabilities and/or addictions should be given the opportunity to assist newly arrived/disabled peers. One of the most devastating effects of illness and placement on younger people is the feeling of lack of usefulness. Providing peer support diminishes this feeling and creates meaning and purpose out of their experiences. Peer support can be facilitated by Recreation and/or Nursing staff.
7. Computers!!!: Our young people, and the coming boomers, need to have internet access. Lack of access increases their sense of isolation, frustration, and confinement. The Internet can be used for education regarding illnesses, contact with family and friends, and connection with peers with similar physical problems, among other benefits. Computers are essential to the mental health of the younger resident.
8. Effective Resident Councils: The resident council, used properly, can be an excellent tool for educating staff and determining which issues are most affecting resident satisfaction. Involving younger residents in the resident council provides a socially appropriate forum for their grievances. An effective resident council is one that is attended by alert, capable residents who see actions taken by the administration to address their concerns and who receive reasonable explanations if their concerns are not actionable.
9. Staff Training: Staff members require education specific to the needs of the younger resident. Training which focuses on dealing with behavior problems, understanding mental illness, resident/staff communication, and stress management can be conducted by the psychologist, psychiatrist, social workers, and psychiatric nurses.
10. Clear and Enforceable Policies: The challenge of providing care to acting out younger residents can be simplified by the creation of and adherence to policies for problematic behavior. Staff members need to know guidelines for handling resident intoxication and resident smoking, for example. Substance abusing residents, in particular, excel at “splitting” staff, creating conflicts between day and evening shifts and between weekend and weekday workers. Clear, consistently enforced policies will create a team that cannot be split.
The challenge of providing care for younger residents can be matched by its rewards. We can help our young people transform from angry, traumatized, and hostile individuals into happy, productive members of our nursing home communities. And, in the process, we can prepare ourselves for the coming wave of active, demanding baby boomers.
Posted by Dr. El - November 15, 2008 - Dementia, Depression/Mental illness/Substance Abuse, Inspiration, Personal Reflections
This week I had the chance to meet with a lovely 97-year old lady whom I admire greatly. Despite her dementia, she can be eloquent and is interested in the world around her. She’s always well-dressed, thanks to her aides and to her family, who provide her with fashionable clothing they wash themselves. She’s often distressed, though, when I come to see her. Why? Because she feels she’s not being useful in the world. Sometimes I say to her, “Rosebud, you’re 97 years old! You’ve contributed a great deal to the world, raising two upstanding children and helping others as a social worker. When do you get to take a break?” Other times I point out that saying hello to the lonely and ailing residents on her floor at the nursing home is doing God’s work and is just as valid as any other kind of assistance. I wonder, though, if she’d be feeling differently if she’d had the opportunity to participate in the campaign of the Presidential candidate of her choice, or if she could help raise money for breast cancer research or some other good cause. I believe many nursing home residents would be excited and energized by the prospect of helping others in the outside world. Taking the focus off their own problems, giving them purpose, making use of their skills and interests toward a higher good — all this would go a long way toward reducing the depression and tedium I see so often in the nursing home environment. Why not a group that crochets blankets for babies, or writes letters to senators about important issues? Is there a recreation therapist out there who’s running these types of groups? Are you part of such a group in your nursing home? How is it going?
