As I discussed in Severely mentally ill residents: A ‘perfect storm’ creates a SNF wave, long-term care has a growing population of severely mentally ill (SMI) residents, with the number of residents diagnosed with schizophrenia or bipolar disorder approaching 20% in some states as of 2017.1
In addition, 46.3% of LTC residents were diagnosed with depression in 2015 and 2016.2 Some were undoubtedly individuals with severe, chronic depression.
People with SMI generally enter nursing facilities for rehabilitation following a fall or some other health crisis. Discharge choices can be limited due to coexisting medical and mental health problems, leading them to become long-term residents despite their relatively young age (an average age of 62 versus 77 in the general nursing home population3).
A review of research on individuals with mental health problems, Physical illness in patients with severe mental disorders, finds that people with SMI have a greater likelihood of physical illness than those without SMI. The authors of the study note that “important individual lifestyle choices, side effects of psychotropic treatment and disparities in health care access, utilization and provision…contribute to these poor physical health outcomes.”
Their research suggests multiple points at which long-term care providers can intervene to assist SMI residents.
Medical assessment
Nurses and physicians can be taught to recognize health problems typical of the SMI population so that they’ll be alert to the increased risk of illnesses such as diabetes, metabolic syndrome, obesity-related cancers, cardiovascular diseases, osteoporosis, hepatitis B/C, tuberculosis, impaired lung function, poor dental status and other concerns.
Staff members who are comfortable physically assessing older residents might need additional training to be at ease evaluating SMI individuals, who may be more physically imposing because of their relative youth, come across as unfamiliar or frightening in their presentation or be themselves uncomfortable with medical tests or interventions.
Mental health treatment
Residents who enter LTC with a history of mental illness should be referred immediately for psychiatry and psychology services even if the resident is stable in mood and on their medications. Doing so helps prevent interpersonal problems from developing with staff and other residents, increases their prosocial connections within the LTC setting, provides an opportunity for the mental health professional to monitor behavior, and allows rapport to develop. This trust can be of particular importance if greater medical needs are identified and a person with SMI must undergo stressful tests or medical procedures.
Psychotropic medications
Teams should be aware that the CMS regulation regarding gradual dose reduction of psychotropic medications is generally inappropriate for this group of residents. It can take many years of medication adjustment to stabilize someone with SMI. Reducing psychotropic usage without clear psychiatric reasoning and close monitoring – which most LTC facilities are unable to provide – could lead to rehospitalization, an outcome as undesired as failing to reduce psychotropics.
Lifestyle factors
Long-term care facilities can assist SMI residents with lifestyle contributors to poor health, such as offering nicotine patches to promote smoking cessation, participation in on-site or off-campus Alcoholics Anonymous meetings to address substance abuse problems, and increased opportunities for exercise, using a stint in rehab as a springboard to an ongoing exercise program.
Discharge support
As I noted in my previous article, many of the mentally ill residents aging into our facilities were those who were deinstitutionalized from psychiatric hospitals in the 1970s and 1980s without adequate community supports. This contributed to difficulties maintaining health, housing, employment and relationships.
The attention received for medical and mental health problems in the LTC setting can lead to a more stable period in their lives, providing an opportunity for them to reconnect with relatives who may have become estranged after a lifetime of struggles with mental illness. Facilitating such connections is not only good for families, but it can make discharge more likely for these relatively young, relatively healthy, relatively low-reimbursement residents.
Future directions
Given the increasing population of aging severely mentally ill residents, more housing and support options are needed. Most of the residents do not require LTC once they’re medically stabilized, many of them don’t have family members willing and able to help with discharge to a supportive yet independent setting, and there aren’t enough of those settings available.
It’s worth noting that virtually all of these residents have been strong enough to make it through life with severe mental illness and a patchwork of care. As challenging as this population can be, there is much to be admired in their resilience and fortitude.
Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition and a Gold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements and/or content writing, visit her award-winning website at MyBetterNursingHome.com.
