Examining the Progressive Demographic Change in Long Term Care - PDF document

2/7/2018 Navigating the Mental Health Complexities of a Progressively Younger Long Term Care Population Michael R. Goldsmith MSW/LMSW Regional Coordinator of Mental Health Services-West Michigan Lake Superior Quality Innovation Network Quality Improvement Organization (QIN QIO) Examining the Progressive Demographic Change in Long Term Care Statistics  Over 1 million new nursing home admissions a year  Of those diagnosed with Schizophrenia and Bipolar across the United States. Disorder – 54% were nonelderly  14-22% of new admissions are  Short Term Care/Rehab admits with a “Severe Mental Illness” are 45.6% more likely to transition to Long 18-64 years old Term Care  Substance Abuse/Use diagnosis are not included  Assisted Living – 37% are 64 or younger  27.4% are diagnosed with a “Severe Mental Illness” 1

2/7/2018 Sociological and Cultural Factors to an Increase in Younger Demographic in Long Term Care  Progressive Closure of State Hospitals in the 1970’s and 1980’s  Limited Resources  Funding  Excessive Caseloads  Poorly Managed Mental Health  APS, Medical Staff and Alternate Authority  Younger Population with Medical Complexities  Nancy Miller with the University of Maryland – 10 year study Patient Testimony “K a thy”  57 y/ o SWF re siding in AL F . Wo rking a s a PA up until 6 mo nths a g o .  Cha ng e in me nta l sta tus first no te d 12+ mo nths a g o (Mo CA Sc o re o f 17/ 30). Ne uro Psyc h Asse ssme nt x2 po st se ve ra l E me rg e nc y De pa rtme nt pre se nta tio ns re sulting in dx o f De me ntia . Pa tie nt ha s no te d 20+ ye a r o f E T OH a b use / de pe nd e nc e .  L a te r dia g no se d with spe c ific ity-We rnic ke K o rsiko ff De me ntia a nd Ma jo r De pre ssive Diso rde r.  “I ’ m to o yo ung . I do n’ t b e lo ng he re ”, “I try to de ve lo p re la tio nships, b ut the y’ re to o c o nfuse d to unde rsta nd me o r we do n’ t ha ve the sa me inte re sts. I t’ s a diffe re nt g e ne ra tio n yo u kno w”. 2

2/7/2018 “Ric ky”  21 y/ o SHM with no c hildre n re siding in SNF / SAR po st MVA re sulting in rig ht side d pa ra lysis, multiple fra c ture s a nd e nc e pha lo pa thy.  Co g nitio n inta c t a nd no histo ry o f me nta l illne ss.  +disruptive b e ha vio rs ie . no nc o mplia nc e with c a re a nd ve rb a l o utb ursts. Sta ff re po rte d iso la tio n in ro o m.  “A lo t o f the m (sta ff) a re a s o ld a s my mo m a nd tre a t me like I ’ m the ir kid. I ’ m no t a kid a nd do n’ t ne e d tha t. I do n’ t e ve n use tha t lig ht a nymo re unle ss I c a n’ t fig ure it o ut o r my g irlfrie nds no t he re to he lp me ”, ”I do n’ t g o o ut until 8 o r so me thing . T ha t’ s whe n the y’ re a ll in the ir ro o ms”. Identifying Mental Health Diagnosis and Needs of a Younger Demographic in Both Assisted Living and Skilled Nursing Facilities Chronic Mental Illness Diagnosis  Schizophrenia  Schizoaffective Disorder  Psychosis Unspecified  Bipolar Disorder  Major Depressive Disorder  Anxiety – Generalized Anxiety Disorder 3

2/7/2018 Sc hizo phre nia  Crite rio n A:  De lusio ns  Ha lluc ina tio ns  Diso rg a nize d Spe e c h  Diso rg a nize d o r Ca ta to nic Be ha vio r  Ne g a tive Sympto ms-la c k o f fe e ling s o r b e ha vio rs tha t a re usua lly pre se nt  Crite rio n B: So c ia l/ Oc c upa tio na l Dysfunc tio n  Crite rio n C: Dura tio n o f 6 + mo nths  Crite rio n D: Sc hizo a ffe c tive a nd Alte rna te Mo o d d iso rd e rs ha ve b e e n e xc lud e d  Crite rio n E :Sub sta nc e o r g e ne ra l me d ic a l c o nd itio ns e xc lud e d  Crite rio n F :Is the re a re la tio nship to a pe rva sive d e ve lo pme nta l d isa b ility. Sc hizo a ffe c tive a nd Unspe c ifie d Psyc ho sis  Sc hizo a ffe c tive Diso rde r  Sc hizo a ffe c tive Diso rd e r F o rms a link b e twe e n psyc ho sis a nd mo o d (d e pre ssio n o r ma nia pre se nt thro ug ho ut the ma jo rity o f the illne ss)  Psyc ho sis Unspe c ifie d  Pre se nta tio n tha t d o e s no t me e t c rite ria fo r a mo re spe c ific d ia g no sis a nd is no t a ttrib ute d to a d e ve lo ping d e lirium. Mo o d Diso rde rs  Bipo la r Diso rd e r  Ha s o ne o r mo re se ve re ma jo r de pre ssive e piso de s with a t le a st o ne hypo ma nic e piso de (we c a n se e psyc ho sis with hype rma nic e piso de s a nd with ma jo r de pre ssive diso rde r).  Ma jo r De pre ssive Diso rd e r  Me nta l diso rde r c ha ra c te rize d b y a pe rva sive a nd pe rsiste nt lo w mo o d tha t is a c c o mpa nie d b y lo w se lf e ste e m a nd b y a lo ss o f inte re st o r ple a sure in no rma lly e njo ya b le a c tivitie s. 4

2/7/2018 Anxie ty (Ge ne ra lize d Anxie ty Diso rde r)  E xc e ssive , unc o ntro lla b le a nd o fte n irra tio na l wo rry, a ppre he nsive e xpe c ta tio n a b o ut e ve nts o r a c tivitie s (so me will e xpre ss physio lo g ic a l/ so ma tic c o mpo ne nts ie . b utte rflie s in sto ma c h, ra c ing he a rt, swe a ty pa lms, c he st pa in o r fe e ling sic k). Recognizing Personality and Character Disorders/Traits Being Identified in this Younger Population  Difficult Resident or Personality Disorder?  General Description – A personality disorder is a type of mental disorder in which you have a rigid and unhealthy pattern of thinking, functioning, and behaving.  Cluster A – Odd or Eccentric  Cluster B – Dramatic or Erratic  Cluster C – Anxious or Fearful  Utilizing Staff Input Differentiating Between Substance Use, Abuse, and Dependence  Substance Use – someone consumes alcohol or drugs, primarily social, but can appear abusive or develop into a pattern resulting in a dependence.  Substance Abuse – a person using drugs or alcohol despite negative consequences in their lives.  Failure to fulfill obligations at work, home or school  Recurrent use in situations that are hazardous  Substance related legal problems  Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the substance  Substance Dependency – someone dependent on drugs or alcohol.  Develops a tolerance  Experiences withdrawal  Takes larger amounts and for longer duration than intended  Social, occupational, or recreational activities suffer or are given up  Substance use continues despite the exacerbation of physical or mental health conditions 5

2/7/2018 Identifying Approaches and Interventions to Best Address Quality of Life and Transitioning Cultures in Long Term Care Analyzing Cultural Changes within Long Term Care environments that promote Quality of Life; Increase Sense of Belonging in Current Long Term Care Environments  Adopting an Intergenerational  Being Mindful of Varied Mindset Schedules for Residents  Meals  Differences in interests and needs  Intergenerational conflicts present in  Activities the “real world” also exists in Long  Volunteers Term Care settings  Varied activities  Environment that encourages residents to grow together  Role Designation Community Resources  Community Based Day Programs  Example: Easter Seals  Offering job, task engagement, and/or training  Mental health treatment  Recreation engagement beyond the Skilled Nursing or Assisting Living Facility  Support Groups  Internal or External  Alcoholic Anonymous  Narcotics Anonymous  Al Anon  Medically related Support Groups  Community Transition Programs  NFT (nifty) Nursing Facility Transition Program (waiver) 6

2/7/2018 Identifying Psychiatric and Psychological Interventions via Utilization of Consulting Entities  Having appropriate mental health resources available to meet the needs of this change in population.  Psychology and Psychiatry services  Psych staff with knowledge and experience in treating substance disorders, personality disorders, and the complexities of life transitions  AA/NA groups Verbal Communication  Use the name of the resident and make sure you have their attention.  When referencing an alternate staff member, use that staff members name and title.  Be mindful of rate, tone, and volume.  Rule of 5  Use statements & questions with 5 words or less, using words with 5 letters or less.  Reasoning: “Magical Number Seven +/- two” – Studies have found that people are able to process up to 7 (+/- two) different types of stimuli within an environment or interaction. Communication and Residents that Present with Traits of Personality Disorders Working Through Counter Projection Time Out Limit Setting 7