Behavioral and psychiatric challenges in SNFS
Dr. Mitchell Gelber, TeamHealth
“Bonnie” was admitted to the skilled nursing facility following surgery for a right hip fracture. Prior to her fall, she said she was living by herself, fully independent. Although she claimed she wanted to return to her apartment following rehabilitation, she was slow to make gains in her therapy, often complaining of great pain and isolating herself in bed.
Because Bonnie's voiced desires appeared to be in contrast to her behavior, and her condition was weakening, I was asked to meet with her for a psychological consultation. I found Bonnie to be unhappy and fearful. And she revealed for the first time a recognition of her frailty, her several earlier falls and a fear that she might need to move into long-term care.
Behavioral and psychiatric concerns like Bonnie's are extremely common in post-acute care and offer a difficult challenge to facilities. Up to 70% of skilled nursing facility residents have a psychiatric diagnosis upon admission, most commonly: adjustment disorder, major depression, bipolar disorder, personality disorders, schizophrenia, dementia and anxiety disorder. An acute change in medical condition — like a stroke, hip fracture, loss of limb or peripheral neuropathy — or an exacerbation of a chronic condition can produce a secondary psychiatric disorder.
There are no easy solutions, but it is vital that SNF leaders come to understand how these various conditions can affect each resident's daily functioning and, when concerning behaviors and symptoms manifest, that they endeavor to identify and address the underlying cause. This can best be accomplished by integrating psychological care into the SNF's comprehensive treatment programs.
Identifying psychological symptoms
SNF staff witness the effects of psychological challenges on a daily basis. When residents are depressed, for example, they may refuse to eat, participate in treatment or take their medications. Other times staff may notice fears and anxieties manifest through overuse of the call light, yelling, demanding or refusing to participate in physical or occupational therapy. Residents can become uncooperative, verbally and physically threatening, or overly dependent or despondent.
At root, often these patients are afraid of what the future holds for them – and it impacts their motivation, attitude and general resiliency to improve their medical situation.
Pain is another factor that affects mood and behavior. It is safe to say that almost every resident entering a SNF experiences some level of pain or discomfort, whether from recent surgery, an injury or a chronic condition. Because the connection between physical pain and emotions is strong, residents who are cognitively impaired – or dealing with dramatic life changes such as the loss of friends, loved ones or even pets – may not be able to clearly note their level of pain or its true location. Additionally, people with dementia or other cognitive impairment may “act out” their pain through resistance, direct aggression or increased anxiety. They are not able to clearly express themselves verbally and their actions are often misunderstood and mislabeled as a primary personality disorder or behavioral issue.
Typically, a variety of interventions will be applied when a resident's behavior is concerning. However, it's critical to treat the cause of the behavior – not just the symptoms – in order to achieve optimal health outcomes. That means the first step toward intervention is trying to understand the underlying cause of the behavior. There is a direct positive correlation between knowing the individual being treated and providing the best care for that person.
When psychologists are integrated into an SNF care team, they have a multi-faceted role in understanding and treating the biopsychosocial functioning of residents. A significant part of that role is directly working with residents who have psychiatric diagnoses or behavioral disorders to provide care and comfort. They may prescribe medications as one ingredient in the formula to ease suffering from a psychiatric illness or general pain – medicines can ease symptoms by modifying moods or behavior problems, fighting infections and alleviating psychotic symptoms.
Yet primary change comes from consistent treatment that encompasses all disciplines working together. So psychologists' work must extend beyond direct patient care to include program planning, behavioral charting, staff training, medication compliance, adherence to rehabilitation programs and coordinating team approaches to care. Psychologists should meet with families and provide education and emotional comfort during difficult changes, and they may assist social services and admissions personnel with creating continuing care options upon discharge.
In short, psychologists work with all disciplines within the SNF when integrated as a vital component of an interdisciplinary approach to understanding and improving residents' health. Psychologists are invested in all aspects of resident care and make every effort to incorporate their expertise into the interdisciplinary structure. Optimal care can best be achieved through this integrated team approach.
What about Bonnie? I diagnosed her with clinical depression, her symptoms fueled by her recent fall and subsequent hip fracture. Our meetings helped her understand her feelings about immediate rehabilitation and her options for the future. With the help of physical therapists and social services, Bonnie and I mapped out a plan for her rehabilitation and future that felt safe and independent. A nurse practitioner was asked to consult on medication management, and Bonnie was started on a low dose of an antidepressant.
As a result of these interventions, Bonnie was able to move into an assisted living facility, where she has her own apartment but immediate access to help when needed. She has regained much of her confidence and sense of purpose. Bonnie now volunteers in her assisted living community, welcoming new residents and helping them adjust to their new home. We maintain outpatient meetings on a monthly basis.
Mitchell Gelber, Ed.D, PC, is a licensed psychologist with TeamHealth who works with several skilled nursing facilities in Northern Arizona. He is the author of “Alzheimer's Shadow: Families Facing Critical Decisions.”