Life interrupted: the impact of young adults in long-term care

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Ask the nursing expert
Ask the nursing expert
There was a time, not so long ago, when nursing homes provided care for the "elderly" who were over the age of 65 and suffering from the effects of chronic and acute aging related diseases. Rarely did you see a younger or middle-aged resident.

In the Northeast area of this country, we are being bombarded with referrals for young adults ranging in age from 18 to 55. Their conditions range from motor vehicle accident to drug overdose, gun shot wounds, alcoholism, AIDS, homelessness, and mental health issues. In the last facility I worked as a director of nursing, 24% of our 155 residents were "young adults". Rarely does a "referral" mention behavior issues, poor discharge potential concerns for fear that a facility will not admit the resident. Once we agree to admit a resident, he/she is ours for better or for worse.

Nursing homes are now being referred to as long-term care facilities or skilled nursing facilities, mostly due to the population they serve. OBRA 1987 federal regulations were written to address quality care and quality of life for the elderly. COMAR 10.07.02 also addresses care of the elderly. Where are the guidelines and regulations to address our growing population of young adults? When surveyed, we are held to the same survey standards that were written with the ill, fragile, disabled elderly in mind.

The biggest challenge for the caregivers in long-term care working with the young adults is developing a plan of care, with the resident's involvement in its development. It has been my experience that very few young adults are interested in participating in development of their care plans. Separate activity programs are needed for the young adults. They often ask for entertainment and activities that the elderly patients are not interested in, and they want it on a regular basis.  Most of them are otherwise healthy. When you are 27 years old and faced with living in a wheelchair, being paralyzed, having an indwelling catheter, and have no other place to live, you have "issues". These "issues" often create behavior problems.

Many 24- to 40-year-old male residents want to go out on Friday night with their buddies and stay out overnight or longer, coming back whenever they want. Often they come back intoxicated or worse, haven't had their medications and are belligerent with staff. They are angry at their lives having been interrupted. Living in a long-term care facility is not how they planned on spending the rest of their lives! They learn very quickly about their rights as residents and often remind staff that they have these rights, getting up after noon and staying up most of the night. They come and go as they want and often tell staff that they cannot be kicked out because they have no place to live.

Now, when you have a combination of both male and female young residents, there are other issues. Most of the women come from the same type of background and are often flirtatious, which sets up rivalry between the young male residents. Rivalry often leads to physical and verbal altercations at any time, day or night.

As a director of nursing, I spent most of my work hours dealing with issues such as resident-to-resident altercations, residents being in the facility under the influence of either drugs or alcohol, verbal abuse of staff, and continuous calls from this population to local authorities insisting that their rights were being violated. My calls during the middle night also increased when some of the young adults returned from being out and were giving staff a hard time.

A new way of approaching the admission of young adult needs to be developed. Staff needs more training in setting boundaries, handling aggressive behavior with this age group, goal setting (future planning), and better understanding of rights of staff, handling residents with addictions, manipulative behavior and more.  For those residents who potentially have 40+ years of living left, some may want job training, education, counseling, goal planning and more. Under the current set-up of skilled nursing facilities, we are not equipped to address the needs of the young adult population. Additional support is needed for caregivers, residents, management and facilities if we are to continue along this referral/admission route.

There is no dispute that disabled young adults need a place to live, but we shouldn't assume that skilled nursing facilities provide post-acute care for anyone over 18, able to address all needs equally.

Anne Marie Barnett writes the monthly "Ask the Nursing Expert" column for McKnight's Long-Term Care News.

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