Young adults in long-term care: the canaries in the coal mine

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Eleanor Feldman Barbera
Eleanor Feldman Barbera
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 led 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.


Eleanor Feldman Barbera, Ph.D., is a licensed psychologist who consults in long-term care facilities in the New York City area.  She is currently seeking representation for her novel about a psychologist in a nursing home. She can be reached at efeldmanbarbera@nyc.rr.com.




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