Dr. El

President Biden’s State of the Union address last week targeted several aspects of the long-term care industry, most of which have received more attention than his mention of reducing the inappropriate use of antipsychotic medications.

As a long-term care psychologist who has closely observed the trend of increasing numbers of residents with severe mental illness who require antipsychotic medications, I’m concerned that attempts to reduce antipsychotics might disregard the needs of these residents.

An effort to comply with, and enforce, regulations around antipsychotic use must be conducted with a recognition that there are many residents who need these medications in order to maintain their emotional stability, with an emphasis on the term, “inappropriate use,” rather than on “reducing antipsychotics.”

My concern is heightened because the industry and its regulators can appear to have a lack of awareness about, or a plan to manage, this growing population. Ironically, this echoes a frequent feature of mental illness — anosognosia, or the lack of awareness of having a mental illness. (Though by the time they arrive at our doors with several decades of experience with mental health problems, these residents are generally long past anosognosia and can often tell us how to manage their own illnesses.)

According to data tracked by LTCfocus.org, the number of severely mentally ill residents has more than doubled in almost every state between 2000 and 2020. Given the changes wrought by COVID-19 (i.e., empty beds), that number will likely be higher once the 2021 data comes in.

Necessary, but insufficient

Maintaining the use of antipsychotic medications is essential for this group of residents, for them as individuals and for the safe management of the living environment, but in and of itself, it is not sufficient care.

As I’ve written about in the past (see “Severely mentally ill residents: A ‘perfect storm’ creates a SNF wave”), these residents generally arrive at nursing homes following a health crisis but are frequently difficult to discharge even after they’re medically stable, due to the need to manage concomitant medical and mental health problems. 

Ideally, there would be more community resources for this group, such as care homes that can manage comorbid physical and psychiatric health problems, paid family caregiver programs to encourage the help of their relatives, and psychosocial supports for individuals who could potentially manage in the community with assistance.

Given that these resources are not yet available to most, and that nursing homes are increasingly filling their beds with this cohort, acknowledging this reality will allow us to better deal with the challenges and the opportunities of the situation.

The challenges

I noted some of the care issues in “Severely mentally ill residents: Staff training, teamwork needed” — such as the need for increased staff training and support in managing individuals who tend to be younger, more physically imposing, and have mental health issues that can compromise their compliance with medical treatments. 

For instance, a recently admitted resident with a diagnosis of paranoid schizophrenia might resist taking medications from a new nurse in an unfamiliar setting, and the nurse might recognize that their usual encouragement tactics could exacerbate the paranoia but not know what alternatives to use. This is not an individual nurse problem, or an individual resident problem, but a systems problem. See the above-mentioned article for some systems solutions.

The opportunities

If we properly manage their wellbeing, we can reap the benefits of having this population in our buildings.

For example, some of these residents are high utilizers of care, going back and forth to medical and psychiatric hospitals. If we can stabilize them psychiatrically and physically, this would be a boon to insurers and increase the value of the nursing home as a partner in a continuum of care.

In addition, this cohort tends to be relatively young and able. Once stable, it would be beneficial to them and to the older, more frail residents to participate in activities that require someone who can walk or see or hear. Picture them reading a book to older residents, handing out bingo cards, or helping a visually impaired resident play a game. In the psychiatric hospital, patients could earn a small stipend for such assistance. We’ll have to be more creative in LTC since regulations currently prohibit “work.”

Another benefit of stabilizing this population is that we may be able to reconnect families that have been torn apart by the societal lack of support for those with severe mental illness. The closing of psychiatric hospitals and the deficit of community services have strained families trying to manage an extremely challenging lifelong illness. 

The safe haven and care of the nursing home might be the first time in decades that these residents and their families have gotten the support they needed to manage their mental and physical health. Reconnecting estranged families is the kind of service that makes frontline workers feel really good about their jobs. (Conversely, admitting psychiatric patients without proper staffing, training and support does not.)

Ideally, there would be better options and assistance for residents with both physical and mental health problems, but since these are currently lacking, the industry would benefit from greater acknowledgment of this cohort, maintenance of needed medications, and increased efforts to provide services appropriate to this population. 

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 andGold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements, visit her at EleanorFeldmanBarbera.com.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.