Sending nursing home residents with dementia to inpatient psychiatric units - Improvement or Retrogression?
Submitted by Michael C. LaFerney RN, PMHCNS, BC, Ph. D
Tags: elderly care homecare nursing assistant nursing care plan Psychiatry
Mary Smith, whose 90-year-old mother is in a nursing home, is notified by phone by a nursing supervisor that her mother was sent to a psychiatric unit 30 miles away from home because shews physically abusive to a certified nurse's aide during her evening care. The nursing supervisor at the inpatient psychiatric unit also notes the patient was sent on an involuntarily status and will need to sign a voluntary paper in order to avoid going to court. Ms. Smith, whose mother is severely demented, non- ambulatory and weighs 95 pounds, is troubled by this and wonders, "What is a voluntary paper and will the nursing home take Mom back?"
As a psychiatric clinical nurse specialist I have observed nothing more disturbing to family members than being informed that their loved one has been involuntarily sent to a psychiatric facility. In many cases it was either unnecessary or could have been done in a much less frightening way. The main reasons I get calls to involuntarily admit from nursing homes are patient aggression, suicidal verbalizations and elopement risks.
How can nursing staff keep patients from needing involuntary psychiatric admissions? And if an admission is needed, how can it be done in a way that works with family members?
Involuntary Commitment
An involuntary commitment is defined as "the practice of using legal means or forms as part of a mental health law to commit a person to a mental hospital or psychiatric unit against their will."1 To meet the criteria for an involuntary admission, most states require that the patient
poses a substantial risk of danger to themselves or others.
There must be a "substantial" mental disorder present and likelihood of serious harm. Is a dementing disorder a "substantial ' mental health disorder in this context?
Once patients are admitted involuntarily they have the option to sign in as a voluntary patient within a period of time. If patients will not or cannot sign a voluntary, the psychiatrist must determine that they are a danger to self or others and petition for a court hearing for the patient to be kept in the hospital (or to be released). Ms. Smith, as the healthcare proxy for her mother, will need to sign the voluntary.
Avoiding Admission
Ms. Young, who visits her mother in the hospital's psychiatric unit, notices a lot of similarities to her mother's nursing home: There are nurses, therapies, activities and a medical physician along with a psychiatrist.
In the hospital Ms. Young's mother receives a medical workup, the psychiatrist makes medication change and the patient returns to the nursing home. Could the medical workup and medication adjustment have been done at the nursing home and the inpatient admission avoided?
Although a 2004 study suggests geriatric patients experience improvement from inpatient treatment comparable to that of younger patients (2) a 2016 report by PBS
indicated that about one-third of patients over 70 years old and more than half of patients over 85 leave the hospital more disabled than when they arrived, research shows. (3) in my practice I often hear, "She's no different than before she left." Nursing staff note little difference in Ms. Smith's mother's behavior after psychiatric unit.
Points to Remember
When considering an involuntary admission for patients with dementia, nurses should remember these important points:
1. The patient must be a clear danger to self or others.
Few demented patients have the cognitive processes to organize or plan assaults on others or carry out the aggressive behavior. 4 Assault is the threat or attempt to strike another, whether successful or not, provided the target is aware of the danger. The patient must be reasonably capable of carrying through with the plan.
Aggression is the willful hurting of someone else.
Many behaviors in nursing homes are
impulsive acts that can be avoided by thoughtful management. For example, a patient who grabs at others can be placed in areas where the traffic is not so high. When possible they can be placed in the hallway or near the nurses station where they can be "watched" when a less stimulating environment is needed.
Most of the aggressive behaviors I see occur during morning and evening care when there is direct contact with the resident. Medicating prior to these times, using appropriate staff for safety and organizing needed supplies prior to providing care(time management) can keep these incidents to a minimum.
Another time I frequently see demented patients get agitated is when their attempts to wanderer leave an area are interfered with. A patient with dementia who frequently is sent to an inpatient psychiatric unit for eloping is often in the wrong setting. Placing this patient in a dementia unit with camouflaged doors, coded alarms and space for wandering is more appropriate.
2. Medical issues create agitation.
As the nurse manager of an inpatient psychiatric unit, I have observed that almost one-third of all patients given medical screening prior to involuntary admissions were never admitted to the psychiatric unit. They were diverted to the medical service with illnesses that could have been diagnosed and treated in the nursing home. These include urinary tract infections, respiratory infections and dehydration. Thinking medical first as a cause of agitated behaviors, rather than psychiatric, and ruling out these common causes of delirium will greatly reduce the need for inpatient referral. These elderly patients can sit in Er's for hour and in some cases days waiting to be seen -a burden on them, their families and hospital staff.
3. Suicide is a rare event in nursing homes.
A recent study indicates suicide is an extremely rare event in the nursing home setting. 5Patients with dementia will often voice statements such as, "I wish I was dead" but with no real intent or plan.
I have received referrals on patients who reportedly have said they wanted to kill themselves, then several minutes later could not recall saying it. They often lack the cognitive ability necessary to carry out a plan. Yes, we must take suicidal statements seriously. But do we really need to send them to an ED or inpatient psychiatric unit to find this out A brief interview by an RN or staff social worker at the nursing home could determine the patient has no short-term recall of the statement or a reality-based plan.
4. Be aware of faulty thinking patterns and know the law.
Nursing homes that frequently send residents to inpatient psychiatric units may need patient management and stress management training. The goal is not respite for the staff or punishment for the patient. The goal is to protect the safety of the patient and others when the nursing home cannot. To take away someone's rights and involuntarily send them to a locked facility is not to be taken lightly.
Nurses must guard against these unconscious thought patterns.
Voluntary Commitments
If attempts to manage patients through medication changes and behavioral interventions do not work, rather than involuntarily sending them to a psych unit, consider utilizing families or proxies to arrange a voluntary admission.
I'd suggest the family member, guardian or healthcare proxy be informed of the problematic behaviors that are preventing adjustment or successful living in the nursing home. Asking the family member or proxy to arrange for an inpatient visit to a psychiatric unit where the patient can get a good medical and cognitive workup, along with psychiatric treatment, allows the family to be a partner in managing the behavior. These strategies prevent the trauma of legal issues and reassure the family we have an interest in keeping them in our facility. Given time, families can find psychogenic units closer to their homes so they can visit their loved one and participate in treatment planning.
Having a nursing home staff member who knows the patient accompany the patient to the inpatient unit is helpful. They often can encourage the patient to sign in voluntarily, and they provide information to the inpatient unit that helps develop a more effective treatment plan.
Staff Training
It is my experience many patients sent to psychiatric units as involuntary patients are sent needlessly. I originally wrote on this topic 20 years ago and this is still an ongoing issue. Given the 24-hour availability of nursing care, rehabilitation staff, available activities and presence of psychiatric services now in nursing homes, most issues can be managed safely in the nursing home. Many demented patients, on review, do not really meet the criteria for an inpatient admission. Their perceived threat is not of the depth and length needed to warrant a move against their will.
Training staff to identify medical issues that create behavioral problems, apply better time and stress management techniques in their own practices, and better understand commitment law swill greatly reduce the need to "send out" as a first action rather than as the last resort.
And in those patients who truly need to be hospitalized, more can be done as a voluntary or with family support - reducing the fear that "legal" involvement often brings.
References
- Involuntary commitment. Retrieved 28 October 2024 from the World Wide Web: HTTP://www.ncbi.nlm.nih.gov/books/NBK557377/
- Snowden, M.B., et al. (2004). Geriatric patients improve as much as younger patients from hospitalization on general psychiatric units. Journal of American Geriatrics Society, 52(10), 1676-1680.
- (2016 )PBS News,For elderly patients, hospital stays often worsen disabilities taken October, 28 2024 from the www at; https://www.pbs.org/newshour/health/elderly-patients- hospital-stays-often-worsen-disabilities
- Black's Law dictioanry Assault. Retrieved Oct. 28, 2024 from the World Wide Web at: https://thelawdictionary.org/assault/
- (2009) Barack,Y MD, Gale,C. MPH, JAMA Network Open,Suicide in Long-term Care Facilities- The Exception or the Norm?