A few months ago, I received a call from a retired post-acute and long-term care practitioner who was trying to help a friend locate and schedule an appointment with a geriatric mental health specialist for his mother. The resident was 85 and lived in a small assisted living community about 90 minutes from a major metropolitan area. She had a long history of depression, anxiety, and what sounded like an undiagnosed dependent personality disorder. She had been admitted to the assisted living community one year earlier, and there was no evidence of a neurocognitive disorder.
The resident had adjusted reasonably well over the first few months after her admission, but her behavioral symptoms deteriorated in the context of COVID-19 isolation. The primary care provider and the staff of the facility worked hard with reasonable changes in antidepressant therapy, virtual visits and frequent telephone calls with the resident’s son, distracting activities that were person centered, and consistent caregiver assignments. Despite these approaches, she yelled out for the staff whenever she was alone, wanted caregivers to help her with activities of daily living that she had the underlying physical and cognitive capability to perform herself, and called her son repeatedly while he was at work. The resident also had a thorough medical evaluation to rule out the impact of her comorbidities, medications, and acute medical conditions. The assisted living community did not have a working relationship with a psychiatric consultant, and the earliest psychiatric telehealth appointment that they could schedule was over two months away.
While the details may be different, many practitioners in PALTC have experienced similar challenges in obtaining timely psychiatric assessment and treatment for their patients, particularly when symptoms become severe. I have had the opportunity to work with geriatric psychiatrists throughout much of my career, and while I knew that there was a shortage, I was surprised to learn that there are fewer than 1,400 board-certified geriatric psychiatrists in the United States (American Board of Psychiatry and Neurology, Inc., “2019 Annual Report”; https://bit.ly/3qROpnp). Similar to geriatric medicine, fellowships in geriatric psychiatry do not enroll enough physicians to meet the needs of the aging population (Psychiatric Times, Dec. 3, 2020; http://bit.ly/2Ntc7bc).
Geriatric psychiatry, like geriatric medicine, is a team sport. Advanced practice nurses, psychologists, and licensed clinical social workers with training and/or experience in geriatric mental health also provide care to patients with mental illness in PALTC settings; however, there are not enough of them either to meet the current need. The American Association of Geriatric Psychiatry has reported that one-third of patients who are admitted to PALTC settings require psychiatric evaluation and ongoing treatment; however, only 50% of PALTC facilities reported they have adequate access to consultative mental health specialists (Clinical View: Geriatric Psychiatry in Long Term Care, 2002–2004; http://bit.ly/2Yf1zyB).
As practitioners in PALTC settings, we must make use of all available strategies to address the mental health needs of our patients. With geriatric mental health specialists in short supply, we can build a geriatric mental health team among our interdisciplinary colleagues, form partnerships with mental health specialists who may lack geriatric training and experience, and use telehealth to increase access to mental health services for older adults.
Building a Geriatric Mental Health Team
Although many PALTC practitioners may not feel comfortable in the primary management of older adults with serious mental illness, such as schizophrenia and bipolar disorder, we do have the educational background and clinical experience to assess and treat more common mental health disorders such as dementia, delirium, and depression. We must not overlook our experience with geriatric prescribing principles that we can apply to the management of psychotropic medications.
We can bring together and motivate the interdisciplinary team to address patient behavioral health challenges. Our pharmacy colleagues can help us to identify and manage behavioral symptoms that may be caused or aggravated by a patient’s medication regimen. Social workers, nursing staff, and psychologists are often well positioned to assess a patient’s past trauma and develop a care plan to decrease the risk of retraumatization for the patient. Team-based behavioral health rounds that actively involve the patient, family, nursing assistants, and other direct-care providers have been used to identify and treat patients’ psychiatric symptoms with both nonpharmacological and pharmacological approaches.
Using the knowledge and experience of the interdisciplinary team to address patient behavioral health concerns can prioritize those residents who are truly in need of a referral to a mental health specialist. The interdisciplinary team column in this month’s issue of Caring provides an excellent example of receiving care recommendations from a variety of team members.
Collaborating With Mental Health Specialists
Given the shortage of mental health specialists with experience in geriatric psychiatry, PALTC practitioners will predominately be partnering with psychiatrists, psychiatric advanced practice nurses, psychiatric social workers, and psychologists who may have mental health training and experience but lack training and experience with older adults in institutional settings. We can advocate for enhanced didactic and clinical experience in behavioral health with older adults, as there currently are no national competency requirements across disciplines. Instead, there is often an “across the life span” approach to education and training, which leads to variations in geriatric expertise that depend on the faculty experience and curriculum of the educational institution.
Before making a referral to a mental health specialist for a new behavioral concern, assess the resident and rule out the possible contribution of delirium. Make a point to meet and collaborate with the mental health specialist in your setting, and invite the specialist to be part of behavioral health initiatives within the facility. This is a bit easier now given our increasing use of virtual meetings. Serve as a resource for mental health care specialists regarding geriatric care principles, and familiarize them with PALTC regulations that impact behavioral health care, such as gradual dose reduction. Better yet, encourage them to join and become active in AMDA – The Society for Post-Acute and Long-Term Care Medicine and other professional organizations that address the needs of older adults.
Tele-Behavioral Health
The COVID-19 pandemic has been stressful for PALTC, but one silver lining has been the decrease in regulatory requirements related to telehealth. While telehealth certainly cannot replace a face-to-face visit, its increased use has resulted in opening PALTC settings to specialists whose services previously would have been unavailable without sending the patient to an office visit.
For patients with serious mental illness or treatment-refractory conditions, a consultation with a geriatric mental health specialist can help to guide assessment and treatment, particularly for patients who are living in rural settings and smaller facilities. As highlighted in the interdisciplinary team case study published in this issue, having a facility-based provider who knows the patient well to facilitate the visit is ideal for making the most of the telehealth visit and provides an opportunity for collaboration.
Given the challenges that so many PALTC practitioners face in providing access to quality behavioral health care, Caring has partnered with the Society’s newly formed Behavioral Health Task Force under the leadership of Lea Watson, MD, and Richard Juman, PsyD, to provide you with more articles that focus on the latest in the assessment and treatment of older adults with psychiatric disorders.
Dr. Galik is the editor in chief of Caring for the Ages. She may be reached at [email protected]
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