Post-acute and long-term care facilities are experiencing increases in the percentage of patients who are admitted with serious mental illness (SMI). According to the National Institute of Mental Health, SMI is a mental, behavioral, or emotional disorder that results in functional disability and hinders or negatively impacts engagement in major life activities (NIMH, 2019, https://www.nimh.nih.gov/health/statistics/mental-illness). SMI includes psychotic disorders, such as schizophrenia and schizoaffective disorder, bipolar disorder, and treatment-resistant depression. It is not uncommon for older adults with SMI to also have co-occurring substance abuse disorders and/or personality disorders.
Older adults with SMI make up approximately 3% to 6% of the population and have a high prevalence of medical comorbidities such as cardiovascular disease, obesity, diabetes, and chronic obstructive pulmonary disease (COPD). Individuals with SMI have a reduced life expectancy compared with the general population, and the cost of their health care is more than double that of older adults who do not have SMI. Older adults with SMI frequently enter PALTC settings for medical and psychiatric support and supervision due to ongoing challenges with self-care management, a limited informal support network, and a lack of care options in the local community.
Historical Perspective on SMI and Long-Term Care
Throughout the early part of the 20th century, underfunding of institutional care for those living with SMI led to overcrowding and patient abuse within state psychiatric hospitals. With the availability of psychotropic medications in the 1950s and 1960s, and the subsequent deinstitutionalization movement, state psychiatric hospitals began to close and community-based care for individuals with SMI became the norm. Unfortunately, when these individuals had difficulty adjusting to their local community’s mental health system after years of institutionalization, nursing homes or prisons often became imperfect solutions.
The Omnibus Budget and Reconciliation Act of 1987 (OBRA) ushered in further changes, including requiring the Pre-Admission Screening and Resident Review (PASRR) for individuals before their admission to nursing homes. The care of individuals with SMI again shifted back to community care settings such as group homes. By 1999, the Olmstead Act, which applied to all state- and Medicaid-funded institutions, including nursing homes, gave individuals with SMI or other disabilities the right to receive state-funded supports and services in the community rather than institutions. Community care had to be provided if the following conditions were met: (1) the treatment team had to indicate that community support services were appropriate; (2) the individual wanted to live in the community; and (3) the provision of services in the community could be reasonably accommodated.
Despite these provisions to support local community-based care for individuals with SMI, we have been seeing more individuals with SMI entering PALTC settings in the past 20 years.
Increasing Prevalence of SMI in PALTC
Although the prevalence of SMI in PALTC settings is always a bit of a moving target and varies by state, there have been significant increases. The average number of patients with schizophrenia in PALTC increased from 6% to 11% between 1985 and 2015 (J Am Med Dir Assoc 2020;21:233–239). Similar increases were also seen in the number of patients with bipolar disorder. There is an even greater increase in SMI prevalence in long-term care facilities run by the Veteran’s Administration (Am J Public Health 2013;103:1325–1331).
The overall increase in prevalence of SMI in PALTC is multifactorial and relates to the closing of long-term psychiatric hospitals and residences, lack of appropriate community-based alternatives, increased life expectancy of individuals with SMI, and lack of compliance with the PASRR or Veteran’s Administration waivers of PASRR screenings (J Am Med Dir Assoc 2019;20:683–688). A recent article in the New York Times also indicates that some of the increase in the schizophrenia diagnoses may reflect false diagnoses used to improve antipsychotic use performance measures in U.S. nursing homes (New York Times, Sept. 11, 2021; https://nyti.ms/3miySfH).
Challenges in Care for Those With SMI
Individuals with SMIs are more likely to be admitted to nursing homes with poorer quality of care indicators, tend to have higher rates of hospitalization, are more likely to report undertreated pain and incontinence without a toileting plan, and are less likely to have completed advance directives. PALTC patients with SMI are also often younger — with half under 65 years of age — and therefore tend to require less assistance with activities of daily living. Yet they are four times more likely to convert from skilled care to long-term care than age-matched patients with other conditions.
PALTC staff report not feeling prepared to care for patients with SMI and fear aggressive behaviors directed at staff and other residents. Staff also have reported that caring for individuals with SMI takes time away from PALTC residents who are significantly older and frailer (Gerontol Geriatr Educ 2008;29:66–83).
There are no easy answers to improving the care of individuals with SMI in PALTC settings, but there are several things that can be done. For one, staff need institutional support and education to better understand the symptoms of SMI and learn interventions that better manage challenging behavioral symptoms. They also need a supportive, collaborative work environment that helps them feel more confident in their ability to provide care to individuals with SMI. The Society’s Behavioral and Mental Health Advisory Council is taking the lead and providing columns in Caring on appropriate gradual dose reduction of psychotropic medications, assessment and management of younger PALTC residents, and trauma-informed care.
We also need to actively decrease the stigma of mental illness in the facilities where we work. This includes teaching staff appropriate terminology to report psychiatric symptoms, behavioral de-escalation techniques, appropriate recreational and self-care training, and strategies to integrate individuals with behavioral and mental health conditions into our settings rather than segregating them into locked units that they may not need.
Given the lower physical care needs and younger age of many of these individuals, we also need to work with our community partners to not see all PALTC admissions as permanent placements. Georgia Stevens and Lori Mannino’s article in this issue shows us how assisted living facilities can increasingly become part of the care continuum for individuals with SMI if appropriate psychiatric services and staff training and support are in place.
Please share with us some of your successful strategies in providing care for individuals with SMI in PALTC settings.
Dr. Galik is editor in chief of Caring for the Ages. The views the editor expresses are her own and not necessarily those of the Society or any other entity. Dr. Galik is a nurse practitioner in LTC- and community-based settings through a clinical practice with Sheppard Pratt Health System. She is a professor at the University of Maryland School of Nursing, where she teaches in the Adult-Gerontology Primary Care Nurse Practitioner Program and conducts research to improve care practices for older adults with dementia and their caregivers in long-term care. She may be reached at [email protected]
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November 25, 2021
November-December 2021 – A Special Issue on Severe Mental Illness
In this episode Wayne Saltsman and Elizabeth Galik discuss our special issue on serious mental illness in long-term care.