For elders confronted with the necessity of living in a nursing home, the choice of facility is a decision with profound consequences-for their health, their quality of life and their family finances. Nursing home care may cost $50,000 a year or even more, and more than half of all elders begin their nursing home stays by paying the costs out of pocket. That imposing sum can purchase excellent care, or can pay the rent for a place that is literally "worse than death" for the unfortunates who live there.
Since many elders in need of nursing home care are cognitively impaired, their spouses, children and other relatives are involved in the decision. For them, feelings of responsibility and guilt add to the weight of the decision. Psychiatrists who treat elderly people, or who treat the adult children of elderly people, encounter the emotional reactions of people faced with the nursing home decision. While the emotional reactions of their patients to the nursing home choice may become themes of psychotherapy, a wise choice regarding nursing home care can mitigate these reactions by reducing the realistic basis for having them. If patients and their families can be sure that facilities will serve them well, they can relax. Specifically, their minds are eased if they know that a facility will provide:
- Compassionate and competent medical care;
- Rehabilitation to the greatest feasible extent;
- Prevention of new medical problems;
- Prevention of functional decline;
- Activities appropriate to the resident's capacities and interests;
- Physical safety;
- Pleasant physical and social environment;
- Respectful, individualized treatment;
- Autonomy for the resident;
- Freedom from abuse and exploitation; and
- Timely availability of any needed medical or mental health services.
Unfortunately, no nursing home fully meets these criteria. So, the elder and the family may profit from the psychiatrist's guidance in determining when an imperfect nursing home can be acceptable for a particular individual.
Goals of Home Placement
A good place to start is with an analysis of the real reason for nursing home placement, which may be different from the reason first given by a doctor, hospital or even a family caregiver. For example, Alzheimer's disease is not a reason for nursing home placement, since the vast majority of people with Alzheimer's disease live in the community. The reason must be some combination of specific conditions, impairments or medical needs (e.g. agitation, incontinence, need for intensive physical therapy), together with a lack of the personal, community, and/or financial resources to manage those conditions and impairments elsewhere. Regardless of the specific problem, an elderly person living alone is more likely to be placed in a nursing home than one married to a relatively intact spouse.
Once the psychiatrist has a general grasp of the elder's unmet needs, he or she should ask whether any of the persons' disabilities are treatable in the community or in a brief hospital stay. Unless comprehensive geriatric assessment has shown otherwise, it is not unusual to uncover treatable causes of excess disability. For example, a major depression can severely limit the ability of the elderly to take care of themselves. Treating depression, even if it requires brief hospitalization, usually should be attempted before committing to nursing home placement. A number of other conditions may push elders and their families toward nursing home placement, but might yield to effective medical intervention. These conditions include paranoid psychosis, incontinence, chronic pain and poor nutrition.
Falling and wandering-two common problems of dementia patients-often can be treated at home by a combination of environmental modifications and scheduled, assisted activity. When these are combined with the use of adult day care and respite services, families can manage many dementia patients at home.
The second question for the psychiatrist is whether a move short of nursing home placement can bring elders into an environment that can meet their needs. The care continuum is expanding, and such options as assisted living, adult day care and intensive home care are becoming available. For dementia patients without major medical comorbidities, specialized group residences that offer specialized activities and environments in a less "clinical" setting than a nursing home are becoming more common. The continuum of care is richer in more sophisticated metropolitan areas. In rural areas, however, residence with a "foster family" may be an option for some elders no longer able to live alone. In almost every region, professional care planners who are familiar with the full range of these options are available.