Even with treatment of geriatric syndromes and exploration of alternatives, some elders will require nursing home placement. At times, the family will be under pressure to decide quickly upon a specific facility, either because the elder is being pushed out of an acute care hospital, or because a behavioral problem has escalated to the point of danger. In either case, the psychiatrist should encourage the family to resist a rushed placement, and advocate for them if need be. The choice is too important to do otherwise. When patients are in acute care hospitals, their right to choose their own residences can be invoked. If patients are too ill to be discharged home, the hospital cannot discharge them precipitously. If behavioral issues are urgent, the patient can be admitted to a geriatric psychiatry inpatient unit until the behavior is stabilized or a suitable nursing home placement is found.
Once the process is slowed down, the elders and their families can be educated about nursing home care, and the huge variations in its quality. For background, the family can be referred to one of the excellent recent books on the subject. For example, The Inside Guide to America's Nursing Homes by Robert Bua (Warner Books, 1997) provides a 10-step system for evaluating the suitability of a facility. Bua's book also lists every nursing home in the country, along with the results of the most recent state inspections. Another useful reference is Nursing Homes: Getting Good Care There by the National Citizens Coalition for Nursing Home Reform (Impact Publishing, 1997). This enables the elder and family to rule out homes with gross problems, and focus on ones that may be suitable.Carefully Evaluate Resources
Using some combination of reference books, the advice of professional care planners, physicians and clergy, and referrals from organizations like the Alzheimer's Association, the elder and family can generate a list of possible nursing homes. These should be facilities generally regarded as better than average, that are conveniently located and which offer whatever specialized services are needed.
To help the elder and family assess the homes on the list, the psychiatrist should elicit what is most important to the elder-personally as well as medically. A suitable nursing home doesn't have to be excellent in every area, but it should excel in areas of particular relevance to the patient. These areas can be organized in terms of problems, preferences and pleasures.
An elder entering a nursing home usually has a few conspicuous problems, such as depression, frequent falls, incontinence or agitation. For each facility under consideration, the family should ask the director of nursing, the medical director or a charge nurse how each of these problems is assessed and managed.
For example, how does the facility tell when a resident with dementia is depressed? Are cognitively intact residents offered psychotherapy to deal with adjustment to the nursing home? How aggressively is incontinence treated before the facility resorts to diapers or catheters? Are frequent fallers given physical therapy to improve their strength and balance, or are they restrained? When evaluating the answers, the family need only determine whether the answer makes sense and implies respectful treatment of both the elder and the family. Defensiveness, obfuscation or inflexibility in the answers should exclude the home from further consideration.
When disease and disability have limited a person's options in life, it becomes critically important that he or she exercise his or her preferences whenever possible. A well-known study of nursing home residents showed that they care more about choice in their food, their roommates and their television shows than about living wills and advance medical directives. If an elder has strong preferences about food, hours of waking and sleeping, privacy, and the like, these should be honored. An administrator, social worker or nurse should be able to tell the family whether each of the elder's important preferences can be accommodated.
Pleasant events and experiences can make life bearable and even enjoyable despite the limitations of an institution. The family should determine which of the elder's favorite activities will be possible within the facility. These activities must not only be offered, but they should be truly accessible. Pleasant activities need to be adapted to the physical, sensory and cognitive levels of the elder. The facility should have a visible program for promoting physical activity, which is associated with longer life, better cognitive function and fewer falls. It should have exercise programs suitable for cognitively impaired people.
Elders with a strong religious orientation should have regular access to religious services and holiday observances. Animal lovers should be able to interact with animals in some way. Those who like to go out to cultural events should have the chance to do so, with appropriate transportation and supervision. People with dementia can, before the end stage, take real pleasure in their favorite foods, music and physical activities. A good facility will find ways to ensure that every ambulatory resident has at least one pleasant experience every day.
Finally, the psychiatrist should talk with the elder and the family about accountability. Care is always better when specific people take personal responsibility. In a good nursing home, the family will know the name of a specific nursing assistant who regularly cares for their relative. They will know the physician in charge, and the physician will know the elder's problems and current state of treatment. They will know when care planning meetings are held, and the facility will make efforts to include them at those meetings.
By taking this approach to helping elders and families with the nursing home decision, the psychiatrist can mitigate some of the anxiety, guilt, grief and powerlessness felt at the time of placement. Psychiatrists have knowledge and skills that are especially helpful at this time. Their knowledge of late-life mental disorders is important because the majority of nursing home residents have diagnosable mental disorders, regardless of their given reason for admission. Equally important are the psychiatrist's skills in eliciting the problems, preferences and pleasures of the person facing nursing home placement.