Maxine was admitted to the skilled nursing facility following surgery for a right hip fracture. Prior to admission she was living by herself. She stated that prior to her fall, she was fully independent. There was no local family.  Although she claimed she wanted to return to her apartment, she was slow to gain in therapies, complaining of great pain and isolating in bed. As the consulting psychologist, I was asked to meet with Maxine as her voiced desires to return to her apartment appeared to be in contrast to her behavior. Staff had recognized her conflicting messages, weakening condition and the need for a psychological intervention. Maxine was unhappy and fearful. What she had not previously revealed was her recognition of her frailty, several earlier falls and fear that she might have to stay in a skilled nursing facility.

Behavioral and psychiatric concerns offer a most difficult challenge to SNF care. Behavior is more unpredictable and medical issues are aggravated. Thinking clearly could be weakened which effects decision-making and reasoning, and as a staff member your emotional reactions could interfere with best practice interventions.

Up to 70% of residents have a psychiatric diagnosis upon admission. The most common psychiatric diagnoses in SNFs include major depression, bipolar disorder, personality disorders, schizophrenia, dementia (there are several common types), and a number of anxiety disorders. An acute change in medical condition like a stroke, hip or other fracture, loss of limb, peripheral neuropathy or any exacerbation of a chronic condition will create secondary psychiatric disorders. Often staff witness the effects of depression when residents refuse to eat, participate in treatment or take their medications. Residents want to give up! Other times you witness their fears and anxieties through overuse of the call light, yelling, demanding, limiting their risk taking in physical or occupational therapy or fear of what the future holds for them.  There are no easy solutions and your understanding of how these conditions affects resident’s daily functioning is vital. Residents can become uncooperative & demanding, tend to isolate, become verbally and physically threatening, or overly dependent or despondent. This will impact a resident’s motivation, limitations, behavior, attitude and general resiliency to improve their medical situation.

Another important factor which affects mood and behavior is pain. It is safe to state that residents entering the SNF are experiencing some level of pain or discomfort.  Physical pain results from surgery, an injury, a chronic condition either recently aggravated or not directly related to admission. Many people suffer emotional or physical pain when a tragic loss occurs like having to give up their home, pets, separation from loved ones or other dramatic change in their life. If there are cognitive concerns, residents may not be able to clearly note the level of pain or the true location. Additionally, people with dementia or other cognitive impairment will ‘act out’ their pain through resistance, direct aggression or increased anxiety. They are not able to clearly express themselves verbally and their actions are often misunderstood and mislabeled as a behavior issue.

Interventions will vary and focus on only treating the presenting behavior and not its cause. There is a direct positive correlation between knowing the person we work with and providing the best care for that person. Medications are one ingredient in the formula to aide residents suffering from a psychiatric illness or general pain. Medicines can ease symptoms by modifying moods or behavior problems, fight infections and work with psychotic symptoms. Yet primary change comes from consistent treatment that encompasses all disciplines working together.

The professional who is most qualified to work with residents having a psychiatric diagnosis or behavioral concern is a licensed psychologist. Their role in the skilled nursing facility is multi-faceted. Following, is a brief overview of a psychologist’s role.

1. Assessments: Psychologists can provide initial assessments which can support:

*program planning

*input for behavioral charting

*providing staff with techniques for residents with communication or emotional blocks

*dialoging with medical staff for medication management

*work with therapies in treatment planning

*coordinating team approaches to care

*staff education and development seminars

*work with all disciplines to show how their interaction is vital to the residents health.

2. Short-term and ongoing counseling to residents who are experiencing dramatic changes in their life due to chronic psychiatric or medical issues and working with end-of-life situations. We meet with families and provide education and emotional comfort during difficult changes, and assist social services and admissions personnel with creating continuing care options upon discharge.
3. Psychologists are advocates for the resident and advocates for staff. We provide insight, education, direction and support.

Maxine was diagnosed with clinical depression. Fueling her symptoms was her recent fall and subsequent hip fracture. Our meetings facilitated her understanding of feelings affecting immediate rehabilitation and options for her future. With the help of therapies and social services, I was able to help Maxine map out a plan for her rehabilitation and future that felt safe and independent. A nurse practioner was asked to consult on medication management and she was started on a low dose of antidepressant. Maxine has since moved into an Assisted Living Facility (ALF) and has her own apartment. She has immediate help when needed and regained much of her confidence and sense of purpose. Maxine volunteers at the ALF, helping to welcome new residents become adjusted to their new home. We maintain outpatient meetings on a monthly basis.

As with all SNF staff, the psychologist looks to provide the best and most comprehensive treatment to residents who will, in all probability, live out their lives with you at their side. Psychologists are invested in all aspects of resident care and make every effort to integrate their expertise with yours: ask questions of you, seek your advice and respond to your queries. Integrating the psychologist into the flow of treatment is facility specific. As professionals, we provide to those who are most infirm, closer to death and most in need of attention, planning and comfort. Recognizing resident limitations while providing optimal care can best be achieved through an integrated team approach.

 Dr. Mitchell Gelber is a licensed psychologist who works with several skilled nursing facilities in Northern Arizona. He is the author of “Alzheimer’s Shadow: Families Facing Critical Decisions”

He can be reached at drmitchellgelber.com