Mental Health Issues in Nursing Homes

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  Mental health relates to any behaviours and conditions which impedes with social functioning capacity to negotiate daily life (WHO | Mental Health, 2019) .  Many older people will have some sort of mental health issue at some point, this may be due to illness, grief and loss, financial stress and loss of independence. Between 2017-18, 9.9 billion dollars was spent in mental health and 4.3 million people received mental health services. Mental health is as important as physical wellbeing for elderly people, this is also true for people with dementia (Mental Health Services in Australia, Prevalence, Impact and Burden, 2019).         The vulnerable group chosen for this paper is elderly people with dementia living in long term aged care homes and in the community. The national health priority in focus is mental health.

        Finding ways to improve mental wellbeing for people living with dementia is important to improving quality of life. Neuropsychiatric symptoms (NPS) are now known to occur universally over the many stages of dementia. They also occur with increasing frequency in early onset of dementia. NPS in the form of mild behavioural impairment in the presence of cognitive impairment may constitute early onset of dementia. A wide range of symptoms have been reported, although they tend to aggregate into predictable groups namely depression, apathy, psychosis and agitation (Smalbrugge et al., 2017). Challenging behaviours are highly prevalent in nursing home residents, and for many it one of the main reasons why they are placed in long term care facility. These challenging behaviours lead to poor quality of life and stress and burden on care givers if not managed properly. This is especially for poorly managed aggression and agitation.  Managing these challenging behaviours demands a multidisciplinary approach, which focuses on finding and treating the underlying cause of the behaviour (Backhouse et al., 2016).

       Treatment and management are dependent on the stage of dementia. It can range from non-pharmacological intervention to pharmacological intervention like the use of psychotropics.  Evidence of the efficacy of psychotropics in the treatment and management of NPS symptoms has been shown to be sub-optimal (Groot Kormelinck et al., 2019). Studies now indicate that their use, may even worsen the symptoms of NPS, they may increase the likelihood of falls and increased hospital transfers. Finding ways to manage these symptoms non pharmacologically will provide dignity and improve the quality of elderly people with dementia (Groot Kormelinck et al., 2019). 

         Recent changes to the National Quality Standards demand, that care homes find different ways of managing these symptoms and only use psychotropics as a last resort ( Aged Care Quality and Safety Commission, 2020). This makes managing mental health issues in elderly people with dementia a lot more challenging. One reason could be the staffing issues. In many nursing homes it is not unusual to have one registered nurse in charge of 40 -50 residents.  In dementia specific wards, there is normally 20-40 resident in a secured location, and staffing ratios is dependent on the acuity of the resident. Hence most nursing homes use group activities to manage behaviours rather than targeted therapies. The use of psychotropics is normally a case of striking a balance between the rights of individual resident with behaviours and the rights of the other residents in the facility. This could account for high levels of inappropriate prescriptions and overuse of psychotropics.

        In conclusion, managing mental health issues in dementia has become increasingly challenging due to the shortage of trained staff. Aged care usually has a high degree of staff turnover and most people use it as a steppingstone to other careers, this means there is no continuity of care (Costello et al., 2019). The high turnover, especially carers means that facilities spend more time constantly training new care staff in the targeted behavioural management strategies of the individual residents in the facility. Low continuity of care is defined as increased fragmentation of health care workers. Low continuity of care has been shown to be associated with higher hospitalisation (Amjad et al., 2016).


References

Amjad, H., Carmichael, D., Austin, A. M., Chang, C.-H., & Bynum, J. P. W. (2016). Continuity of Care and Health Care Utilization in Older Adults With Dementia in Fee-for-Service Medicare. JAMA Internal Medicine, 176(9), 1371–1378. https://doi.org/10.1001/jamainternmed.2016.3553

Backhouse, T., Killett, A., Penhale, B., & Gray, R. (2016). The use of non-pharmacological interventions for dementia behaviours in care homes: Findings from four in-depth, ethnographic case studies. Age and Ageing, 45(6), 856–863. https://doi.org/10.1093/ageing/afw136

Costello, H., Walsh, S., Cooper, C., & Livingston, G. (2019). A systematic review and meta-analysis of the prevalence and associations of stress and burnout among staff in long-term care facilities for people with dementia. International Psychogeriatrics, 31(8), 1203–1216. https://doi.org/10.1017/S1041610218001606

Groot Kormelinck, C. M., van Teunenbroek, C. F., Kollen, B. J., Reitsma, M., Gerritsen, D. L., Smalbrugge, M., & Zuidema, S. U. (2019). Reducing inappropriate psychotropic drug use in nursing home residents with dementia: Protocol for participatory action research in a stepped-wedge cluster randomized trial. BMC Psychiatry, 19(1), 298. https://doi.org/10.1186/s12888-019-2291-4

Self-assessment tool for recording consumers receiving psychotropic medications | Aged Care Quality and Safety Commission. (2020). Retrieved May 16, 2020, from https://www.agedcarequality.gov.au/resources/self-assessment-tool-psychotropic-medications

Smalbrugge, M., Zwijsen, S. A., Koopmans, R. C. T. M., & Gerritsen, D. L. (2017). Challenging Behavior in Nursing Home Residents with Dementia. In S. Schüssler & C. Lohrmann (Eds.), Dementia in Nursing Homes (pp. 55–66). Springer International Publishing. https://doi.org/10.1007/978-3-319-49832-4_5

WHO | Mental Health. (2020). WHO; World Health Organization. Retrieved May 16, 2020, from http://www.who.int/mental_health/en/

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