Best Practices in Long-Term Care, Spring 2020 Issue
By: Beverly Faubert, RN, BScN, GNC(C), CHPCN(C), CPMHN(C) and Heather Woodbeck, RN, HBScN, MHSA, LTC best practice co-ordinators
*Mary is a 57-year-old woman living with schizophrenia in a long-term care (LTC) home because there are no assisted-living facilities in her small town. Anti-psychotic medications keep her stable. Schizophrenia is a challenging brain disorder that often makes it difficult to distinguish between what is real and unreal, to think clearly, manage emotions, relate to others, and function normally. It affects the way a person behaves, thinks and sees the world. As a result, it is not surprising that Mary is not always interested in participating in activities that other residents enjoy. Schizophrenia is a chronic disorder, and staff in LTC homes need to know how to provide support, medication management and therapy in order for residents with schizophrenia to manage their symptoms, function independently and enjoy full, rewarding lives.
*Johan was a prisoner in a concentration camp in World War II. He has been diagnosed with Post Traumatic Stress Disorder (PTSD) and worsening dementia. He frequently cries, and seems afraid most of the time. He strikes out aggressively when staff members approach him. PTSD is a mental health condition that's triggered by a terrifying event, and symptoms may include flashbacks, nightmares, severe anxiety, as well as fearful thoughts, insomnia, anger, irritability and depression. Learning about PTSD is crucial for staff in order to provide appropriate care for Johan, as treatment usually involves psychotherapy and counseling, medication, or a combination of both.
These are two stories of residents living in LTC homes with severe mental illness (SMI) and the daily challenges that staff face in caring for them. Statistics from the Canadian Institute for Health Information show 41 per cent of residents in Ontario LTC homes have psychiatric conditions. According to the World Health Organization, here are some key facts about mental illness:
- There are many different mental illnesses, with different presentations. They are generally characterized by a combination of abnormal thoughts, perceptions, emotions, behaviour and relationships with others.
- Mental illnesses include: depression, bipolar disorder, schizophrenia and other psychoses, dementia, and developmental disorders, including autism.
- There are effective treatments for mental illness and ways to alleviate the suffering caused by them.
- Access to health care and social services capable of providing treatment and social support is key.
Unfortunately, access to appropriate health care and support to provide treatment for residents living with SMI in LTC homes is not consistent across the province. Many LTC homes lack timely access to practitioners such as psychiatrists, psychologists or social workers who have specialized mental health skill and knowledge regarding assessments, interventions, therapies, and specialized pharmacological interventions.
Three LTC homes in Thunder Bay are leading the way with a model for individualized care that includes all of these aspects. This enhanced care for residents living with SMI is a result of close collaborations between staff in the LTC homes and partners that have expertise in SMI. The Regional Geriatric Program psychiatrists attend the regular rounds in the LTC homes along with the Behavioural Support Outreach Team, which includes staff with mental health expertise. Individualized strategies for each resident with an SMI include careful medication adjustments, close monitoring, one-to-one care when necessary, and recreation programming. Teams work together for weeks, and sometimes months, testing changes and supporting staff to help residents with SMI.
Nurses and the LTC sector need to advocate for an increase in community services and resources, and collaborate with relevant associations so homes are able to provide optimal care for these residents. LTC homes remain committed to reassuring families that their loved ones are safe and receiving appropriate care, which includes stability for the residents living with SMI and safety for everyone. Following are some resources that have been developed for both residents and the staff who care for them:
- RNAO LTC Toolkit on Mental Health
- RNAO supporting mental health in LTC - Psychosis in Long-Term Care
- RNAO upcoming webinar events
- RNAO Mental Health and Addictions evidence-based information
- Canadian Coalition for Seniors’ Mental Health in Long Term Care
- Health Quality Ontario’s Quality Standards for:
- Anxiety Disorders
- Major Depression
- Obsessive Compulsive Disorders
- Schizophrenia for Hospital and Transitions out of hospital
- Schizophrenia and Care in the Community
*Pseudonyms have been employed to protect the identity of individuals in long-term care.