Minding Our Elders: Mental Health in Long-Term Care
By Nicole Zahradnik
Network, Winter 2007
Research shows that between 80 and 90 percent of older adults living in long-term care facilities have some form of mental disorder. Dementia and Alzheimer’s disease are widespread, but depression and other mental illnesses are also common.
Dr. David Conn, psychiatrist-in-chief at Baycrest in Toronto and co-chair of the Canadian Coalition for Seniors’ Mental Health, cites delirium, adjustment disorder, personality disorder, psychosis and major depression as common mental disorders in residents of long-term care homes. The Canadian Study of Health and Aging, for example, revealed that 12.7 percent of long-term care residents aged 65+ suffer from major or minor depression. Other studies indicate that more than two-thirds of residents have some form of dementia, and 40 percent of those suffering from dementia have other psychiatric complications such as depression, delusions or delirium.
Mental illness, however, may go unrecognized in the elderly. As Dr. Conn explains in a report for the National Advisory Council on Aging, ‘It can be difficult to make a diagnosis of depression, particularly in patients with co-existing dementia and/or chronic medical illness.’ Left untreated, mental illness can seriously affect physical health. ‘There is evidence to suggest,’ continues Dr. Conn, ‘that depression can contribute significantly to a general deterioration of health in seniors…. Studies also suggest that depression is associated with increased mortality rates in long-term care,’ where seniors with depression are up to three times more likely to die, as compared to non-depressed patients.
Regrettably, specialized psychiatric service in Ontario’s long-term care homes is scarce. A 1992 study of long-term care facilities in the province revealed that 88 percent of nursing homes received five or less hours per month of care by a psychiatrist for their entire institution. The average number of residents in a long-term care home currently exceeds 130.
In the years since that study was released, the government of Ontario has made some attempts to improve the quality of mental health services for seniors. In 1999 they announced Ontario’s Strategy for Alzheimer Disease and Related Dementias, a five-year plan that included annual training for long-term care staff and access to psychogeriatric resource consultants who provide education and advice on how to work with people who exhibit ‘challenging behaviours.’ In addition, the Ministry of Health and Long-Term Care began funding psychogeriatric community outreach teams to provide services to older persons with mental illness and/or dementia, both in the community and in long-term care homes. Yet despite these initiatives, the mental health needs of seniors in long-term care are not being adequately met.
For Ron Baxter (not his real name), getting a proper assessment and specialized psychiatric care for his mother is an ongoing challenge. She was diagnosed with schizophrenia when Baxter was young, and later with bipolar disorder. There have been issues with violence and pharmaceutical drug abuse. She also has physical health problems and is highly susceptible to infections – infections that have led to delirium and catatonia. Yet she has periods when she is ‘capable of having a lucid conversation,’ says Baxter, and despite being verbally abusive, she is usually assessed as being ‘a bit cranky but [mentally] healthy.’ When her psychiatrist retired several years ago, he told her she was ‘cured,’ recalls Baxter, although her family doctor continued to prescribe antidepressants, among other medication.
She first went into a retirement home four years ago, when her husband passed away and she could no longer take care of herself. Soon afterwards, she was hospitalized for self-mutilation, and the retirement home director advised Baxter they were no longer equipped to deal with his mother’s medical and mental health needs. Baxter had no choice but to place his mother in a long-term care home, where she would have 24-hour supervision, nursing care, and other supports.
Baxter was also advised to have his mother undergo a psychiatric assessment. Acting on the healthcare professional’s advice, he immediately contacted a Community Care Access Centre (CCAC) in his mother’s home town. In Ontario, CCACs are responsible for conducting the initial assessment of care needs and making referrals for placement in a long-term care home. Because of his mother’s recent experience of self-mutilation and her history of mental illness, Baxter questioned whether a long-term care home would be able to meet all his mother’s needs, including specialized psychiatric care. The CCAC assured him that long-term care homes do deal with individuals with mental health issues. Unfortunately, in Baxter’s mother’s case, she has not received the mental health care she so clearly needs.
Although he was counselled by the CCAC staff that availability might be an issue, Baxter’s mother was placed in a home almost immediately. The whole process took just over a month. The home was not Baxter’s first choice, and so shortly thereafter, he succeeded in having his mother transferred to a ‘gentle care’ facility. Gentle care homes adopt a holistic philosophy and are designed to improve and continually enhance their residents’ quality of life. But once again, he questioned the staff’s knowledge of mental illness and their ability to respond to someone with mental health issues. He was repeatedly told they were equipped to provide his mother with both medical and psychiatric care.
Baxter soon discovered that the woman who was completing his mother’s assessment was a recreational supervisor who had no medical background. Baxter was outraged. He felt his mother’s medical and mental health needs should take precedence over her recreational needs. ‘It was not the kind of attention to detail I was looking for,’ he recalls. ‘It’s great that they have activities, but my first concern was not about finding a country club environment.’
‘Throughout all of my mother’s health issues, the medical professionals involved with her care were not acknowledging or responding to her mental health issues. They were only responding to her medically and never responding to the whole person. This is one of the biggest issues I have regarding her care. You cannot separate her medical issues from her mental health issues. It is all entwined together.’ Eventually, Baxter was able to speak with the director of care and address some of his concerns. But despite his best efforts as an advocate for his mother, to this day Baxter has been unsuccessful in getting her assessed by the one practicing geriatric psychiatrist in the area.
Long-term care is a vital component of the Ontario health care system. While most seniors can expect to reside in the community throughout their later years, a significant number will require institutional care to ensure safety and well-being. The need for long-term care services and supports is often greatest for those who are considered the most vulnerable – those who are frail, or have complex health conditions, or psychiatric disorders.
Today, adults over 65 years of age represent 12 percent of the total population in Ontario, but they consume over 44 percent of the province’s health care budget and account for 50 percent of acute hospital days. By 2026, seniors will amount to approximately 21 percent of the population and consume about 60 percent of health care spending.
Considering that seniors 85 and older are the fastest growing age group and the most likely to require long-term care facilities, it is not surprising that over the next 30 years, the number of long-term beds in Canada is expected to triple. Currently, Ontario has 618 long-term care facilities, totalling 81,000 beds.
Long-term care homes are spread across the province, but depending on the community and where an individual is placed on the priority list, wait times can range from immediate admission to a few years. Larger, urban communities may have enough beds to meet local demand, but province-wide there’s a shortage of spaces. The ideal placement means staying close to the person’s home community, which makes it easier for family and friends to visit and to continue providing much-needed support.
Beyond the issue of bed availability, one of the first challenges in finding appropriate long-term care for older adults with a mental illness is the admission process. ‘CCACs are not guided by a mental health mandate,’ according to Randi Fine, executive director of the Older Persons Mental Health and Addictions Network of Ontario. People are admitted for a variety of reasons, but ‘an individual’s mental illness is very often secondary,’ she explains. ‘Placement is not based on their mental health but on their physical mobility issues, other than in the case of dementia.’
Indeed, most long-term care homes are designed for people who are physically immobile and not for those with a mental illness. For instance, the majority of social/recreational activities offered in long-term care homes are very sedentary. For some people living with a mental illness, physical activity may play an important role in their treatment plan.
To complicate matters, a complete social history may not be taken, resulting in an incomplete assessment prior to admission. ‘For a variety of reasons, Community Care Access Centres do not always receive complete and accurate information pertaining to an individual’s needs,’ says Margaret Ringland, director of member relations and professional services with the Ontario Association of Non-Profit Housing and Services for Seniors. ‘The individual may not be able to give an accurate social and life history, family members may want to protect their loved one’s privacy, or they may experience barriers when trying to release information to a third party.’
Screening for mental illness is not a standard part of the intake process for all long-term care homes. To improve the quality of care planning, the province recently introduced an automated tool called the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0. This tool provides a comprehensive and standardized assessment of each resident’s cognitive, behavioural, functional, and psychosocial status, as well as strengths, preferences and medical status. The RAI-MDS assessment can flag the need for more detailed psychiatric assessment when certain MDS items are ‘triggered’ based on the resident’s responses. The triggered areas help staff to develop outcome-oriented resident care plans to improve quality of care and the resident’s quality of life through early recognition of problems and risk factors that can be avoided, managed, or reversed. The RAI-MDS 2.0 will eventually be used in all long-term care homes throughout Ontario. To date, it has been implemented in 89 homes.
Whether a mental illness is identified or not, many long-term care homes are still not prepared nor appropriately resourced to adequately respond to a person’s mental health needs. Not surprisingly, when mental health issues are identified prior to admission, there may be some resistance to accepting those applicants. As Ringland states, ‘The biggest challenge for a long-term care home is to take the residents they can manage with the staff resources they have. The majority of staff at long-term care homes are non-regulated health care professionals comprising of health care aids and personal support workers. Professional staff, such as registered nurses and social workers, are very limited. Staff-to-resident ratios are approximately 1:60 for nurses, to 1:45 for registered practical nurses, to 1:10-12 for personal support workers.’
Appropriate training for staff continues to be an issue. ‘Personal support workers get six months of training, when in fact they should be getting at least two years,’ says Baxter. ‘They don’t have any mental health training, and usually the nurses don’t either. If they do, it’s because they got it somewhere else, but they aren’t required to have it to work in the long-term care home.’
While directors of care receive both dementia and Alzheimer care education, training concerning the broader spectrum of mental health issues is not provided by long-term care homes.
‘If staff do not have an understanding of mental illness, it affects how they provide care,’ observes Gerri Yerxa, a geriatric mental health therapist with the District Mental Health Services for Older Adults Program (DMHSOAP), a program of the Canadian Mental Health Association, Fort Frances Branch. ‘If they understood mental illness better, they might provide care in a different fashion.’
Educating caregivers and staff about mental health issues is one of the services provided by DMHSOAP in northwestern Ontario. CMHA Fort Frances Branch operates DMHSOAP in the Kenora/Rainy River District. Running since 2000, DMHSOAP covers Red Lake, Sioux Lookout, Dryden, Atikokan, Fort Frances, and Kenora. The program provides services to older adults (60+) living with a serious mental illness and/or dementia (including Alzheimer’s disease) both in the community and in care facilities.
Staff backgrounds are diverse, ranging from nursing to social work to psychology, which allows a variety of services to be delivered. Direct services may include counselling or clinical intervention, assessment and cognitive screening, care and treatment planning, referral and advocacy, and monitoring and followup. DMHSOAP also provides support services to caregivers and assists caregivers by offering a much-needed planned break each week. Other services include case management, as well as education for the community and care providers.
The DMHSOAP team is quite unique compared to other teams in the province. Because the program serves six different communities within a 1,200-kilometre radius, it has needed to be very creative in the way it delivers service, developing partnerships to meet the unique needs of rural, remote communities. The use of telehealth technology, for example, provides access to scarce specialty resources. The staff meet through teleconference with geriatric psychiatrist Dr. David Conn, working out of Baycrest Hospital in Toronto, for client assessments, consultation and education. This unique arrangement allows ongoing mentoring with specialists in the field of geriatric psychiatry.
DMHSOAP provided services to 311 individuals in 2003/04, 533 people in 2004/05, and 633 in 2005/06. Sandy Skirten, district coordinator of the program, anticipates that ‘the need for service will continue to increase as the older adult population continues to grow.’
A typical DMHSOAP consultation begins with a letter or referral form from the resident’s general practitioner or the facility nurse manager, requesting an assessment. During the initial stage, detailed information is gathered about the current situation, such as the resident’s behaviour and challenges experienced by staff. A list of the resident’s medications is also required. The geriatric therapist then goes to the facility to begin the assessment. Often the therapist will gather information from the resident’s chart, staff (nurse, personal support worker, and nurse manager), and family, including a social history. This information helps the therapist develop a better understanding of the person’s needs. One of the final stages in the assessment is to observe the resident in their own environment, requesting staff to identify those times that are most challenging for both themselves and the resident. Ideally, two or three observations take place before the information is compiled into a report with recommendations for the staff to implement in the long-term care home.
The program provides the home with ongoing follow-up as required, but there are still many challenges. ‘We can provide recommendations but it is up to the home to implement them,’ explains Gerri Yerxa. ‘We can only help to facilitate the process.’ For those with a serious mental illness, such as chronic major depression, dementia or an adjustment disorder, the program goes beyond individual services like counselling, support, and medication consultation, to provide ongoing education to staff in the home about different aspects of a particular resident’s diagnosis and about serious mental illness in general.
Accountability is very important within DMHSOAP, according to Sandy Skirten. ‘Program evaluations from consumers, caregivers and service providers continually confirm that this service is accessible, appropriate and meeting the needs of older persons with a serious mental illness and dementia in their home community.’ Skirten encourages other programs to conduct evaluations for program and goal development.
Dr. Franklin Wong, a geriatric psychiatrist at North York General Hospital in Toronto, provides a similar service for seven long-term care homes in North York. His team has been operating since the spring of 2006. He is most commonly consulted for depression and dementia. The program is designed to respond to urgent or crisis situations, with short-term follow-up care provided by a case manager. In future, Dr. Wong would like to see the program include a long-term follow-up component and also provide services during the initial transition period from home or hospital to the long-term care facility.
‘Long-term care residents with mental health issues require more care,’ explains Dr. Wong. ‘They often do not have access to hospital mental health programs, and specialized dementia care units are difficult to get into. Staff resources in long-term care homes are already stretched – the patient-to-staff ratios are too high, staff do not receive enough training around mental illness, and there’s a high burnout rate. Staff have the most contact with residents, not the psychiatrist. If all staff had increased training, they could help a lot, even before we see the resident.’
While the province’s psychogeriatric teams are helping to improve the quality of mental health services in long-term care homes, there are still many system-level issues. As Randi Fine observes, ‘If we really had a system of continuity, then people would be assessed along the way and placed in the most appropriate and properly resourced facility available. We need better services within the community to identify, assess and support older adults living with a mental illness in their own homes for as long as possible so that only those who really require 24/7 care are placed in a long-term care facility. If you look at the funding for senior care in general, such a tiny proportion is for community care, but 90 percent of seniors are living in the community and only a small percentage are in long-term care.’
Margaret Ringland agrees. ‘A broader acknowledgment of the importance of support for this population is needed. Older persons must not be looked at as a burden. We must look at our entire healthcare system and recognize each part has value. By developing cross-sector support and continually strengthening supports in the community, long-term care homes would become part of the continuum. Furthermore, there is a greater need for research and data collection on older persons with intractable mental illness and dementia in long-term care facilities.’
Currently, the long-term care system in Ontario is governed by three different statutes, introduced in 1990: the Nursing Homes Act, the Charitable Institutions Act and the Homes for the Aged and Rest Homes Act. In October 2006, the Ontario government introduced Bill 140, the Long-Term Care Homes Act. If passed, the new legislation will promote zero tolerance of abuse and neglect of long-term care home residents, provide whistle-blower protection for staff, residents and volunteers who report abuse or neglect, require that a registered nurse be on duty in the home 24 hours a day, seven days a week, and restrict the use of restraints to circumstances where it is deemed absolutely necessary and only with appropriate safeguards.
The new Act will address some key issues, but as Dr. Wong notes, ‘It is important that the government put money behind their efforts in order to support their benchmarks and standards of care.’ Similarly, Ringland is concerned that ‘without the appropriate funding for many of the proposed operations, one will definitely see a reduction in care.’
Regardless of Bill 140′s outcome, a real shortage of mental health services for those living in long-term care facilities continues. As Ron Baxter states, ‘People ask me, ‘Why don’t you go somewhere else?’ But where else do you go? The situation is the same everywhere in the province.’
Nicole Zahradnik is a community mental health analyst with CMHA Ontario.
Percentage of long-term care residents aged 65+ who suffer from depression
Number of long-term care facilities in Ontario
Total number of long-term care beds in the province
Growth rate of long-term care beds over the next 30 years
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