Mental Health Needs of Persons Residing in Skilled Nursing Facilities A Learning Module for Effective Social Work Practice with Older Adults Dr. Robin P. Bonifas, MSW, PhD Arizona State University School of Social Work

Acknowledgements The development of this curriculum module was made possible through a Gero Innovations Grant from the CSWE Gero-Ed Center's Master's Advanced Curriculum (MAC) Project and the John A. Hartford Foundation.

Geriatric Mental Health: Psychiatric Conditions and Behavioral Management Overview: Behavioral management principles Common causes of behavioral symptoms and potential interventions Understanding federal regulations regarding psychotropic medication usage in skilled nursing facilities (SNFs)

Behavioral Management Components of behavioral management: Recognition and documentation of behavioral symptoms Common causes of behavioral symptoms Potential behavioral interventions Monitoring behaviors

Behavioral Management Things to keep in mind: Behavioral symptoms are very common among older persons with mental health conditions. The incidence of behavioral symptoms is very high in SNFs because of the extent of mental health conditions among facility residents. Behavioral symptoms are a form of communication: All behavior has meaning. Behavior represents an expression of some need or desire. Behavioral symptoms are influenced by physiological function and medical illnesses. All behavioral symptoms have underlying causes.

Perhaps at this point you are wondering, what are these “behavioral symptoms?” This terms captures behaviors such as hitting, kicking, pinching, throwing things, continuous disruptive yelling, making verbally abusive comments, throwing things, sexually acting out…

Recognition and Documentation One of the primary components of behavioral management is recognizing it and documenting it - this is how you determine the severity of the problem and whether or not your intervention is working. Effective clinical documentation requires: The ability to recognize, describe, and document behaviors. The ability to analyze and address specific underlying causes (with the help of other disciplines as needed). The ability to describe the behavior's characteristics: its nature, scope, severity, duration, frequency, and consequences, including its impact on other individuals.

Characteristics of Behavior Key Questions Nature & Relevant Factors When did the behavior start, and what were the circumstances surrounding its onset? What happens while the behavior is occurring? Did any specific circumstances contribute to the behavior? What makes it better? What aggravates it? Extent Why is the behavior a problem, and to what extent? For example, does it affect the individual, others in the same living environment, or his/her caregivers? Scope How often does the behavior occur? Severity What risk does this behavior pose to the individual or to others? What is the degree of social or household disruption?

Common Causes of Behavioral Symptoms Several things can contribute to behavioral symptoms: Medications Physical health status Psychiatric illness Environment Personal or health care tasks Interactions with others Next we’ll look at the specifics of each of these things, plus potential social work interventions for each…

Medications Review medications that could be contributing to change in mental status or behavior, examples: Cardiac antiarrhythmics (i.e. verapamil, digoxin) Anticholinergics (i.e. artane, cogentin) Consultant a pharmacist as needed to help recognize medications that may be associated with changes in mental status or behavior. If high-risk or problematic medications are identified, the individual’s physician or other appropriate health care provider should be notified.

Physical Health: Conditions that May Contribute to Behavioral Symptoms Medications or noncompliance with medication regimen Fluid or electrolyte imbalance Infections Hypo- or hyperglycemia Recent hospitalization Recent surgery under general anesthesia Recent change in living situation or environment Recent fall or other trauma

Physical Health: Conditions that May Contribute to Behavioral Symptoms Significant pain Alcohol or drug abuse Hypo- or hyperthyroidism Nutritional deficiency Recent stroke or seizure Primary or metastatic brain tumors or other malignancies Cardiac arrhythmia or myocardial infarction Source: American Medical Directors Association (AMDA). (1998). Altered mental states: clinical practice guideline. Columbia, MD: American Medical Directors Association (AMDA).

Physical Health If delirium or another medical cause is suspected or identified, the client’s physician or other appropriate health care provider should be notified promptly. Remember delirium is a medical emergency and requires medical rather than social work intervention - our role here is educating the family to decrease their fears.

Psychiatric Illness It is important to consider whether psychiatric illnesses might be causing problematic behavior. For example, worsening of schizophrenia or recurrence of major depression. Consult a psychiatrist if necessary. While not a psychiatric illness per se, anniversary reactions associated with grief and loss can also contribute to behavioral symptoms.

Environment Review and identify environmental factors that could be causing or contributing to problematic behavior - this is a common issue in SNFs. For example: Not enough structured activity Space too large Too much noise Another person’s behavior contributing to agitation Recognize that boredom is a form of anxiety that commonly results in agitation and is not an indication for drug treatment.

Personal or Health Care Task Consider functional causes of problematic behavior. For example a task (such as getting dressed or using the toilet) may: Be too complicated Involve too many steps Not be modified for increasing impairment Be unfamiliar in a new environment Here, the solution may be as simple as helping the individual approach the task differently.

Interactions with Others Consider causes of problematic behavior related to interactions with others. For example: The caregiver may be too loud or seem threatening - many persons living in SNFs, due to the culture of their birth cohort, are afraid of men or persons of color. The individual may be unable to understand or make him/herself understood. Examples of relevant approaches might include changing a caregiver’s approach or separating two individuals who are not getting along.

Seek and Address Complications of Treatments Some treatments for problematic behavior, such as medications and physical restraints, can have adverse consequences. Monitor clients for complications related to drugs and devices. Change in appetite, falling, gait problems, decline in function, exacerbation of behavioral problems, or onset of new symptoms. Complications may occur within days of the initial use or after weeks or months of longer-term use.

Consider and Address Adverse Drug Reactions (ADR) Psychotropic medications can affect other body functions, such as blood pressure, appetite, and urinary continence. If a possible ADR is identified, this needs to be communicated to the individual’s physician or other appropriate health care provider, who can then address possible complications.

Psychotropic Medications as Interventions for Behavioral Symptoms A review of federal regulations guiding usage

Psychotropic Medications Psychotropic medications may be used as an adjunct to behavioral interventions in skilled nursing facilities. Sometimes the combination of both types of interventions helps residents to achieve better control of distressing symptoms, thereby enhancing quality of life. Sometimes residents are so distressed that such medications are necessary before behavioral interventions can even be effective. Because of the negative side effects discussed in proceeding slides, and the potential for misuse, the prescription of such medications in SNFs is highly regulated; it is important for social workers to be aware of these regulations.

Psychotropic Medications F-tag 329: Unnecessary drugs F-tag 330: Antipsychotic drugs specific conditions F-tag 331: Antipsychotic drugs dose reductions

F-tag 329: Unnecessary Drugs Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drugs ia any drug when used: In excessive does (including duplicated therapy); or For excessive duration; or Without adequate monitoring; or Without adequate indications for its use; or In the presence of adverse consequences witch indicate the dose should be reduced or discontinued; or Any combinations of the reasons above.

F-tag 329: Unnecessary Drugs The goal of these regulations and guidelines is to stimulate appropriate differential diagnosis of “behavioral symptoms” so the underlying cause of the symptoms is recognized and treated appropriately. The goal of these regulations is also to prevent the use of psychopharmacological drugs with the “behavioral symptom” is cause by conditions such as: Environmental stressors Psychosocial stressors Treatable medical conditions

F-tag 329: Unnecessary Drugs Long-acting Benzodiazepine Drugs Should not be used unless a shorter-acting benzodiazepine has failed. After a shorter-acting benzodiazepine has failed, longer-acting benzodiazepine should not be used unless: Evidence exists that other possible reasons for the resident’s distress have been considered and ruled out. Its use results in maintenance or improvement in the resident’s functional status. Daily use is less than four continuous months unless an attempt at gradual dose reduction is unsuccessful; and Its use is less than or equal to the total daily dose listed in Guidance to Surveyors (see pp-313) unless contraindicated.

F-tag 329: Unnecessary Drugs Benzodiazepine or other Anxiolytic/Sedative Drugs Use for purposes other than sleep induction should only occur when: Evidence exists than other possible reasons for the resident’s distress have been considered and ruled out. Use results in a maintenance or improvement in the resident’s functional status. Daily use is less than four continuous months unless an attempt at gradual dose reduction is unsuccessful (Twice within one year).

F-tag 329: Unnecessary Drugs Use is for one of the following indications: Generalized anxiety disorder Delirium, dementia, and amnesic and other cognitive disorders with associated agitated behaviors, which are quantitatively and objectively documented, which are persistent and not due to preventable reasons and which constitute sources of distress or dysfunction to other residents or represent a danger to the resident or others. Panic disorder Symptomatic anxiety that occurs in residents’ with another diagnosed psychiatric disorder. Use is equal to or less than doses listed in Guidance to Surveyors, (see pp 316) unless contraindicated.

F-tag 329: Unnecessary Drugs Drugs for sleep induction should only be used if: Evidence exists that other possible reasons for insomnia have been ruled out. The use of a drug to induce sleep results in the maintenance or improvement of the resident’s functional status. Daily use of the drug is less than ten continuous days unless an attempt at gradual dose reduction is unsuccessful (3 times within 6 months). Use is equal to or less than doses listed in Guidance to Surveyors, (see pp 318) unless contraindicated.

F-tag 329: Unnecessary Drugs Antipsychotic Drugs Dosage limitations exist for use in delirium, dementia, and amnesic and other cognitive disorders unless contraindicated (see Guidance to Surveyors, pp-321) Monitoring required: Tardive dyskinesia Postural hypotension Cognitive/behavioral impairment Akathisia; and Parkinsonism See pp-326 for examples of documentation supporting use outside of the guidance when it is in the resident’s best interest.

F-tag 330: Antipsychotic Drugs Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record.

F-tag 330: Antipsychotic Drugs Antipsychotic drugs should not be used unless the clinical record documents that the resident has one or more of the following “specific conditions”: Schizophrenia Schizoaffective disorder Delusion disorder Psychotic mood disorder Acute psychotic episodes Brief reactive psychosis Schizophreniform disorder Atypical psychosis Tourette’s disorder Huntington’s disease

F-tag 330: Antipsychotic Drugs Antipsychotic drugs should not be used unless the clinical record documents that the resident has one or more of the following “specific conditions”: Delirium, dementia, amnesic and other cognitive disorders with associated psychotic and/or agitated behaviors Which have been quantitatively and objectively documented Which are persistent Which are not caused by preventable reasons Which are causing the resident to: Present a danger to himself/herself or to others,or Continuously scream, yell, pace if these specific behaviors cause impairment in functional capacity, or Experience psychotic symptoms which cause the resident distress or impairment

F-tag 330: Antipsychotic Drugs Antipsychotic drugs should not be used if one or more of the following is/are the only indication: Wandering Poor self care Restlessness Impaired memory Anxiety Depression (without psychotic features) Insomnia Unsociability Indifference to surroundings Fidgeting Nervousness Uncooperativeness Agitated behaviors which do not represent danger to the resident or others.

F-tag 331: Antipsychotic Drugs Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Clinically contraindicated when: Resident has specific condition Gradual dose reduction attempted twice in one year resulting in return of symptoms Physician provides justification, see Guidance to Surveyors pp-341 for details on what justification must include.

An Example Care Plan for Psychotropic Medications

An Example Care Plan for Psychotropic Medications