Long Term Care for Geriatric Health Care Professionals

Fellow clinical gerontologists, prior to our regular papers, we are featuring an essay by one of our Associate Editors Nancy Pachana (2019), followed by a response from Cameron Camp Camp, 2019). You should be alerted that some of their comments are very powerful and thought-provoking. I find Pachana’s derivation of the Five Freedoms for dementia care from Australian zookeeping standards, and Camp’s push for dementia care to be considered an issue of disability rights as clarion calls for “thinking outside the box” to transform dementia care into true person-centered care.

In keeping with Clinical Gerontologist being published in cooperation with the Psychologists in Long Term Care (PLTC), this issue focuses on residential long-term care. The authors of these articles come not only from the USA but also from Australia, Korea, and Taiwan reflecting a trend for interest in geriatric mental health and long-term care to be found across the globe (Pachana & Laidlaw, 2014; Sadeq & Molinari, 2019). In keeping with a theme of the 2017 issue on long term care (Molinari, 2019) the articles in this series continue to address aspects of care that may ultimately lead to improved quality of life (and death) experiences for those who have depression, serious mental illnesses, pain, and dementia in assisted living facility, nursing home, and hospice settings. This series of articles demonstrates that there are multiple contexts in long-term care delivery encompassing individual, family, treatment team and health care system perspectives.

On a broad national note, it has been gratifying to see CMS tackling the thorny issue of the over-use of psychiatric medications in nursing homes by promoting behavioral interventions to improve the quality of life of long-term care residents. However, Winter, Kerns, Winter, & Sabo (2019) suggest that the recent positive findings regarding the reduction of anti-psychotic medications in nursing homes should be interpreted with caution given the concomitant increase of diagnoses that are excluded from such auditing. Although nurses appear to prefer non-pharmacological interventions, their perception of prevalence of anti-psychotic usage in their facility is associated with intentions to use anti-psychotic medications (Ludwin & Meeks, 2019). These two studies indicate that efforts to increase non-pharmacological mental health care in nursing homes must target medical and administrative decision-making, nursing home norms, and the public policy context of psychiatric medication prescription. Indeed, the Parker et al study (Parker et al., 2019) found that staff members in VA NHs perceive that quality standards are not necessarily always consistent with resident centered care, again suggesting both educational and national policy efforts to align the two endeavors.

On a more individual resident tailored basis, Chau, Kissane, & Davison (2019) identify cognitive impairment, functional disability, and depression scores as risk factors for depression at follow-up in long term care. Residents with these factors may need to be targeted on admission for special attention and remedial efforts to reduce depression. It is heartening that there are a variety of such initiatives underway that are testing new tools to intervene in the life of nursing home residents. Ellis, Wells, & Ong (2017) developed a pain management program that appears to be effective in residential care settings, especially when 2 or more components are combined. Han and Kunik’s article (2019) suggest that training in Compassionate Touch in long-term care is feasible and acceptable to staff, and may yield a primary prevention alternate to secondary pharmacological treatment. In preliminary studies, two papers used variants of life review to foster positive family or individual mental health in nursing homes. O’Hora & Roberto (2019) used a family life review to promote adjustment to assisted living, making a case for tailored family-centered care by addressing unique family dynamics. Biassoni, Cassina, and Balzarotti (2019) found that assisting new nursing home residents construct their own autobiographical narratives promotes subjective well-being, as reflected in a measure of positive & negative affect, but not necessarily psychological well-being. Further psychological intervention studies are clearly warranted.

Finally, from an educational perspective related to a cutting edge area in long term care, Aeling and Chavez (2019) found that more information is needed by older adults to make informed decisions about hospice care. Long-term care is an obvious setting to prepare for end-of-life decision-making. Advanced care planning information has been found helpful in improving knowledge and in signing DNR orders for Taiwanese LTC residents (Sung, Wang, Fan, & Lin, 2019). Advanced care counseling packaged in culturally competent materials may be especially helpful for older Latino patients (Maldonado et al., 2019), with personal values particularly important in guiding end-of-life choices (Supiano, McGee, Dassel, & Utz, 2019).

The articles in this issue document the progress that has been made for geriatric mental health practice in long-term care, and also point to future directions to explore. CMS has been great at publicizing the consistent reductions in anti-psychotic usage in nursing homes, but it appears that there are few ongoing national program evaluation projects that identify “best practices” to guide reduction of anti-psychotic usage. Indeed more attention needs to be paid regarding which residents need psychiatric medications and which do not, and how to assure the judicious prescription of psychiatric medications by physicians and nurse practitioners trained both in psychiatry and geriatrics essential. Finally, long-term care delivery is most frequently conducted in community households, yet the research regarding in-home long-term care is lacking. We have come a long way, but there is still a long way to go to assure good quality non-pharmacological and pharmacological person-centered care for those people in long-term care.

Disclosure statement

No potential conflict of interest was reported by the author.