Editor’s Note: For the purposes of this report, “nursing home residents” refers to those in long-term care. There is a distinction between nursing home residents who live in long-term care facilities who are unable to live independently [those discussed in this article] and those who need short-term care after, for example, a surgery or acute medical difficulty. These residents also are distinct from individuals living in long-term facilities that are called “assisted living” facilities. Assisted-living facilities have no federal oversight, unlike nursing homes which are federally regulated.

 

With seniors and staff in long-term care facilities among those receiving the first rounds of COVID-19 vaccines, it is hoped that the nearly year-long hardships imposed by a virus that disproportionately affects the elderly, particularly in congregate settings, will hasten to a close. Notwithstanding the delays and challenges of actually getting the vaccine into arms of these seniors, not the least of which is vaccine hesitancy reported among nursing homes residents, the fact that a vaccine is available is being heralded as the light at the end of the tunnel.

However, the vaccine itself will not mitigate the widespread mental health challenges faced by seniors – and those treating them. Mental health issues have long been under-recognized in this population, even before the pandemic.

Prevalence of Psychiatric Disorders in Nursing Homes May Surprise Some

“Nursing homes basically have become psychiatric institutions,” said Brent Forester, MD, chief of the Center of Excellence in Geriatric Psychiatry at McLean Hospital and medical director for Behavioral Health Integration, Quality and Patient Experience at Mass General Brigham.

Epidemiological data show rates of depression, severe mental illness, or dementia, in 70% to 80% of nursing home residents, he told Psycom Pro, noting, “I don’t think people appreciate that enough.” (For comparison, Grabowski et al cite a range of 65 to 91% of nursing home residents with a significant mental disorder, namely mood disorders, psychotic disorders, anxiety disorders and other mental illness.1)

Enter COVID-19 and Further Isolation

What people have appreciated is the added isolation and loneliness the pandemic has wrought on the mental health issues that many elderly individuals struggled with prior to the pandemic. Lisa Lind, PhD, a licensed psychologist and chief clinical leadership team member for Dear Oaks, a behavioral health provider focused on long-term care, underscored the effect of the pandemic on exacerbating symptoms of anxiety and depression among long-term care facility residents following the implementation of visitor restriction guidelines.

“Residents at that time were reporting an increase in anxiety related to the fear of contracting COVID, anxiety related to witnessing other residents and staff contract COVID, and some contracting COVID themselves and having to isolate,” she said, adding that depressive symptoms have also increased.

Although some data suggest that older people in community settings are actually faring better than younger people in terms of mental health during the pandemic due to factors such as increased longer life experience and wisdom,2 others note that no detailed information yet exists on the true impact of the pandemic on residents of long-term care facilities.

According to David Grabowski, PhD, professor of Health Care Policy at Harvard Medical School, “We do not yet have data yet on exactly how the pandemic has impacted individuals with mental health needs but all signs point towards this having dire consequences for residents of long-term care facilities. He cited the combined effects of more isolation (less engagement with family and other residents) with the increased stress and anxiety of the pandemic on residents’ mental health. “Tending to the mental health needs of residents will be a key priority in the post-pandemic period,” he pointed out.

It is said that the strains placed on people during a period of significant change or trauma often reflect the situation they were in prior to the change – the same holds true for the COVID-19 impact. For those living in long-term care facilities, the pandemic has further revealed the endemic mental health issues present in these communities and, more importantly, the urgent need for better integrated mental healthcare.

Statistics on Long-Term Care Facilities in the US

In February 2019, the National Center for Health Statistics published updated information on long-term care providers and service users in the United States. The report, based on the 2015-2016 National Study of Long-Term Care Providers, describes the most current information available on the number and kind of providers and service users in five major sectors of paid, regulated long-term services:

  • adult day service centers
  • home health agencies
  • hospices
  • nursing homes
  • assisted living and similar residential care communities

Following are some key findings focused on nursing homes:

  • Total number of long-term care service providers in all five categories: 65,600 serving more than 8.3 million people in the United States
  • Number of nursing homes: 15,600 service providers serving 1,347,600 residents
  • Employed nursing home staff: 945,700 full-time nursing and social workers
  • Residents by age: 83.5% were 65 years and older
  • Percentage of nursing homes that provide specific services:
    • skilled nursing or nursing services (100%)
    • dietary and nutritional services (100%)
    • therapeutic (99.5%)
    • pharmacy (97.2%)
    • social work (88.5%)
    • mental health or counseling (87.6%)
    • hospice services (80.7%)
    • dementia care units (14.9%)
  • Percentage of residents with diagnosed mental health issues:

Understanding the scope of mental illness in nursing homes is complex given the different data sets used to estimate the size of the population in nursing homes with mental illness, as described in 2009 study by Bagchi and colleagues . Data from Gabrowski published in 2010 – based on 1,150,734 new nursing home admissions in 2005 – showed that 2.7% (31,335) admissions indicated schizophrenia or bipolar disorder when using a narrow definition of mental illness. When using a broader definition, that number grew to 27.4% (315,003) admissions, including schizophrenia, bipolar disorder, depression, or anxiety.

Pandemic or Not, Treatment Gaps Plague the Mental Health Needs of Long-Term Care Residents

Whether due to the pandemic or not, better quality care is needed to address the mental health needs of the individuals living in long-term care facilities. Calling the mental health needs of these residents “tremendous,” Dr. Forester specifically emphasized the need for more integrative behavioral health support in nursing homes to address the myriad of issues that often, if not addressed, lead to poor outcomes.

Typically, nursing home staff provide care via a medical team with psychiatric consultations brought in as needed.

Severe, Persistent Mental Illness Coupled with a Shortage of Mental Health Professionals

“Individuals with severe and persistent mental illness, such as treatment-resistant bipolar disorder and schizophrenia, have poor preventative healthcare and high rates of obesity and cardiovascular disease leading to premature mortality and premature institutionalization in long-term care facilities,” he explained

Dr. Forester stressed that behavioral complications associated with dementia (eg, agitation, aggression), anxiety, depression, and substance abuse are highly treatable. “Unfortunately, we have an inadequate workforce of geriatric mental health providers with expertise in the assessment, prevention, and treatment of these common psychiatric conditions in long-term care settings,” he said. Further, general preventive care such as exercise and nutrition, addressing nonadherence to medication, and other lifestyle factors are not addressed.

Dr. Grabowski also cited the shortage of people to address these issues in long-term care facilities. “Before the pandemic, we had a shortage of mental health professionals working in long-term settings,” he said. “During the pandemic, this issue has been magnified in that many mental health needs are going unmet.”

“There are major gaps in care,” he said.

Exacerbating the shortage of mental health professionals is the lack of access during the pandemic due to facility restrictions. “Psychologists and other mental health professionals have experienced difficulty accessing their patients at the time due to outbreaks in long-term care,” said Dr. Lind. “While some facilities have provided staff to facilitate telehealth services, many facilities have been unable to reliably do so resulting in a significant disruption in mental health services for many residents.”

In a 2010 literature review that looked at the quality of mental healthcare in long-term care facilities, Dr. Grabowski and colleagues detailed the extent of these gaps and others.3 Data from one study, for example, showed that 80% of nursing home residents with mental illness did not receive help from a psychiatrist, clinical psychologist, or licensed social worker as evidenced on Medicare Part B claims.1,3 Overall, when available in nursing homes, psychiatric services were commonly provided by psychiatric consultants who were not members of the nursing home staff, despite recognition by clinicians and administrators that these “as-needed” consultants were not adequate to address the mental health needs of residents.1,4,5

When looking at effective models of mental health services provided to nursing homes, data showed that a multidisciplinary team approach, in conjunction with a “train the trainer” nurse specialist model (in which nurse training focused on identifying and addressing mental health needs in nursing home residents), was the preferred model. The train the trainer model was further linked to improved staff knowledge and performance as well as decreased staff turnover.1,6

A decade later, however, and not much has changed in care access or models.

Restrictions on Psychiatric Medications

Another – perhaps more recent – gap in care, according to Dr. Forester, is the disincentive to provide the full array of psychiatric medications to nursing home residents given the regulatory environment. “There is a federal mandate to reduce the use of psychiatric medications, anti-psychotic medications in particular,” he said, explaining that current regulations incentivize nursing homes to not use these agents even in situations where patients are doing well on them and continuity of care is needed.7 This CMS mandate was put into action before COVID-19.

 

How to Help Long-Term Care Residents Now

Integrate Teams and Bolster Training

In addition to the findings noted by Dr. Grabowski’s team above, Dr. Forester, who, as co-president of the American Association of Geriatric Psychiatry, is involved in educating HCPs and mental health professionals on geriatric mental health issues, emphasized that a holistic approach utilizing integrated teams is needed to adequately care for the mental health of older adults. “There will never be enough of us [mental health professionals] to do this work, so that is why the integrated, multidisciplinary teams are helpful,” he explained.

Improving the education of nursing home staff on mental health challenges is also crucial, he said. Among the scalable models of education being implemented is an educational nursing home program through Project ECHO. The program includes training on how to address pandemic-related social isolation issues for residents, families, and staff. Project ECHO (Extension for Community Healthcare Outcomes) provides virtual educational programs to underserved and remote areas through telementoring by expert teams.

“These types of programs are helpful,” said Dr. Forester. “They do not provide direct care but they support people who provide direct care so they can appropriately intervene when necessary and prevent a worse outcome.”

Address Grief in Older Adults

Grief, over the many losses associated with aging, losing loved ones, and nearing one’s own death, is a common experience among older adults.

Calling deaths from COVID-19 in long-term facilities a “tsunami of loss” for residents and staff, Toni P. Miles, MD, PhD, a physician and professor in the Department of Epidemiology and Biostatistics in the College of Public Health at the University of Georgia in Athens, underscored the toll accumulated and ongoing grief can have mental health. During the pandemic, grief has taken on different hues given the sheer numbers of people dying in close congregate settings and the inability to say proper goodbyes or hold funeral services due to infection concerns.

(More on how to identify grief in psychological assessments.)

Acknowledging the role grief can play in mental health issues, Dr. Forester emphasized the need to distinguish between normal grief and complicated grief, recently approved for the DSM as prolonged grief disorder. “I would argue that grief can become a mental health issue when it is complicated by disturbances in sleep, appetite, energy, and motivation,” he said.

To help both residents and staff of nursing homes grapple with grief, Dr. Miles developed two toolkits – one for staff and one for residents – that offer best practices in coping with death. Developed with support from the state of Georgia and available upon request through Leading Age of Georgia, Best Practices in Bereavement Care catalogues strategies used by residents and staff to navigate loss and grief. To date, Dr. Miles has mailed out 400 toolkits to nursing homes and offers webinars to supplement the training.

Support Long-Term Care Facility Staff: Helpful Resources

Staff who care for residents in long-term care facilities also need to manage their own mental health needs, particularly during the ongoing stress of the pandemic. Compassion fatigue and burnout are particularly challenging given the impact on staff of seeing so many people getting sick and dying, said Dr. Forester.

Along with fearing for their own health, staff also face anxiety and depression. “I don’t think enough guidance has been put in place for either residents or staff,” he said. “There is always a lot of staff turnover in these facilities and this is escalating [during COVID-19].”

In Summary

Residents of long-term care facilities have had to weather long periods of isolation even before COVID-19 further restricted access to visitors and to mental healthcare. The toll all of this is taking on facility and nursing home residents is not completely known – what is known is that their needs are not going to disappear with a vaccine or an end to the pandemic.

Better measures are needed now to address the ongoing mental health needs of older needs, starting with hiring, training, and the integration of care teams. By bringing together behavioral and medical treatments, the quality of life for these already vulnerable seniors may be salvaged.

References
Last Updated: Jun 2, 2021