Supporting Resident Mental Health: A Comprehensive Approach

ECRI and Annals of Long-Term Care: Clinical Care and Aging (ALTC) have joined in collaboration to bring ALTC readers periodic articles on topics in risk management, quality assurance and performance improvement (QAPI), and safety for persons served throughout the aging services continuum. ECRI is an independent, nonprofit organization improving the safety, quality, and cost-effectiveness of care across all health care settings worldwide.

Providing person-centered care requires addressing the “whole person,” which includes mental health. However, several barriers impede the efforts of aging services organizations to support resident and client mental health, including stigma about acknowledging the need for help among residents or family members; lack of trained staff; less-than-ideal payment models; and organizational structures that make it difficult to provide adequate support.

Fortunately, aging services organizations can take a comprehensive approach that requires both broad measures to support the mental health of all residents and targeted strategies to meet the specific needs of individual residents. Aging services staff must be able to acknowledge the widespread prevalence of mental health problems in their residents; recognize risk factors; understand the organization’s pathways to intervene, diagnose, and treat mental health problems; and be able and ready to set residents on an established pathway. This article discusses the challenges related to addressing the mental health needs of older adults, takes a closer look at a few common mental health issues experienced by those in aging services settings, and describes evidence-based approaches to overcome barriers to mental health care.

The Current State of Mental Health in Aging Services

The bulk of mental health services for older adults is focused on symptom management of Alzheimer disease and other dementias, given their vast prevalence and the support these conditions warrant. However, the needs of older adults who live with depression, anxiety, and other nondementia mental health illnesses have historically fallen to the wayside. According to the US Department of Health and Human Services’ Administration on Aging, for example, two-thirds of nursing home residents exhibit mental and behavioral issues, but less than 3% of older adults report seeing a mental health professional, often in part due to¹:

• inadequate funding;
• lack of collaboration and coordination among primary care, mental health, and aging services providers;
• access barriers; and/or
• lack of trained professionals in geriatric mental health services.

Other studies have indicated similar prevalence rates and contributing factors, though most also acknowledge the challenge of analyzing prevalence rates and the limited availability of such data. A 2012 National Academies report acknowledged this challenge but suggested that at least 14% to 20% of older adults in the United States live with mental health and substance use disorders, such as the following²:

• Adjustment disorder
• Anxiety disorders (including posttraumatic stress disorder) and symptoms
• Bipolar disorder
• Depressive disorders and symptoms
• Personality disorders
• Schizophrenia
• Substance-related disorders 
• Behavioral and psychiatric symptoms of dementia
• Complicated grief
• Severe self-neglect or domestic squalor (eg, hoarding)

Apart from health system-based contributing factors, prevalence is challenging to analyze because symptoms of mental health conditions may manifest differently in older adults compared to younger individuals. Older adults may be more inclined to acknowledge physical symptoms of depression, for example, such as body aches, sleeplessness or insomnia, and poor appetite, rather than emotional symptoms such as anxiety, crying spells, and social
isolation. The challenge is exacerbated when residents and physicians are dealing with complex, comorbid, or chronic physical illnesses that make recognition, assessment, and diagnosis exceedingly difficult due to overlapping or overshadowing symptoms.³

Older adults are also more vulnerable to experiencing common life stressors known to be associated with increased risk, such as⁴:

• grief and bereavement;
• drop in socioeconomic status or retirement;
• reduced mobility, functional and cognitive decline, and frailty;
• chronic pain and other chronic health conditions; or 
• being a victim of elder abuse.

Other factors include genetic predisposition, prior experience with mental health struggles, and brain chemistry.⁵ Older adults living in long-term care facilities, in particular, are almost twice as likely to experience symptoms of depression, self-harm, or suicidal ideation as community-dwelling older adults.⁶ Polypharmacy and the use of antidepressants, anxiolytics, and analgesics have also been shown to worsen depressive symptoms among older adults over time.⁷ 

Even if the majority of aging services staff understood the prevalence and risk factors, identifying at-risk individuals is still problematic. Older adults generally believe that mild depression is a “normal” reaction to the aging process and stressful experiences, but they also generally prefer self-management strategies as opposed to professional interventions, a preference that is often influenced by a balance of judgments: perceptions about potential adverse effects or events; the level of trust, familiarity, or comfort with intervention leaders; and experiences with past interventions.⁸ Staff members may exhibit similar biases, and when coupled with a lack of training, it may affect their ability or willingness to make the mental health of older residents a priority. 

Evidence-Based Strategies to Enhance Mental Health Care

Train Staff in Mental Health Basics

It behooves staff across the continuum to be trained in mental health basics, but training should be required for all direct care workers in aging services settings. For example, nurse aides in long-term care facilities are required to receive competency training in mental health and social services needs in addition to other standard competencies (eg, resident rights, communication skills).⁹ Although many staff training programs focus on identifying individuals who exhibit symptoms of mental health disorders or signs of needing support, staff are often left unsure of how to respond.¹⁰ 

Therefore, training programs should aim to cover the
following topics:

• Mental health needs among older adults, including general issues and specific disorders
• Signs and symptoms of mental health needs
• Establishing familiarity and recognizing changes in residents
• Myths about and attitudes toward mental health illnesses (eg, ageism)
• Interpersonal skills (eg, communication, conflict resolution)
• Responding to behaviors that challenge staff or other residents
• Stress management and coping skills for staff
• Abuse prevention
• Organizational policies and procedures

Intensive training of frontline workers in evidence-based mental health care, training in cultural competence and interprofessional collaboration, and supervision and coaching of staff are also needed. Providing incentives for staff to participate in nonmandatory continued education or training to supplement required training may also be helpful.

Establish Screening, Assessment, and Care Plan Protocols

Many organizations use the Geriatric Depression Scale for assessment of depression risk, which is a short questionnaire for residents regarding their mental and emotional status.¹¹ Additional assessment questions may cover nutrition, hydration, and substance use; sleep quality; social engagement; concentration or focus ability; interferences with daily routines or activities; social and familial relationships; and trauma history.

Assessment techniques can include observation, discussions with residents and their caregiver(s) or family members, behavioral checklists, and rating scales. Mental health professionals can conduct a standard mental status or state exam (MSE), which is often used to know how an individual is functioning, identify the presence of cognitive decline, or assess decision-making capacity (see MSE examples from the University of California – San Diego and the University of Nevada – Reno).^12,13

The Centers for Medicare & Medicaid Services (CMS) requires that assessments and screenings be included in comprehensive care plans, along with measurable objectives and timeframes to meet a resident’s mental and psychosocial needs.¹⁴ As with all care planning, the resident and their caregiver or representative must be informed of and consent to treatments as applicable by state law and regulatory requirements. In the same vein, it is essential that all communication regarding mental health care is provided in a manner the resident understands, as required by accreditation and regulatory agencies.

Explore Mental Health Interventions

According to CMS, mental and behavioral health services provided in skilled-nursing facilities must include⁸:

• person-centered care that reflects the resident’s goals for care and maximizes the resident’s dignity, autonomy, privacy, socialization, independence, choice, and safety;
• direct care staff that interact and communicate in a manner that promotes mental and psychosocial well-being;
• meaningful activities that promote engagement and positive meaningful relationships (activities should address the resident’s customary routines, interests, preferences, etc, and enhance well-being);
• an environment and atmosphere that is conducive to mental and psychosocial well-being; and
• pharmacological interventions that are only used when nonpharmacological interventions are ineffective or when clinically indicated. 

To fulfill this effort, CMS also requires long-term care facilities to provide the following care and services, often through an interdisciplinary team that includes the resident’s informal caregivers, family members, or representatives⁸:

• Adequate hydration and nutrition, exercise, and pain relief
• Individualized sleep and dining routines, as well as toileting schedules, to reduce the occurrence of incontinence and constipation without the use of medications (eg, laxatives)
• Homelike physical environments according to individual preference
• Consistent caregiver assignment to foster familiarity
• Utilize therapeutic techniques such as music, art, massage, aromatherapy, and reminiscing
• Counseling programs to assist with substance use disorders

Nonpharmacological Interventions

Effective “holistic” nonpharmacological interventions are often led by highly qualified facilitators, involve community resources, and span activities that are educational, social, and group-centered to entice active participation.¹⁵ In a literature review of studies on loneliness and social connectedness in older adults, researchers identified nine intervention types that support engaging in purposeful activity and maintaining contact with one’s social network¹⁶:

• Personal contact
• Activity and discussion groups
• Animal contact
• Skills course (eg, mindfulness-based stress reduction or computer use)
• Varied/nonspecific programs (eg, fitness or art classes, financial or housing consultations)
• Model of care (eg, “Eden philosophy”¹⁷)
• Reminiscence (a themed group activity related to a holiday or historical event)
• Support group
• Public broadcast (eg, generation-specific radio programs)

Crisis Response

Aging services organizations should also have procedures in place for responding to a crisis, such as suicidal ideations, attempts, and deaths. Substance Abuse and Mental Health Services Administration’s “at-risk approach”—as described in its toolkit on suicide prevention¹⁸—involves training all staff to identify and respond to suicide warning signs, understand risk and protective factors for suicide, and recognize symptoms of depression, alcohol abuse, and medication misuse. 

Conclusion

Effective delivery of mental health services requires systematic outreach and diagnosis, education and self-management support for older adults and their caregivers, provider accountability for outcomes, and close follow-up monitoring.¹ These objectives can be facilitated by care that is patient-centered, accessible, and coordinated by trained personnel with access to specialty consultation—all of which may involve sweeping administrative and cultural changes within the organization. However, with executive leadership advocating for and supporting the continued education for frontline caregivers and through partnerships with community-based mental health specialists or programs, organizations can work to overcome the perceived difficulties in managing mental health needs of older adults and ensure they fulfill their ethical and legal obligation for providing comprehensive health care.  

References

1. US Department of Health and Human Services, Administration on Aging. Older adults and mental health: issues and opportunities. January 2001. Accessed January 15, 2021. https://copgtp.org/wp-content/uploads/2015/08/Older-Adults-and-Mental-Health-Issues-and-Opportunities.pdf 

2. Eden J, Maslow K, Le M, et al, eds; Institute of Medicine. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? The National Academies Press; 2012. 

3. Bor JS. Among the elderly, many mental illnesses go undiagnosed. Health Aff (Millwood). 2015;34(5):727-731. doi:10.1377/hlthaff.2015.0314

4. World Health Organization. Mental health in older adults. December 17, 2017. Accessed January 15, 2021. https://www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults 

5. National Institute on Aging. Depression and older adults. Reviewed May 1, 2017. Accessed January 15, 2021. https://www.nia.nih.gov/health/depression-and-older-adults 

6. Gleeson H, Hafford-Letchfield T, Quaife M, Collins DA, Flynn A. Preventing and responding to depression, self-harm, and suicide in older people living in long term care settings: a systematic review. Aging Ment Health. 2019;23(11):1467-1477. doi:10.1080/13607863.2018.1501666

7. Chau R, Kissane DW, Davison TE. Risk factors for depression in long-term care: a systematic review. Clin Gerontol. 2019;42(3):224-237. doi:10.1080/07317115.2018.1490371 

8. Nair P, Bhanu C, Frost R, Buszewicz M, Walters KR. A systematic review of older adults’ attitudes towards depression and its treatment. Gerontologist. 2020;60(1):e93-e104. 

9. State Operations Manual Appendix PP - Guidance to Surveyors forLong Term Care Facilities. 42 CFR §483.40. Accessed January 15, 2021. https://go.cms.gov/3tquKgH

10. Beuscher L, Dietrich M. Depression training in an assisted living facility: a pilot study. J Psychosoc Nurs Ment Health Serv. 2016;54(5):25-31. doi:10.3928/02793695-20160201-01

11. The National Dementia Office. Geriatric Depression Scale (short form). Accessed January 15, 2021. https://dementiapathways.ie/_filecache/0c8/57e/37-gds.pdf 

12. UCSD School of Medicine and VA Medical Center. The Mental Status Exam (MSE). Accessed
January 15, 2021. https://meded.ucsd.edu/clinicalmed/mental.html

13. University of Nevada, Reno School of Medicine. Mental status examination. Accessed January 15, 2021. https://med.unr.edu/psychiatry/education/resources/mental-status-examination 

14. State Operations Manual Appendix PP - Guidance to Surveyors forLong Term Care Facilities. 42 CFR §483.21[b]. Accessed January 15, 2021. https://go.cms.gov/3pLMn8m 

15. National Academies of Sciences, Engineering, and Medicine. Social isolation and loneliness in older adults: opportunities for the health care system. The National Academies Press; 2020. doi:10.17226/25663 

16. O’Rourke HM, Collins L, Sidani S. Interventions to address social connectedness and loneliness for older adults: a scoping review. BMC Geriatr. 2018;18(1):214. doi:10.1186/s12877-018-0897-x

17. Mission, values, principles. The Eden Alternative. Accessed January 15, 2021. https://bit.ly/39Hp367  

18. U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Mental Health Services. Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Communities; 2011. Accessed January 15, 2021.
https://bit.ly/3cH7ll1