Understanding Patient Needs and Wants

Long-term care (LTC) clinicians and caregivers need to keep on top of an overwhelming amount of information, rules, restrictions, and care challenges, all while addressing obstacles such as staff shortages. The complexity of care that is required to manage so many patients’ varying needs is as complex as in any other healthcare setting. Having so many needs to contend with may result in providers not adequately addressing critical patient requests. Of course, in some cases, patients may express an outrageous desire that can’t be honored, but in other cases, taking the time to understand patients’ underlying motivations can facilitate and improve care. This is a particularly important consideration when facing behavioral problems in patients who appear to be cognitively intact. In this issue of Annals of Long-Term Care: Clinical Care and Aging^® (ALTC), we tackle two behavioral problems that LTC providers may encounter: personality disorders and conversion disorders, both of which may be more prevalent in LTC settings than realized.

In our first article, “Difficult Resident or Personality Disorder? A Long-Term Care Perspective”, Drs. Gibson and Ferrini note that when caring for difficult patients, LTC providers should consider whether a personality disorder is behind these patients’ undesirable behaviors, as residents may not always arrive at LTC facilities with an existing diagnosis of a personality disorder. The authors highlight one such scenario, describing the case of a demanding and abusive male resident who became difficult for caregivers to manage. The patient often made unusual and uncomfortable requests, such as asking to have rubber bands placed on his extremities during clothing changes. He also incessantly used the call button and frequently complained about and yelled at staff. Eventually none of the staff felt comfortable around him and limit-setting strategies, such as telling him that his behaviors would be reported, were backfiring. A multidisciplinary approach was subsequently used to analyze his behaviors, which led to a diagnosis of personality disorder not otherwise specified (PDNOS). Prior to this diagnosis, many of his behaviors were seen as a conscious expression of his undesirable and outrageous wants. But once the PDNOS diagnosis was realized, his actions were attributed to an underlying psychological need. This insight enabled the staff to intervene in more meaningful ways, making his life at the facility more pleasant while also easing staff stress and burden.

In our second article, “Mr. Smith is Falling Every Day: Conversion Disorder in an Elderly Man”, Drs. Haque and Alavi provide a case report of a patient whose frequent falls were eventually attributed to an unmet psychosocial need. The patient had experienced many losses, including that of his wife, house, social support networks, and, ultimately, his freedom upon admittance to an LTC facility. After interviewing the patient and his family and ruling out any clinical causes of his falls, they were attributed to a conversion disorder. During the patient’s interview, he expressed a desire to spend more time with his family. He also stated his disappointment of not having anyone at the facility to play bridge with. Although these might seem like trivial wants, to him these were important psychological needs that were not being addressed. Once care measures were implemented to meet these needs, such as regular weekly visits from all of his daughters, his falls stopped.

In this issue of ALTC, you’ll also find a case report, “Care Transitions From Skilled Nursing Facilities to the Community”, describing a care transitions program at the James A. Haley Veterans’ Hospital in Tampa, FL. The author, Dr. Park, demonstrates how a patient who went through a series of care transitions avoided potentially dangerous lapses in the continuity of care because of this program. Unfortunately, not all institutions have such programs in place, and there are considerable challenges to implementing them. However, the American Geriatrics Society, in association with other institutions, has made considerable progress on this front. As of January 1, 2013, the Centers for Medicare & Medicaid Services will begin paying physicians and other qualified healthcare providers for coordinating Medicare beneficiaries’ care transitions during the 30 days following their discharge from hospitals or skilled nursing facilities. To find out more about this, turn to our Washington Update on page 13.

As always, we welcome your feedback on the articles contained in this issue of ALTC. Your feedback can be sent to our assistant editor, Allison Musante, at amusante@hmpcommunications.com. Letters may be published in an upcoming issue of the journal.

Thank you for reading!