​Behavioral health has been on the radars of long term care facilities and their teams for years, but the COVID-19 pandemic brought it front and center. According to data from the American Geriatrics Society, between 65 percent and 90 percent of nursing home residents have a mental or behavioral health issue.

“We’ve learned that facilities have to prioritize mental health as well as physical conditions,” said Lisa Lind, PhD, ABPP, chief of quality assurance and compliance at Deer Oaks – The Behavioral Health Solution. This requires a person-centered, team approach to care with an eye toward innovative interventions and tools.

Changing the Paradigm

Long gone are the days when behavioral health management meant picking up the phone and asking a physician for medication. This was a quick fix that often had negative implications and didn’t have good long-term outcomes. To determine the best solution for sustained results, “you have to know the resident, the staff, the system, and geriatrics,” said Elizabeth Santos, MD, MPH, DFAPA, DFAAGP, clinical chief, Division of Geriatric Mental Health and Memory Care at the University of Rochester School of Medicine and Dentistry.

Lind said, “There is a tendency to assume a behavior is mental health-related, but we need to look at all factors—changes in medications, unrecognized pain, infections, etc.” It is essential to look at medical reasons for behaviors, as well as possible trauma-related triggers. The good news, she said, is that “facilities are asking questions they weren’t asking a few years ago. We’re moving in the right direction.”

Moving the Needle

Lind suggested several steps that can improve behavioral health care:

• Be proactive instead of reactive. She said, “We often get referrals for crisis situations, such as a resident expressing suicidal ideation or becoming significantly agitated or hostile. When we do our evaluation, we often find that the individual has a long-standing history of a mental health condition, but they weren’t initially referred for mental health services because they appeared stable on admission.”

It is important to identify and document a mental health history on admission and refer residents for psychiatric services as necessary. The consultant pharmacist should be engaged to review the individual’s medication regimen, paying special attention to psychotropics or other psychiatric drugs the resident may be taking. It also is important to identify and communicate with the team any situations that may trigger a change in emotional status, such as the loss of a loved one.

• Respond calmly. “As in most areas of our life, using a calm approach when communicating with others will be more beneficial in obtaining the achieved outcome and will also minimize anxiety for anxious residents. Staff should never respond in an angry, defensive, or demeaning manner, as this can easily trigger a negative response from residents,” Lind said.

• Focus on person-centered care. There is no question that residents have their own unique life experiences, personality traits, coping strategies, medical conditions, mental health history, levels of support and family connections, job history, and so on. Lind said, “It is important to refrain from making generalizations based on age, observed cognitive level, cultural background, diagnoses, or other characteristics.” Instead, the care team needs to get to know residents as individuals, and this information needs to be shared as necessary and appropriate so clinicians and caregivers know what interventions have been tried, which ones have worked, and which ones haven’t.

• Communicate and document. “One of the most common situations is being told of a resident’s perceived maladaptive behaviors and then finding no documentation of the events in nursing notes and a lack of consistent communication among staff,” said Lind. When there are gaps in communication and/or documentation, it is more time-consuming for staff to identify and address behavioral issues successfully, and it increases the risk of survey citations and concerns from family members.

• Refrain from unintentionally reinforcing unwanted behaviors. Residents sometimes learn that negative behaviors get the attention they want. For instance, say a resident who is a former coach blows a whistle when he wants something. Instead of ignoring him, chastising him, taking away his whistle, or jumping every time he makes noise, consider reminding him to use the call light and explaining that when things get busy, it may take a few minutes to respond. Thank him for his patience and cooperation.

Nonpharmacologic Focus

A focus on nonpharmacologic efforts to manage behaviors takes time. When you’re short-staffed and everyone already has a full plate, this can be challenging. However, there are many fairly simple activities, interventions, and ideas that can be integrated into daily routines. At best, these can help prevent behaviors. At the least, they can help staff address behaviors before they become problematic.

On admission, consider working with the family to create the resident’s life story. This can be as simple as completing a worksheet or one-pager that offers information about the resident’s former occupation, hobbies and preferred activities, morning and evening routines, pet peeves, and favorite foods, music, and movies. This information can be kept secured in a book, and people who care for the residents should review this information before interacting for the first time and when there is an issue or problem.

This knowledge of the resident also can be integrated into the care planning process with efforts such as pet visits, headsets with a music playlist, art therapy sessions or classes, and personalized videos (e.g., clips of Fred Astaire and Ginger Rogers for a woman who loved dancing).

Small details can make a big difference. For instance, one facility had a woman who got very agitated when her caregiver tried to put socks on her. Talking to her family, caregivers discovered that she always put her socks on inside out because she hated the way the seam felt on her toes. Once they accommodated this personal preference, she became cooperative.

Happy memories can be positive distractions and can help improve mood when someone gets agitated. For instance, Lind suggested hanging a shadow box on the resident’s wall with important reminders of the past or providing a photo album to peruse. Let residents hold things that seem to bring them comfort, such as a war medal, favorite blanket, trophy, doll, or stuffed animal. Have families leave recorded messages that you can play for residents when they get upset or agitated.

It is important to remember that people’s interests and tastes may change, especially as their cognition declines. For instance, a resident who used to love her doll now throws it in the corner and says it’s not her baby. In this case, instead of correcting or arguing with the resident, try to pivot the conversation and find something else that makes her happy or brings her comfort.

Don’t forget that even people with dementia need a sense of purpose. Lind suggested, “Provide active engagement that is meaningful. Assign roles to residents who could benefit from a sense of usefulness and purpose while reducing idle time and boredom.” Consider having activity stations throughout the building where residents can do things such as putter in a play kitchen or workshop, arrange flowers, or play games.

It is important for staff to realize that well-intentioned efforts can have negative consequences. Lind recalled a normally docile nonverbal resident in memory care who started yelling, scratching at her legs, and covering her head with her blanket. A chart review indicated no infection or other issues that could explain the behavior. Lind noticed that there were paper spiders and cotton cobwebs in the corner of the resident’s room, put there by staff as Halloween decorations, and she was able to confirm the decorations were put up right before the resident’s behaviors started.

Lind instructed staff to take the spiders and webs down with the resident in the room to watch them and tell her they were taking the paper spiders away. They then replaced the spiders with flower decorations. Lind said, “The next time I was at the facility, I was told that her yelling and swatting had stopped, and she was no longer putting the blankets over her head.”

When Medications Are Needed

While behaviors should be managed with nonpharmacologic interventions whenever possible, this doesn’t mean medications will never be necessary. However, the care team can work with clinicians to make sure the right drugs are being used in the right doses.

For instance, one facility had a resident who was screaming in the middle of the night and accusing staff of trying to kill her. She also claimed that she had killed someone. Talking to her family, Santos discovered the resident had been sexually assaulted as a young woman, and she had stabbed one of her attackers.

Ultimately, it was determined that the woman had undiagnosed post-traumatic stress disorder. Santos treated her with antidepressants and cognitive therapy, a type of psychotherapy that seeks to alter unwanted behavior patterns. The resident stopped screaming and acting out and seemed more content.

Another resident with schizophrenia and a history of violence was on multiple antipsychotics. Santos and her team were able to reduce her regimen to a low dose of one antipsychotic by providing staff with behavioral techniques and encouraging them to be consistent in their care. They also played the resident’s favorite music when they came in her room to take her to activities or bathe her. Staff were provided with scripts so they could use language that was comfortable for the resident.

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