Facilities Struggle to Treat Alzheimer’s Patients

It’s Dr. Allan Anderson’s weekly visit to the nursing home’s special dementia unit, and problems await: Someone has hit a nurse. One woman abruptly pinches another patient’s face and yells curses. Another breaks into loud, gasping sobs for no apparent reason. Agitation keeps still others awake all night.

Anderson is a rarity: A geriatric psychiatrist employed to care regularly for nursing home residents like these because he is specially trained in treatments to calm, even prevent, such problems.

Although up to 80% of the nation’s 1.6 million nursing home residents have a mental illness, mostly dementia or depression, experts say few nursing homes provide proper psychiatric care crucial to seniors’ quality of life.

“These are largely forgotten psychiatric hospitals. . . . They are not in any way prepared to take care of mental health problems,” said Dr. William Reichman, president of the American Assn. for Geriatric Psychiatry. The group is beginning a campaign to change that by modeling care on practices like Anderson’s.

Nursing homes were set up to treat chronic physical problems, not the explosion of Alzheimer’s, other dementias and depression accompanying the nation’s booming elderly population.

Typically, nursing home doctors are primary care physicians with little mental-health training, Reichman said, who thus often don’t know about new treatments that help such patients without sedating them into zombies.

Many homes will seek special psychiatric consultations for a very ill patient, but that can take weeks. And nursing homes are suffering a severe shortage of nurses and aides--largely because fast-food restaurants can pay higher salaries--which means staff training on day-to-day handling of demented patients isn’t common.

A survey of 900 nursing home directors in six states suggests facilities themselves see a big need for mental health improvement: Half termed inadequate the frequency of their homes’ psychiatric consultations. In one-fourth of rural nursing homes, directors reported that psychiatrists were never called to their facilities.

“You’re entitled to better care than this. We all are, as a society,” Reichman said.

What does a nursing home psychiatrist really offer? Follow Anderson at the Chesapeake Woods Center in this Eastern Shore town, where he’s something of a detective--because demented patients can’t tell you what’s bothering them.

“You’ve got to do more than just write the typical Alzheimer’s prescription and leave,” he said. “You’ve got to have an ongoing relationship. You’ve got to hunt the underlying problem.”

First on his agenda: violent outbursts and evening agitation, which leaves Alzheimer’s patients walking the halls all night. Check for a urinary tract infection, Anderson orders. Nursing home doctors seldom test for them unless a resident complains. But demented patients can’t explain symptoms, so they often lash out or become agitated instead, something a simple antibiotic may solve.

Down the hall, Anderson discovers one woman’s memory is declining not from dementia but because the oxygen mask for her sleep apnea doesn’t fit, not giving her enough air.

Then he’s got to juggle medicines. Some newer antipsychotic drugs like Risperdal and Zyprexa can lower Alzheimer’s agitation without the sedation or side effects of older Haldol.

The epilepsy drug Depakote can calm combative Alzheimer’s patients, but while Anderson was on vacation, one patient was wrongly switched to a similar drug called Depakene that irritated his stomach and thus agitated him again.

One frail woman can’t take these popular Prozac-like antidepressants because they cause weight loss in the elderly. Instead, Anderson tries an older antidepressant that causes weight gain. And some Alzheimer insomniacs are about to try his new experiment to see if light therapy will help them sleep.

Then it’s time for staff training on nonmedical ways to keep demented patients calm, something Medicare doesn’t pay for but that Anderson and Chesapeake Woods consider crucial. Distract the yelling Alzheimer’s patient, for example, and she’ll forget why she was mad without anyone getting hurt.

The geriatric psychiatry association is writing the first nursing-home mental health guidelines and searching for ways to help facilities pay for better care. There are some simple fixes, Reichman suggests: If a home needs six nurses, make sure two have mental health backgrounds.

Next, the association plans a consumer campaign teaching families how to choose care.

“Most people, when they visit a nursing home, don’t think to ask, ‘If my mother gets agitated or combative, to what extent are you prepared to manage that?’ ” Reichman said. “They should. It’s key.”

*

For additional information, contact the American Assn. for Geriatric Psychiatry at 7910 Woodmont Ave., Suite 1050, Bethesda, MD 20814-3004; (301) 654-7850; or https://www.aagpgpa.org. Or try the Alzheimer’s Assn., 919 N. Michigan Ave., Suite 1100, Chicago, IL 60611-1676; (800) 272-3900; or https://www.alz.org.