This Editorial is based on background information from a symposium entitled, "Aggression Management Among Behaviorally Impaired Elderly: The Pivotal Role of Nursing," presented last October at the American Psychiatric Nurses' Association's annual conference in New Orleans. Members of the panel included Marianne Smith, MS, RN, Geropsychiatric Clinical Nursing Specialist, Abbe, Inc. and the symposium organizer and text author; Mary Eccard, MS, RN, Director of Nursing, Emory University, Wellsley Woods Geriatric Center; Ellen Maxson, Geropsychiatry Unit Leader, JR Bowman Geriatric Center; and myself. The 7:00 a.m. breakfast symposium was sponsored by an unrestricted educational grant from Abbott Laboratories and played to a standing-roomonly crowd of psychiatric nurses. How gratified and amazed we all were that so many of our psychiatric nursing colleagues braved the early morning hour (after a late night in the French Quarter) to address this important issue. Apparently they appreciated that geriatrics, once considered an "option" in the realm of health care, is really no longer a choice for most nurses, as care of older adults surpasses that of other age groups in nearly every specialty and setting. Because of this positive response and my own interest in geropsychiatric nursing, in the paragraphs that follow I will share (with permission) an abbreviated version of Marianne's introductory remarks with the readers of the Journal of Gerontological Nursing.
For many, advanced age is accompanied by increased physical and mental frailty, unwanted dependency, and interference with usual coping methods. Older adults experience a wide variety of problems that interact with one another: social challenges, "normal* physical declines, multiple chronic disease processes, use of multiple prescription and nonprescription medications to treat their various maladies, and increased occurrence of both functional limitations and need for assistance with personal care with advancing age (e.g., from 2% at 65 years to more than 45% at 85 years and older). Although the physical health problems of older adults are both numerous and substantial, the overlap of mental illness/disorder is often "the straw that breaks the camel's back" - for both the person and the caregiving system. Depression, dementia, and delirium are all common problems among older adults. Existing alone or in combination with one another and compounded by other existing physical and social challenges, these disorders often lead to hospitalization, and later institutionalization, for older people.
The prevalence of mental illness/disorder among older adults living in long-term care facilities came to light in the mid-1980s. Nursing home surveys revealed that the vast majority of people living in these institutions were being treated with psychotropic medication - particularly antipsychotic medications but without the benefit of ongoing psychiatric treatment or even a psychiatric diagnosis. To address this dearth of psychiatric care in nursing facilities, the Omnibus Reconciliation Act (OBRA) of 1987 (Public Law No. 100-203) included provisions that required facilities to provide appropriate assessment and intervention, including:
* Prescreening at admission to assure psychiatric evaluation and treatment was provided.
* Active intervention for those with mental illness diagnoses.
* Specific guidelines limiting use of both physical and chemical restraints.
Implemented in January of 1989, OBRA caused (and continues to cause) substantial changes, both positive and negative, in the provision of care to frail older adults in nursing homes.
Although the OBRA's goals are worthy, lack of preparation on the part of direct care providers in nursing homes made the transition to "restraint appropriate" care difficult for many institutions. Some facilities adjusted well, finding methods to manage behaviorally impaired residents while accurately documenting use of psychoactive drugs and other restraints to assure quality care (and avoid repercussions during state surveys). Many, however, struggled to effectively manage behaviorally impaired residents who typically suffer from dementia or other mental disorders. Requests for inpatient evaluation and treatment of behaviorally impaired nursing home residents, particuUrly those who are aggressive or combative, has become increasingly common as nursing facilities search for answers.
Unfortunately, the "solutions" offered during inpatient stays are often oriented to accurate diagnosis and medication management rather than exploration and documentation of behavioral interventions. Elderly patients who are reasonably stabilized and well-managed on the inpatient unit too often return to a facility that is unprepared or unable to continue the program of care. Viewing psychoactive drugs as an "invitation for trouble" during state surveys, or attempting to comply with mandates to "routinely reduce" psychoactive drugs, carefully titrated drug regimens may be abruptly changed on return to the facility. Behavioral interventions devised by inpatient psychiatric nursing personnel are not commonly included in discharge information and so can be "lost" when elders return to the nursing home. In the absence of specific guidance and stressed for time because of staffing shortages and competing demands for their time, nursing home staff often return to their "usual" care routine. As a result, care problems and aggressive episodes re-emerge. The absence of effective communication and documentation within and between care settings increases the likelihood that behaviorally impaired elderly are subjected to the "revolving door syndrome," "dumping" from one care setting to the next, and "transfer trauma" which ultimately results in further deterioration in their status.
Nurses are pivotal in the care and treatment of behaviorally impaired older adults. In fact, nursing care, rather than medical care, is frequently the primary determinant of quality of care for chronically ill and behaviorally impaired older people. Nurses have unique opportunities to positively influence the course and outcome of care by: * Taking a proactive role within the multi- or interdisciplinary team.
* Conducting ongoing, independent, and interdependent nursing assessments.
* Carefully collecting, interpreting, and communicating historical information that is so often influential in the care of older adults.
* Devising highly individualized plans of care that respect both the individual's and family's needs.
* Communicating and documenting information that is often critical to the individual's stability and well-being.
Although more opportunities exist today than perhaps ever before, nurses must take a proactive role to assure that their full influence is felt. Of utmost importance in the care of physically and mentally frail, behaviorally impaired older people is the need for close collaborative working relationships within and between nursing care settings. Increased sensitivity to, and understanding of, other arenas of care is needed to assure that older adults receive quality health services across disciplines, settings, and specialties. Psychiatric nurses, who are typically not specialists in the care of older people or the peculiarities of regulation guiding nursing home personnel, must develop additional expertise in the care and management of older people with psychiatric problems. Likewise, nurses working in geriatric care settings such as nursing homes must develop rudimentary skills in psychiatric assessment. Both geriatric and psychiatric nurses must hone diverse skills in behavior management. In short, the complex biopsychosocial interactions that dominate care of older adults demand that nursing personnel cultivate an array of effective management techniques and then communicate and document those practices nurse-to-nurse within care settings (e.g., from one shift to another) and between care settings (e.g., as patients are hospitalized or rehospitalized and placed or returned to long-term care facilities).
Kathleen C. Buckwalter