DILEMMAS IN GERIATRIC PSYCHIATRY PART TWO:
Society’s Treatment of the Elderly
By Mickey Skidmore, ACSW
In May of 1997, this web site featured a “Perspective” entitled “Dilemmas in Geriatric Psychiatry: A Critical Exploration of Health Care Delivery for the Elderly.” This piece addressed the looming Medicare crisis; exposed the ambiguous conceptualization of “Geriatric Psychiatry”; and by way of my own professional experiences, presented an argument that psychiatric health care delivery for the elderly under the guise of such circumstances is at best “smoke and mirrors” or at worst unethical and fraudulant. This issue is revisited again in this month’s “Perspective”.
In President Clinton’s 1998 State of the Union address, while discussing a possible surplus in the near future, he made a plea to save every penny until the Medicare crisis is resolved first. “Save Medicare first” were among the headlines the following day. And while this may be a noble and fiscally responsible thing to consider as a nation, until our society takes a hard and honest look at the way we treat our elderly, I submit it will make little difference.
Many cultures have found honored and respected positions and roles for their elderly. Yet our culture and society has been woefully unsuccessful at addressing this issue. In earlier times, the family took care of their own elderly. I’m certain that elderly people suffered from dementia related conditions earlier this century, but I’m equally certain that many more are living longer, and family units have eroded considerably (divorce rates, absentee parents, drugs, poverty, etc.), leaving them with fewer resources to manage either their children or their parents.
Over a period of time Nursing Homes emerged in our society as our response to addressing these issues. And while these facilities are regulated by state and federal guidelines (and other organizions as well) to provide 24 hour skilled nursing care, and also have doctors overseeing their care, we continue to struggle with our discomfort in dealing with the elderly in this manner. Despite some exceptions, ask anyone who’s had to deal with a loved one being placed in a SNF (Skilled Nursing Facility) to share their experiences. On numerous occassions I hear a litany of complaints including: the place reeks of urine; they have one CNA to care for 10-15 patients; the various allied health professionals will present to provide and bill for their services until the Medicare allotment runs out, then they dissappear — and have difficulty explaining to family members the rationale of their interventions; they let them lay in their beds so long they develop ulcers and get infected, thus risking their health further; and on and on it goes.
Increasingly SNF’s (and perhaps society as well) are looking towards psychiatry to assist with these issues. And while this may seem reasonable at face value, I believe we should consider some additinal questions as well. If SNF’s are designed for 24 hour skilled nursing care, overseen by physicians, and regulated by state and federal regulating bodies, what is it that acute care psychiatric facilities can realistically provide that they cannot? If you are elderly, fraile, your bodily functions decompensated, and your cognitive abilities detiorated, does that mean that you suffer from a psychiatric condition? A what messages does this send to surviving family members that such a facility cannot manage the care of their elderly loved ones? (And if they can’t manage them, why not?).
Let’s face it. They can provide medication therapy in SNF’s. SNF’s and Rest Homes have even begun to develop dementia-related units or wings, realizing that the primary focus of managing such patients is on the patients environment. Given this then, the only realistic benfit afforded these patients is a change in milieu. One marked with better staffing ratios and greater awareness (training and education) of behavioral and geriatric issues. So, is this an appropriate use of medicare and medicaid tax dollars? And what are the implications for the patient and/or their family during this acute-care-stabalization? Will the SNF’s hold the patient’s bed? Or do they directly or indirectly force them back into one of the most convoluted and beauracratic systems ever created?
Despite these disturbing and unsettling questions, the intent of this article is not to criticize the Nursing Home Industry, but rather to emphasize a simple but hard fact. Until we as a people and a society decide how we are going to better care for our elderly, it will do no good to point fingers at SNF’s, hospitals, doctors, home health agencies, hospices, medicare, or any state or federal regulating body. And as tempted as we might be, we must realize that we have developed far too unrealistic expectations for psychiatry and for medicine in general. Despite all the marvels of science and technology, there still are numerous afflictions which medical science cannot adequately address — and natural aging, and all that comes with that falls into this category.
Consequently, as the Baby Boomer generation is rapidly approaching this developmental milestone, perhaps the following recommendations are a reasonable starting point:
*society should demand that the federal and state regulations for SNF’s are realistically examined to provide realistic staffing ratios with proper training and education, increased and adequate medical coverage to address an increasing demand, and clear policies (including penalties) to reinforce them;
*given the ambigous nature of “geriatric psychiatry” perhaps a more appropriate medical focus for this population would be “biopsychosocial gerontology”;
*these issues must be openly and realistically considered in any viable attempt to resolve the Medicare crisis;
*families, churches, neighborhoods, cities, communities, culture, and our society must honestly examine and take more responsibility for caring for our elderly with passion and dignity — and not rely or expect governmental agencies to assume this responsibility for us.
If we as a society do not step forward to challenge the status quo, then we should not be surprised that the care of the elderly will increasingly go unchecked into hands of greedy unethical practices of corporations and unscrupulous individuals who’s primary motivation is predominantly mercenary in nature, and disregarding of ethical and professional integrity. The choice and the responsibility is ours.
Skidmore, Mickey. Dilemmas in Geriatric Psychiatry: A Critical Exploration of Health Care Delivery for the Elderly. “Perspective” (May 1997), http://www.turning-points.com.au/2017/09/05/may-1997/.