ICD vs DSM: More Than Codes

Times are changing in long term health care.  Typically, the average age of a resident is somewhere between 70- 100 years of age.  Their diagnosis is always along the same lines: dementia, forgetfulness related to aging, CVA, Heart disease,  lung disease, paralysis, mini-strokes….on and on the list goes.  Recently, the trend has changed to a younger , more complicated group of incoming residents : those with  Traumatic Brain Injuries (TBI), medication- managed schizophrenia, early onset dementia, ETOH induced dementia,  clinical depression and numerous psychotic disorders that are medication managed.

What I see happening now in Virginia, is  the mental health system weeding out the long term “dwellers” and finding placement  in assisted living  facilities and nursing homes across the state.  The question I pose is this ; Are such facilities prepared for a younger, more diversified group of residents with complex psychological issues?    Let’s face it.  A 92 year old dementia resident has different needs than a 32 year old schizophrenic resident.   The mechanism of action of dementia  and psychotropic  medications certainly  stand a world apart from medications meant to maintain those suffering from delusional disorders.

Let’s look at it this way. Grandma is 95 years old,  fraile, partially blind, extremely hard of hearing and wheelchair bound.  John is 37, paranoid schizophrenic, and was found not guilty by reason of insanity due to his mental health issues.  How comfortable are you with Grandma living down the hall from him?  Would you worry about her well-being and safety?

Another angle to think about: Mary is a 19 year old caregiver who has completed dementia training. She has been a CNA for only 2 years and is a great caregiver to the elderly in her care.  She sees John and becomes fearful and intimidated by his ” constant staring”. John can walk, talk, meet most of his own personal care needs….but John needs someone to insure he stays on the correct medications.   Should Mary quit her job because of her fear?

Don’t get me wrong, I personally enjoy working with psych patients. I started my career many moons ago working in psych hospitals and found it to be my “calling”.  But as a very young professional, I found myself cornered by a patient that  turned violent quickly.  The textbook learning and clinical rotations had not taught me everything I needed to know , including the part about never turning your back on a patient who is having a loud discussion with himself.  Thankfully, I was only battered and bruised and walked away from the incident.  The next day, I quit my job because I was scared it would happen again….and  the next time, it could be a lot worse.     So, I left the field of mental health and entered the world of long term health care- tada– and I’m still here!  

Now.….the two areas of practice are merging, and I have mixed feelings about it.  I understand that mental health beds are needed by those in immediate crisis and the long term patients need somewhere to live, someone to manage their care and some type of structure to insure their well-being.  But is mixing these two populations the right fit?

A unique characteristic in most dementia patients is that they are unpredictable. They may be fine and dandy one minute and aggressive and combative the next. One of the reasons for the shift in their behavior is the progressive deterioration of brain cells. Frustration or even physical pain/ailments that can not be expressed is also another reason why some turn aggressive.. The dementia patient has very little, if any, control of their behaviors.

Menalzheimer_braintal health patients have such a plethora of possible disorders, that it is difficult to judge which DSM 5 code is the one staff need to focus on. How do we as caregivers know exactly what to expect when a long term mental health patient has been admitted into a nursing home or assisted living facility?  There must be a reason the patient has not mainstreamed back into society…….Mental Health professionals consider those with inappropriate behaviors  to be manage by medications, but the patient must be willing to  comply with the treatment plan.      Hmmm. This is a wee bit different than the treatment plan of a dementia patient. 

So, what are we to do? Mix the two populations and hope the staff can adapt to the needs of both populations?    Hope the two populations can share communal living without incident?  schizophrnic

Long term care is just what it says. “Long term care” for those who can no longer care for themselves safely independently.  Hopefully the field can expand  and meet the needs of those suffering from both conditions in the ICD-10 and the DSM-5.




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