Dementia Patients and Virginia’s Law of Unintended Consequences

This examiner has been following the state of Virginia’s efforts to reform its public mental health care delivery system for a number of years. This professional and personal interest of mine was accelerated and intensified after the tragedy of Dr. Creige Deeds several years ago when his schizophrenic son had a relapse of his psychosis and stabbed his father who is both a veteran Virginia state legislature or an actively practicing clinical psychologist. By way of short review for those readers who are not familiar with the situation, I will recap it as briefly as I can. Dr. Deeds endeavored to have his son hospitalized emergently but at that time in 2013, Virginia had a very dysfunctional statewide system for ensuring timely emergency hospitalizations of people in a mental health crisis. For a variety of factors, all of which from my point of view is bad and inexcusable but are found all over the country, Dr. Deeds’ son Gus could not be emergently hospitalized for ongoing treatment. He spent several days in his local hospital emergency room and the practitioners there instituted stopgap emergency treatment resuming some sort of antipsychotic medication regimen but then had to discharge the then 23-year-old psychotic son (and to this date I still do not know specifically how much of a symptomatic remission was achieved in the son Gus at the time of his release from that hospital’s emergency room surface). In any case, the son then tragically suicided successfully a few days later. The father Dr. Deeds, to his credit, began to very responsibly undertake in his dual role as a mental health skilled practitioner and state-level legislator, a very long term bipartisan effort to spur Virginia’s state legislative body into addressing the grievous holes at all levels in Virginia’s state psychiatric mental health care delivery system.

One of his accomplishments was to help craft and see the passage of the law that instituted a statewide database registry of all empty inpatient psychiatric beds in both state and private psychiatric facilities. Further, this law mandated  individuals in mental health psychiatric crises, after being evaluated and confirmed as needing emergency hospitalization, had to be accepted by private psychiatric facilities if they had available beds in any part of the state, and further to provide transportation to a facility that had an available inpatient bed for such a patient.

This mechanism has been in place for several years and by all accounts has helped a great deal. However, it cannot address the ongoing issue of the fact that Virginia still has a relative shortage and an absolute shortage of inpatient psychiatric beds both in private services and especially at the state hospital level. Private psychiatric beds have been in decline in Virginia just like in every other state in this country, for at least 20 years. Part of this is, of course, do to the fact that inpatient psychiatric hospital services lose money hand over fist for just about any private entity whether University medical center-based, community hospital-based, or large private hospital conglomerate based. Until the last very few years, private hospitals certainly have not been expanding or constructing new inpatient psychiatric units. There have been notable exceptions in a small number of states. For instance in Iowa, the four cities or Quad cities area as it is called, have seen a number of private hospital systems banding together and opening new inpatient psychiatric units in novel cooperative financial and bed-sharing arrangements. Similar efforts have begun to happen in other states that have a critical mass of population sufficient to furnish psych patients at adequate numbers. Some states have seen University medical centers renovate or open new psychiatric units in spite of the financial disincentives that still exist largely having to do with the low rate of financial reimbursements for inpatient psychiatric services. One example is the Seattle Washington area. New medical schools that have come into being in a few states, especially those that are dedicated in their missions to serve their local communities in areas, have seen fit to open new psychiatric residency training programs to begin to turn out desperately needed new psychiatrists. To become accredited nationally in order to start these psychiatric residency programs, they have had to, but also have willingly opened new inpatient psychiatric treatment services in their areas of operations which is all to the good.

Back to the state of Virginia and this discussion.

Virginia like virtually every state in the union here in the United States, overall still has too few inpatient psychiatric beds of any kind whether public or private. And the dreaded phenomenon of “psychiatric boarding” in local hospital emergency rooms has continued. For the international reader or American reader who is not quite sure what this phrase refers to, psychiatric boarding means that psychiatric patients in emergency rooms being referred for urgently needed inpatient psychiatric care may have to wait for days or weeks until there is a psychiatric bed available somewhere. In many states, state and federal level courts have outlawed this practice, declared it virtually unconstitutional, and have actually rendered statewide level judgments with rather large monetary fines because of the persistence of this practice. This is no small insoluble riddle since this is a systemic problem and in areas where sufficient inpatient psychiatric beds simply are not available, there is no immediate solution.

But two patient populations are hit especially hard by the issue of scarcity of appropriate inpatient psychiatric beds. These two populations are the elderly experiencing acute psychiatric crises, and children and adolescents. In almost all states in this country, there still are not enough beds for the elderly and youth. Within the elderly population, there is a subpopulation that is even more poorly served. This subpopulation is the demented – psychotic elderly.

The state of Virginia currently has one main geriatric psychiatric state hospital facility. As one might expect since this facility serves the entire state it runs full all the time. This is not a new phenomenon and other states share this systemic difficulty. And it is easy to see why.

One of the very large state hospital patient populations in this country since the late 1800s was that of the mentally ill and/or demented elderly. They were also a patient population who suffered some of the worst physical, medical, and civil rights abuses for decades in those facilities nationwide.

The blunt-hammered legally driven solution beginning in the 1960s with the state hospital reform movement was that of deinstitutionalization, closing of state hospital beds and trans-institutional transfer of the elderly largely into nursing homes in the last 50 years. This so-called temporary and very imperfect solution finally began to be curtailed approximately in the 1990s in this country as nursing homes began to be regulated and have their care reviewed and upgraded by legal mandate of the mentally ill – the demented elderly psychiatric patients within their settings. For instance, nursing homes came to be regulated and not permitted to cross a certain threshold of numbers of psychiatric patients within their facilities. This had the effect of reducing the numbers of mentally ill elderly who could be stuffed into nursing homes.

Similarly as a result of the Omnibus reconciliation budget act that was initially enacted under Pres. George H. W. Bush Sr. and finally fully activated in 1997, the use of psychotropic medications especially benzodiazepines and antipsychotics were severely regulated and curtailed in the nursing home setting. This had the unintended effect of making nursing homes ever poorer places for the treatment, management, and housing of the psychotic elderly patient. This was largely dependent on the treatment philosophy of the medical and nursing staff of any given nursing home. If they were particularly zealous in the beginning, to arbitrarily curtail the use of psychotropic medications, care was altered in deleterious ways. What would happen is a nurse administrator, or an independent nurse family practitioner or nursing physicians assistant or the medical physician director of the nursing home would arbitrarily begin to stop the administration of these medications because a reviewer would call attention to their utilization. These care reviews always carried with them the institutional-bureaucratic admonition to decrease their utilization. Over time without these medications, these elderly patients with a history of psychotic psychiatric illness of any sort would sooner or later become acutely psychiatrically symptomatic and of course, need discharge, and transfer to some nearby inpatient psychiatric unit.

Now I am a board-certified geriatric psychiatrist since the early 1990s. I was fortunate enough to be empathically trained during my residency years in working with elderly patients. I have consulted in nursing him settings throughout my entire career no matter where I have lived and practiced. I have to say that the following, which sounds kind of bad in certain ways and could be viewed as biased and perhaps pejorative, nonetheless reflects my honest experience in a number of nursing home settings that indeed rendered very good care.

Nursing homes who did not like working with chronic psychiatric elderly patients tellingly would permit the resumption of psychiatric psychotic symptoms in their elderly patients all too willingly through this mechanism that was always bureaucratically correct. It was not lost on me that this reflected everyone’s distaste for psychiatric issues and psychiatric patients which is a prejudice still widespread even within treatment communities. And of course, I was a firsthand witness to the fact that when these patients often were denied readmission at their previous nursing home placements.

I remember many exceptions to this rule and wish to name two of them on purpose because of their wonderful non-prejudicial commitment to their patients. One was the very first nursing home that I consulted to for approximately 15 years in Durham North Carolina after I had finished my psychiatric residency training. I was fortunate enough to be asked by the then medical director of this facilities medical services, the wonderful Dr. Eugene Stead MD the long-standing chairman of the Department of medicine at the Duke University Medical Center to be his psychiatric consultant at this nursing home facility. He had a reputation as the most exacting and fearsome medical instructor who had been recruited in the early 1960s from Johns Hopkins School of Medicine in Baltimore to put Duke Hospital’s Department of medicine on the national map competitive with Harvard, Johns Hopkins and all the other great powers in internal medicine. Duke was always nicknamed the” Harvard Medical School of the South” and it certainly achieved that in a very short period of time under the leadership of Dr. Stead and many other chairpersons of surgery, neurosurgery, pediatrics, etc. But I found Dr. Stead to be a very gentle and empathic physician in his role with the geriatric patients at this facility, the Methodist Retirement Home. This facility had a true continuum of care before this became a politically correct phrase. It had apartments, dormitory rooms with and without kitchens, assisted living dormitory rooms, and initially when I started working there, a small medical hospital which later expanded to well over 100 beds in the 1980s. Dr. Stead was very unusual for his time as he recognized and supported the need for ongoing readily available general psychiatric services for the patients in that facility. I was a new young rookie fresh out of residency training when I began my parallel work with Dr. Stead rounding with him at least two half-days a month throughout the facility providing psychiatric care and management. I learned an enormous amount from Dr. Stead even though he was not a psychiatrist. Early on I realized that this was a miraculous stroke of luck, being afforded this kind of at the elbow of the master training and mentoring. The Methodist RetirementHhome was and still is an incredibly wonderful facility and program. It had a mission of treating and being a retirement home in residence for retired Methodist ministers and their widowed spouses from all over the Southeast. Because of that institutional and wonderful commitment, this facility never showed or displayed antipathy or prejudice to any of their residents who had dementia or psychosis or a combination of both. They always accepted them back if a resident had needed out of facility inpatient psychiatric care usually of course at Duke University Hospital which was just across the road!

The other facility that I wish to name but by no means, not the only other one, was a Cherokee tribal nursing home facility “Tsali Care” of the Eastern Band of Cherokee Indians in Cherokee North Carolina on the Qualla Boundary reservation. Through my three decades plus acquaintance with the Eastern band of Cherokee Indians through my wife’s family most of whom were enrolled members of the tribe, I was fortuitously able to serve as the first full-time psychiatrist at the newly organized mental health and substance abuse service for the tribe from 2007 through 2010. As always, I requested to be able to consult at this nursing home facility and was able to do so. The nursing home there, of course, had an ironclad commitment to all members of the tribe and of course did not, and never would have, displayed any antipathy toward the Cherokee elders in the nursing home setting who had dementia and/or psychosis. The care that this facility afforded its tribal elders was second to none and always left me in appreciative awe of how well they cared for those patients and residents.

The current article for the reader’s review that documents quite well and objectively the dilemmas and huge challenges that Virginia faces in meeting the complex needs of this patient population is “When patients with dementia become combative, there’s often nowhere to go but a state psych ward..”