Imagine you are sitting in your kitchen at a table handed down to you from your parents, sipping coffee from your favorite mug, when there’s a knock at the door. It’s a county employee who very politely explains that she has been asked by your landlord to check on you. A bit perplexed, you assure her that you are fine. A week later the worker returns with a few others to inform you that you are being moved to a place where you’ll get nice new furnishings and three meals a day, that all your needs will be met, and this is permanent. The favorite mug can go with you, but you will not be allowed to take the heirloom table – or most of your personal belongings. Does this scenario sound improbable? Not if you are one of the many elders who are involuntarily relocated each year, either from their own homes to eldercare facilities or from one facility to another.
This may seem an extreme example, but it is true that Adult Protective Service (APS) workers, social service agencies, and well-meaning family members can remove elders from their homes with little time to prepare. Discharge planners are in a similar predicament: If an older adult cannot be discharged to his or her home safely, then home has to become somewhere else. The scenario above is told from the older adult’s point of view. What’s missing is the part about the strong odor of urine throughout the apartment, the empty refrigerator, and newspapers stacked on the radiator. Naturally someone does not swoop down and forcibly remove someone from a situation that is just fine, but that is exactly how it feels to the older person who is living in questionable or unsafe conditions. The reasons for relocation may be an unclean environment, history of falls, household hazards, medication errors, neglect by self or others, or physical changes that make self-care impossible.
Consider another scenario. A client comes to you with symptoms of caregiver burnout, even though she moved her mom from her home to an assisted living facility two months ago. Even though she and her mother had made the decision together and hired a mover, her mother is exhibiting some very odd behaviors at the facility. Staff calls your client almost daily to inform her that if her mother continues to “get lost, miss meals, and overuse her call button,” she may not be able to stay. Your client is overwhelmed at the prospect of moving mom – again.
PACK UP 40 YEARS IN 30 DAYS
Moving at any age and under the best circumstances, such as a new job or to be near family, is stressful. The logistics of planning, packing and paying for a move are one thing, but the emotional element of changing one’s primary residence can lead to a condition called relocation stress syndrome (RSS) (Malick & Whipple, 2000). RSS, also known as transfer trauma, is the combination of physiological and/or psychological disturbances as a result of transfer from one environment to another (Jackson, Swanson, Hicks, Prokop, and Laughlin, 2000). It does not discriminate among those who have chosen to move, been involuntarily relocated, or been placed in a care facility for mental or medical needs.
Symptoms of RSS are the same in all age groups. They can include exhaustion, sleep disturbance, anxiety, financial strain, grief and loss, depression, and disorientation. In older people, these symptoms can quickly become exacerbated by dementia, mild cognitive impairment, poor physical health, frailty, lack of support system, and sensory impairment. Does the client understand why they were relocated? Did they participate in the decision? Can they see and hear in their new accommodation to learn their way around a new building or neighborhood? Do they have anyone to help them pack or move? Will they remember that this is no longer their home? Can they keep their doctor? Friends? Pet?
WHO CHOOSES TO LIVE IN A NURSING HOME?
It is widely accepted that seniors want to stay in their own homes for as long as possible. Difficulty arises when there is disagreement about what possible means. Who determines that conditions are unlivable? In a 2005 survey at one Los Angeles assisted living, an MSW intern was interviewing residents about the relocation experience for her macro project. While reviewing the facility census to identify survey candidates she discovered that 17% of residents had moved in reluctantly. One gentleman was losing his eyesight and could not see well enough to keep his apartment clean. His landlord called APS who, in turn, called a social service agency to move him. Another had a history of mental illness and was found by neighbors unkempt and undernourished. A woman had exceeded the charitable guidelines from the agency that was supplementing her rent and, hence, had to move from her apartment and leave her book collection of over thirty years. The agency paid a moving company to bring only what would fit in her new room. She never stopped grieving the loss of her books, which had been her best friends. The scope of the problem can be summed up in one national statistic: according to U.S. Administration on Aging data, about 1.6 million seniors live in some sort of institution and they all moved there under some circumstance or another. That means many potential cases of RSS.
Moving someone into a nursing home is a relocation as well, even though in the professional vernacular we call it a placement, a transfer, or an admission. Those residents who are mentally able will tell you they believe the nursing is home is where they go to die, but that’s not necessarily true. Health and Human Services cites that in 1997, 73% of nursing home residents were discharged alive (Gabrel, 2000). They either went home, went to another facility, or most likely, were moved to an acute hospital after an injury or illness. That means that the most aged and frail elders, in their most compromised condition, are not given immunity from the stress of relocating.
A current trend is the development of age-in-place facilities that offer tiered levels of care. As the resident ages and care needs increase, he or she can stay at the facility. This is a positive trend; however, it has two significant drawbacks. First, as care needs increase, so might the monthly cost of residency, making asset conservation a serious concern. Second, even age-in-place facilities have licensing regulations that limit the acuity they can handle. Therefore, an acute illness or injury may force a move at a very inopportune time. Like the nursing home patient, if the resident does not recover significantly from the acute episode, he or she will not be allowed to return to the facility and will have to move again.
TAILOR-MADE FOR INTERDISCIPLINARY TEAMWORK
For social workers, RSS symptoms meet the diagnostic criteria for adjustment disorder (Diagnostic and Statistical Manual of Mental Disorders IV). Moving is an adjustment that some people make more easily than others. Mood and mental changes that can occur include depression, anger, suicidal ideation, confusion, anxiety, and paranoia. Some may exhibit denial by over-idealizing the move (Isn’t this place wonderful. Everything is just perfect!). Behaviors we are likely to see in older people are somatic complaints, wandering, aggression, isolation, excessive demands for medical and non-medical attention, and substance use, abuse or misuse. Physical signs may include pain, agitation, aggression, incontinence, appetite or weight changes, sleep disturbance, and the most dreaded yet too common – falls. Adjustment disorder can take up to three months to manifest. Those can be three very hard and heart-breaking months for residents, family, and staff. At the L.A. facility surveyed, one-third of new residents had an acute hospitalization within thirty days of moving into the residential care facility. At the affiliated nursing home, 11% of new residents expired within 30 days. If the disorder does not resolve after six months, it is no longer about adjustment, and the relocation may have triggered another chronic illness.
SO MANY WAYS TO HELP
Care plans should begin with a comprehensive mental and medical assessment, including a medication review. A thorough history of the client should include how often the person has moved and past coping skills used for other relocations. These first steps provide a baseline from which staff can measure changes that may result from RSS. Next, a new resident must be given a proper orientation to both the physical layout of the facility and the rules of living there. Too often the staff have expectations of a new resident, such as what he or she should wear to breakfast, and the newcomer has other expectations, such as a habit of dining in his or her slippers and these are never discussed, but immediately cause problems. Sometimes these early problems lead to labeling new residents as troublemakers or even demented. Explain to new residents that while this is their new home, it is still an institution that has policies and regulations that transcend their individual needs and desires.
Establishing trust and a safe feeling for new residents cannot be understated. We are asking someone who may have moved unwillingly to trust a set of strangers to help them shower, give them their pills, handle their finances, take away their laundry. It is normal for a newcomer to have some trepidation, so staff need not get offended if help is refused or questioned initially. One helpful tool is to let newcomers get together and share their concerns, frustrations, and successes with each other. Encourage connections with long-time residents through a buddy system. There are always friendly residents who are willing to show the “new guy/gal” the ropes. Supportive counseling from knowledgeable staff is also helpful. Allow the new resident to grieve the loss of their old residence, examine and accept the need to move, and to explore the meaning of home.
A frequent barrier to intervention in older clients is mild cognitive impairment or dementia. Memory problems can be downright dangerous if clients cannot remember that they’ve moved and head back to his old place. Another common obstacle is the lack of a thorough assessment. Family members may underestimate the level of care needed, or underreport the difficulties of the prior living situation. A rushed relocation can easily result in an unfit placement, which will make adjustment unattainable. Elders with little or no community support are also at a disadvantage, as friends and family can help by reinforcing newly acquired information about facility life. The greatest barrier for everyone is time. Adjustment takes time, during which the resident can become frustrated, staff can burn out, and finances can be drained.
REFRAME CHALLENGES AS OPPORTUNITIES
There are many positive aspects of elder relocation and, of course, these are always what we have in mind when we think about moving someone. Increased socialization, freedom from the demands of maintaining a home, and increased opportunities for both mental and physical activity can vastly improve quality of life. Moving a loved one into facility can also do wonders to alleviate caregiver burden if the family has been working hard to keep an older person at home. And the most important positive aspect of moving is that the older adult’s care needs are met on a daily basis.
These benefits are highlighted in the messages elders hear when it is time to move into a facility, voluntarily or involuntarily. However well-intentioned, the messages often conflict with the emotional reality of relocation. Phrases like “You’re going to love it here” ring hollow when the new resident feels like I’ve come here to die. Other messages such as “You’ll make new friends” or “We take care of all your needs” set up impossible expectations for the new resident who may have never been at ease with new people, does not think he or she has many needs, or thinks he or she cannot afford to pay for the needed services.
The risk of RSS and adjustment disorder can be minimized prior to moving day by doing for clients basically what we would do if it were our own move. Respect individuals by telling them that it is an adjustment for them as well as for others and letting them know it takes time. Allow as much time as possible before the move to prepare. Give a floor plan of the room and a list of things the person will need from home. Encourage the new resident to retain patterns from home, such as subscribing to the newspaper, having afternoon tea, or taking walks. Can they bring a pet or favorite plants? Counsel new residents on the ups and down of communal living after years of being on their own. Help educate the rest of the team on how to see the whole person coping with a new environment.
HEALTHY ADJUSTMENT IS ALWAYS THE GOAL
Chances are that senior residences are popping up all over your city with enticements to move yourself in, or choose this place for loved ones. We know most people prefer to age in their own homes, and statistically, most do. But when relocation is inevitable, remember that elders are adults and should participate in the decision to move however they can. Less move-related stress benefits the facility staff, other residents, family, friends, and seniors. Planning, teamwork and adjusting expectations can create a positive outcome when you really have to set up camp somewhere new. During a move at any age, these efforts are helpful. For our elders they are essential.
About the Author
Tracy Green Mintz joins the OpenPlacement team as the Training and Resources Advisor. Tracy is a Licensed Clinical Social Worker (#23964), trainer and long-term care consultant based in Southern California. As a social worker, Ms. Greene Mintz believes that knowledge is power, and our elderly clients deserve all the power we can shift to them in our complicated healthcare service delivery system. She is a nationally recognized expert on the topic of Relocation Stress Syndrome in the elderly and has given workshops across the U.S. to case managers, administrators, nurses, social workers, skilled therapists and other disciplines that serve seniors. She also offers Medicare-covered one-on-one counseling to seniors in their homes.
Her trainings are popular and memorable because her common sense approach includes lots of laughter and team-building that validate the very difficult work of eldercare. “I’m not trying to change the system in as much as I am trying to help clients become more effective consumers in that system. I prefer to train direct care staff to recognize and reinforce consumer-based choices because it is in their interest to do so. Encouraging seniors to participate in their care makes everyone’s job easier, which reduces costs and leads to positive outcomes for all, including the organization. I always address the business angle because health care in the U.S. is a business and all staff should appreciate the crucial link between good customer service and good care.” Her philosophy is that best practices build the best facilities, and our seniors deserve the best. Through social service consultation and SSD training in long-term care, she focuses on quality of life for residents and substantial compliance for facilities as a mutually beneficial outcomes.
Ms. Greene Mintz has worked with seniors and their families at all levels of care, from independent living through end-of-life since 2000. She holds a master’s degree in social work and a gerontology certificate from the Institute on Aging at Portland State University in Oregon and master’s degree in film and television from UCLA. She is a proud member of the California Society for Clinical Social Work and the National Association of Social Workers, of which she has served on the CA State Board. She was recently appointed to the faculty of Boston University’s School of Social Work. Prior to becoming a geriatric social worker in, Ms. Greene Mintz worked for twelve years in the film and television industry. She likes to comment that the similarities between working in showbiz and working in mental health are staggering!