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Alzheimer's

The story of the 60-year-old man who died at Montana State Hospital tells us what's wrong with our mental health and long-term care systems. Community nursing homes refused to admit him. He was confined to a private room in the state psychiatric hospital — far from home — for his own safety. Relatives who visited him reported that the staff advised them that the door would be locked from the outside for their safety.

That story haunts Lynn Mullowney Cabrera, executive director of the Alzheimer's Association Montana Chapter, as she works for greater awareness of a disease that is on the rise nationally and in our state.

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21,000 Montanans

The Alzheimer's Association estimates that 21,000 Montanans are living with Alzheimer's disease, which accounts for about 65 percent of all related dementia. By 2025, it's projected that 27,000 Montanans age 65 or older will be living with Alzheimer's.

This year, Alzheimer's disease will cost Montana Medicaid $157 million, and the cost will increase 28% in the next five years, according to an Alzheimer's Association estimate.

"There are folks in the community who do a really good job," Cabrera said. "For a person without resources, there are very few options."

Asked about dementia cases in which no community care can be found, Cabrera said: "It does come up quite a bit. It seems so grievous that we don't have better options for people. We need better options for people, for families and for care staff. It's hard work, demanding work that requires extensive and ongoing training. The caregiver has to be a detective to understand what's going on."

Some Montana nursing homes have staff trained to respond appropriately to people with dementia and some facilities have units dedicated to memory care. But there may not be any placement for a person whose behavior is deemed a risk to himself or others. For one thing, Montana Medicaid doesn't offer significantly higher compensation for the care of significantly higher need nursing home residents. That's a problem the 2021 Legislature should address in collaboration with Montana nursing homes and home care programs.

Deputy County Attorney Kevin Gillen, who handles civil psychiatric commitment cases for Yellowstone County, is "seeing more and more dementia cases with elders." Sometimes these cases involve "nursing home push-outs" where a long term care facility is no longer willing or able to care for a resident with dementia whose behavior is difficult or unsafe for the resident, staff or other residents.

The Montana Mental Health Nursing Home in Lewistown should be a more appropriate placement for elderly dementia patients than Warm Springs. But in Gillen's experience, the Lewistown facility very rarely accepts commitments directly from Yellowstone County. Usually, the patient would be committed to Montana State Hospital at Warm Springs and then might be transferred to Lewistown.

At Warm Springs, the Spratt unit, a one-story brick building on the hospital's sprawling campus, has been largely used for elderly patients for many years.

Forty patients were admitted to the Warm Springs hospital last year with a diagnosis of neurocognitive disorder, Alzheimer's disease or other dementia, according to the Montana Department of Public Health and Human Services. That number, which includes some with long-term substance abuse disorder, is about 5% of the total civil commitment admissions for the year.

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Lewistown transfers

Seven of the 40 were discharged to the state nursing home in Lewistown, five to other nursing facilities, one to a hospital, one to the VA and five to private residences. Nine died and one remained at Warm Springs when DPHHS responded to The Gazette's request for information. Two other patients were released as required by law when their court commitment expired and their location is unknown.

The department noted that use of anti-psychotic medication is a challenge with patients at the Lewistown nursing home. Patients transferred from Warm Springs to Lewistown "are usually stabilized by anti-psychotic or psychotropic use." Federal regulations require nursing homes to attempt gradual dose reductions of these medications within the first year of admission. That process may cause agitation, anxiety, insomnia and psychotic episodes that result in the patient being transferred back to Warm Springs.

With the aging of Montana's population and the projected increase in the number of Montanans living with Alzheimer's and related dementia, the state needs to prepare to care properly and compassionately for the increasing numbers of Montanans living with Alzheimer's and related dementia.

No Montanans should be forced to die far from family in a hospital that was not meant to be a home or a hospice.

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This editorial originally appeared in the Billings Gazette. 

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