Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SATURDAY, March 30, 1991 TAG: 9104020503
SECTION: NATL/INTL PAGE: A-1 EDITION: METRO
SOURCE: CHARLES HITE MEDICAL WRITER
DATELINE: CATAWBA LENGTH: Long
Perdue likes this place - the place she thinks is a doctor's office - well enough. It's got a greenhouse, crafts, music, a beauty salon, TV, good food. In the summer there's a garden near the woods where sometimes, in the early morning, she spies a deer.
The garden and the deer remind her of home, which is not the trailer in Fincastle she lived in before coming here, but the Floyd County homeplace where she and 11 brothers and sisters milked cows and helped with the plowing and where Perdue used to get a lot of spankings because one sister just wouldn't let her alone.
Perdue recalls her time in Floyd County like it was yesterday and she can usually recollect what's happened in the past couple of days. But the time between is dim in her memory.
She doesn't remember the days she lived alone in the trailer and would introduce Teresa to characters on TV shows just like they were real people. She doesn't remember phoning Teresa and asking her, "What time is it?" and then calling back a few minutes later and asking the same thing. She doesn't remember falling and hurting herself or eating only soft drinks and candy for days at a time. One day Teresa went to fix her some supper and Perdue told her plenty of food was in the refrigerator. Teresa peeked in and found a ham, all green and moldy, that appeared at least seven years old, judging from the date on the wrapper.
So Perdue is glad enough to be in this place she thinks is a doctor's office where the people are friendly and do her hair on a regular basis. And she's happy to have her granddaughter who she thinks is someone called Betty come and visit and show her pictures of her great-granddaughters and her son who she thinks is a brother who has gone off hunting.
And Teresa Hosey, the granddaughter, is glad that her 78-year-old grandmother is putting on weight and is no longer afraid and paranoid and going off on crying jags and worrying that people are coming to steal the baby that is crying down the hallway.
Hosey always swore to herself that she wouldn't put a loved one in an institution. "But people don't realize there comes a point when you can't take care of them," Hosey says. "I can't take care of granny. One time I took her to the grocery store. As we left, I went out first. And before I could turn around, she had wandered all the way to the end of the parking lot."
For Hosey, Catawba Hospital, one of five state facilities serving the elderly mentally ill, is a godsend.
"I don't worry about her now. I know she's fine," she says. "The hospital staff never knows when I'm coming to see her. And each time I visit, there's never been anything wrong."
A former tuberculosis sanatorium that was taken over by the mental health department in 1972, Catawba - just 15 miles from downtown Roanoke - is relatively unknown to most Roanoke Valley residents.
Over the past decade it has been built into a well-staffed, well-run facility that provides more than basic custodial care for up to 182 elderly patients. Catawba's goal is to aggressively treat patients and place them where they can enjoy life in the least restrictive environment.
"I have a lot of respect for Catawba," says Dr. Dan Herrington, a University of Virginia psychiatrist who worked at the hospital last fall. "I don't think the Roanoke Valley knows what it has there. When I got to Catawba, I was pleasantly surprised. People really get incredibly good care there."
Yet Catawba and the state's other mental hospitals face an uncertain future at a time when they are becoming recognized for their ability to treat patients more effectively and quickly.
Their fate hangs on the outcome of two opposing trends: moving patients out for humanitarian and budget-saving reasons vs. mounting evidence that, as the elderly live longer and become a larger part of the population, more mental health services will be needed.
"These two trends are clearly on a collision course," says Ivo Abraham, an associate professor of behavioral medicine and psychiatry at the University of Virginia. Caring for the growing population of elderly mentally ill with downsized state facilities will be "like trying to row a small boat into a tidal wave," Abraham says.
Elderly patients like Reba Perdue are difficult to treat. For them, imagination and reality often are the same. Their delusions can make them fearful and paranoid. Their tempers can flare violently for no apparent reason. They forget to eat and don't want to take their medications. They are confused and disoriented. They get depressed and cry. They wander and get lost. They suffer from serious physical ailments.
After decades of being shoved into stark, understaffed back wards and simply forgotten, the number of elderly patients in state institutions has fallen dramatically. In 1975, more than 3,200 patients over 65 years old resided in Virginia's state mental institutions. Today there are just over 800. Nationally, their numbers have dropped from nearly 55,000 to 18,000 in the same period.
The decline is due in part to a reform movement launched in the 1970s to stop warehousing mental patients and place them in outpatient programs or facilities near their home communities.
Money also is a factor in the exodus. Nationwide, care of the elderly in mental institutions costs more than $1 billion a year. In Virginia, the annual cost for just one patient is nearly $80,000, twice the amount spent on a typical nursing home patient.
Saving dollars clearly was behind the decision last year to close a 120-bed geriatric unit at Western State Hospital in Staunton. With Virginia facing a $2 billion budget deficit, closing the unit was one way the state's mental health department responded to Gov. Douglas Wilder's order to cut spending. The closing will save the state $3.2 million by the end of the 1992 fiscal year.
Mental Health Commissioner King Davis says the closing was inevitable.
"The budget crisis changed the timetable but not the event," Davis says. "The numbers of people on the geriatric side continue to plummet in our system. If the decision had not been made to close the geriatric center at Western State in 1990, it might have been made in 1992 or 1993. But it was to be made."
Shutting down the Western State unit follows a widespread scaling back of geriatric beds in the past several years. That included the closing of a 332-bed unit at Central State Hospital in Petersburg and cutting the geriatric beds at Southwest Virginia Mental Health Institute in Marion from 96 to 48.
Davis sees the trend continuing. New drugs, improved therapies and more community-based programs - including adult homes and nursing homes - will mean fewer elderly will need to be in state hospitals, he says. By the end of the decade, he estimates, the system will need only 400 geriatric beds, half of what it has now.
The sun streams through the wall of windows on the porch of the annex building, which is broken into rooms used for music and arts and crafts and exercise classes.
Mary Walter sits in a "gerry chair" - sort of an armchair on wheels - not too far from the Panasonic stereo rack system and the record stand that has among its titles "144 Genuine Sound Effects" and "Best Loved Symphonies."
Walter listens to the young lady with the long, straight brown hair who is helping Mary and three other patients make up the second verse of their very own song, called the "Hello Song," which goes something like, "We wish you happiness and good health and send you on your way."
Walter hums along with several tunes that the lady with the long, straight brown hair strums on her guitar, one of which Walter thinks is a Kate Smith song but later realizes is not. The last song is one the lady with the long, straight brown hair learned when she was a Girl Scout. She asks Walter, who is 75, if she was ever a Girl Scout, and Walter can't contain a guffaw and says, "No, I had too work too darn hard when I was a little girl. I had to work with my daddy on Saturday and cut wood all day. I had to bring in the water."
Walter talks about what life was like when she was growing up on a farm in Albemarle County, about raising chickens and selling eggs, and slaughtering hogs to have enough to eat during the winter, and the bag of hard candy her daddy brought her every Friday evening.
It isn't long before Walter's words stimulate some childhood recollections from the other three patients, which is exactly the effect desired by the lady with the long, straight brown hair, otherwise known as Leigh Grimm, music therapist.
Grimm and other therapists at Catawba are part of a treatment team that meets periodically to discuss how each patient is doing and what might need to be changed to make them do better. Grimm's insights into a patient's behavior help the team evaluate the patient's progress and whether he or she might be discharged to a nursing home, an adult home, or maybe even to their own home.
Walter, who suffers from a chronic lung disease, cancer and is nearly blind as a result of diabetes, has been in and out of state mental facilities since 1955. Her diagnosis is chronic paranoid schizophrenia.
She's upbeat these days, content with her life. The staff says Walter has "appropriate" concerns and behavior for someone her age.
When Walter shares her recipe for biscuits made from scratch or confides that she needs to shed a few pounds, she seems like anybody's grandmother. There's no mention of the voices that urged her to attack people with a butcher knife, not a word about the rocks she threw at the imaginary men from Richmond who were out to kill her, no fear of the mysterious strangers who were trying to infect her with germs.
Walter's first admission to a state mental facility came in 1955 when she became upset after breaking up with her boyfriend. She spent 14 years at Western State, worked three years as a nursing home aide, then ended up at Western State five more times before being transferred to Catawba.
Of the 118 patients who were transferred when the geriatric unit at Western State closed last year, 35 came to Catawba. Walter, who was transferred several days ago to a nursing home, says she didn't mind the move.
"I knew we were all going to have to go. There wasn't any point to hesitate," she says. "I'm doing all right."
Margaret Roberson is another of the 35.
"I like it here," she says. "Except for arts and crafts class. They give me things that make me nervous."
Roberson, 68, seems constantly on the verge of tears. In conversation, she jumps from topic to topic and is unable to talk more than a few minutes before becoming anxious and agitated. When she isn't talking, she constantly hums in a low, deep sing-song.
In art class, she does indeed get nervous. Staring at a line drawing of a bird in a tree, she frets about where to begin painting and what color to use. When the bird is almost filled with bright blues and greens, Roberson says it reminds her of a pet parakeet. "She died such a horrible death," Roberson says, and tears begin to stream.
"They were bad to me at Western State," she confides to a visitor. "They drugged me. My mind swelled up. But God put it back together. God can do anything."
Chronic mental illness in the elderly comes in all shapes and sizes, and the patients transferred from Western State run the gamut. Roberson's illness is commonly known as manic-depressive disease. The doctors call it bipolar disorder.
Bipolar patients vacillate between extreme moods. For days or weeks, they are manic: Their outlook is euphoric, optimistic, hyperactive, fanciful. Then comes a depressed period: Patients feel worthless, hopeless, jumpy, irritable, distracted, lethargic and complain of ailments that can't be explained.
The Western State transfers included schizophrenics, like Mary Walter, and patients with severe dementia, like Reba Perdue, as well as patients who were extremely depressed.
"We had some rather complicated cases to take care of," says Dr. Marvin Perkins, Catawba's medical director. "We did find the patients both psychiatrically and medically a little more ill than our patients on average."
The closing of the Western State unit was challenged by an in-house human rights committee, which claimed the hurried nature of the transfers might hasten the patients' deaths or slow their recovery. Some families of patients also feared the treatment at other state facilities wouldn't be as good as at Western State, which had developed a long-term relationship with the UVa psychiatry department.
A half-dozen of the transfer patients have had to get medical treatment at Roanoke Valley hospitals, but that's not unexpected in such a frail, vulnerable group, Perkins says.
"I'd have to say there was a strain," replies Michael Marsh, Catawba's director, when asked about the effect of the transfers on his staff. Not only were there some very sick patients with severe behavior problems, he says, but the transfers had to be done in a few weeks. For that period, there were one or two new patients coming nearly every day.
"I came here on Christmas day and the staff was extremely busy," Marsh recalls. "You could feel it. But they kept a stiff upper lip."
Overall, Marsh says, the transfers went better than expected and he's proud of how his staff handled the job. Most families of those who were transferred, he says, have lost their fear about Catawba being unable to treat seriously ill patients.
Marsh, a retired Army colonel with a background in medical administration and drug abuse programs, presided over Catawba's transformation from a so-so elderly rehabilitation center into an accredited psychiatric hospital.
When Marsh arrived in 1978, Catawba was primarily a receiving center for large numbers of patients from Western State and other old state mental hospitals that were scaling back. Many patients had been inappropriately confined to mental wards for years, and Catawba's job was to train them in everyday living skills and get them back to the community.
Marsh remembers signing discharges for patients who had been hospitalized before he had been born. He has first-hand knowledge of how that might have happened. While working at the Medical College of Virginia in the mid-1950s, Marsh recalls a confused and disoriented elderly woman who had been found on a bus on a hot summer day. The hospital staff held a commitment hearing and she was sent to Eastern State hospital.
"She could have been caught up in the system the rest of her life," Marsh says. "And we thought we had done a good job."
Over the next several years, the role of Catawba and other state mental hospitals changed. As the number of elderly patients declined, those who remained needed more intense treatment if they were to be stabilized and sent back to their communities.
Marsh set about the task with military fervor. Typical of his zeal was his attitude toward housekeeping. Marsh insisted on a spit-polished cleanliness that persists today. Nearly every patient and family interviewed about Catawba remarks on the gleaming hospital floors, which are so bright that they have been criticized on accreditation reviews. The reviewers fear the shine could disorient patients. But Marsh keeps the floors sparkling.
"Clean floors impress people. It impresses the staff," he says. "It's just psychologically better for everybody."
The most important change during Marsh's tenure has been the quality and size of the hospital staff.
A decade ago, 18 of the hospital's 281 staff members had college degrees. Today, 70 of 350 staffers have advanced degrees. Even though there are fewer patients, there are two more physicians, one more psychologist, 26 more nurses, three more social workers, six more therapists and a dentist. Four of the seven doctors have faculty appointments at UVa's medical school, including a former head of psychiatry at the Salem Veterans Affairs Medical Center.
Six years ago, Maureen Schnittger was the only nurse with a master's degree. Now there are five others and Schnittger, who has since earned her doctorate, is clinical director of the hospital.
The improved staff stems from a decision by state mental health officials to get each state hospital approved by a national accrediting body. The difference, Schnittger says, is a staff more knowledgeable about the special needs of elderly psychiatric patients.
As a result, Catawba is able to treat more patients who stay shorter periods of time. In 1980, the hospital had 52 admissions and 77 discharges. Ten years later, the hospital took in 154 patients and discharged an equal number. During that period, the average stay for all patients dropped from 1,034 days to 597 days.
"Just five or six years ago, patients assumed when they came here that this would be their home," Schnittger says. "We are very clear with people now that we shouldn't be viewed as a nursing home. We're here to treat people's psychiatric problems."
In early spring, 10 months after she came to Catawba, Reba Perdue is leaving. She is being transferred to a nursing home in Salem. Her belongings are packed in a cardboard box and she's sitting in a gerry chair waiting for the elevator to take her to the lobby.
"I love you," she tells her granddaughter, Teresa Hosey, who she thinks is her sister, Hazel.
"I love you," Teresa says.
Perdue's spirits are high. She banters with the staff that has come to see her off.
"I don't know whether I should take her with me or leave her here," she says, nodding toward Teresa.
"You probably ought to take her with you," says Dr. Dave Sheiderer, psychiatrist for the unit.
"Well, all she'll do is tell lies about me," Perdue replies.
Perdue is aware that she's going to a new home but she's not sure where it is or what it will be like. But the move clearly excites her.
"Tally ho, let's go," she shouts as the elevator doors open.
Head nurse Lanette Jordan hugs Perdue. "I wish you could come and stay with me," Perdue says.
Jordan wanders back to the nurses' station as Perdue is wheeled into the elevator.
"She's a sweet lady," Jordan says. "I hate to see her go. But she's ready."
Catawba Hospital
One of five state mental health hospitals treating patients over 65.
Budget: $13.3 million. Payroll: $10.8 million. Employees: 347. Beds: 182 geriatric, 35 short-term.
Located on 752 acres at the site of Red Sulphur Springs, a resort founded in 1858.
In 1901 the state purchased the resort and built a tuberculosis sanatorium there.
In 1972 the state converted the sanatorium into a facility to rehabilitate elderly residents being transferred from state psychiatric facilities.
While there are 51 buildings on the Catawba property, most are vacant. The main facility is an eight-story concrete building completed in 1953. Patients live on five floors. The fifth floor is vacant but could be used for another 46 beds if the hospital expands.
by CNB