Transcript Slide 1

Community Solutions for Late Life Behavioral
Challenges
Presented by:
Meet the Presenters
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Jill Chaffee, MSW, earned a Bachelor’s degree and a Master of Social Work degree from the
University of MI in Ann Arbor, MI. Early in her career; she worked within a county system
(children and families) and had the opportunity to directly provide on-call, mental health crisis
services. She has experience as a clinician within an outpatient setting as well as ten years of
experience as an administrator and supervisor. She is currently the Director of Organizational
Development for Northwest Counseling and Guidance Clinic (NWCGC) and Northwest
Passage. She also oversees the Emergency Services Program for NWCGC, as well as manages
program contracts and leads the continuous quality improvement process with in the system.
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Donavon Schumacher received his Bachelor’s degree in Sociology and Criminal Justice from
North Dakota State University in 1991. He has worked for Washburn County HHSD for 16
years, serving as the lead worker in the area of Guardianships and Adult Protective Services
since 2003. Donavon serves as chairperson of the Washburn County Elder Abuse and Adult-atRisk Interdisciplinary Team. Donavon also provides mental health and AODA services to
voluntary and involuntary clients, as well as mental health crisis assessment in the community
and in the jail.
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Colleen E. Warner, Psy.D.LP, is a licensed clinical psychologist who completed her
Doctorate of Psychology at the Minnesota School of Professional Psychology (Argosy
University), and is a member of the National Registry of Health Services Providers in
Psychology. Dr.Warner has presented on a variety of mental health topics as a speaker for
PESI Healthcare. She is the author of the book “Borderline Personality Disorder: Struggling,
Understand, Succeeding”. Currently Dr.Warner is the Program Director for Amery Regional
Behavioral Health Center, which specializes in the treatment of adults aged 55 and older. Dr.
Warner’s expertise in assessment of behavioral health disorders includes those problems
typical of older adults. She provides supervision and training to staff in dealing with the
behavioral challenges presented by clients of all ages, but especially those presented by adults in
late life. Dr. Warner can be reached at [email protected].
Meet the Presenters
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Cindy O’Keefe received her Bachelor’s degree in Social Work and Criminal
Justice from the University of Wisconsin-Oshkosh. Her Master’s degree in
Counseling and Psychology was received from St. Mary’s College in Winona, MN.
She has worked for over 12 years as a therapist working with individuals and
families of all ages. Currently Cindy is working at Amery Regional Behavioral
Health Center as the Assessment and Outreach Coordinator. This program is
providing both inpatient and outpatient care to adults who are age 55 and older.
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Cynthia M Koller, RN, MSN has a Bachelor's degree from University of
Maryland, Walter Reed Army Institute of Nursing and Master's degree in
Community Mental Health Nursing from Oral Roberts University in Tulsa, OK.
She has been an RN since 1976, specializing in the psychiatric field for the past 25
years. Currently, she is the Director of Clinical Services for Diamond Healthcare
with offices in Richmond, VA and Houston, TX. As a part of that role, she is
presently working with the new Senior Behavioral Unit at Amery Regional
Medical Center in Amery, WI.
Today's Agenda
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8:15 to 9:00
Check in (continental breakfast)
9:00 – 9:30
Introduction – Chapter 51(Jill Chaffee) and Chapter 55
(Donovan Schumacher)
9:30 – 10:30
Assessment (Colleen Warner)
10:30 – 10:45
Break
10:45 – 12:00
Medication Challenges in Older Adults (Cindy Koller)
12:00 – 12:45
Lunch
12:45-1:45
Managing Difficult Behaviors (Cindy O’Keefe)
2:00 – 3:00
Ombudsmen
Forum – Panel to include: Providers, Adult Protection, DQA, and
3:00 to 3:30
Pick up Certificate of Participation
Information to Consider
DHS 34 Crisis Services work to improve collaboration and as
a result:
1. Reinforce procedures among disciplines – provide crisis
services consistent with a treatment plan
2. Maintain the balance between civil liberties and the need
to protect: provide the least restrictive environment
necessary to meet the persons needs
3. Uphold respect for the individual experiencing crisis
Chapter 51
The Wisconsin Statute number that pertains to
involuntary mental health and AODA
placements
a.k.a. Emergency Detention
Criteria for a Chapter 51.15
Mentally Ill
or
Drug Dependant
or
Developmentally Disabled
AND
Dangerousness to self
and/or
Dangerousness to others
and/or
In-ability to care for oneself
Mental Illness
“Mental illness”, for purposes of involuntary
commitment (Chapter 51.15), means a
substantial disorder of thought, mood,
perception, orientation, or memory which
grossly impairs judgment, behavior, capacity
to recognize reality, or ability to meet the
ordinary demands of life, but does not include
alcoholism
Drug Dependency
“Drug dependent” means a person who uses one or
more drugs to the extent that the person’s health is
substantially impaired or his or her social or
economic functioning is substantially disrupted, but
does not include alcoholism
Developmentally Disability
“Developmental disability” means a disability attributable to
brain injury, cerebral palsy, epilepsy, autism, Prader−Willi
syndrome, mental retardation, or another neurological
condition closely related to mental retardation or requiring
treatment similar to that required for individuals with mental
retardation, which has continued or can be expected to
continue indefinitely and constitutes a substantial handicap to
the afflicted individual. “Developmental disability” does not
include dementia that is primarily caused by degenerative
brain disorder. “Developmental disability”, for purposes of
involuntary “Developmental disability”, for purposes of
involuntary commitment, does not include cerebral palsy
or epilepsy.
Dangerousness to Self
A substantial probability of physical harm to
himself or herself as manifested by evidence of
recent threats of or attempts at suicide or
serious bodily harm
Dangerousness to Others
A substantial probability of physical harm to other
persons as manifested by evidence of recent
homicidal or other violent behavior on his or her part,
or by evidence that others are placed in reasonable
fear of violent behavior and serious physical harm to
them, as evidenced by a recent overt act, attempt or
threat to do serious physical harm on his or her part
Inability to care for oneself
Behavior manifested by a recent act or omission that,
due to mental illness or drug dependency, he or she is
unable to satisfy basic needs for nourishment,
medical care, shelter, or safety without prompt and
adequate treatment so that a substantial probability
exists that death, serious physical injury, serious
physical debilitation, or serious physical disease will
imminently ensue unless the individual receives
prompt and adequate treatment for this mental illness
or drug dependency
Remember…..
Must be imminent risk
The officer’s or other person’s belief shall be based on any of
the following:
– A specific recent overt act or attempt or threat to act or
omission by the individual which is observed by the
officer or person.
– A specific recent overt act or attempt or threat to act or
omission by the individual which is reliably reported to
the officer or person by any other person, including any
probation, extended supervision and parole agent
authorized by the department of corrections to exercise
control and supervision over a probationer, parolee or
person on extended supervision
If community services are available to
meet the persons needs, then those
options must to be utilized
Least Restrictive is the Law
Dementia and Alzheimer's
• Dementia and Alzheimer's do not fall under
criteria for a Chapter 51.15
• Dementia and Alzheimer’s are not considered
to be “mental illnesses.”
• Chapter 55 will address these specific
diagnosis.
Chapter 55
Protective Services
System Overview
Donovan Schumacher-Washburn County
Adult-at-Risk Agency
• 55.01(1f)
• "Adult-at-risk agency" means the agency
designated by the county board of supervisors
to receive, respond to, and investigate reports
of abuse, neglect, self-neglect, and financial
exploitation.
Adult Protective Services
Definitions
• Adult at Risk – As defined in Wis. Stat. 55.043(1e), means any adult
who has a physical or mental condition that substantially impairs his
or her ability to care for his or her needs and who has experienced,
is currently experiencing, or is at risk of experiencing abuse,
neglect, self-neglect, or financial exploitation.
• Elder Adult at Risk – As defined in Wis. Stat. 46.90(br), means any
person age 60 or older who has experienced, is currently
experiencing, or is at risk or experiencing abuse, neglect, selfneglect, or financial exploitation.
Adult Protective Services may
include any of the following:
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Outreach
Identification of individuals in need of services.
Counseling and referral for services
Coordination of services for individuals
Tracking and follow-up
Social Services
Case Management
Legal counseling or referral
Guardianship referral
Diagnostic evaluation
55.06
Protective Services and Protective
Placement; Eligibility
• Court Ordered protective placement or
protective services may be ordered under
Chapter 55 only for an individual who is
adjudicated incompetent and found in need of
a guardian of the person and/or estate as
allowed under Chapter 54.
Establishment of a Guardianship
Chapter. 54
• Competency Evaluation
• Filing of Petition
• Establishment of a guardianship of the Person.
• Establishment of a guardianship of the Estate.
Guardianship
• Wisconsin statutes require the individual to be
examined by a licensed physician, or psychologist
and found to have a permanent impairment that
causes them to be unable to meet the essential
requirements for his or her physical health and safety
and unable to communicate decisions related to
management of his or her property or financial
affairs. Less restrictive options that the individual
would accept shall be considered prior to the pursuit
of a guardianship petition. The determination may
not be based on mere old age, eccentricity, poor
judgment, or physical disability.
Alternatives to Guardianship
• Representative Payee
• Durable Power of Attorney for Finances
• Power of Attorney for Health Care
• Voluntary Services
• Conservator of the Estate
Protective Placement
• 55.01(6)
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(6) "Protective placement" means a placement that is made to
provide for the care and custody of an individual.
• 55.01(6m)
• (6m) "Protective placement facility" means a facility to which
a court may order an individual to be provided protective
placement for the primary purpose of residential care and
custody.
Allowable Admissions Without
Protective Placement Orders
• 55.055(1)(a)
• The guardian of an individual who has been
adjudicated incompetent may consent to the
individual's admission to a foster home, group
home, or community-based residential facility
without a protective placement order if the
home or facility is licensed for fewer than 16
beds.
Nursing Home Placement
• 55.055(b)
• The guardian of an individual who has been
adjudicated incompetent may consent to the
individual's admission to a nursing home or
other facility for which protective placement is
otherwise required for a period not to exceed
60 days.
Verbal Protest Remedy
• 55.055(3)
• If an individual verbally objects to or otherwise actively
protests such an admission, the person in charge of the home,
nursing home, or other facility shall immediately notify the
county department in which the individual is living.
Representatives of that county department shall visit the
individual as soon as possible, but no later than 72 hours after
notification.
Emergency Protective Placement
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(1) If, from personal observation of, or a reliable report made by a person
who identifies himself or herself to, a sheriff, police officer, fire fighter,
guardian, if any, or authorized representative of a county department or an
agency with which it contracts under s. 55.02 (2), it appears probable that
an individual is so totally incapable of providing for his or her own care or
custody as to create a substantial risk of serious physical harm to himself or
herself or others as a result of developmental disability, degenerative brain
disorder, serious and persistent mental illness, or other like incapacities if
not immediately placed, the individual who personally made the
observation or to whom the report is made may take into custody and
transport the individual to an appropriate medical or protective placement
facility.
Converting
a Chapter 51 to a 55
• 51.20(7)(d)1.
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1. If the court determines after hearing that there is probable
cause to believe that the subject individual is a fit subject for
guardianship and protective placement or services, the court
may, without further notice, appoint a temporary guardian for
the subject individual and order temporary protective
placement or services under ch. 55 for a period not to exceed
30 days, and shall proceed as if petition had been made for
guardianship and protective placement or services.
Involuntary Administration of
Psychotropic Medication
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"Involuntary
administration of psychotropic medication"
means any of the following:
• 1. Placing psychotropic medication in an individual's food or
drink with knowledge that the individual protests receipt of the
psychotropic medication.
• 2. Forcibly restraining an individual to enable administration
of psychotropic medication.
• 3. Requiring an individual to take psychotropic medication as
a condition of receiving privileges or benefits.
A petition under statute 55.14 shall
allege that all of the following are
true:
• (a) A physician has prescribed psychotropic medication for the
individual.
• (b) The individual is not competent to refuse psychotropic
medication.
• (c) The individual has refused to take the psychotropic
medication voluntarily or attempting to administer
psychotropic medication to the individual voluntarily is not
feasible or is not in the best interests of the individual.
Community Solutions
for Late Life Behavioral Challenges:
Assessment
Presented by:
Colleen E. Warner, Psy.D.
Licensed Psychologist
Program Director
Amery Behavioral Health Center
Common Late Life Behavioral
Challenges
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Aggression
Psychosis/ “paranoia”
Agitation
Non-compliance with Treatment
Other disruptive behavior (e.g. screaming, calling out,
wandering, pacing)
• Suicidal or Intentional Self Injurious Behavior
• Unintentional Self Injurious or Risky Behaviors (e.g.
Falls, Poor Driving, Not Eating Properly)
Old age ain't no place
for sissies.
~Bette Davis~
Most Likely Causes of
Late Life Behavioral Challenges
• Delirium: A MEDICAL Emergency
• Dementia or other Cognitive Issues
• Mental Health Conditions: Anxiety,
Depression, Psychosis
• Iatrogenic Effects (i.e.. Treatment/Medication
Induced)
• Perceived Threat to Well Being/Changes in
Environment/Changes in Health Status
• All the same things that cause early life
behavioral challenges
Key Diagnostic Questions
in Late Life Behavioral Challenges
• Onset – When did it start?
• Duration – How long has it lasted?
• Frequency – How often and under what
circumstances do symptoms occur?
• Course – How has it changed over time? When
& where is it most likely to occur.
• Symptoms: Be as specific as possible
Behavioral Analysis: It’s Over
(Gray Clin Geriatr Med 2004; 2069-82)
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Identify: What is the Problem Behavior
Timing: When Does it happen?
Surroundings: Where does it happen?
Others: Who else is involved?
Very Troubling: How Dangerous?
Evaluation: What else might be causing it?
Recommend: How do I respond?
Assessment Process
• Rule Out Delirium, especially if sudden
onset
• Comprehensive review of medical,
medicinal, social/environmental, and
psychiatric/psychological factors that
could be contributing.
Understanding & Addressing Complex Problems:
The Wisconsin “Star” Method
slide resented with the permission of Dr. Timothy Howell
Medication
Issues
Social
Issues
Medical
Issues
Symptom,
Problem
Personal Issues
(Personality)
Psychiatric
Issues
Medical Issues
Thirty-five is when
you finally get your head
together
and your body starts falling apart.
~ Caryn Leschen ~
Physical/Medical Issues
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Delirium
Urinary Tract Infection/Renal Failure
Upper Respiratory Infection
Stroke/TIA’s
Sepsis
Electrolyte Imbalance
Sleep disturbance
Sensory Impairment/Deprivation
Pain
Medication/Chemical
• Often have multiple providers with multiple medications
(Older adults average 4.5 meds daily; 15-17 scripts/year)
• 1/3 of residents in institutions take 8-16 meds at one time
• Regimes become more complex which reduces
compliance
• Body does not metabolize medication in the same way
• Complicated side effect profiles
• Don’t underestimate risk of chemical dependency in older
adults – especially abuse of prescription meds
Psychiatric
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Cognitive Decline
Delusions
Psychosis
Anxiety
Depression
Personality
Social/Environmental
Inside every older person is a younger person –
wondering what the hell happened.
~ Cora Harvey Armstrong ~
Social Environmental
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Family Issues
Lack of/ or change in social support
Caregiver Fatigue
Change in residence: new people, new sensory,
new caregivers
Loss of loved ones/ Change in contacts
Loss of control
Financial Pressures
Elder Abuse/Neglect
Psychiatric Admissions:
Legal Considerations
• The PRIMARY diagnosis must be a psychiatric
diagnosis.
• Rules re: psychiatric admissions are different
than for other health care facilities.
• Patient MUST consent (or at least not protest)
regardless of their competency OR
• May pursue involuntary admission under rules
of Chapter 51.
Community Solutions for Late Life
Behavioral Challenges:
Managing Difficult Behaviors
Presented by:
Cindy O’Keefe,MA LCSW
Assessment/Outreach Coordinator
Stress Model of Crisis
Four Questions
• What am I bringing to the situation?
• What effect does the environment have on the
situation?
• What does the person’s behavior mean?
• What is the most appropriate response?
What am I bringing to the
situation?
Factors
• Cultural
• Ethnicity
• Personal Experiences
• Current Events
What effect does the environment
have on the situation?
Physical
• Adequate space
• Lighting and noise levels
• Safety
What affect does the environment
have on the situation?
Continued…..
Program, Structures, and Routines
• Predictable
• Consistent
• Client centered activities
What does the person’s
behavior mean?
• Is this behavior typical for this person?
• Is this person expressing a need?
What is the most
appropriate response?
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Staff Involvement
Patient Involvement
Family Involvement
Behavioral safety plan
Communication style
Placement options
ROLE PLAYS