Presented by:

Community Solutions for Late Life Behavioral Challenges

Meet the Presenters• 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.

• 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-at-Risk 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.

• 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 colleenw@amerymedical.com.

Meet the Presenters

• 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.

• 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• 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 Forum – Panel to include: Providers, Adult Protection, DQA, and

Ombudsmen•  • 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 51.15Mentally Ill

orDrug Dependant

orDevelopmentally Disabled

ANDDangerousness to self

and/orDangerousness to others

and/orIn-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, self-neglect, or financial exploitation.

Adult Protective Services may include any of the following:

• 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)    •   

(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

•  (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.    •   

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

• "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 PsychologistProgram Director

Amery Behavioral Health Center

Common Late Life Behavioral Challenges

• 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)

• 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

Symptom, Problem

MedicationIssues

Social Issues

Personal Issues(Personality)

PsychiatricIssues

Medical Issues

Thirty-five  is when you finally get your head

together and your body starts falling apart.

     ~ Caryn Leschen ~   

Medical Issues

Physical/Medical Issues

• 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

• Cognitive Decline• Delusions• Psychosis• Anxiety• Depression

Personality

Inside  every older person is a younger person – wondering what  the hell happened.

  ~  Cora Harvey Armstrong ~  

Social/Environmental

Social Environmental

• 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

0

20

40

60

80

100

120

Pre-Crisis Trigger Phase Escalation Phase Outburst Phase Recovery Phase

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?

• Staff Involvement• Patient Involvement• Family Involvement• Behavioral safety plan• Communication style• Placement options

ROLE PLAYS