case studies: navigating new routes to improved mental health care

PART 2

TRIAGE OF GERIATRIC MENTAL HEALTH CRISISCASE PRESENTATIONS

GINA O’HALLORAN, MARICH GODDARD, RN, BSN, MA

DEFINITIONSADL: Activities of Daily Living

CSB: Community Services Board

ICU: Intensive Care Unit

CHF: Congestive Heart Failure

HR: Heart Rate

BP: Blood Pressure

CBC: Complete Blood Count

WBC: White Blood Count

COPD: Chronic Obstructive Pulmonary Disease

LTC: Long Term Care Facility

ES: Emergency Services

UTI: Urinary Tract Infection

TDO: Temporary Detention Order

ECT: Electroconvulsive Therapy

MDD: Major Depressive Disorder

CT: (CAT) scan

Recent Hospitalization?Recent Medication Change?Recent Change in Environment?

Immediate safety concern?Polypharmacy?

Acute signsandsymptoms?

Previous mentalhealth diagnosis

TRIAGE QUESTIONS

WHAT SHOULD YOU DO NEXT?

Mr. Johnson, 78 year old male, has past medicalhistory of depression; has been taking anantidepressant for 7 years with good results

Stays in hospital for 7 days for congestive heartfailure

Daughter stays with Mr. J most admission

Mr. J is medically cleared and sent to your facility.

Day 5 at your facility, Mr. J starts calling for hisdaughter and reports he wants to go back home.

CASE PRESENTATION 1

• CALL CSB ES BECAUSE THIS CLIENT IS A RISK TOOTHERS AND TO SELF AND NEEDS TO PLACED IN AMENTAL HEALTH FACILITY?1.

• CALL POLICE?2.

• CALL FAMILY?3.

• CALL PHYSICIAN AND OBTAIN AN ORDER FORATIVAN TO CALM THE CLIENT DOWN?4.

• COMPLETE FULL ASSESSMENT AND RE-EVALUATE(CLIENT IS WILLING).5.

SELECT ALL THAT APPLY

CBC elevated WBC

ASSESSMENT

Neuro client Alert to person, butrequires reorientation to place, time.

In and out catheterUrine positive forbacteria and WBCs

HR 122 regular rhythm

BP 130/78

RR 22

Temp 101.5 Axillary

Both?

Medical?

MentalHealth?

Prevalence of Delirium inLTC: 22-70%(Voyer et al., 2012)

Over 94% of cases of Delirium aremisdiagnosed and under treatedinternationally.(Ski & O'Connel, 2006)

94% 22-70%

You can be

DELIVEREDfrom Delirium

VIRGINIA’S INVOLUNTARY ADMISSION PROCESS

The involuntary treatment process; what is necessary in this case:

Crisis Contact

Court Hearingon Petition

EmergencyCustody

TemporaryDetention

Releaseor

Dismissal

MandatoryOutpatientTreatment

VoluntaryInpatient

InvoluntaryInpatient

Mrs. Smith, 67 year old female resides in yourfacility.

History of bipolar disorder with previousinpatient psychiatric hospital admission 2 yearsago. Is prescribed a mood stabilizer.

She has COPD which is treated with Albuteralnebulizers.

Rapid speech

Up all night stating “My car will be here to pick me up at0700. I am going to be in a Groucho Marx look-alike contest.When I win the prize I’m going to buy a mansion and bringthe rest of the residents with me.”

WH

ATS

HO

ULD

YOU

DO

NEX

T?

CA

SE

PR

ESEN

TATI

ON

2

VIRGINIA’S INVOLUNTARY ADMISSION PROCESS

CSB CrisisContact

Court Hearingon Petition

EmergencyCustody

TemporaryDetention

Releaseor

Dismissal

MandatoryOutpatientTreatment

VoluntaryInpatient

InvoluntaryInpatient

CASE PRESENTATION 3Mr. Jones, 79 year old male, has a history of stating hewants to die but has never reported he wants to killhimself; has history of depression successfully treatedwith antidepressants.

He had been transferred to a different wing with differentresidents/care givers due to financial reasons 4 monthsprior.

Mr. J has reported to nursing staff he was going to killhimself.

He has a decreased appetite and has lost over 20%weight for not eating in the past 3 months; requires sonto buy him a new wardrobe.

The client has been refusing all medications for onemonth.

WHAT SHOULD YOU DO NEXT?

Medical records indicateclient had the following labs on

monthly lab draws

ASSESSMENT

Potassium 2.5meq/L

Sodium 120meq/LGlucose 120mg/dlBun 24

URINALYSIS FALL RISK

Treatment records reportthe client has fallen 2times in the last monthand neurochecksperformed by nursingstaff were normal

PHYSICIAN’SORDERS

2/1/2013

In and out sterilecatheter presentswith increased WBCand bacteria in urine.

2/1/2013

Administer

40meq Potassium by mouth Qday

Cipro 100mg BID twice a day by mouth

Ativan 2mg PRN as needed for agitation

Zoloft 50mg QHS at bedtime

COURSE OF TREATMENT

• Client had been refusing medication for the last monthe.g. antidepressant.

• All medications were discontinued on 2/2/2013

WHAT HAPPENS NEXT?

Call ES because clienthad threatenedsuicide?

Call Family?

Call Physician?

ASSESSMENT

ES completed anassessment;

the client was voidof any psychotic

features;

reported depressionand some thoughtsof wanting to die but

no plan and noprevious attempts.

UTI andHypokalemia (↓K+)

were noted

Client’s son waspresent throughout

the evaluation.

ES learned thatclient would take

medication with sonpresent.

LEAST RESTRICTIVE

TDO to mental healthfacility?

(what will a TDO do for the patient?)

Will the client deteriorate ifhandcuffed, moved to alocked facility with high

acuity clients?

OUTCOME

Client’s medication times were adjusted whenthe son could be there to assist in administration

Client began taking medications

Client’s diet improved

Client’s in-home counselor was informed andtherapy was provided daily.

HOLISTIC CARE

FamilyCSB

ES

Long TermCare Staff

In homecounselor

Client

VIRGINIA’S INVOLUNTARY ADMISSION PROCESS

The involuntary treatment process; what is necessary in this case:

CSB CrisisContact

Court Hearingon Petition

EmergencyCustody

TemporaryDetention

Releaseor

Dismissal

MandatoryOutpatientTreatment

VoluntaryInpatient

InvoluntaryInpatient

CASE PRESENTATION 4

78 year old woman long history of MDD withpsychotic features.

Successful remission of depression with ECTon multiple occasions.

Client presented with similar signs andsymptoms as before.

Per protocol client needed a CT scan of thehead was ordered to r/o intracranial etiology.

PROGRESSION

Client wasbumped from CT

due to otherTrauma

emergencies.

Family becamefurious and

demanded ECTbegin without CT

rule out

Two initialtreatments were

ordered andproduced

brightening ofmood

OUTCOME

After 3rd ECT treatment client squatted in thedayroom and defecated on the floor whileappearing totally disoriented.

Stat Neurology consult was ordered and CTrevealed bilateral symmetrical frontalinoperative tumors

Client was believed to have brightening of moodfrom function loss of frontal area from tumors(Castro & Billick, 2013).

VIRGINIA’S INVOLUNTARY ADMISSION PROCESS

The involuntary treatment process; what is necessary in this case:

CSB CrisisContact

Court Hearingon Petition

EmergencyCustody

TemporaryDetention

Releaseor

Dismissal

MandatoryOutpatientTreatment

VoluntaryInpatient

InvoluntaryInpatient

Client

Family

Medical

Psychiatric

DietarySocial

Spiritual

EMS

HOLISTIC CARE

STOP!SAFETYFIRST!

• PREVENTION !

• Consider the whole picture

• Utilize all resources

• ES will ask the triage questions due to rule outmedical

• Older adult clients will require medicalclearance and will usually not be admitted forpsychiatric treatment until medical problemsare treated or resolved.

IMPORTANT CAVEATS

REFERENCES

• Castro, J., & Billick, S. (2013). Psychiatric presentations/Manifestations ofmedical illnesses. Psychiatric Quarterly, 84, 351-362. doi:10.1007/s11126-012-9251-1

• Ski, C., & O'Connel, B. (2006, May 1). Mismanagement of delirium placespatients at risk. Australian Journal of Advanced Nursing, 26(3), 42-45.

• Voyer, P., McCusker, J., Cole, M. G., Monette, J., Champoux, N., Ciampi, A.et al. (2012). Prodrome of delirium among long-term care residents: Whatclinical changes can be observed in the two weeks preceding a full-blownepisode of delirium? International Psychogeriatrics, 24(11), 1855-1864.doi:10.1017/s1041610212000920

• Medical Screening and Medical Assessment Guidance Materials

• https://www.dbhds.virginia.gov/documents/140401MedicalScreeningGuidance%20(2).pdf

QUESTIONS?