case studies: navigating new routes to improved mental health care
DESCRIPTION
CASE STUDIES/Navigating new routes to improved mental health care for older adults - Gina O'Halloran and Richard Goddard at live session of May 20, 2014: http://worldeventsforum.blogspot.com/p/l-ive-event-to-be-held-tuesday-may-20.htmlTRANSCRIPT
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?