Bad Reps and Bum Raps

Advocacy for Residents with Mental Health Conditions

presented by

NORCWith special guest

Susan Wehry, M.D., Geriatric PsychiatristConsultant, Vermont Department of

Disabilities, Aging and Independent Living

© S WEHRY 2009

What Ombudsmen Bring

→ Optimism→ Conviction/Hope→ Energy→ Communication skills→ Knowledge→ Assumptions→ Experience

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What Ombudsmen face

Residents rights in conflict with behavior plans

Antiquated mental health approaches

A resurgence of us and them

Aggressive and threatening behaviors

Conflicts between physically frail and physically fit

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What ombudsmen are asking

How do ombudsmen proceed?

Who needs to participate?

What resources may be available?

What can be done if the community mental health system refuses to help?

How to address the rights of one and rights of all?

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Reflective exercise

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See the Difference?

The person with DEMENTIA

THE PERSON with dementia

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See the Difference?

The person with SCHIZOPHRENIA

THE PERSON with schizophrenia

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Ombudsmen experiences

A resident, Miss Lillian, says she was given the wrong medication

The nurse says “Oh, she has dementia - she's just confused"

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Approaching the problem

Consider: what is this person telling me

Look at root causes

Obtain collateral information

Consider: what do I know about dementia

Re-create or observe the situation

Help staff see THE PERSON

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Miss Lillian

Medication practices improved

Medication refusal was new

Pill was too large to swallow

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Mr. George

82 years old, widowed

Has dementia

Makes lewd comments, swears

Placed on medication, no change

Struck another resident

Discharge notice

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Ombudsman’s Role

Advocate seeing the person strength-based, individualized care planning non-pharmacological interventions

Utilize root cause approach

Facilitate referral

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The 'truth' about violence

Recent Maryland stories

Risk factors Age

Rarer among seniors Past history Substance abuse (Mental health conditions)

Usually intimates

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Mental Health Problems in Long Term Care

Dementia Behavioral disturbances Capacity concerns

Delirium

Depression

Schizophrenia

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Delirium

A medical emergency

Frequently missed

Characteristics Sudden onset Fluctuating course Impaired attention Disorganized thinking Altered sensorium

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Delirium

Drugs misuse interaction intoxication withdrawal

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Ombudsman’s Role

Raise awareness

Advocate Prevention Intervention

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Depression

Depression is…a medical disordera chronic conditionnot a normal part of aginga public health issuea worldwide cause of disabilitypreventable, treatable, and

common

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Suicide

Growing concern in nursing homes

People who threaten to kill themselves DO

Asking about suicide does not put the idea in someone's head

Thoughts of suicide are a SYMPTOM as well as an expression of CHOICE

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Ombudsman’s Role

Be aware

Recognize

Listen

Ask questions

Educate

Arrange screening

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Assumptions about mental illness

…People with mental illness are different

…Mental health not as important

…Mental health is somebody else’s problem

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Common Encounters

A resident, Mr. Davis, refuses his medication.

The facility threatens him with an involuntary discharge saying: 'he has schizophrenia and will get out of control if he doesn't take his medications –we can't risk the safety of the other residents'

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My Assumptions

Just because a person has a mental illness, it doesn’t mean it’s responsible for everything.

People with mental illness…Have good days

Have bad daysJust like you and

me…

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Schizophrenia

▪ Delusions

▪ Hallucinations

▪ Disorganization Thought Behavior

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Schizophrenia

Trouble paying attention

All behavior interpreted as mental illness

Limited reservoir

Anxious

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Mental Health Recovery

YESIndividuals

with schizophrenia

recover from

the illness

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Ombudsman’s Role

Challenge assumptions

Support recovery

Advocate Services

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Communication Skills

Talking with Residents Who Have

Cognitive Impairment

▪ memory loss

▪ disorientation

▪ aphasia

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Communication Skills

Talking with Residents Who Have:

Hallucinations Delusions Severe Anxiety

or are… Not making senseVerbally abusive

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Set the Stage

Consider▪sensory deficits▪level of understanding

Commit to listening▪allow time▪be patient ▪private▪quiet

Face-to-face▪perceived lack of power▪fear, anger sadness

Communicate respect▪Tone, posture, gestures

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Communication TipsDepression

What Helps:

▪Active Listening

▪Empathy/Hope

“I know you feel this way now, but you won’t always”

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Communication TipsSchizophrenia

▪Be patient

▪Signal confidence in recovery

▪Maintain attitude of hope, empowerment

▪Listen actively

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Communication TipsFearfulness

▪ Do not use gestures which threaten

▪ Take care with touch

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Assessing Capacity

Capacity and Competency: what's the difference?

Standards and Thresholds

Impact on autonomy, self-esteem

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Capacity

Capacity is Task specific, not global Situational Contextual

Capacity can fluctuate

Determining capacity in older adults withcomplex impairments can be difficult

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Context

What decision needs to be made?

What is interfering with decision-making?

Is capacity likely to change?

Issues of undue influence?

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Capacity Can Fluctuate

Lucid and confused days

Fluctuations make it difficult to discern capacity

May result in misleading conclusions

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Ombudsmen experiencesShare your stories

Closing

► Mental health problems are common

► Recognize, refer, advocate for services

► Determining capacity can be difficult and crucial

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Ombudsman Resources

Advocating for Residents with Mental Health Needs: Engaging and Changing the System http://www.ltcombudsman.org//uploads/File/Advocating-for-Residents-with-Mental-Health-Needs.pdf

Mental Health Ombudsman Training Manual I'm Glad You Asked Help for the Ombudsman: Assisting the Adult Home Resident http://www.ltcombudsman.org

Mental Health Advocacy for Ombudsmen DVD and Self-Study Guide Distributed in 2006

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