PART 2
TRIAGE OF GERIATRIC MENTAL HEALTH CRISIS
CASE PRESENTATIONS
GINA O’HALLORAN, MA
RICH GODDARD, RN, BSN, MA
DEFINITIONS
ADL: Activities of Daily Living
CSB: Community Services Board
ICU: Intensive Care Unit
CHF: Congestive Heart F...
Recent Hospitalization?
Recent Medication Change?
Recent Change in Environment?
Immediate safety concern?
Polypharmacy?
Ac...
WHAT SHOULD YOU DO NEXT?
Mr. Johnson, 78 year old male, has past medical
history of depression; has been taking an
antidep...
• CALL CSB ES BECAUSE THIS CLIENT IS A RISK TO
OTHERS AND TO SELF AND NEEDS TO PLACED IN A
MENTAL HEALTH FACILITY?1.
• CAL...
CBC elevated WBC
ASSESSMENT
Neuro client Alert to person, but
requires reorientation to place, time.
In and out catheter
U...
Both?
Medical
?
Mental
Health?
Prevalence of Delirium in
LTC: 22-70%
(Voyer et al., 2012)
Over 94% of cases of Delirium are
misdiagnosed and under treate...
You can be
DELIVERED
from Delirium
VIRGINIA’S INVOLUNTARY ADMISSION PROCESS
The involuntary treatment process; what is necessary in this case:
Crisis Contact...
Mrs. Smith, 67 year old female resides in your
facility.
History of bipolar disorder with previous
inpatient psychiatric h...
VIRGINIA’S INVOLUNTARY ADMISSION PROCESS
CSB Crisis
Contact
Court Hearing
on Petition
Emergency
Custody
Temporary
Detentio...
CASE PRESENTATION 3
Mr. Jones, 79 year old male, has a history of stating he
wants to die but has never reported he wants ...
Medical records indicate
client had the following labs on
monthly lab draws
ASSESSMENT
Potassium 2.5meq/L
Sodium 120meq/L
...
URINALYSIS FALL RISK
Treatment records report
the client has fallen 2
times in the last month
and neurochecks
performed by...
COURSE OF TREATMENT
• Client had been refusing medication for the last month
e.g. antidepressant.
• All medications were d...
WHAT HAPPENS NEXT?
Call ES because client
had threatened
suicide?
Call Family?
Call Physician?
ASSESSMENT
ES completed an
assessment;
the client was void
of any psychotic
features;
reported depression
and some thought...
LEAST RESTRICTIVE
TDO to mental health
facility?
(what will a TDO do for the patient?)
Will the client deteriorate if
hand...
OUTCOME
Client’s medication times were adjusted when
the son could be there to assist in administration
Client began takin...
HOLISTIC CARE
Family
CSB
ES
Long Term
Care Staff
In home
counselor
Client
VIRGINIA’S INVOLUNTARY ADMISSION PROCESS
The involuntary treatment process; what is necessary in this case:
CSB Crisis
Con...
CASE PRESENTATION 4
78 year old woman long history of MDD with
psychotic features.
Successful remission of depression with...
PROGRESSION
Client was
bumped from CT
due to other
Trauma
emergencies.
Family became
furious and
demanded ECT
begin withou...
OUTCOME
After 3rd ECT treatment client squatted in the
dayroom and defecated on the floor while
appearing totally disorien...
VIRGINIA’S INVOLUNTARY ADMISSION PROCESS
The involuntary treatment process; what is necessary in this case:
CSB Crisis
Con...
Client
Family
Medical
Psychiatric
DietarySocial
Spiritual
EMS
HOLISTIC CARE
STOP!
SAFETY
FIRST!
• PREVENTION !
• Consider the whole picture
• Utilize all resources
• ES will ask the triage questions due to rule out
med...
REFERENCES
• Castro, J., & Billick, S. (2013). Psychiatric presentations/Manifestations of
medical illnesses. Psychiatric ...
QUESTIONS?
CASE STUDIES: Navigating new routes to improved mental health care
CASE STUDIES: Navigating new routes to improved mental health care
CASE STUDIES: Navigating new routes to improved mental health care
CASE STUDIES: Navigating new routes to improved mental health care
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CASE STUDIES: Navigating new routes to improved mental health care

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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.html

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CASE STUDIES: Navigating new routes to improved mental health care

  1. 1. PART 2 TRIAGE OF GERIATRIC MENTAL HEALTH CRISIS CASE PRESENTATIONS GINA O’HALLORAN, MA RICH GODDARD, RN, BSN, MA
  2. 2. DEFINITIONS ADL: 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
  3. 3. Recent Hospitalization? Recent Medication Change? Recent Change in Environment? Immediate safety concern? Polypharmacy? Acute signs and symptoms? Previous mental health diagnosis TRIAGE QUESTIONS
  4. 4. WHAT SHOULD YOU DO NEXT? Mr. Johnson, 78 year old male, has past medical history of depression; has been taking an antidepressant for 7 years with good results Stays in hospital for 7 days for congestive heart failure 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 his daughter and reports he wants to go back home. CASE PRESENTATION 1
  5. 5. • CALL CSB ES BECAUSE THIS CLIENT IS A RISK TO OTHERS AND TO SELF AND NEEDS TO PLACED IN A MENTAL HEALTH FACILITY?1. • CALL POLICE? 2. • CALL FAMILY? 3. • CALL PHYSICIAN AND OBTAIN AN ORDER FOR ATIVAN TO CALM THE CLIENT DOWN?4. • COMPLETE FULL ASSESSMENT AND RE-EVALUATE (CLIENT IS WILLING).5. SELECT ALL THAT APPLY
  6. 6. CBC elevated WBC ASSESSMENT Neuro client Alert to person, but requires reorientation to place, time. In and out catheter Urine positive for bacteria and WBCs HR 122 regular rhythm BP 130/78 RR 22 Temp 101.5 Axillary
  7. 7. Both? Medical ? Mental Health?
  8. 8. Prevalence of Delirium in LTC: 22-70% (Voyer et al., 2012) Over 94% of cases of Delirium are misdiagnosed and under treated internationally. (Ski & O'Connel, 2006) 94% 22-70%
  9. 9. You can be DELIVERED from Delirium
  10. 10. VIRGINIA’S INVOLUNTARY ADMISSION PROCESS The involuntary treatment process; what is necessary in this case: Crisis Contact Court Hearing on Petition Emergency Custody Temporary Detention Release or Dismissal Mandatory Outpatient Treatment Voluntary Inpatient Involuntary Inpatient
  11. 11. Mrs. Smith, 67 year old female resides in your facility. History of bipolar disorder with previous inpatient psychiatric hospital admission 2 years ago. Is prescribed a mood stabilizer. She has COPD which is treated with Albuteral nebulizers. Rapid speech Up all night stating “My car will be here to pick me up at 0700. 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 bring the rest of the residents with me.” WHATSHOULDYOUDONEXT? CASEPRESENTATION2
  12. 12. VIRGINIA’S INVOLUNTARY ADMISSION PROCESS CSB Crisis Contact Court Hearing on Petition Emergency Custody Temporary Detention Release or Dismissal Mandatory Outpatient Treatment Voluntary Inpatient Involuntary Inpatient
  13. 13. CASE PRESENTATION 3 Mr. Jones, 79 year old male, has a history of stating he wants to die but has never reported he wants to kill himself; has history of depression successfully treated with antidepressants. He had been transferred to a different wing with different residents/care givers due to financial reasons 4 months prior. Mr. J has reported to nursing staff he was going to kill himself. He has a decreased appetite and has lost over 20% weight for not eating in the past 3 months; requires son to buy him a new wardrobe. The client has been refusing all medications for one month. WHAT SHOULD YOU DO NEXT?
  14. 14. Medical records indicate client had the following labs on monthly lab draws ASSESSMENT Potassium 2.5meq/L Sodium 120meq/L Glucose 120mg/dl Bun 24
  15. 15. URINALYSIS FALL RISK Treatment records report the client has fallen 2 times in the last month and neurochecks performed by nursing staff were normal PHYSICIAN’S ORDERS 2/1/2013 In and out sterile catheter presents with increased WBC and 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
  16. 16. COURSE OF TREATMENT • Client had been refusing medication for the last month e.g. antidepressant. • All medications were discontinued on 2/2/2013
  17. 17. WHAT HAPPENS NEXT? Call ES because client had threatened suicide? Call Family? Call Physician?
  18. 18. ASSESSMENT ES completed an assessment; the client was void of any psychotic features; reported depression and some thoughts of wanting to die but no plan and no previous attempts. UTI and Hypokalemia (↓K+) were noted Client’s son was present throughout the evaluation. ES learned that client would take medication with son present.
  19. 19. LEAST RESTRICTIVE TDO to mental health facility? (what will a TDO do for the patient?) Will the client deteriorate if handcuffed, moved to a locked facility with high acuity clients?
  20. 20. OUTCOME Client’s medication times were adjusted when the son could be there to assist in administration Client began taking medications Client’s diet improved Client’s in-home counselor was informed and therapy was provided daily.
  21. 21. HOLISTIC CARE Family CSB ES Long Term Care Staff In home counselor Client
  22. 22. VIRGINIA’S INVOLUNTARY ADMISSION PROCESS The involuntary treatment process; what is necessary in this case: CSB Crisis Contact Court Hearing on Petition Emergency Custody Temporary Detention Release or Dismissal Mandatory Outpatient Treatment Voluntary Inpatient Involuntary Inpatient
  23. 23. CASE PRESENTATION 4 78 year old woman long history of MDD with psychotic features. Successful remission of depression with ECT on multiple occasions. Client presented with similar signs and symptoms as before. Per protocol client needed a CT scan of the head was ordered to r/o intracranial etiology.
  24. 24. PROGRESSION Client was bumped from CT due to other Trauma emergencies. Family became furious and demanded ECT begin without CT rule out Two initial treatments were ordered and produced brightening of mood
  25. 25. OUTCOME After 3rd ECT treatment client squatted in the dayroom and defecated on the floor while appearing totally disoriented. Stat Neurology consult was ordered and CT revealed bilateral symmetrical frontal inoperative tumors Client was believed to have brightening of mood from function loss of frontal area from tumors (Castro & Billick, 2013).
  26. 26. VIRGINIA’S INVOLUNTARY ADMISSION PROCESS The involuntary treatment process; what is necessary in this case: CSB Crisis Contact Court Hearing on Petition Emergency Custody Temporary Detention Release or Dismissal Mandatory Outpatient Treatment Voluntary Inpatient Involuntary Inpatient
  27. 27. Client Family Medical Psychiatric DietarySocial Spiritual EMS HOLISTIC CARE
  28. 28. STOP! SAFETY FIRST!
  29. 29. • PREVENTION ! • Consider the whole picture • Utilize all resources • ES will ask the triage questions due to rule out medical • Older adult clients will require medical clearance and will usually not be admitted for psychiatric treatment until medical problems are treated or resolved. IMPORTANT CAVEATS
  30. 30. REFERENCES • Castro, J., & Billick, S. (2013). Psychiatric presentations/Manifestations of medical illnesses. Psychiatric Quarterly, 84, 351-362. doi:10.1007/s11126- 012-9251-1 • Ski, C., & O'Connel, B. (2006, May 1). Mismanagement of delirium places patients 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: What clinical changes can be observed in the two weeks preceding a full-blown episode 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
  31. 31. QUESTIONS?

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