1. Community Solutions for Late Life Behavioral Challenges
Presented by:

2. 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 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 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

3. 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.

4. Today's Agenda 8:15 to 9:00 Check in (continental breakfast)
9:00 – 9: Introduction – Chapter 51(Jill Chaffee) and Chapter 55 (Donovan Schumacher)
9:30 – 10: Assessment (Colleen Warner)
10:30 – 10: Break
10:45 – 12: Medication Challenges in Older Adults (Cindy Koller)
12:00 – 12: Lunch
12:45-1: Managing Difficult Behaviors (Cindy O’Keefe)
2:00 – 3: Forum – Panel to include: Providers, Adult Protection, DQA, and Ombudsmen
3:00 to 3:30 Pick up Certificate of Participation

5. 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

6. Chapter 51
The Wisconsin Statute number that pertains to involuntary mental health and AODA placements a.k.a. Emergency Detention

7. Criteria for a Chapter 51.15
Mentally Ill or Drug Dependant Developmentally Disabled AND Dangerousness to self and/or Dangerousness to others In-ability to care for oneself
Jill wants this all on one

8. 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

9. 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

10. 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.

11. 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

12. 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

13. 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

14. Remember…..
Must be imminent risk

15. 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

16. If community services are available to meet the persons needs, then those options must to be utilized Least Restrictive is the Law

17. 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.

18. Donovan Schumacher-Washburn County
Chapter 55
Protective Services
System Overview
Donovan Schumacher-Washburn County

19. 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.

20. Adult Protective Services Definitions
Adult at Risk – As defined in Wis. Stat (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 (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.

21. 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

22. 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.

23. 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.

24. 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.

25. Alternatives to Guardianship
Representative Payee
Durable Power of Attorney for Finances
Power of Attorney for Health Care
Voluntary Services
Conservator of the Estate

26. Protective Placement 55.01(6)
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.

27. Allowable Admissions Without Protective Placement Orders
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.

28. 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.

29. Verbal Protest Remedy 55.055(3)
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.

30. 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 (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.

31. 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.

32. 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.

33. A petition under statute 55
A petition under statute 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.

34. Community Solutions for Late Life Behavioral Challenges: Assessment
Presented by:
Colleen E. Warner, Psy.D.
Licensed Psychologist
Program Director
Amery Behavioral Health Center
Jill

35. 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)
Jill

36. Old age ain't no place for sissies.   
 ~Bette Davis~

37. 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
Jill

38. 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
Jill

39. 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?
Jill

40. Assessment Process Rule Out Delirium, especially if sudden onset
Comprehensive review of medical, medicinal, social/environmental, and psychiatric/psychological factors that could be contributing.
Jill

41. Understanding & Addressing Complex Problems: The Wisconsin “Star” Method slide resented with the permission of Dr. Timothy Howell
Medication
Issues
Symptom,
Problem
Social
Issues
Medical
Issues
Some definitions
Method – a way of thinking about a problem
Features of the method
Five major contributors to various problems
Cognitive-Behavioral – I.e. thoughts, actions, and feelings
Older - ?physiology vs. chronology
Each of the contributing factors can interact with each or all of the other factors
We can use the method to examine normal aging, several cognitive-behavioral syndromes, as well as how to address these issues.
Personal Issues
(Personality)
Psychiatric
Issues

42. Medical Issues Thirty-five is when you finally get your head together
and your body starts falling apart.      ~ Caryn Leschen ~   

43. Physical/Medical Issues
Delirium
Urinary Tract Infection/Renal Failure
Upper Respiratory Infection
Stroke/TIA’s
Sepsis
Electrolyte Imbalance
Sleep disturbance
Sensory Impairment/Deprivation
Pain
Jill

44. Medication/Chemical
Often have multiple providers with multiple medications (Older adults average 4.5 meds daily; 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
Jill

45. Psychiatric Cognitive Decline Delusions Psychosis Anxiety Depression
Jill

46. Personality
Jill

47. Social/Environmental
Inside  every older person is a younger person –
wondering what  the hell happened.   ~  Cora Harvey Armstrong ~  

48. 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
Jill

49. 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.
Jill

50. Presented by: Cindy O’Keefe,MA LCSW Assessment/Outreach Coordinator
Community Solutions for Late Life Behavioral Challenges: Managing Difficult Behaviors
Presented by: Cindy O’Keefe,MA LCSW Assessment/Outreach Coordinator

51. Stress Model of Crisis

52. 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?

53. What am I bringing to the situation?
Factors
Cultural
Ethnicity
Personal Experiences
Current Events

54. What effect does the environment have on the situation?
Physical
Adequate space
Lighting and noise levels
Safety

55. What affect does the environment have on the situation? Continued…..
Program, Structures, and Routines
Predictable
Consistent
Client centered activities

56. What does the person’s behavior mean?
Is this behavior typical for this person?
Is this person expressing a need?

57. What is the most appropriate response?
Staff Involvement
Patient Involvement
Family Involvement
Behavioral safety plan
Communication style
Placement options

58. ROLE PLAYS