The Frustrating Matron

73-year old white female 73-year old white female Angry with placement in long-term care Angry with placement in long-term care Multiple illnesses on record Multiple illnesses on record Mad at her family Mad at her family Yells at staff members, belittles workers and residents Yells at staff members, belittles workers and residents Refuses meds and therapy on an intermittent basis Refuses meds and therapy on an intermittent basis Family frustrated with her behavior Family frustrated with her behavior

Denies all problems except pain Denies all problems except pain No explanation for why she cannot walk No explanation for why she cannot walk No real source for pain No real source for pain Often appears to be able to complete ADL tasks that she requests help with Often appears to be able to complete ADL tasks that she requests help with Off to report workers to the office near daily for their “poor care” Off to report workers to the office near daily for their “poor care” Your staff is either exasperated or crying Your staff is either exasperated or crying

Illnesses Heart disease Heart disease Back pain Back pain Hip replacement years ago Hip replacement years ago High blood pressure High blood pressure High cholesterol High cholesterol Incontinence Incontinence Constipation Constipation Fibromyalgia Fibromyalgia

Medications Metoprolol Metoprolol Furosemide Furosemide Acetaminophen Acetaminophen Tramadol Tramadol Hydrocodone Hydrocodone Senna Senna MOM MOM Gabapentin Gabapentin

Psychiatric history Vague Vague “maybe” in the past “maybe” in the past Unsure about providers or treatments Unsure about providers or treatments Might have been hospitalized “but so long ago” Might have been hospitalized “but so long ago” Uncomfortable with “shrinks” Uncomfortable with “shrinks” Abbreviates this line of questioning as “it is not relevant now.” Abbreviates this line of questioning as “it is not relevant now.”

Personal History Personal History “she’s always been like this…” “she’s always been like this…” No close friends No close friends Pits children against one another Pits children against one another Daughter wants to quit as DPOA, but no other child wants the job Daughter wants to quit as DPOA, but no other child wants the job First engaged, then refused counseling with spouses, children many times when she believed the provider was against her First engaged, then refused counseling with spouses, children many times when she believed the provider was against her Manipulates situations for attention Manipulates situations for attention “Chest pain” at granddaughter’s wedding reception “Chest pain” at granddaughter’s wedding reception

Personal History Personal History Married twice “both were drunks.” Married twice “both were drunks.” Family says she drank also Family says she drank also Three children “never see them.” Tells you she likes her son-in-law the best Three children “never see them.” Tells you she likes her son-in-law the best Variety of jobs, mainly less than a year Variety of jobs, mainly less than a year Uninvolved as a mother Uninvolved as a mother Rarely at events, school meetings, games Rarely at events, school meetings, games Has an alcohol history herself Has an alcohol history herself “quit cold turkey” “quit cold turkey”

Workup No acute changes in physical or cognitive status No acute changes in physical or cognitive status No tests to run No tests to run Readily denies mood problems Readily denies mood problems Depression likely with stress of change, loss of control Depression likely with stress of change, loss of control Will not consider referral to a mental health provider Will not consider referral to a mental health provider

Care Plan Education of staff Education of staff Concerning the basics about her narcissistic, dependent and borderline personality traits Concerning the basics about her narcissistic, dependent and borderline personality traits So they know what to expect from her behaviorally So they know what to expect from her behaviorally Establish boundries, but provide for choices within those boundries Establish boundries, but provide for choices within those boundries “we can help with bathing…do you want to bathe on tuesday, wednesday or friday…at 6, 7 or 9pm?” “we can help with bathing…do you want to bathe on tuesday, wednesday or friday…at 6, 7 or 9pm?”

Care Plan Reward appropriate behavior Reward appropriate behavior Find out what motivates the resident Find out what motivates the resident Keep some distance emotionally Keep some distance emotionally To avoid getting burned To avoid getting burned Encourage independence Encourage independence Assess for true dependency needs Assess for true dependency needs Listen to criticism Listen to criticism Respond to the distress not the content Respond to the distress not the content “that daughter seems to cause you stress” “that daughter seems to cause you stress”

Care Plan Initially these poor coping styles will emerge Initially these poor coping styles will emerge Make a designated “therapist” to listen to the complaints at scheduled weekly meetings Make a designated “therapist” to listen to the complaints at scheduled weekly meetings 30 minutes at most 30 minutes at most Social Service Director, Director of Nursing, Administrator Social Service Director, Director of Nursing, Administrator With consistent approach over time things will settle down With consistent approach over time things will settle down The personality traits will re-emerge with physical or emotional stress The personality traits will re-emerge with physical or emotional stress

Care Plan Do not judge family too harshly Do not judge family too harshly You didn’t grow up with her as your mother You didn’t grow up with her as your mother Be comfortable with their involvement from a distance Be comfortable with their involvement from a distance Be aware of depression, anxiety and psychosis Be aware of depression, anxiety and psychosis Not uncommon when these residents experience stress Not uncommon when these residents experience stress With time, may accept outside consult for help with psychiatric issues With time, may accept outside consult for help with psychiatric issues