1.  Bad Reps and Bum Raps Advocacy for Residents with Mental Health Conditions presented by NORC With special guest Susan Wehry, M.D., Geriatric Psychiatrist Consultant, Vermont Department of Disabilities, Aging and Independent Living © S WEHRY 2009

2. What Ombudsmen Bring → Optimism → Conviction/Hope → Energy → Communication skills → Knowledge → Assumptions → Experience 2

3. 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 3

4. 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? 4

5.  Reflective exercise 5

6. See the Difference?  The person with DEMENTIA  THE PERSON with dementia 6

7. See the Difference?  The person with SCHIZOPHRENIA  THE PERSON with schizophrenia 7

8. Ombudsmen experiences  A resident, Miss Lillian, says she was given the wrong medication  The nurse says “Oh, she has dementia - she's just confused" 8

9. 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 9

10. Miss Lillian  Medication practices improved  Medication refusal was new  Pill was too large to swallow 10

11. Mr. George  82 years old, widowed  Has dementia  Makes lewd comments, swears  Placed on medication, no change  Struck another resident  Discharge notice 11

12. Ombudsman’s Role  Advocate  seeing the person  strength-based, individualized care planning  non-pharmacological interventions  Utilize  root cause approach  Facilitate referral 12

13. The 'truth' about violence  Recent Maryland stories  Risk factors  Age  Rarer among seniors  Past history  Substance abuse  (Mental health conditions)  Usually intimates 13

14. Mental Health Problems in Long Term Care  Dementia  Behavioral disturbances  Capacity concerns  Delirium  Depression  Schizophrenia 14

15. Delirium  A medical emergency  Frequently missed  Characteristics  Sudden onset  Fluctuating course  Impaired attention  Disorganized thinking  Altered sensorium 15

16. Delirium  Drugs  misuse  interaction  intoxication  withdrawal 16

17. Ombudsman’s Role  Raise awareness  Advocate  Prevention  Intervention 17

18. Depression Depression is… a medical disorder a chronic condition not a normal part of aging a public health issue a worldwide cause of disability preventable, treatable, and common 18

19. 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 19

20. Ombudsman’s Role  Be aware  Recognize  Listen  Ask questions  Educate  Arrange s creening 20

21. Assumptions about mental illness …People with mental illness are different …Mental health not as important …Mental health is somebody else’s problem 21

22. 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' 22

23. 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 days Just like you and me… 23

24. Schizophrenia ▪ Delusions ▪ Hallucinations ▪ Disorganization  Thought  Behavior 24

25. Schizophrenia  Trouble paying attention  All behavior interpreted as mental illness  Limited reservoir  Anxious 25

26. Mental Health Recovery YES Individuals with schizophrenia recover from the illness 26

27. Ombudsman’s Role  Challenge assumptions  Support recovery  Advocate  Services 27

28. Communication Skills Talking with Residents Who Have Cognitive Impairment ▪ memory loss ▪ disorientation ▪ aphasia 28

29. Communication Skills Talking with Residents Who Have: Hallucinations Delusions Severe Anxiety or are… Not making sense Verbally abusive 29

30. 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 30

31. Communication Tips Depression What Helps: ▪ Active Listening ▪ Empathy/Hope “I know you feel this way now, but you won’t always” 31

32. Communication Tips Schizophrenia ▪ Be patient ▪ Signal confidence in recovery ▪ Maintain attitude of hope, empowerment ▪ Listen actively 32

33. Communication Tips Fearfulness ▪ Do not use gestures which threaten ▪ Take care with touch 33

34. Assessing Capacity  Capacity and Competency : what's the difference?  Standards and Thresholds  Impact on autonomy, self-esteem 34

35. Capacity Capacity is Task specific, not global Situational Contextual Capacity can fluctuate Determining capacity in older adults with complex impairments can be difficult 35

36. Context  What decision needs to be made?  What is interfering with decision-making?  Is capacity likely to change?  Issues of undue influence? 36

37. Capacity Can Fluctuate  Lucid and confused days  Fluctuations make it difficult to discern capacity  May result in misleading conclusions 37

38.  Ombudsmen experiences Share your stories

39. Closing ► Mental health problems are common ► Recognize, refer, advocate for services ► Determining capacity can be difficult and crucial 39

40. 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 http://www.ltcombudsman.org  Mental Health Advocacy for Ombudsmen DVD and Self-Study Guide  Distributed in 2006 40