Repeated ER Trips Initiated by Memory Care Facility

Mike79

Hi friends.

I'm writing with respect to my mother who recently moved into a memory care facility. She's been acting out with aggression towards other residents from time to time. We know that there is no evidence of any underlying medical conditions beyond dementia itself. She's simply very angry at this point in her progression. This brings me to the emergency room visits.

Each time there is an 'incident' they automatically call an ambulance and exile her to the local hospital. This is ostensibly for an 'evaluation' but I feel that they use it more as a easy way to get her out the facility when all else fails. The thing is that it's just a really expensive and counterproductive experience.

I have attended one of these 'evaluations'. This particular hospital has no idea what they're doing with dementia sufferers. They achieve nothing, except to further agitate or even mildly traumatize her each time she's there. Not intentionally of course. But it's a frightening and lonely experience for her. They often don't let me in to sit with her (COVID) and she's made to sit in a small windowless room by herself for hours upon end, with no food or water offered and not even a TV or magazine for distraction. Even the walls are bare It's just awful.

So while the hospital trip fails in it's stated purpose, I know from experience, that I am almost always able to de-escalate her where others fail. Also, I live just 20 minutes away by car. To me, it seems like the most appropriate response when there is an 'incident' is for them to simply call me, so that I can come and pick her up, and take her out of the situation for a few hours.

However, they're insisting that they are bound to send her to the ER for an 'evaluation' every time this happens irregardless of how effective it may or may not be. How can I prevail upon the memory care facility to exercise common sense here? And are they correct in their insistence that they have no options, or is it just butt-covering liability-driven behavior I'm observing? I would really appreciate advice from anyone who's been in a similar situation.

 Thank you! -Mike

Marta

Hi, Mike.  Yes, it is a liability issue for the MC.

Has your Mom been evaluated by a geriatric psych provider who could help address the underlying anger/agitation?  Medications are available and can be very helpful.  Be aware that many come with a black box warning against use in elderly patients with dementia.  Having said that, for many caregivers there has come a point when the benefits gained do outweigh the risk - more or less a quality vs. quantity of life dilemma.

dayn2nite2

Calling you to calm her would be an inappropriate thing for a facility to do.

ER is the appropriate thing.  If you are unhappy with their solution to aggression that may hurt patients or staff, perhaps another facility that is more willing to work with her in facility might work.  Any time a patient is aggressive, the safety of other residents must be ensured and much of the time the aggressor needs to be removed.

Mike79

Thanks. I think I get your reasoning. But what if the family member coming to pick up the individual is more effective in resolving the situation (i.e. removing the person) and the family member can arrive to remove the resident in the same amount of time as it would take for an ambulance to get there? Would you still say its inappropriate under those assumptions? If so, why? Thanks again.

dayn2nite2

Calling a family member to solve the problem is always inappropriate.

What is always appropriate is to have the patient removed for a Geri-psych stay to get medication for the aggression.  The aggression needs to be treated.  Taking her for a ride isn’t treating her.

If they keep having to send her, I would expect that eventually they won’t allow her back.  You really need to request a meeting with the administrator on getting her admitted to a psychiatric ward.

Cynbar

I am assuming you are called immediately each time they have to send her out. Have you tried proactively getting on the phone (if you aren't allowed there in person) and talking to the ER doctor and nurse about what their plan is for her, and directly requesting a geripsych eval? What are they "evaluating" while she is there? I agree with the other posters that her behaviors need to be dealt with or she will soon be asked to leave that facility. Is she on any medication now to control the aggression?

Marta

Hey, Mike. I think you can see that calling you every time your mom needs calming is not a viable long-term solution. BUT, neither is sending her to ER every time, unless that results in an in-patient psychiatric admission. This is where you need to step in and inform nursing/management that you want her admitted for psychiatric evaluation. You may even want to initiate this proactively, without waiting for another crisis. 

I had to do this a number of times for my husband. I admit that I waited for a crisis ( these can come out of the blue). Perhaps you can be a step ahead and get her admitted without a crisis having to trigger it. 

It is the loving thing to do, in my opinion. I know this is hard. You can do this. Expect a stay of about two weeks. 

Mike79

Thanks for all the helpful posts. She is on medication, but it doesn't always seem to work. I'll insist on speaking with the director to come up with a consensus for a plan of some kind. I'm skeptical about the psych eval, but probably better to at least be seen to be trying something new, if nothing else is working. Thanks again.

King Boo

Medication prescribed for behavior from a PCP or a neurologist can often be an ineffective dosage, cocktail or less than ideal medication.

A Geriatric Psychiatrist MD - this is their wheelhouse.   One who works with dementia patients knows the correct medications to assess, dosage amounts, tapers, etc.  It's not a couch and talk therapy - it's medical intervention that can make your Mom's quality of days vastly better (it's her personal hell to be angry and agitated all the time), can make her care easier, which makes your range of choices for facilities larger.   There's a lot a risk, if you like her current facility.

Since you are not staff, calling you to take care of the incident is not viable or advisable, other than notifying you that they need to take action.

Some Memory Care facilities are more skilled than others in dealing with behaviors.  Visit others.  Hang in there.  She is lucky to have you as her son.

MN Chickadee

They have their policies. It's their policy to send the person to the ER if they meet this criteria of aggression they set, and it would be difficult to have an exception for you. Shifts change, staff come and go so they can't say for this one person we ignore the policy and call her family. Many families would NOT want to be called in this scenario. They would wonder why they were paying $8,000 per month to be called in constantly to de-escalate aggression. Others do not have family local to call in. So there is the policy. 

While my mother did not go, I have known friends who utilized in-patient geriatric pshychiatry. it was a lifesaver. The only one dedicated to geriatric patients was a couple hours away but totally worth the trouble. They get stabilized and return to memory care. I agree with others, one of these times the facility will not accept her back if this continues and it will be difficult to find another who will take someone with aggression. The geri-psychiatrist is the best for the job. You might be able to arrange to take her to an in patient unit and admitted sooner than later before there is another crisis. Ask her PCP for a referral or see if the facility works with one, also perhaps talk to your local chapter of the Alz Assoc. At the very least, next time she is in the ER they should be able to transfer her to one from there. And as someone else said, some facilities are much better than others at handling behaviors and keeping them at bay. Are the staff trained in dementia care? 

dayn2nite2

Optics are definitely important here - you want to be seen as being proactive in SOLVING this problem, so requesting a care planning meeting or meeting with the director/administrator of the facility to plan a geri-psych admission and stabilization (even if at a hospital farther away than the local ER) would be seen favorably by the facility rather than just doing the same thing over and over and possibly losing her bed because they won't take her back one day.

If you're generally happy with her care at this place, this is the route you want to take.  If you feel that there are other things you're not happy with, I would plan the meeting and admission anyway and start looking at other facilities that may have a treatment plan you like more.  In the meantime, she is getting stabilized by professionals who specialize in geriatric issues and dementia and not at the mercy of some ER doc or general psychiatrist and the doctor serving the facility.

Mike79

Thanks again everyone. Really good context. Much appreciated.

Marta

Dayn2nite2 has the right idea about being proactive, not just letting the inevitable boot your mom out of her facility with nowhere to go.

towhee

I would second that you need to look at other facilities and options. However, if your LO gets a reputation as being combative few facilities will want to accept her. So I am going to throw out a couple of long shots because at this point they might be worth trying. 

One- You say she is on medication but that sometimes it does not seem to work. It is possible that she is not always ingesting her medication. Pills can be dropped and not noticed or our LOs can pocket pills (that is hold them in their cheeks, either accidentally or on purpose), not swallow them, and spit them out later. Med techs and LPNs are supposed to watch out for this but they don't always notice, especially if they have a heavy case load. Be very careful bringing this up though, as no one likes someone to suggest they are not doing their job properly.

Two- Try to work with the facility to see if there is any kind of pattern in your moms' aggression. Is it occurring at a particular time of day, in a particular area, when there is a particular activity, or triggered by a particular person? If there is any kind of pattern, it is easier to do something to break that pattern beforehand than to de-escalate a situation later. The facility should have a strong interest in maintaining calm, as it upsets other residents to see ambulance crews in and out frequently.

Three- You can make it very clear to the facility that you have some knowledge of your mothers routine and of what upsets her and what calms her and that you have no objection to being consulted and asked for information. Some families don't want to be called and some facilities don't want to be seen as not being competent, but a really good facility will work with you. 

Hope things improve-

Mike79

 Hi. Just posting a quick follow up here for posterity. Maybe this can serve as a cautionary tale for someone else who comes down a similar road. I had her admitted to the geri-psych place - proactively. It has been an unmitigated disaster. She went in with behavioral problems, but otherwise in good physical shape. After just three weeks and three major changes in medication, her behavioral issues were slightly mitigated, but not enough to allow for a return to her assisted living (memory care) community. The cost of that ultimately no-so-helpful change has been a total loss of mobility (previously able to walk and climb stairs), loss of continence (previously no problem there), and a near complete loss of ability to engage with the world or other people. I would call it a chemical lobotomy. The consensus is that it will be difficult or impossible to undo the decline they’ve inflicted on her, even with a moderation of the meds. In cutting off her mobility, they essentially accelerated her into a skilled nursing home and cut off all other options. Indeed, their initial advice was hospice even though she has no sign of bodily decline unattributed to medication! My advice to anyone facing a similar choice would be to try everything else first before geri-psych, including home-based care. We would have had a much better outcome with that, even though it would have been a lot of work. These places are just not nearly as capable as they make out to be. When they run out of ideas, the shift quickly into recommending what I can only describe as ‘compassionate euthanasia by over-medication'. In our case, it was a clear mistake.

dayn2nite2

You sound upset at how things have unfolded, but really your mother could not continue in that facility being aggressive with other residents.  The facility has a duty to protect them from that.

If you are unhappy with the care she was getting at the facility, you can look for another facility that is more to your liking.  Or she can go back to her old facility if she is under control.  It's up to you.

Medication is not "euthanasia" as you put it.  I'm sorry you feel this is what is happening with her.  From your description of her situation, there is nothing else that could have been done.

King Boo

Posts: 8

 Hi. Just posting a quick follow up here for posterity. Maybe this can serve as a cautionary tale for someone else who comes down a similar road. I had her admitted to the geri-psych place - proactively. It has been an unmitigated disaster. She went in with behavioral problems, but otherwise in good physical shape.

I am extremely sorry to hear this.  There can be points with this challenging disease when disaster after disaster seems to happen, despite our best efforts.   Degenerative neurological disease is so very difficult.  

 After just three weeks and three major changes in medication, her behavioral issues were slightly mitigated, but not enough to allow for a return to her assisted living (memory care) community. 

Was it a true Memory Care that really had dementia trained staff, or was it an assisted living, claiming they had residents with dementia?  There can be a world of difference between residences.  Challenging dementia behaviors are usual and 'par for the course' in a quality MC, whereas an AL often cannot accomodate this.  What exactly were Mom's aggressive behaviors?  Was she hitting and angrily engaging other residents, where there was the risk of harm?  Or did she just get mildly agitated, needing re-direction?  (or the range in between).   If it was the former, you had no choice but to get her treatment.  Even a strong MC will address physical aggression through geriatric psych consult.  

The cost of that ultimately no-so-helpful change has been a total loss of mobility (previously able to walk and climb stairs), loss of continence (previously no problem there), and a near complete loss of ability to engage with the world or other people. I would call it a chemical lobotomy. 

Do you feel her care was competent?  I realize this is hard to answer given the disastrous outcome you describe.  But some Geriatric Psych units are far superior to others.  A second opinion may be in order, both for Mom and your peace of mind.  If you have an elder law attorney (www.nelf.org) they often have the pulse on the good and bad from their clients.  Or a Geriatric Care Manager RN may have additional insight.  

The consensus is that it will be difficult or impossible to undo the decline they’ve inflicted on her, even with a moderation of the meds. In cutting off her mobility, they essentially accelerated her into a skilled nursing home and cut off all other options. 

 Virtually all elderly come out of a hospitalization so mewhat de-compensated and weak, requiring time to gain strength and re-orient to even a familiar living situation.  Has a short term rehabilitation stay in the nursing home not been done?  Usually they assess for care level after rehab has progressed somewhat.  Some stay in a snf, some can go to memory care.   Key here is to also ask whether the disease has progressed itself to another level, or is it all medication related.  It is not unusual for a crisis of sorts to occur as the disease progresses and care needs increase.  That second opinion would be useful here.  

Indeed, their initial advice was hospice even though she has no sign of bodily decline unattributed to medication! My advice to anyone facing a similar choice would be to try everything else first before geri-psych, including home-based care. We would have had a much better outcome with that, even though it would have been a lot of work. These places are just not nearly as capable as they make out to be. When they run out of ideas, the shift quickly into recommending what I can only describe as ‘compassionate euthanasia by over-medication'. In our case, it was a clear mistake.

Be gentle with yourself.  If your Mom was truly aggressive and a threat to others, you had no choice.Get a second opinion.  Find out from her PCP if she was on the verge of changing to another stage level prior to admission.  

Hospice providers themselves are the best professionals to get information from after an assessment.  Alas, too, all hospice providers are not created equal.  If this is truly where she is at, interview several, and know that you can change between recertification periods.  I am so sorry this is such an upsetting situation.   Hearing the recommendation for hospice can be shocking; we are so close to the dailies of our family member