PLACEMENT AGAINST ALL ODDS

A client has been discharged from a rehabilitation facility following a brief hospital stay for pacemaker insertion.  She’s had a past history with depression and has been followed by a psychiatrist. She has been diagnosed with an Alzheimer’s type dementia by a neurologist after a series of exams and brain scans.  She has kidney problems, has recurrent anemia, and elevated potassium levels apart from cardiac issues. Out of town family member has taken her mother home to her condo but has already contracted with an ALF where she will be moved to in approximately 6 days.  Some of the mother’s furniture was already transferred to the ALF.  Somewhere between the hospital and rehab discharge her medications were changed with new prescription for Xanax added, and the Namenda discontinued.  Client is fully ambulatory and presents well except for some dysphasia which has gotten worse and new symptoms of confusion and anger at the prospect of having to leave her condo.  In order to help with the transition, I contacted a licensed clinical social worker and scheduled her for a session with the client and family member to help make this transition.

 

Yesterday I received information from in-town family member stating that her mother was calm at bedtime but was awakened within the hour saying she couldn’t sleep and had “fire in her eyes”.  She was given a Xanax and returned to bed.  In the middle of the night she awoke and left the condo.  When the family member awoke, the client was coming in from out of doors in the middle of the night.  The tantrums then began and didn’t stop all night.  The family member stated that yesterday they had a terribly volatile situation.  The mother became angry and nasty, insisting on not going anywhere and verbalizing repeatedly that she would kill herself before moving.  She has made similar threats to her 4 children in the past as well.  Although the family member states the move was discussed with the mother in the past and she’s made visits to the facility, client denies this (or just doesn’t remember).  She despises her children for not taking her to live with them and has spent yesterday screaming this dozens of times.

 

I’ve discussed several options with the family member.  I have proposed touring a highly rated dementia-specific ALF on the campus of a well known skilled nursing facility.  I have explained that the best living arrangement was ultimately aging in place in her own home with a live-in caregiver.  I even shared the fact that we know of an excellent caregiver who is available for live-in at the present time, suggesting that a Reverse Mortgage could help pay the caregiver expense.  I was informed that the condo is now listed under ownership by the adult children.

 

Not having many options I decided to tour the proposed ALF they are under contract with and divulged her new cognitive and behavioral change to the Resident Services Nurse.  Because they have a dementia lock-down unit, I decided to take a tour.  On the first floor where residents live, the apartments are identical to the ALF apartments.  All activities (meds, meals, etc) are held on the second floor which is overcrowded, filthy, and smells.  They don’t have an Activities Director so the dementia residents are warehoused with little or no stimulation.  Last night I received an email from the family member asking me to cancel the LCSW that I had hand selected to meet with this client; explaining how she was impressed with the facility’s lock-down unit (although she never toured the second floor).  I responded how concerned I am with any threat of suicide and called my client’s psychiatrist who is out of town this week.  I also informed his on-call person.  I left the family member their service emergency number with a warning that in the event mom continues to make threats of suicide, they need to be called immediately.  In canceling today’s appointment with the clinical social worker she suggested there might have been some exploitation and that Adult Protective Services should also be contacted. What would you do?

 

Is it enough to contact the psychiatrist’s nurse practitioner and family member?  The family is obviously forcing a move and has deeded mother’s property in a sibling’s name.  They are not receptive to anyone’s advice other than what’s given by the staff at the ALF wishing to keep this resident against all odds.  I am concerned that my client who is already emotionally fragile might be placed at risk given the conditions in this lock-down dementia unit.  She is a flight risk and is no longer appropriate for a standard license ALF apartment.  She will be followed by a psych nurse at this facility, will be kept medicated, will become a fall risk, and will surely decline. 

 

What are the rights of a cognitively impaired senior when four adult children advocate for placement against all odds?

 I welcome all comments below.