Modules

Mental health

Bipolar mood disorder and elder abuse, A

  • Dr. Lee: Amanda, wasn’t Mr. Cirillo supposed to come in for an appointment today?

    Nurse: Yeah. I confirmed with his son last week. He sounded kind of funny, but he said okay.

    Dr. Lee: Well, you know, he’s missed his last three appointments. Can you get him on the phone for me please?

    Nurse: Yeah.

    Dr. Lee: Thanks.

    ––

    Mr. Cirillo: Yeah, yes … who, who, who’s there?

    Dr. Lee: Mr. Cirillo, it’s Dr. Lee. How are you doing?

    Mr. Cirillo: What?

    Dr. Lee: You, you missed an appointment with me today.

    Mr. Cirillo: Who … who are you?

    Dr. Lee: May I speak to Jerry please?

    Jerry: Come here! Hey! Who’s that on the phone … who’s that on the phone?

    Dr. Lee: Jerry?

    Jerry: Hello? Hello, who’s calling?

    Dr. Lee: Jerry, Jerry, it’s Dr. Lee.

    Jerry: What?

    Dr. Lee: You were supposed to bring your father in for an appointment today.

    Jerry: No, no! It’s not time. Okay?

    Dr. Lee: He is really overdue for a check-up and a medication renewal.

    Jerry: He’s fine, okay? He’s fine. He’s just …

    Dr. Lee: Jerry, how are you doing? You sound agitated. Are you still taking your pills?

    Jerry: I don’t need pills. Okay, I’m feeling just great. Alright doctor?

    Dr. Lee: Jerry I think it’s really important that you come in with your dad.

    Jerry: Oh, I think there is a call coming in here. I’m, I’m feeling … oh. There is another call coming in dad. Uh!

    Dr. Lee: Uh. Okay. He’s off his medication and it sounds like he’s manic again.

Dr. Lee asks the public health nurse to visit the Cirillo house. She has difficulty persuading Jerry to let her in to see his father. She finds the house dirty and disorderly and Mr. Cirillo looks wasted and gaunt and obviously has not bathed recently. The kitchen has a few dirty dishes but there is no food in the refrigerator.

After speaking with Dr. Lee, the nurse arranges transportation to the office for Mr. Cirillo and insists that Jerry accompany his father.

  • Dr. Lee: Hi, Mr. Cirillo, and Jerry, thanks for bringing your dad in. Now how are you doing?

    Jerry: He’s just fine, he’s fine. I’m fine. Everybody is fine here, right? He’s just an old man, don’t worry so much about him. Okay? Just don’t worry about him. He’s fine, doing just fine.

    Dr. Lee: So, Jerry … Jerry, you agreed to take care of your dad right?

    Jerry: Yeah, yeah, yeah, I did. I did. (mumbling)

    Dr. Lee: His arthritis is getting worse and he needs some help getting around.

    Jerry: I’ve been doing that, I’ve been doing that. There is no arthritis.

    Dr. Lee: Now, listen, we’ve, we’ve spoken, and I know you have a list of things that your dad needs help with.

    (Jerry mumbles)

    Dr. Lee: Like bathing, like getting to the bathroom, taking care of things.

    Jerry: (mumbling) Pissing off, pissing off. Doing good, you know. (he continues flipping pages and mumbling)

    Dr. Lee: Jerry, have a seat.

    Jerry: Don’t worry, don’t worry.

    Dr. Lee: No, no, I … Mr. Cirillo …

    Jerry: Look he is, look he is fine.

    Dr. Lee: … you look like you’ve lost some weight.

    Jerry: Look, look at him, he’s…

    Dr. Lee: How are you doing today?

    Jerry: He’s getting a lot, like he’s getting plenty okay. So, just don’t worry about it, because I’ve got an important, I got an important business one. I’ve got to sell houses to money-come, I’ve got to go now, I’ve got to go. (mumbling)

    Dr. Lee: Jerry, no. Jer … Jerry, when did you stop taking your lithium?

    Jerry: Wait no, no lithium.

    Dr. Lee: How long ago?

    Jerry: Okay? No, no time, no time for lithium, because lithium gets in the way of my thinking and, do you understand, gets in the way of my thinking. They sell house, lithium is no good for real estate, do you understand.

    Dr. Lee: Okay. You know …

    Jerry: Don’t tell me. (mumbling)

    Dr. Lee: … when the nurse visited your house, she told us you were obviously struggling to take care of your dad. He is not bathing, he is not eating.

    Jerry: (mumbling) The nurse, the nurse, okay. (mumbling)

    Dr. Lee: Your dad needs to be taken care of, do you understand that?

    Jerry: (mumbling) Sure. (mumbling)

    Dr. Lee: And, she said there was no medication. Not …

    Jerry: Yeah, told you she was a spy, I told you she was a spy! Do you understand?

    Dr. Lee: … your medication, not his medication.

    Jerry: Right? No pills, nobody takes the pills.

    Dr. Lee: What are you doing with medication?

    Jerry: The pills make him stupid okay? You notice he doesn’t even tie his shoe right, so it’s not good right. The pills, no no pills, nobody takes the pills because … (mumbling)

    Dr. Lee: Okay, Jerry!

    Jerry: … It’s the way the government gets the money for like, to get, for like the war right?

    Dr. Lee: Jerry!

    Jerry: Nobody gets the pills, nobody …

    Dr. Lee: Jerry. You need …

    Jerry: … I told you she is a spy. No, no, they got to stop the war. They got to stop the war. That’s what they got to do.

    Dr. Lee: … to get back on your lithium.

    Jerry: Pass me the … (mumbling)

    Dr. Lee: You need to get back on your lithium. Otherwise …

    Jerry: No, no.

    Dr. Lee: … I may have to put you both in the hospital …

    Jerry: No.

    Dr. Lee: … and appoint a guardian for your father.

    Jerry: You, you can’t …

    Dr. Lee: Do you understand that?

    Jerry: You can’t, you can’t put me in a hospital because I have to write my whole business.

    Dr. Lee: Okay.

    Jerry: I’ve got to sell houses and doing business and that.

    Dr. Lee: Mr. Cirillo, I’ll be back.

    Jerry: Do you understand? I got to … nobody understand instructions anymore.

    Dr. Lee: Jerry, Jerry, Jerry. We’re going to go and have a talk in the other room. Mr. Cirillo, I’ll be back to talk with you …

    Jerry: Okay, okay I got to keep going writing these instruction manuals. You see, I’ve got to keep writing, because the other day, remember about the fan … (mumbling)

    Dr. Lee: … and we’ll do a physical exam, and I’ll get Amanda to bring in some water, okay? Jerry, Jerry, we’ll have a conversation in the other room?

    Jerry: (mumbling) … Who does your instructions, alright?

    Dr. Lee: No, another room.

    Jerry: … tie your shoes, tie …

    Dr. Lee: … we’ll have a conversation about this in the other, okay?

    Jerry: You cannot take me, take me to the hospital.

    Dr. Lee: Come on.

    Jerry: … no, okay? You cannot. No you can’t.

    Dr. Lee: Come on. We’re going to go and have a talk, okay?

    Jerry: I’m going to keep writing my manuals alright?

  • Dr. Lee: Okay Jerry. Do you want to sit down and talk for a minute?

    Jerry: I don’t have time to sit, I don’t have time to sit down, do you understand? I have a very important appointment. I’m telling you about this, I’ve got to go. Okay? (mumbling)

    Dr. Lee: That’s what I wanted to talk to you about. We need you to come into the hospital for a couple of days …

    Jerry: No, no, I can’t, I can’t, I can’t, I can’t, like I’ve got a big …

    Dr. Lee: … until we get your medication sorted out.

    Jerry: … like a big business venture. Okay? What do you — okay? I have no time. What, what do you invest your money in doc?

    Dr. Lee: So?

    Jerry: You really into investing? You got to invest in this, okay?

    Dr. Lee: Jerry are you still working?

    Jerry: What job? I think job …

    Dr. Lee: What, what happened to your job?

    Jerry: … shmob! Like I, like I, I quit that a week, it’s for losers, okay? Losers! I’m not a loser. I’ve got a, I’m in a bigger game right now, okay? Big game, I’m going to make millions in this one.

    Dr. Lee: So, Jerry …

    Jerry: I’m going to keep writing, that’s what …

    Dr. Lee: … when the nurse was at your house, she said there was no food.

    Jerry: (mumbling) That was a spy, that was a spy.

    Dr. Lee: Are you and your father eating?

    Jerry: She was a spy, okay? A government spy.

    Dr. Lee: No, she’s not a spy.

    Jerry: I’m not hungry. Do I look hungry? I’m not hungry. He is not, he’s fine.

    Dr. Lee: Well, both you and your father have lost weight, okay?

    Jerry: (mumbling) You know what, he is fine, he just complains all the time. Getting on my nerves …

    Dr. Lee: So are you missing meals? Are you missing entire days without eating?

    Jerry: (mumbling) Never mind the food. We’re fine with the food, okay? He is just complaining, that’s the thing …

    Dr. Lee: How about your medication? What is the last time you took your lithium?

    Jerry: (mumbling) Pills! I don’t need any pills, okay? It’s been like two weeks or something. I’ve never felt better. It dawned on me then, it’s the government. They’re trying to control us okay? It’s all written down in this one. Here, I’ve got green for government, and they, they’re just trying to do this whole thing about war …

    Dr. Lee: Okay, Jerry.

    Jerry: It’s a plot to keep the war going, that’s what?

    Dr. Lee: We’ve been here before, right? We’ve been here before.

    Jerry: (mumbling) … not good.

    Dr. Lee: The government is not controlling you.

    (Jerry mumbles and shakes his head)

    Dr. Lee: They have nothing to do with your medication or your father’s medication, okay? And …

    (Jerry mumbles and nods)

    Dr. Lee: … they are not controlling me, but I’m really worried about your safety, and your father’s safety, okay?

    Jerry: (mumbling) Okay? Safety, safety? Look, I’m not going to kill him, okay? I love my father. Okay, I’m trying to make a million dollars. Millions from this this instruction manual, instruction manual to understand the instructions. Do you understand? I love him okay?

    Dr. Lee: So Jerry, what happened, what happened to the money? What happened to your father’s money?

    Jerry: What … we have no money, what … what are you talking about with that?

    Dr. Lee: Exactly.

    Jerry: I’ve invested into entrepreneur stuff, okay?

    Dr. Lee: … what happened to the money?

    Jerry: Like, there is a lot of stuff going on. Do you want to see the list? I’ve got all these invites, I’ve got like things, I have a conference, you know what … (keeps talking)

    Dr. Lee: Jerry, you know what, it’s your father’s money.

    Jerry: … selling a house in my new company, all that.

    Dr. Lee: You are responsible for taking care of him.

    Jerry: No no no. What’s with you asking about my my money. Right?

    Dr. Lee: It’s not your money. It’s, you’re responsible for taking care of your father.

    Jerry: What’s with you asking? My father is too old for this. You know, he doesn’t care. He’s too … he’s just getting in my way.

    Dr. Lee: Okay, Jerry.

    Jerry: He’s just … look, listen. (keeps talking)

    Dr. Lee: No. We need you to come into the hospital.

    Jerry: He’s getting in my way. (keeps talking)

    Dr. Lee: We need you to come into the hospital.

    Jerry: … He’s getting in my way. I can’t come into the hospital.

    Dr. Lee: Yes, you can.

    Jerry: I have no time to get … (mumbling)

    Dr. Lee: We’ll take care of your dad. You need some rest. You alright? Right?

    Jerry: I’ve got, I’ve got lots of sleep, I’ve … (mumbling)

    Dr. Lee: No, you know what?

    Jerry: … why, I feel fine, I’m feeling fine doctor … (mumbling)

    Dr. Lee: No, you’re not fine.

    Jerry: … my manuals, can I keep writing my manuals? (mumbling)

    Dr. Lee: Okay, you know what, you can. You can keep writing your manuals.

    Jerry: Yes?

    Dr. Lee: Yes. The hospital will be quiet. You won’t have to take care of your dad.

    Jerry: … keep writing, even sitting? (mumbling)

    Dr. Lee: You can keep writing, yes, you can sit and write your manuals, okay? Okay, good.

    Jerry: But I need lots of pens.

    Dr. Lee: So …

Reflective exercise 1

Hospitalization in mental illness

Dr. Lee finally persuades Jerry to accept hospitalization. If Jerry had refused hospitalization and you decide that involuntary hospitalization is required, access the relevant documents necessary for involuntary admission (e.g., provincial mental health act or regulatory authority) in your province or territory and consider the following:

  • Criteria for involuntary admission
  • Number of physicians who must sign an initial involuntary admission/medical certificate
  • Maximum duration for initial assessment

Knowledge check

Part 1

    Select as many as apply.

Commentary on knowledge check 1, part 1

Dr. Lee gathers a good deal of additional information about Mr. Cirillo, some of which is part of the more complete mental status examination.

  • Appearance: Thin, wearing dirty sweat shirt and dirty pants
  • Speech: Slow, halting
  • Mood: Anxious, fearful, sad
  • Affect: Concerned and frightened
  • Thought form: Coherent
  • Thought content: Normal
  • Cognition: No gross impairments – he understands what the physician is asking him
  • Perception: He is realistic in his assessment of his needs
  • Insight and judgment: Insight into his predicament is good

Given this information, Dr. Lee can assess Mr. Cirillo’s competence to make certain decisions. As we know, competence is contextual. That is, one can be competent to make decisions in some parts of life but not others.

For instance, if Dr. Lee suggests that Mr. Cirillo be admitted to hospital:

  • Is Mr. Cirillo competent to make this decision?
  • Is he competent to make decisions about his medication (e.g., pros/cons of a certain medication)?
  • If Jerry has a prolonged illness, is Mr. Cirillo competent to make decisions about where he wants to live?
  • Are there any aspects of his life in which Mr. Cirillo lacks the capacity to make decisions (e.g., financial, personal issues)?

Part 2

    Select as many as apply.

Part 2

Reporting requirements
If Dr. Lee thinks that Mr. Cirillo is a victim of abuse, should she report this to the authorities?

While there is a mandatory reporting requirement for child abuse, there may or may not be a reporting requirement in your province or territory for spousal abuse or for the elderly living at home. Check with your Ministry of Health and medical regulatory authority.

Although elder abuse is an offence under the Criminal Code of Canada, it does not apply to Jerry because his actions are not done deliberately and from malice to do harm; this is a feature of Jerry’s illness.

Reporting requirements differ across the country. See the “Practical Guide to Elder Abuse and Neglect Law in Canada.”

For definitions and other information about elder abuse, read the following articles:

Bipolar mood disorder and elder abuse, B

  • Dr. Lee: So, Mr. Cirillo, how are things going at home?

    Mr. Cirillo: Uh, it’s … it’s bad. I don’t know.

    Dr. Lee: I know. I haven’t seen you in a while.

    Mr. Cirillo: Well, I haven’t been able to come in for my appointments because I need Jerry to help me, and he’s, he’s so busy.

    Dr. Lee: Uh-hm. Yeah, Jerry, Jerry is in pretty rough shape right now. And um, he’s, you know, we’re going to be taking care of him. Um, I do have an important question for you about how Jerry has been taking care of you. Um, has he ever hurt you or hit you in the course of being frustrated or irritated about things?

    Mr. Cirillo: No. No, but I … I want him to get some food and I don’t know what happens. Um, we don’t have any, any food, and I look for the money. The money is important.

    Dr. Lee: Uh-hm.

    Mr. Cirillo: I, I think Jerry’s got my bank card, and you know, when I, when I ask him to get some food, he …

    Dr. Lee: Uh-hm.

    Mr. Cirillo: … he yells at me.

    Dr. Lee: Okay. So, Mr. Cirillo, you do seem confused to me, and you’re really not your old self. Now there are a number of possible explanations. You know, you haven’t been on your medication for arthritis, or for blood pressure, or for your memory. Um, so …

    Mr. Cirillo: What’s going to happen to Jerry? I need someone at my house.

    Dr. Lee: Okay, you know, we, we’re going to arrange for Jerry to go into the hospital. And I’m going to make sure that you have home-care in place, and I’m going to promise you to talk about all those details, how we’re going to work through this. Ah, but right now, what I would like to do is ask you a few questions, uh, just to check your recall. Okay?

    Mr. Cirillo: Okay.

    Dr. Lee: Do you remember? We’ve done this before? We did this.

    Mr. Cirillo: Yeah.

    Dr. Lee: Okay? So now, the first question is do you know what day it is?

    Mr. Cirillo: Wednesday.

    Dr. Lee: Great. Okay. Do you, uh, do you know what date it is? What’s the date today?

    Mr. Cirillo: July 18.

    Dr. Lee: Great. Okay. Do you know where you are?

    Mr. Cirillo: Your office.

    Dr. Lee: Okay. Do you know which hospital we’re in?

    Mr. Cirillo: Jerry brought me in the back door, so I … I don’t know.

    Dr. Lee: Okay. And do you remember your phone number?

    Mr. Cirillo: 370 … I don’t call myself … um, 6643.

    Dr. Lee: Okay. Alright. Um, Mr. Cirillo, I’m going to ask you to repeat three words for me. The words are: black, tulip and honesty. Can you repeat those?

    Mr. Cirillo: Black, tulip, honesty.

    Dr. Lee: Great. Now, I’m going to ask you to remember those words, and repeat them back to me in five minutes. Okay?

    Mr. Cirillo: (nods)

    (a short while later)

    Dr. Lee: Mr. Cirillo, can you remember those three words that I asked you to remember?

    Mr. Cirillo: Um … I don’t … black.

    Dr. Lee: Uh-hm.

    Mr. Cirillo: No, I …

    Dr. Lee: Okay, the other one was a flower.

    Mr. Cirillo: No.

    Dr. Lee: No? Okay. There was tulip.

    Mr. Cirillo: Oh.

    Dr. Lee: And the last word was honesty.

    Mr. Cirillo: Oh.

    Dr. Lee: Okay. Okay. So I’m not concerned about your memory Mr. Cirillo. There’s been no change. Okay? What I would like to do now though is find out a little bit about your day-to-day; how are you getting on day-to-day. Um, your arthritis is getting worse, it seems, and tell me about getting in and out of the shower.

    Mr. Cirillo: Oh, I can’t get into the bath with my hips.

    Dr. Lee: Okay.

    Mr. Cirillo: I need Jerry to help.

    Dr. Lee: Right. And how about getting to the bathroom?

    Mr. Cirillo: Jerry … I need help.

    Dr. Lee: Okay. Now, I know you used to enjoy going out to the church and visiting your friends at the church. Are you still able to do that?

    Mr. Cirillo: Jerry sold the car, and, and I don’t want them to see me like this.

    Dr. Lee: Okay. Alright. So … okay, so Mr. Cirillo we, as I said before, we’ve arranged for Jerry to come into the hospital. I’d like to do the same with you. Uh, I think you’re malnourished, you’re dehydrated. We have to get you back on your medication and you’ll be feeling like your old self again in no time. It won’t be for very long. Okay?

    Mr. Cirillo: Okay.

    Dr. Lee: Does that sound okay?

    Mr. Cirillo: Yeah.

    Dr. Lee: Alright, what I’d like to do now is do a physical exam.

    Mr. Cirillo: Okay.


 

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