Modules

Mental health

Bipolar mood disorder and elder abuse, A

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

    Amanda: Yes, 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.

    Amanda: Sure, no problem.

    Dr. Lee: Thank you.

    Patient: Hello, hello. Who’s there?

    Dr. Lee: Mr. Cerillo, it’s Dr. Lee, how are you doing?

    Patient: What?

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

    Patient: Who are you?

    Dr. Lee: Mr. Cerillo, may I speak with Jerry, please.

    Patient: Jerry?

    Jerry: Hey, come here, who’s that on the phone? Who’s that on the phone? Hello, hello. Who’s calling?

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

    Jerry: Oh no, no, no, it’s not time. It’s not time, okay.

    Dr. Lee: Jerry, he is really overdue for a checkup and a medication renewal.

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

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

    Jerry: I don’t need pills. I feel just great, all right doctor.

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

    Patient: Oh I think there’s another call coming in. I think it’s another call.

    Jerry: Dad.

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

Dr. Lee asks the public health nurse to visit the Cerillo house. She has difficulty persuading Jerry to let her in to see his father. She finds the house dirty and disorderly and Mr. Cerillo 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. Cerillo and insists that Jerry accompany his father.

  • Dr. Lee: Hi, Mr. Cerillo it’s good to see you and Jerry thanks for bringing your dad in. Okay, Mr. Cerillo, how are things going?

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

    Dr. Lee: Okay so Jerry, you did agree to take care of your dad right?

    Jerry: Yeah, yeah. I did, I did, I did, I did.

    Dr. Lee: Well his arthritis is getting worse and it seems that he needs some help getting around.

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

    Dr. Lee: Okay, Jerry, now we’ve spoken about this and I know that you have a list of things that your dad needs help with like bathing, like getting to the toilet, taking care of things, yes? Okay, Jerry, okay. All right, Mr. Cerillo you look as though you have been losing some weight. So how are you doing today?

    Jerry: Look, Look at him, he’s fine. He’s getting plenty, he’s getting a lot, okay, so just don’t worry about it because I’ve got an important business. I’ve got to sell houses and then money come in and I’ve got to go. I’ve got to go. I’ve got to go.

    Dr. Lee: Jerry, Jerry when did you stop taking your lithium?

    Jerry: No, no lithium.

    Dr. Lee: How long ago?

    Jerry: No time, no time for lithium, right? Because lithium gets in the way of my thinking, do you understand it. It gets in the way of my thinking. I sell houses and then lithium is no good for real estate do you understand?

    Dr. Lee: Okay, Jerry you know what when the nurse visited your house she told us that you are obviously struggling to take care of your dad. He’s not bathing. He’s not eating, now your father needs to be taken care of. Do you understand that?

    Jerry: Shoo, shoo, shoo.

    Dr. Lee: And she said that there was no medication.

    Jerry: Yeah, I told you she was a spy, I told you she’s a spy, do you understand?

    Dr. Lee: No, no your medication not his medication?

    Jerry: Right, no pills. Nobody takes the pills.

    Dr. Lee: Jerry, what are you doing with the medication?

    Jerry: The pills make him stupid okay. He doesn’t even tie his shoe right, so it’s not good. No pills, nobody takes the pills.

    Dr. Lee: Jerry, we need you to go back on your lithium. We need you to go back on your lithium, otherwise, I may have to put both of you in the hospital.

    Jerry: No.

    Dr. Lee: Yes and appoint a guardian for your father. Now do you understand that?

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

    Dr. Lee: Okay, Jerry, okay. Now Mr. Cerillo I will be right back and we will do a physical exam and I’ll ask Amanda to bring in some water for you okay? So Jerry, you and I are going to go and have a conversation in the other room, okay?

    Jerry: Who does your instructions, all right?

    Dr. Lee: We’ll discuss that in the other room.

    Jerry: You can’t take me to the hospital.

    Dr. Lee: No, just another room for now okay.

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

    Dr. Lee: Yes, Jerry come on we are going to go and have a talk now, all right.

    Jerry: I’m going to keep writing my manuals.

    Dr. Lee: Yes you can, all right. Come on. Thank you. Good.

  • 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. I have a very important appointment. I’m telling you about this, I’ve got to go okay, I’ve got to go.

    Dr. Lee: Okay, Jerry, this is what I wanted to talk to you about, now please sit down. Sit down Jerry please. Thank you. Okay, Jerry, now we need you to come into the hospital just for a couple of days until we get your medication sorted out.

    Jerry: No, no, no, no, I can’t, I can’t, I can’t because I’ve got a very big like a big business venture and like I don’t have time ok? Like there’s no time like where do you invest your money? Are you willing to invest, you got to invest in this okay.

    Dr. Lee: Jerry, are you still working at your job?

    Jerry: What job?

    Dr. Lee: Well, what happened to our job?

    Jerry: Oh job, shmob, I quit that like a week ago, it’s for losers, losers and I’m not a loser. I’m into a bigger game right now, big game. I’m going to make millions on this one.

    Dr. Lee: Okay, Jerry, you know what? When the nurse visited your house she said that there was no food. Now are you and your father eating?

    Jerry: I told you she was a spy, a government spy, right.

    Dr. Lee: No, she’s not a spy.

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

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

    Jerry: You know what, he’s fine. He just complains all the time. He’s getting on my nerves.

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

    Jerry: Look we’re fine. We’re fine with the food like never mind about the food it’s okay.

    Dr. Lee: Now what about your medication? Now when was the last time you took your lithium?

    Jerry: Because I don’t need pills like it’s been like two weeks maybe. I’ve never felt better. It dawned on me that it’s the government, they’re trying to control us, you know. I have it all written down here.

    Dr. Lee: Jerry, we’ve been here before, right. We’ve been here before, now Jerry the government is not trying to control you and they have nothing to do with your medication or your father’s medication okay? And they are not trying to control me but I am really worried about your safety and your father’s safety, okay?

    Jerry: Okay safety, safety look, I love him okay? But I’m trying to make a million dollars, millions in this instruction manual, instruction manual to understand the instructions, you understand? I love him, okay.

    Dr. Lee: Jerry, has anything happened to your father’s money?

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

    Dr. Lee: Well, what happened to the money?

    Jerry: I’ve invested it into entrepreneurs stuff like there is a lot of stuff going on. Do you want to see the lists? I’ve got like, I’ve got like all these invites and I have got like things, I’ve got a conference. I’m selling houses…

    Dr. Lee: Jerry, You know what? It’s not your money, it’s your father’s money and you are responsible for taking care of him.

    Jerry:    No, no, no, what did you ask about, my money right?

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

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

    Dr. Lee: Oh, okay. Jerry, you know what? We need you to come into the hospital. We need you to come into the hospital.

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

    Dr. Lee: Yes you can. Now we’re going to take care of your dad and you need some rest right.

    Jerry: I’m getting lots of sleep.

    Dr. Lee: No, you know what?

    Jerry: I’m feeling fine doctor, I’m feeling fine.

    Dr. Lee: No you are not fine.

    Jerry: Can I keep writing my manuals?

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

    Jerry: Yes?

    Dr. Lee: Yes, the hospital will be quiet and you won’t have to take care of your dad.

    Jerry: Keep writing even sitting?

    Dr. Lee: Yes, you can keep writing your manuals even while you’re sitting, okay.

    Jerry: But I need lots of pens.

    Dr. Lee: And you shall have them. Okay, so Jerry are we ready to go, okay. All right, good.

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. Cerillo, how are things going at home?

    Patient: It’s bad. I don’t know.

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

    Patient: I wasn’t able to come to my appointments. I need Jerry to help me and he’s so busy.

    Dr. Lee: Yes, well Jerry is in pretty rough shape right now and we’re going to be taking care of him but now I do have a very important question to ask you about how Jerry has been taking care of you. Has he ever hit you or hurt you in the course of being frustrated or irritated about things?

    Patient: No, no but I’d like him to get some food. I don’t know what’s happening. We have nothing to eat. I can’t find my money. Money is important. I think Jerry’s got my bank card and you know, when I want him to get some food he yells at me.

    Dr. Lee: I see. Okay. Now Mr. Cerillo you do seem a little bit confused to me. You’re really not your old self. Now there are a number of possible explanations for this. You know you haven’t been on your medication for your arthritis or your blood pressure or for your memory.

    Patient: What’s going to happen to Jerry? I need someone at home.

    Dr. Lee: Yes, well we’re going to arrange for Jerry to go into the hospital.

    Patient: No, no.

    Dr. Lee: And I assure you that we will have home care in place for you and I promise you that we’ll discuss all those details. Okay? Okay but what I would like to do right now is just ask you a few questions just to check your recall. Okay? Do you remember we’ve done this before? We did this?

    Patient: Yes.

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

    Patient: Wednesday.

    Dr. Lee: Great, good. And do you know what date it is today?

    Patient: July 18th.

    Dr. Lee: Good and do you know where you are?

    Patient: In your office.

    Dr. Lee: Good, good and do you know which hospital we’re in?

    Patient: No, I don’t know. Jerry brought me in through the back door.

    Dr. Lee: Okay, I see. And do you know, do you remember your phone number?

    Patient: 555, I don’t call myself, 6643.

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

    Patient: Black, tulip, honesty.

    Dr. Lee: Good. Now I’m going to ask you to remember those words and repeat them back to me in five minutes, okay. So, Mr. Cerillo what are those three words that I asked you to remember?

    Patient: Black.

    Dr. Lee: And the second word was?

    Patient: I can’t remember.

    Dr. Lee: It was a flower.

    Patient: No.

    Dr. Lee: It was tulip and the last word was?

    Patient: I don’t know.

    Dr. Lee: Honesty.

    Patient: Oh yeah.

    Dr. Lee: So Mr. Cerillo I’m not really concerned about your memory. There’s been no significant change since the last time but now, what I would like to do is ask you a few questions to find out a little bit about how you’re getting on from day-to-day. Now it seems as though your arthritis is getting worse, yes. So tell me about getting in and out of the bathtub.

    Patient: I can’t get into the bath, not with my hips. I need Jerry to help me.

    Dr. Lee: Okay, and how about going to the toilet?

    Patient: I need help.

    Dr. Lee: I see. Now I know that you used to enjoy going out to church and visiting your friends afterwards are you still able to do that?

    Patient: Jerry sold the car. I don’t want my friends to see me this way.

    Dr. Lee: It’s all right Mr. Cerillo, it’s going to be all right. Now as I’ve said before we have arranged for Jerry to come into the hospital and I would like to do the same with you. I think you were malnourished and dehydrated. Now, we have to get you back on your medications and you will be feeling like your old self again in no time, okay? and this won’t be for very long, okay?

    Patient: Okay.

    Dr. Lee: Does that sound okay?

    Patient: Yes.

    Dr. Lee: Okay, good. All right well now what I would like to do is a full physical exam, okay, good.


 

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