When a Family Member’s Mental Illness Puts Them at Risk

In this episode, Lisa Shoalmire and John Ross discuss dealing with a family member who’s affected by some cognitive dysfunction, mental illness, or dementia to the point that they’re not making good decisions for themselves or they may even be at risk of harm.

Episode Transcript
Lisa
Welcome to another edition of Aging Insight. I'm Lisa Shoalmire and I'm here with my partner, John Ross. And we're here today to provide you with some insight and information into some of the issues that seniors, their families, and those with disabilities may have as they're getting through. So, today we wanted to focus our topic today on some of the mental changes that can occur as we age, perhaps. It may be dementia or it could just be severe depression. And of course, those type of mental changes aren't just in the category of seniors, those can really affect anyone. And there are some legal issues that the individual and the family has to deal with or may be confronted with in trying to provide the best care and treatment for an individual going through those changes.
John
Yeah. This is one of those situations where I would say that in our practice of assisting people who have had strokes, who have had heart attacks, who have been in accidents where they've lost limbs or become paralyzed, but most of those situations we can, using the tools that are available to us, figure out the best ways to provide resources so that they can maintain themselves in a home environment, so that they can have a good quality of life. Most of the time, those sort of things, although they're complicated, they're still relatively simple.
John
Some of the hardest cases that we deal with are those involving mental illness and mental deficiencies. And of course, when I say that, you might be thinking "Oh, you mean like Alzheimer's." Well, things like Alzheimer's. Of course, I think, these days, I think they've developed about 32 different forms of dementia, Alzheimer's just being one of them, but there's lots of others. But this can also impact even young people who are diagnosed with things like Schizophrenia, or people who have been in accidents and have suffered head injuries, that have caused a change in the personality. And these are tough situations because the law is not well suited to deal with the challenges of these sort of mental issues.
Lisa
That's right. And so I guess, let's start where the law starts. And the law says that once you turn 18, every single individual in the state, Texas, Arkansas, you are considered a legally competent individual who can make your own decisions. They may be good decisions, they may be bad, but they're your decisions. And the law says that you're capable of making those. And so, what happens however, is if we have a senior who is suffering from dementia to the point where they cannot make appropriate decisions for themselves or appropriately care for themselves, the law doesn't automatically recognize that. The same is true for a younger person, who through mental illness or accident or just organic condition, they are still considered legally competent under the law until there's some action in a courtroom setting.
John
That's right. And if you've watched the show before, you've heard us talk about the importance of things like powers of attorney. And the reason that we encourage people to have powers of attorney, well-drafted powers of attorney...
Lisa
Yes. [chuckle]
John
I'll always caution that, this is not simple stuff.
Lisa
It is not a page.
John
But good powers of attorney. But the reason we encourage that is because if you become incapable of making your own decisions, then somebody else can step in. And that's a good concept when somebody goes from being perfectly fine one day, and then maybe they have a heart attack or a stroke that has left them completely incapacitated the next day. Well, clearly, that person is incapacitated, they can do nothing for themselves, and so now, somebody else with those powers of attorney can be able to do things for them. Maybe pay bills, maybe talk to the doctors, get access to medical information, sign their tax return, all of those sort of things. But unfortunately, especially when it comes to issues involving the mind, it's not always clear cut. It's not always one day you're there and one day you're not. There could be a period days, weeks, months, years in some cases, where you're not who you were but you're still not completely incompetent. There's this gray area there, and those are the tough decisions.
John
When that person you love, who doesn't necessarily... They don't necessarily understand the world around them the same way you and I do. Their reality is different than our reality. Maybe they're living in the past. Maybe they haven't worked for a company for 15 years and one day they start showing up at their old employer, thinking that they're supposed to be there working. Maybe they just have this urge to get out and go some place, and they just need to go and walk. And yet, they're physically frail and shouldn't be out there walkin' in the streets. And Lisa, one of the things that people come in and they say all the time is they'll say, "Well, my loved one is in this dangerous situation but I have power of attorney over them."
Lisa
That's right. We do hear that quite frequently. Particularly with adult children who are trying their best to care for an aging parent and maybe they're experiencing some of those mental status changes with dementia or whatever, and the adult child just wanting to care for that parent is thinking that maybe a secured unit or a memory care facility is the right place for mom or dad. And so they come to us and say, "Well, I have power of attorney over mom, but she won't move in to the wonderful facility that I have found for her," and "Don't I have power of attorney? Can't I just sign her in and take her? It's for her best interest." And the answer of course in that situation is "No." A power of attorney we often say, you don't have power of attorney over someone, frankly you have power of attorney with that person. But the principal, typically the parent, has the veto power and their decision trumps yours as an agent under a power of attorney. And this can be particularly frustrating when we're dealing with mental health situations where we need to access care and we're just trying to care for that loved one. So you know what? I think what we're gonna do is we're gonna take a break and we're gonna come back and talk about some of the other legal tools in our toolbox that we can use to help care for that mentally frail family member.
John
Hi, I'm John Ross, Elder Law Attorney and Board Member for the Alzheimer's Alliance, and welcome to Our Place. Our Place is a day program designed to provide rest and relief for the caregivers of people with Alzheimer's and related dementias. Our Place is a safe environment where our friends benefit from socialization in a home-like environment. Alzheimer's is devastating and affects over 17,000 families in our area. To find out how Our Place can benefit you, please visit our website.
John
Welcome back to Aging Insight. I'm John Ross, this is Lisa Shoalmire, and today on Aging Insight, we're discussing how to deal with mental illness. What tools are out there? And of course, the first thing that we talked about was the importance of powers of attorney, and we've talked about that before. But when it comes to mental illness, where a person may be making poor decisions.
Lisa
Yeah, irrational decisions.
John
Right, but not necessarily incompetent decisions. There's this gray area. If you think about it, if it's you, you wanna be able to make your own decisions even if other people don't agree with them. Even if those kids don't like your decision, it's still your decision. And the law protects that. And we want that, we want those protections, we want the protections that make us independent. The problem is, when you're struck with mental illness or some sort of cognitive deficiency in whatever form it comes, you may not necessarily be thinking straight. And so there's one day, it's just your decision and nobody else should be able to tell you what to do, but the next day, you still think it's your decision, but your decision is not a competent decision. And these are very difficult situations. And of course, while we recommend powers of attorney, to avoid having to get any sort of court involvement, oftentimes, even with the powers of attorney, sometimes you have to reach out and get some court assistance in these cases.
Lisa
Well, that's right. When we're dealing with cognitive issues, a person of course, thinks that their decision-making is right on par, just as it always was. While those around them, can see the real difficulties and the incongruencies, if you will, with those decisions. So, what ends up happening is a lot times, the final straw that really pushes a family to seek guardianship is often situations where their loved one has put themselves at risk in some way. Perhaps wandering away from the home, engaging in activities they never would have engaged in before that could have brought some harm to them, and at that point a family typically is looking for help in order that they can substitute their decision-making for the individual that they now think is troubled. And in order to do that, we have to engage the court system, because remember, at the top of this show, I said that everyone over the age of 18 in the state is considered to be legally competent.
Lisa
So we have to engage the system, and someone has to file an application with the court that says, "My family member, I believe is legally incompetent, here's why." And perhaps there's a doctor's letters or a doctor's opinion that substantiates that. And that gets filed to go before a judge who has to evaluate if that evidence is sufficient to take away that individual's legal capacity and decision-making authority.
John
Yeah, and this can certainly be a big deal. And, if you don't have very clear evidence that the person is completely incapacitated, this tool may not be available. The guardianship process, which is what Lisa is talking about, you're gonna get that guardianship on the basis that that person can no longer make their own decisions. But, oftentimes, in many cases, the mental deficiency, or the cognitive deficiency that's going on at the moment, it might not be a permanent situation. One of the things that surprised me... I'm not a medical doctor and so...
Lisa
You don't even play one on TV. [laughter]
John
And I don't play one on TV, that's exactly right. But I'm exposed to a lot of medical stuff. And one of the most surprising things I heard recently is that the number one cause of dementia, the single number one cause of dementia is a urinary tract infection, of all things.
Lisa
Well, and of course, that typically is temporary, if it's caught and diagnosed, and appropriate prescriptions are prescribed. But a lot of times if that type of infection is going on that's building up that toxicity in your system, and it is disturbing your decision-making process. Then a lot of times, we've had clients and all that have messed up their medications which exacerbates the problem, because they weren't able to competently take their medication in the regimen that they were supposed to.
John
Right. And so, in these situations where you've got a temporary type situation, and maybe you need some immediate assistance right this very second, there are some tools available out there for this. There's something called an "involuntary civil commitment", and this is still a legal proceeding. But oftentimes, we see these where somebody has wandered off and gotten lost, or they've created some sort of disturbance, maybe at the grocery store or out in public, or maybe just a concerned loved one called the police who came over to the house, and talked to that person.
John
But when law enforcement or Adult Protective Services and these other organizations, when they come across a situation that they see might be dangerous to that person, or to those around them, one of the things that they can do is have a local judge sign an emergency order that requires that person to go to inpatient hospital treatment. Many hospitals have a, what they call a behavioral unit. But this is typically a locked facility, inside the hospital, where a person can be confined, and then all of their medical care can be looked at. And they can start doing things like checking to see if they have a urinary tract infection, seeing what medicines they're on and whether they've been taking them properly. And so, oftentimes in an emergency situation, something like an involuntary civil commitment, can be a tool to get control of whatever is going on. So that's available out there if it's an emergency type situation.
Lisa
Well, and a lot of times, our first responders, obviously, "We don't want our family members necessarily to be arrested or anything like that." That's not really what we're talking about, but sometimes dementia and cognitive issues can get out of hand and lead toward violence toward other family members, or just get to a point where it's not safe. And so we do need to get control of the situation and get it back to a more normal situation and this involuntary commitment can give you the services, can get you into access for the services that you need to calm things down.
John
Right. But notice the first part of all of this is it's a temporary involuntary civil commitment. That temporary is very temporary. Typically, there has to be a hearing within, in many cases, within the first 24 to 48 hours to determine whether the initial commitment was even correct. And assuming that the initial commitment was correct, generally, you're not gonna get much more than about 14 days worth of involuntary commitment in a place like the behavioral center at one of the hospitals. The question that a lot of times we get is "Our mom has been involuntarily committed. She's up there at the behavioral unit, but they say they're gonna release her tomorrow. What do we do?"
Lisa
Yeah. So we'll take a break and we'll come back and talk about that. Be right back.
John
Hi. I'm John Ross, Elder Law Attorney and Board Member for the Alzheimer's Alliance, and welcome to Our Place. Our Place is a day program designed to provide rest and relief for the caregivers of people with Alzheimer's and related dementias. Our place is a safe environment where our friends benefit from socialization in a home-like environment. Alzheimer's is devastating and affects over 17,000 families in our area. To find out how Our Place can benefit you, please visit our website.
Lisa
Welcome back to Aging Insight. I'm Lisa Shoalmire and I'm here with John Ross, and today we're talking about a very difficult subject which has to do with dealing with a family member who's affected by some cognitive dysfunction, mental illness, or dementia to the point that they're not making good decisions for themselves or they may even be at risk of harm. And John, this has to be the most frustrating scenario for the families that we talk to because the state law is such that it gives so much differates to the legal independence of each individual, which we're all glad for, but when these families are trying to deal with these situations, sometimes the law is a little clunky and it doesn't really provide much help. Now, before the break, we were talking about there is a possibility of a temporary commitment that hopefully can address some of the issues and maybe get things evened out if you're experiencing that. But what happens though when a temporary commitment doesn't address issues sufficiently for that loved one to come back home and live back at home, or their mental condition has just not improved?
John
Right, and this is where we started talking about where that family has come to us and they say that "Mom's leaving the Behavioral Unit tomorrow, what do we do?" Well, the first thing we can talk about is guardianship like we talked about. But again, from a legal standpoint, you're either competent or you're incompetent. There's no gray area in the law. Well, ask a physician whether or not there's any gray area in the realm of cognitive dysfunction and they'll tell you it's all gray area, that there's a whole range between competent and incompetent. And so, in many cases, the guardianship is just not available because the person is not clearly incompetent. There's something less than that, and this is where there are not a lot of good tools out there. What it becomes particularly important in these type of situations is using your judgement, your knowledge about the person to not try to force them into your reality, but try to change your reality into something that they're more familiar with. And that may sound a little strange, so I'll put it in plain terms.
John
When I've talked to folks who are dealing with somebody who has Alzheimer's, one of the first things I'll often tell them is "Get real good at lying." And they look at me like I'm crazy, like I have just said the worst thing in the whole world. But what you've gotta realize is sometimes you have to lie to the disease in order to speak to the person. In order to take care of that person, sometimes you have to lie to the disease. Maybe changing that environment... If they get upset because they don't want to have to go to a facility, maybe say, "Look, it's temporary. Let's just try it for a little while," or, "Maybe let's go have lunch everyday until you get into a routine of going to that facility." If they think that they're 20 years younger, then change the environment to the environment like it was 20 years ago. Change the pictures in the house, change the furniture in the house. Whatever you can do to change, not their reality, 'cause you'll never change their reality. The key is changing your reality to fit theirs.
Lisa
Well, that's right, because a lot of folks that are going through these cognitive issues, they get very frustrated, because they don't understand why the world around them is different than what they expect it to be. So, for instance, if they're asking about a relative of theirs and expecting them to walk in any minute for a visit, but yet that relative has been deceased for 10 years, this is a time where you might lie and say, "Oh, well, they must be running late. They're not here yet." But a lot of times, we try to force the actual reality back onto that person and, "Oh Martha, you know Uncle Jim's been dead for 10 years. What are you talking about?" Well, this can create frustration and upset the individual, and then we start building up to a blowout again. So sometimes, we just have to massage the situation in order to keep a more even keel.
John
Yeah, and this is hard for some people to realize, but imagine, if I were looking, and I'm talking to you right now, and I said, "There's only one person on that TV screen, that John is sitting there by himself. There is nobody sitting here next to him." And you would say, "No, there's a lady sitting right there next to him." And I said, "Nope, that's just a figment of your imagination." You'd probably start getting mad at me. You'd probably start saying, "John, you're lying to me. I don't know why you're trying to trick me." And you know what? We've started a fight. And you don't wanna start that fight, so don't argue. Just try to work around the situation, and in fact, a lot of what we do is trying to figure out ways to work around these situations. And frankly, that's what Aging Insight's all about.
Lisa
Well, that's right. And of course in this area, there's a lot of help out there for you. There's behavioral assistance, there's professionals out there that can help you. So make sure and reach out for it.
John
Yeah, find you a support group, call some of the non-profits. They're there to help, use them, and get some guidance on doing all of these things. And of course, keep watching.
Lisa
Yeah, that's right.
John
We've got a lot more information for you in the coming episodes, so stick around with us on Aging Insight and of course, feel free to catch us on the radio every Saturday at noon on 107.1. Until next time, we'll see you later.
Lisa
Bye-bye.

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