Clear Communication in High-risk Transitions

Husband’s escalating aggression appears not to have been appreciated by clinicians

A review into the homicide of a woman by her elderly husband revealed missed opportunities for communication between police, hospital clinical staff, and home care providers, says an expert committee of the Chief Coroner of Ontario. 

This Geriatric and Long-Term Care Review Committee looked into the circumstances involving  the death of the 76-year old woman at the hands of her 82-year-old  husband, who had an 18-month history of cognitive decline, worsening agitation, and intermittent psychosis as part of his major neurocognitive disorder (likely Alzheimer’s Dementia). Given the extensive blunt impact injuries sustained by the woman, it is likely her husband was in a psychotic state at the time of the assault; it is possible he was responding to delusional beliefs about his wife’s behaviour or who she was.

Prior to her death, the woman had been seeking assistance to help care for her husband and notes indicated she felt “overwhelmed,” and that she “was wary …. about how to manage his outbursts.”

A week before the homicide, on December 28, 2017, the husband was apprehended at his home by police under the Mental Health Act and taken to the local hospital for assessment. He was reported to have had a prolonged period (i.e. 24 hours) of irritability and agitation where he was “verbally abusive towards his wife” and threatened to kill himself by hanging. 

At hospital, he was seen by the geriatric emergency room nurse (GEM nurse), the emergency room physician, and the on-call psychiatrist. The man was not felt to be delirious. The GEM nurse noted that the “patient was uncontrollable today and hence family decided to bring him to hospital for check up.” 

In none of the notes from the GEM nurse, emergency room physician, or psychiatrist is it documented that the man was in fact apprehended under the Mental Health Act

The psychiatry note stated the patient “began accusing [his] wife of trying to steal from him and trying to kill him. Started yelling at son and daughter-in-law. Began saying he wanted a divorce and that he was going to kill himself. Was shouting and carrying on and not settling down, so family called EMS who brought him to hospital.” The psychiatrist also noted that over the last 18 months or so, the patient  had been having roughly monthly episodes of worsened agitation that his wife had been able to de-escalate; over the past month, these periods of agitation had happened approximately four times. 

The current episode of agitation was described as the most severe. The psychiatrist noted, “family is willing to take him home, but are wary of how to manage these outbursts going forward.” On the mental status exam, it was noted that “affect is soft spoken and gracious.” The patient thought he was 36 years old and living in another province. He did not know he was in hospital and he did not know why he had been taken to one. He indicated he remembered saying he wanted to kill himself, but that he said it out of frustration. Blood work was ordered, but was refused by the patient and medical staff “did not want to force the issue.”

The degree of agitation and behavioural dysregulation demonstrated by the man prior to his presentation at hospital on December 28 does not appear to have been appreciated by the clinical staff, stated the Committee.

In none of the notes from the GEM nurse, emergency room physician, or psychiatrist is it documented that the man was in fact apprehended under the Mental Health Act by the police to enable him to be assessed in hospital. A 24-hour history of escalating agitation, poor sleep with expressed delusions, and threat to commit suicide, in the presence of rational thought loss (i.e. dementia) led the police to invoke the Mental Health Act to enable the male to be apprehended by police. The hospital clinical staff relied to a large degree on the man’s mental status while in the emergency room, at which time he was described as “gracious,” and a full assessment was not done (including no blood work) as the man had refused.

A week earlier, the patient was seen by his geriatric medicine specialist. At the time of the assessment, he “was alert and had excellent social graces.” He was reported to have had “some minor behavioural issues for which he is treated with paroxetine with significant benefit.” It was noted home care supports were put in place, including long-term care admission. It was also noted his wife “was anxious to get more help for herself in regard to caring for her husband.” The donepezil was increased to 10 mg (by mouth, daily). For the geriatrician visit and the emergency room visit, community-based follow-up was through home and community care. Yet it is unclear what specific plan was in place as there did not appear to be any return correspondence from home and community care back to the referring care providers. It appears there was no mechanism to obtain crisis support for the man and his family in the community. A referral for further support is not actually timely access to care, wrote the Committee.

Dr. Michael Szul, a CPSO Medical Advisor, believes this was a case that presented learning points for the profession. “It is important to note that the police had brought the patient into emergency under provisions of the Mental Health Act. It was not clear what attempts to seek additional collateral information from family and others (including home care) might have been made, but such information, if available, could have assisted in understanding the context, including risk. The professional judgment to discharge might still have taken place, but there might have been more consideration of hospitalization,” he said.

Recommendations:

To the Ministry of the Solicitor General, College of Physicians and Surgeons and Ontario Medical Association:
When an individual is apprehended by the police under the Mental Health Act, a short, written summary of the reasons for apprehension should be provided to the receiving hospital, both as a record of events and as evidence the patient was apprehended under the Act.

To Local Health Integration Networks, Ontario Hospital Association and College of Physicians and Surgeons:
For specific, high-risk transitions between hospital and home, it is essential that clear communication and treatment plans be established and maintained.

To the College of Physicians and Surgeons:
A pattern of escalating aggressive behaviour in the presence of psychosis where there is an underlying major neurocognitive impairment is a known risk factor for physical violence, impulsive decisions and possibly suicide and/or homicide. Hospital admission to establish clear diagnosis and establish an effective treatment plan may be required prior to safe re-integration into the community.

To the Ministry of Health and Local Health Integration Networks:
Rapid, easy access to respite beds for community crisis should be accessible within 24 – 48 hours for dementia patients/families in crisis.