Crisis Care Management

“People with dementia are twice as likely to seek emergency care compared to older adults who don’t have dementia. The emergency department can be a loud, bright, fast-paced environment, which can amplify cognitive issues and present communication challenges for someone with dementia. But there are steps you can take to improve an emergency department visit for someone with Alzheimer’s disease or another cause of dementia.” - : 6 Tips for Emergency Visits with Dementia Visitors and Their Caregivers 

Once the Patient is Admitted to the Hospital

Be an Advocate. Once admitted to the hospital, the most important role of a caregiver is to serve an attendant and advocate for their loved one.  This means asking questions, being persistent, and understanding why treatments and services are being recommended as part of the care plan.   When possible, have more than one person present to take notes and listen to what the medical professionals are sharing. In addition, the following are steps to consider: 

• Check to make sure medical records are on site. If your loved one is at a hospital outside of their usual system, it is unlikely that their care team will have access to their medical records automatically. When admitting your loved one, make sure to provide copies of your folder of legal healthcare documents including: updated medication list, allergy, illnesses and diagnosis, contact information for specialists and primary care physicians, MOLST, and any health care proxies. 
• Make sure that your contact information is also included so that the care team can easily keep you informed of any updates. (A MOLST is a portable, medical document that specifies a patient's preferences for end-of-life care, including resuscitation, intubation, and other life-sustaining measures. It includes all directives previously included in a DNR) 
• Inform emergency department staff if the person has dementia, has had a history of hospital-delirium, is dehydrated, or needs caution with IV ports and blood work. If the person you are accompanying has dementia or memory issues, ask the staff member to record this information in the medical record.  When seniors are brought to emergency rooms with non life-threatening concerns, they can be left for long periods of time unattended.  In unfamiliar places without friends or family nearby, they may experience anxiety, anger, depression or delirium. Share any insights on approaches to proceed with communication and care.   

“I found out about my father being in the hospital two days after he was admitted.  By then he was so aggressive they had to restrain him so he wouldn’t pull out his IV.  Being able to speak with the nurse about his anxieties would have made a world of difference in managing his hospital delusions.    As soon as you can, talk with the nurse on duty and let them know what you do about how your patient experiences hallucinations or hospital delirium. ” - Caregiver 

Limit or avoid hospital delirium and hallucinations -Also called “sundowning”, managing hospital delirium requires a collaborative effort from healthcare professionals, caregivers, and the individual. 

Patients experiencing sundowning may have difficulty remembering names, dates, or locations.  They may see or hear individuals not present, act out of character or ask for relatives long passed. They may be out of character, agitated, nervous, acting out or being unusually withdrawn. These patients are at a greater risk for long hospital stays, functional decline, risk of complications, and mortality. Once experienced, they tend to experience on future hospital stays. 

Here are some practical steps as you advocate for your loved one: 

• Encourage orientation: Help the person stay oriented to their surroundings by placing familiar objects in their environment and providing regular updates about the date, time, and location. 
• Maintain sleep routine: It is diffcult to ask nurses to allow patients to rest through the night, but encourage daytime activity to promote restful sleep. 
• Stay hydrated and nourished: Encourage loved ones to continue to eat.  Some hospitals have protein shake “ice cream cups”. Do what you can to keep them on a balanced diet with regular fluid intake. Dehydration and nutrient deficiencies can exacerbate delirium. 
• Promote social interaction: Encourage social engagement, whether through conversations, visits from loved ones, or movement around the hospital. 
• Create a calm environment: Reduce noise, ensure proper lighting, and minimize disruptions to create a relaxed and reassuring atmosphere. 
• Support sensory stimulation: Provide sensory stimuli such as familiar music, photographs, or tactile objects to help maintain cognitive engagement. 
• Communicate with healthcare providers: Keep an open line of communication with the medical team, promptly sharing observations of any changes in behavior or cognition. 
• Be patient and compassionate: Individuals experiencing delirium may become frustrated or agitated. Maintain a patient and empathetic demeanor while providing reassurance and support. Don’t try to force them to live in our world.  Allow them to feel comfortable in their reality. 

Mobility & UTIs -  If your loved one has been admitted due to falls or weakness when standing and suffers from incontinence, it is possible that the care team may recommend the use of a catheter rather than a portable toilet.  Using a urinary catheter increases the risk of developing a urinary tract infection (UTI). About 75% of UTIs developed in hospitals are associated with a urinary catheter, especially when they are left in place for a period rather than used periodically.  If your loved one presents as delusional, this can be an indication that they have develop an infection, Covid or some other illness while in the hospital.   

Dementia & Anesthesia - To limit the impacts of anesthesia on dementia, the most important steps are to consult with a healthcare professional before surgery, discuss the patient's specific cognitive status, and opt for the least invasive anesthetic options like regional anesthesia when possible, while avoiding medications that can worsen cognitive function, particularly benzodiazepines and anticholinergics; additionally, meticulous post-operative care with close monitoring and cognitive stimulation can help manage potential cognitive decline.  

Once the Patient is Discharged

When leaving a hospital after care, expect a discharge plan, follow-up care instructions, and potentially referrals to other facilities or services, all coordinated by a discharge planner or case manager.  In the event that the patient is not mobile, transportation will also be coordinated by the same case manager or planner. 

After a hospital stay, especially an ER visit, elderly individuals or their caregivers should immediately review their bills carefully for accuracy and contact the hospital's billing department to request an itemized bill and clarify any discrepancies. They should also appeal to their insurance company and explore financial assistance programs, negotiation options, and potentially explore prompt-pay discounts or payment plans. 

If the Patient is Recommended for a Rehabilitation Residence

In the event that your loved one may be unable to return to their former home without a stop at a rehabilitation residence, here are a few items to keep in mind: 

Selecting a Rehab Facility

A few days prior to discharge the case manager will reach you to introduce themself to you and to explain what services are or are not covered by your insurance.  It is appropriate at this time to request a private room at a facility, especially if the patient presents with dementia or cognitive decline.  Within a few days the planner or case manager will provide you with a list of available rehabilitation centers that have beds available for you.  You will be given a window of time in which to decide a first, second and third choice selection.   

TIP - While rankings (Medicare.gov) are important to evaluate a rehab center, the most important qualification is its proximity to the caregiver who is most likely to visit. More than ever, the patient will need an advocate at the rehabilitation residence!   

Arriving at the Rehab Residence

Be aware that rehab facilities are essentially nursing homes.  So do not be surprised when you walk in the door, and they are not quite what you might expect a therapeutic residence to be.  And if you arrive on the weekend, physical and occupational therapy service may not begin until the work week. 

This is also yet another unfamiliar location.  Clothes and personal effects need to be brought in, and need to be monitored as they are washed and returned by staff.  The patient who has had a long hospital stay will need to be bathed, groomed and checked for bed sores. Sleeping patterns, eating and behavior will once again be off kilter.  Sundowning is extremely prevalent and if mobile, patients are known to wander. Expect to spend extra time with your loved one these first few days to help them get acclimated and comfortable.  Get to know the staff that will be with them on a regular basis.

“A note about guilt - You will feel guilt as a caregiver, especially if you are unable to care for your loved one in your home.  You may project that guilt into criticism of quality, regardless how nice any care residence. The food is awful, the nurses not attentive, the facilities unkept, etc.  Be aware of this.  Take a deep breath. Advocate as much as you can, while recognizing the limitations of the people who are providing care for your loved one 24/7.” - Caregiver from a distance

Leaving the Rehab Residence 

Typically Medicare coverage for rehab residences lasts about 21 days or  3 weeks. (Usually stay length is determined shortly after arrival.) After that time, patients are required to pay out of pocket per day.  Many people will be involved with the discharge from rehabilitation including a Medicare representative.  Make sure to ask exactly what home care services will and won’t be covered post illness once your loved one returns home.  This may require getting written assessment records from the rehab Physical Therapy/Occupational Therapy (PT/OT) staff prior to discharge or upon their arrival back home. Typically, senior or assisted living residences will have partnerships with companies for ongoing pt / ot providers on site, as well as home-care nursing, but make sure to ask for multiple referrals before leaving the rehab center.   

Once the Patient Returns Home or to an Assisted Living

Regardless of where your patient is returning from or to, accommodations may need to be made to increase services and care to ensure a smooth transition back home and return mobility and agility. Several services are available and are covered by Medicare.  Do as much research as possible before your loved one has returned.  For more information and advice about home care services and how to select care professionals, go to the Aging in Place section.  

Winchester Hospital offers traditional inpatient care, but also incorporates a Hospital at Home program to deliver hospital-level care in the comfort of the patient's home. This program allows some patients with acute illnesses or conditions to receive treatment and monitoring in their homes, rather than in a traditional hospital setting.  Other hospitals around the country are also beginning to utilize this approach ask your local hospital if they have a similar program.

Returning to a Family Member's Home 

See section on Moving Parents In With You 
for more information

Crisis Intervention & Hotlines

911 Silent Call Procedure​

The silent call procedure helps people with certain disabilities or concerns to communicate their needs. This method works using a touch-tone, landline telephone, or a cell phone.  Here’s how to use it:

• Call 911
• When the dispatcher answers, use your telephone’s keypad to “talk” to the dispatcher.
• Press 1 if you need police. Press 2 for fire. Press 3 for an ambulance.
• If the dispatcher asks you questions:
• Press 4 for “yes”. Press 5 for “no”.

If a Massachusetts dispatcher answers a 911 call and it is silent, they will go through these steps to see if there is a response. You do not have to remember the procedure; they will ask you while on the telephone. 

Crisis & Emergency Hotlines 

Elder Abuse Hotline - National - (800) 922-2275 Mass. - (855) 530-1796 

Massachusetts: Disabled Persons Protection Commission  - (800) 426-9009 - TTY - (888) 822-0350 

Mobile Mental Health Crisis Services  - (800)540-5806 

National Domestic Violence Hotline  -  (800)-799-7233 - TTY - (877)-521-2601 

National Substance Abuse and Mental Health Service Administration Helpline - (800) 662-4357 - TTY: 1 (800) 487-4889 

National Sexual Assault Hotline - (800) 656 4673 [24/7 hotline] 

Suicide Hotlines (Massachusetts) - Dial “988” Suicide and Crisis Lifeline - Boston: (617) 247-0220 

Poison Control - Phone: 1 (800) 222-1222 

Veterans Crisis Line - Phone: 1(800) 273-8255 - TTY: 1 (800) 799-4889 

Winchester Fire Department 32 Mount Vernon St. - (781) 729-1802 

Winchester Hospital 41 Highland Ave - (781) 729-9000 

Winchester Police 30 Mt Vernon St - (781) 729-1214