Paige Hector, LMSW
Ms. Hector has over 25 years’ experience in post-acute and long-term care settings as a social worker and clinical educator.
On an individual basis, cognitive impairment, alcohol use, and falls can be challenging, but when all three are present, it may feel like the perfect storm to the staff and the family. Balancing Mrs. G’s right to self-determination with the responsibility of the assisted living facility to maintain a safe living environment requires collaboration with the IDT, the resident, and the family. This balance occurs through ongoing discussions with Mrs. G and her family about the risks associated with her choices, her medical and cognitive states, the interventions to mitigate the risks, and how the family and staff can work together. Consistent, well-documented entries in the chart by all members of the IDT are critical — all efforts to uphold the plan of care, discuss risk, and keep track of resident outcomes not only demonstrate great resident care but also build a defensible record.
A comprehensive cognitive and psychosocial assessment is key. The information learned may help inform the IDT of how best to collaborate with Mrs. G and the family. The areas to explore include coping mechanisms (past and present), significant relationships, history of mental health treatment and interventions, work and career history, finances, personal goals, past and current functional abilities and challenges, spiritual beliefs, and how Mrs. G defines quality of life. As part of the psychosocial assessment, I would conduct a depression screening such as the Geriatric Depression Scale (GDS) or Patient Health Questionnaire (PHQ-9). Although it is not mandated in the assisted living arena, I would also screen for a history of trauma because this information could be very informative. Transitioning into a new living environment and diminishing functional ability and cognition are all emotionally traumatic, and the staff needs to understand how these experiences inform Mrs. G’s current status and her choices.
So often in health care settings we tend to focus on what a person is “doing wrong” or on behavior the staff perceives as frustrating or irritating (and sometimes it really is!). From a person-centered care perspective, Mrs. G is much more than her diagnoses and choices. As the IDT works with her and the family, it is important to identify and incorporate her strengths. Ask about things she does (or used to do) for enjoyment (other than alcohol), what she used to do well, and her values and beliefs around quality of life. As the care plan is developed, use those strengths as a focal point.
So instead of setting a goal to stop or decrease alcohol use, we would approach it from a different perspective: identify what she would be doing instead. If she were drinking less (or not at all), what would she be doing with her time? The care plan should emphasize increasing that activity or state of being as a positive goal. Another important aspect is to consider the times during the day when the problem isn’t happening. What is she doing at those times of the day? How are those times different from when she is drinking? Is it possible to create more of that atmosphere/circumstance?
And it is important to be aware of the human tendency to judge, especially in those situations in which a person is making choices that might be perceived as “wrong” or “inappropriate.” As a social worker, I would be attuned to staff attitudes and how they approach Mrs. G around the alcohol issue. If necessary, I would help them find ways to engage with her without shame or judgment.
I would also review her advance directives and code status in light of her diagnoses, prognosis, and risk of injury due to a fall. I would engage Mrs. G and the family (if she agrees) in a more comprehensive discussion of advance care planning, beyond just the completion of directives. What challenges might she and the family expect should she sustain a fall with injury or if her other medical conditions progress? How would her quality of life, treatment decisions, and living situation be affected?
Finally, I would explore the discharge planning possibilities in the event Mrs. G’s needs can no longer be accommodated in the assisted living setting.