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My 61-year-old sister lives in a wonderful assisted living facility but is a bully and very disruptive to staff and residents. This is an amazing facility with top notch staff. My family has no complaints, but my sister (the resident) does. She calls and pesters the staff constantly, bullies patients to the point their families complain about her. We don't know what to do, she does not qualify for a nursing home because she is mobile, but she suffers from advanced diabetes that has progressed where she is blind in one eye, her kidneys are failing, and she is asthmatic on top of it. She loves to call emergency (we think she is addicted to the attention) and we think the AL is ready to ask us to move her. She can't live by herself and we are seriously considering calling adult protective services because we have no other solutions at this point. My elderly parents can no longer transport her to hospitals for emergency visits or regular dr. appts or her shopping needs. In fact my dad went to emergency we suspect due to exhaustion trying to help my sister. We suspect my sister has some mental issues going on maybe due to minor strokes or whatever else? We have been dealing with this for 10+ years but in the last week it has escalated to an impossible situation at the assisted living facility. Does anyone have experience letting an assisted living facility call adult protective services? We don't want them to get into any kind of trouble.

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MRHMS: I don't understand how "you can Medicaid help to place her in assisted living." Qualifying for Medicaid means the applicant is allowed to own $2,000 in countable assets.
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My mom is in a nursing facility she has moderate dementia that she can get around with a walker fairly well well home she fell three times fracturing her tailbone twice and her Spohn once she is very incontinence having to be changed every two hours of the night and having repeated episodes of incontinence during the day which requires clothing changes constantly she has had UTIs in the past she is not adjusting to this situation me and my sister have kept her home over two years my sister cannot longer help with her and I cannot do it on my own she is trying to remove me as her POA and trying to what they call transition from the nursing home even though her doctor tells her she is no longer able to live on her own and she does have Medicaid and she is mobile she cries a lot and threatens to leave and we don't know what else to do she's always been an unhappy person and she just seems to be getting worse not adjusting she's blind in one eye has had a brainstem stroke mini small strokes and a heart attack so any suggestions on helping your mother make the transition from living in my home to the nursing home right now she is mad at me mostly because I'm her POA and she's mad at my sister her grandchildren and her great grandchildren basically mad at the world even though she has made a number of friends over there and seems to really care about them I don't know from here
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MRHMSfamily: Are those 23 prescriptions in some way counteracting one another? That seems excessive. Also another thought I had is the patient is possibly turning into very child-like behavior.
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Dear M, thanks for clarifying. I hope this inpatient evaluation brings you and your family asnwers...and YIKES....23 PRESCRIPTION MEDS!!!
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Hi BarbBrooklyn, my parents have medical POA but not guardianship. They never knew to have her diagnosed since in the late 50's early 60's, that was not common. She was able to attend regular public school but was always a C to D average student. She was able to live on her own, but always had jealousy issues, terrible money management skills, and made poor choices regarding her diet even though she was diabetic and asthmatic. On the other hand, she was extremely generous to friends often to her detriment as she would not have enough money to pay her bills and rent. She was always able to hook up with people who would help her and enjoyed her company, but was never able to hold on to the friendship for any longer than a year. It was not until I had a daughter that was diagnosed with Asperger's in the early 2000's that my family started thinking there was more to my sister's physical health issues...that there may be something else going on. She has always been able to manage though until very recently when her personality has taken a drastic change. Today, when she was entered into the geriatric psychiatric unit, she told everyone she has no issues whatsoever. That she believes everyone is lying about her and she has witnesses that she behaves. Like we have said, we are praying we can stabilize the 23 prescriptions she is on (yikes!) and bring back the sister we knew and loved. She is very definitely a different person and the change took place within a month. I will keep posting as we know more.
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Are your elderly parents your sister's guardians?

Have they set up their estates so that a special needs trust with hold any monies she inherits, so as not to disqualify her from Medicaid when they die?

I have the same questions as CM, beyond asthma as a child and needing to be "kept quiet", what were your sister's diagnosed mental impairments up until this time? Is she intellectually disabled?
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My sister was admitted today to what we believe to be a very good geriatric psychiatric facility. They have assured us the first step they take is to evaluate all her meds through lab/blood tests as well as observe her in individual and group therapies. She signed herself in, but was very angry as she feels everyone is lying about her behavior. That everywhere she has ever lived she has never had any "issues" behavioral or otherwise. Thank you to DoN. I will be sure to have our family read your recommendations. Step one in process!!
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She should not be allowed to bully other patients. This (young) patient needs a mental eval stat.
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MRHMSfamily:

I am very knowledgable when it comes to senior citizen bullying--and am considered to be an expert on the topic.

I know it's time consuming to read up on senior citizen bullying, but do go to the web site http://www.stopbullyingcoalition.org/resources and at least read the .pdf manual written by Marsha Frankl, et. al. from the Boston Community Housing for the Elderly / Jewish Childrens and Family Services. This training manual was written for all employees of JCHE, educating them about mental health problems in the elderly. JCHE does a lot of in-service training, and they use that manual as part of it. Also, the resident service coordinators and social workers routinely give it to families when their resident elder appears to have behavioral problems. That way, you'll know what to expect from the AL going forward. Also, you'll learn some of the terms used by people who work to house seniors with behavioral issues.

First of all, the AL *is* doing the right thing by your sister--putting you in touch with a psychiatric hospital with a really good geriatric unit. There are many reasons why an elder becomes a bully, and it really does take a team of experts to get to the bottom of it and do right by the elder and the AL. Your sister will get a medical workup, for many times an undiagnosed or under treated physical problem (or problems) can cause behavioral problems (UTI for example). Sometimes, side effects from medications or bad medication interactions can cause or worsen behavioral issues. Sometimes, it's not just one problem, but a host of problems that interact, causing your sister to behave badly. Get her admitted to the facility the AL suggested and work with them to figure out what's going on, get her stabilized, get her a treatment plan and figure out what sort of living arrangement would be best for her going forward. From what you have said, it sounds like your sister is in a good AL, an AL that is following 'best practices'. (Many unenlightened senior citizen living situations will just try to evict / get rid of a senior who is a bully and who won't stop. That's not the right way to handle the situation.)

Please let us know how she's doing--what you feel comfortable writing about online.

I hope that helps.
DoN
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OH my gosh, don't misunderstand. My entire family is heavy hearted about the suffering my sister is going through. It is why we are working so diligently to find help. As of now, her AL put us in touch with a wonderful inpatient facility that is going to test her meds, and observe her to help improve her situation. We love my sister and are not willing to do anything to compromise or put her in a bad situation. I may have not represented the situation in a clear concise way, but it is why I reached out on this forum to educate ourselves and find the options that will best help her.
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Blind
Complications of diabetes
Severely asthmatic
Renal failure

I can understand that you feel that your sister's life has suffered because her attention-seeking behaviours have been reinforced and it has left her unable to function. But looking at that list, your heart doesn't ache for her at all? Sixty one years old, totally dependent and with disabilities of much later age.

Asthma is an under-estimated disease which kills many, many people every year in spite of steroids and inhalers and all the wonders of modern medicine. The typical local newspaper probably carries a story about a dead school-age child once every couple of years or so, and everyone gets reminded of how dangerous it is, and then everyone forgets again. But all the same. Most asthmatics learn how to manage their condition and go on to lead perfectly normal, fulfilling lives.

So I wonder if there was also some additional factor your parents perhaps preferred to keep private. Did your sister ever live independently? Hold down a job? Complete her education?
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Wow! I can't begin to thank you all! Country, you are very perceptive. My sister has been sickly her whole life with asthma. My parents have always been caretakers and back when she was a baby, Drs advised my parents to keep her quiet with activities that were not physical. She obviously became used to having the attention focused on her. In her later years, when it became obvious her health was declining, my parents took over her care and put her back on their insurance. My mom handled all her finances and my dad would drive her everywhere. As my parents have aged, it has become far more difficult for them to help my sister. I live out of state and have asked if I could research this situation and see if we could get relief care for my parents. This is when we discovered we could get Medicaid help to place my sister in assisted living. I think because she is spoiled, she wants specialized attention and is now acting out because she is not getting it. Her "bullying" is in the form of lying, and creating hurtful rumors about the staff and other patients and my family. She has not been physically abusive. But in my book, it is still bullying. The staff knows we are diligently working on getting help for her and they are nothing but supportive. My heart aches though, for the trouble my sister is causing.

We are at the beginning of this voyage as I arm myself with knowledge and learn how to best handle this situation so my parents have peace and my sister is comfortably taken care of. Your suggestions have been invaluable.
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That is a good idea to have the social worker or case manager at the hospital recommend a memory walking memory lock down unit, but she may need a physical and psychological testing for the memory loss diagnosis. If you care close to a medical school or college facility that performs research for memory problems, or that test for memory problems, that is a good place to start. Or have her Primary care physician refer you to a good psychiatrist that is a specialist for memory problems.
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You may be able to get the hospital your sister will be an outpatient  at to recommend placement in a nursing home. If it is determined that she has mental issues more than physical ones, you could even ask for referral to a memory care unit. When she becomes a patient of this hospital, she should be assigned a caseworker. When the staff and physician observe her actions, you may find them more than willing to help. I would caution confronting her. She does sound unstable. When challenged, my mother became combative with everyone around her. She was amazingly strong for an elderly woman. If people (like other residents of the AL) start confronting and challenging her and she does physical harm to someone, for sure she will get tossed. Good luck!
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Sounds like sis has been this way a long time--and altho she is young (I'm also 61!!) she is getting something out of acting this way--attention? Likely there is some underlying issue now. Mental disorders can come on at any age. Having her evaluated since she is already in an ALF shouldn't be too hard.
Why are your elderly parents so involved? I'm sure the facility is mighty expensive and helping with sister's care, physical and emotional is part of what they're being paid to do.

If she's disruptive enough, yes, she can be "kicked out" but I think that would only occur in the direst situation, after all available tactics have been exhausted!

And as always, I imagine they would check for a UTI. Those things are wicked.
If your sister has an underlying mental disorder, it may have lain "dormant" for many years. With a lot of other health issues, perhaps that has never been addressed.
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Just to highlight the very unusual factor here: the person needing care in this post is only 61 years old, and her family has been struggling with her physical and behavioural challenges for ten years.

I don't like to pry, but has anyone ever put a name to your sister's difficulties?
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Bullying is an extremely common problem in senior living situations. According to research I saw by ProMatura (behind a paywall, because it was done for a trade organization), the researchers concluded that practically all Independent Living Senior Residences have bullying. All residents are entitled to 'quiet enjoyment' of the residence.

Here's what I would do: first get educated about the problem. Go to http://www.stopbullyingcoalition.org/resources. Start with the Essentials page and watch all the videos/webinars and read all the sites. Once finished with that, you'll know about 95% of what there is out there on this topic. Then, go to the Comprehensive Resources list and check out links that might be of interest. Right now, the links pages are current, but the person who developed them butted heads with the man who owns the web site so it's unlikely that the links pages will be diligently maintained. Pay particular attention to the training manual developed by Marsha Frankl and her colleagues at the Jewish Community Housing for the Elderly--this discusses how a very good housing provider manages elderly residents who bully, who appear to have psychiatric problems and are creating problems for other residents and staff.

This is important: you want to keep *very* good notes. You definitely want the staff at the assisted living to help tackle this problem. Your sister does need to know that bullying behavior will not be tolerated here, and there are serious consequences. You definitely want your sister to get both a full medical and psychiatric workup--with the medical workup coming first. In a well-run assisted living, when management knows that you want to see your sister's behavior back under control and the bullying stopped, the staff is much more likely to do right by your sister and the other residents, that they are less likely to threaten to evict her while experts are trying to figure out what's going on and get her behavior under control. Because, after doing your homework, you might be able to suggest ways to help calm the situation down, using established best practices. Why do you need good notes? Your sister is probably in danger of being evicted--and you might need to get a lawyer to stave off an eviction so that you can get her admitted to a more appropriate place. Also, your observations and notes will be very useful to medical and psychiatric staff who are trying to treat her and get to the bottom of the situation. Keep a log book--document every interaction you have with her and if you think she bullied, you really want to document what she said or did to someone. You will want to keep notes at all meetings you attend on her behalf. If it comes to getting Adult Protection Services involved, the case worker will be glad that you kept good notes.

Good luck. I hope that helps.
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to jeannegibbs: It used to be that a patient needed 3 deficits in ADLs to be eligible for nursing home care. Many people who are mobile are unable to bathe, dress and feed themselves with out assistance and need monitoring with medications, for instance. As for this particular patient issue, agree that she needs further evaluation: both medical and psych.
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Thank you all for caring enough to answer with experiences and good advice. I researched and found a hospital that offers in and outpatient psychiatric and behavioral evaluations. We took her there and they have put her in the outpatient program for at least the next 5 days beginning on Monday. We are all praying this has something to do with the cocktail of meds she is on...we will see. Yes, I do agree my sister will be miserable wherever she lives. It is truly sad. She is on Medicaid but we have been told she has no specific caseworker assigned to her. I am still working on that since as Country pointed out, my parents are in their 80's, and we need a plan. (we truly thought we had that when we moved her to the assisted living home 5 months ago). And as for not qualifying for a nursing home where we were hoping 24/7 medical care would be available, we have not been able to prove a medical necessity for her to qualify. We will test for a uti if this route through the psych and behavioral Evals don't show anything. Thank you all. I will post more as we know.
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My mom was kicked out of memory care and went to a smaller care home. Her behaviors were more than over the top. She did not have a uti, the behavior had been present since she first moved two years ago. The facility kept trying to find a med solution. They were effective up until February this year, the move happened. Mom's new facility had 16 residents all of which had been kicked out of previous facilities because of behaviors. They had become a danger to themselves and others.

Mom had Alzheimer's Disease, that was killing her brain, just a bit at a time and is different for everyone. Mom was not being picked on, but she certainly was out of control with other people. The problem was mom and her disease not how she was treated by others.

Get your sister a psych evaluation a different level of care is needed. And as Jeanne said have her checked for infection.
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It sounds to me like people need to start standing up to her and putting her in her place, this is about the only thing you can do with a bully. No matter where she goes, she's going to be a problem no matter where you move her. Just encourage everyone to start standing up to her, I sure would if approached by a bully. I don't put up with crap from no one, especially not a bully
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I'm not sure who you think could get into trouble for seeking help with your sister's care? In fact, I'm if anything surprised that she hasn't already been assigned a caseworker. Your parents must be in their eighties, at least; and it is high time that thought was given to who is going to take over responsibility for your sister's welfare once they are no longer able to manage it.

So all round, yes, for goodness' sake, go right ahead and call APS - not a moment too soon!
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Lots of people in my mother's nh were mobile ... I don't understand why that would be a requirement for your sister. But there is no guarantee that she would suddenly become cooperative and happy there, either.

Since this escalated severely suddenly, have her tested for a uti. That sometimes causes behavior issues in older people.

I agree with Glad that the next step should be an inpatient psych evaluation, to sort out mental health issues and come up with a treatment plan.
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She needs a psychiatric evaluation, in patient. They will work with her to determine what meds and how much she should take to try to control her behavior.
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