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Similar to Assessing risk and managing behavior may 6 2015
Assessing risk and managing behavior may 6 2015
- 1. 5/3/2015 1 Cindy Mann, RN,BSN Unit Manager Centra Senior Psychiatric Program Cindy Mann, RN, BSN Unit Manager Centra Senior Psychiatric Program Identification of Problematic Behavior Sundowning Wandering Hiding possessions Combativeness with interaction Verbal aggression Physical aggression CONSIDER Type of dementia Area of brain affected Stage of disease
- 2. 5/3/2015 2 E Is NOT aspecific disease. Alzheimer's disease is the most common cause of a progressive dementia. Is a GROUP OF SYMPTOMS affecting intellectual and social abilities severely enough to interfere with daily functioning. Memory loss generally occurs in dementia, but memory loss alone does not imply you have dementia. Alzheimer’s Disease Vascular Dementia Dementia with Lewy Bodies Mixed Dementia Frontotemporal Dementia Parkinson’s Disease Dementia ALZHEIMER’S DISEASE Brain disorder, most common form of dementia Affects 5% of people at age 65 Affects 50% of people age 85+ Late-onset (65+) is most common, slowest- progressing Average course of DAT: 6-20 years Increased Confusion Increased Anxiety Increased Frustration
- 3. 5/3/2015 3 VASCULAR DEMENTIA Poor ImpulseControl Impaired Judgment Inability to Make Decisions 2nd most common dementia after Alzheimer's disease Result of a damage to the brain caused by problems with the arteries serving the brain or heart ASSOCIATED SYMPTOMS: Confusion and agitation; depression Unsteady gait Problems with memory Urinary frequency, urgency, incontinence Night wandering Decline in ability to organize thoughts/actions, difficulty planning Poor attention/concentration Approx. 25-30% of all dementias are VaD LEWY BODY DEMENTIA Deposition of Lewy bodies in both, cortical and subcortical SYMPTOMS - Core criteria (must have two): Fluctuating attention and concentration Recurrent, well-formed visual hallucinations Newly emerged PD-type motor problems Affects 1% of those age 65, 5% over age 85 Usually progresses more rapidly than DAT (average = 6 years) Visual Hallucinations FRONTOTEMPORAL DEMENTIA Group of diseases characterized by the degeneration of nerve cells in the F-T areas of the brain (Fronto-temporal areas of the brain are generally associated with personality, behavior and language). In these dementias, portions of these lobes atrophy. ASSOCIATED SYMPTOMS: socially inappropriate behaviors loss of mental flexibility decline in personal hygiene language problems, and movement disorders difficulty with concentration and thinking. Begins earlier and progresses faster than AD Occurs at ages younger than AD, i.e., 40-70. Changes in personality Changes in temperament Changes in demeanor
- 4. 5/3/2015 4 Comorbidities??? …Physical Changes, Illnessor Injury? Is the person responding to Changes in hearing/vision OR Delirium OR Pain Fall Risks FALLRISKS Vision Changes Medications Sedation Orthostatic Hypotension Muscle Weakness Orthopedic changes
- 5. 5/3/2015 5 …Is there anunderlying Mood Disorder? Are they depressed? Are they anxious? SUICIDE RISK History of depression, suicidal ideation/attempts Family history of suicide reduces the taboo Medical advances increase life expectancies Fear of institutionalization Financial stressors of growing older Grief (family, friends, career, autonomy, health, wealth) …Is there an Underlying Thought Disorder? Fearful Psychotic Having Trouble Processing
- 6. 5/3/2015 6 Identification of Triggers Whatprecipitated the behavior? Could it have been….. Over- Stimulation? Fatigue? Change of Residence or Caregiver? Misinterpretation of Situation? Receptive Aphasia? Know the Person… Know their Life Story… To better understand WHY a person responds the way they do – Understand WHO a person is and has been.
- 7. 5/3/2015 7 Are their behaviors or responses relatedto …. A traumatic or abusive history? The lifestyle or work history they led? Their level of education? Relationships they’ve had? Religious or Cultural backgrounds? Medical history? Are their needs being met? • Potty • Positioning • Pain • Personal Items • P.O. intake Tools and measures have been developed to help predict aggression in acute inpatient psychiatric settings
- 8. 5/3/2015 8 BRØSET VIOLENCE CHECKLIST (BVC) HCR-20CLINICAL SCALE DYNAMIC APPRAISAL of SITUATIONAL AGGRESSION (DASA) IRRITABILITY IMPULSIVITY UNWILLINGNESS TO FOLLOW DIRECTIONS SENSITIVITY TO PERCEIVED PROVOCATION EASILY ANGERED WHEN REQUESTS ARE DENIED NEGATIVE ATTITUDE ANXIOUS OR FEARFUL LOW EMPATHY OR REMORSE PAST VICTIM OF SEXUAL OR PHYSICAL ABUSE PHYSICAL AGGRESSION TOWARD OBJECTS IN PAST 24 HOURS VERBAL AGGRESSION TOWARD A PERSON IN PAST 24 HOURS PHYSICAL AGGRESSION TOWARD A PERSON IN PAST 24 HOURS Responses to Warning Signs Inform ALL Care Providers and Increase Monitoring Re-assess Behavioral Strategies Possible Changes in Medication
- 9. 5/3/2015 9 Remain Positive &Focus upon the feelings of the individual, not the facts. In most situations, their behaviors are telling you what the person no longer can. Beth B. Ulrich, LCSW Community Liaison, Centra Senior Psychiatric Program Beth B. Ulrich, LCSW Community Liaison, Centra Senior Psychiatric Program PREVENTION Basic Needs Security Affection Control Inclusion
- 10. 5/3/2015 10 Challenging behaviors, including aggression,are usually the person’s search for security, control, identity, affection or a sense of purpose or achievement. PREVENTION Goal of Prevention Not stopping the behavior but addressing the needs that lie behind it. PREVENTION Fundamental Questions How do we perceive behaviors? • Person’s effort to cope/communicate a need – NOT something that must be eliminated. • The approach is to identify alternatives and increase understanding rather than imposing controls. PREVENTION
- 11. 5/3/2015 11 REWARDS AND CONSEQUENCES DONOT WORK Fundamental Questions How do we see our role with cognitively impaired patients? • Paternalistic versus becoming her partner • Paternalistic—determining what she needs or what is best for her • Becoming her partner—entering her world PREVENTION It is important to engage with the patient. Get to know the patient •Life story •Preferences •Food •Activities •Values •Identity •Mother •Husband •Vocation • How do we see our role with cognitively impaired patients? • Paternalistic versus becoming her partner • Paternalistic—determining what she needs or what is best for her • Becoming her partner—entering her world
- 12. 5/3/2015 12 Fundamental Questions How dowe understand the behavioral and functional manifestations of dementia? • Caregiver must understand the disability in order to meet the needs of the patient. • Apraxia • Aphasia • Amnesia • Agnosia • Executive dysfunction PREVENTION PREVENTION Do we ask our patients to do things that are impossible for them to do? Fundamental Questions How do we respond to an individual’s needs? • The need to meet physical & psycho-social needs Security or Restriction? • Identify compensation measures to meet the needs of the patient—i.e. , providing specific activities and forms of assistance, addressing specific needs. PREVENTION
- 13. 5/3/2015 13 Define Observations, details, facts Where, when, how,with whom, after/ before what? Decode What may be contributing to cause the problem? Devise Treatment Plan: What are we going to do? Determine What outcome is expected? Do the interventions work? THE 4-D APPROACH DIFFICULT BEHAVIORS VERBAL yelling, screaming, threatening through body posture PHYSICAL hitting, pushing, shoving, kicking, spitting Focus on specific behavior – e.g., “hits while being bathed” Usually a precipitant or provocation can be identified related to the behavior. DEFINE DIFFICULT BEHAVIORS It is important to describe: The form the behavior takes Against whom it is directed The context in which it occurs Consequences, such as injury Also to examine: Time of day Frequency What the patient says Serious problem leading to injury, distress in patients & distress to others DEFINE
- 14. 5/3/2015 14 Health & MedicalConditions Environment Approach Resident Factors Decode: HEAR Decode:HEAR A thorough medical exam including consideration of psychiatric history should be conducted. Include a head CT. Health and Medical Conditions Psychiatric Disorder or History may be related to delusions, hallucinations, suspicious behavior or paranoia Also depression, mania, sleep deprivation Medical Disorder/History Delirium Pain Constipation Visual/Hearing Impairments Certain medications (steroids, etc.) Hydration and nutrition Decode:HEAR Environment over stimulating or under stimulating? Is there a lack of structure and activity?
- 15. 5/3/2015 15 Decode:HEAR Approach being pushed, approached from behind,inadequate communication A supportive and attentive approach helps to prevent problematic behaviors. Decode:HEAR Resident Factors Be aware of patients’ Needs Wants Habits Desires Consider the symptoms of dementia or other cognitive disorders Aphasia patient may be frustrated by an inability to express himself or to understand something being said to him. Agnosia patient may not recognize a person who is approaching him and may strike out in self defense Apraxia patient cannot identify an object so he throws it (i.e. TV or lamp) Amnesia patient tells the same story repeatedly or cannot remember what he had for breakfast Executive Disorder inhibitions related to aggressive urges no longer exist Decode
- 16. 5/3/2015 16 • Could itbe a catastrophic reaction? Decode Catastrophic Reaction Sudden expression of negative emotion – i.e., crying, yelling precipitated by an environmental event or a task failure Person behaves as if a catastrophe has happened even though the precipitant is minor. Decode DEVISE Change caregiver approach Remove the precipitant Use distraction Stay calm Keep patient out of harm’s way even if it means • grabbing the patient or blocking him Make environmental changes Pay attention and spend time with your patient – • develop a trusting relationship Know how to identify precipitants especially related • to catastrophic reactions
- 17. 5/3/2015 17 CHANGE CAREGIVER APPROACH Stopcorrecting Don’t argue (delusions and hallucinations) The patient is always right Walk away and try again later with a different approach Show the person what you want him or her to do by demonstrating and praising nonverbally through hugs or a caring smile Don’t talk about the person in front of him/her DEVISE REMOVE THE PRECIPITANT Certain people Time of day Certain places Understand the task failure Reassure And use distraction DEVISE USE DISTRACTION What does he/she like to do? •Reminisce •Favorite foods •Favorite music Avoid TV, especially soaps and talk shows (old sit coms and old Westerns are better). DEVISE
- 18. 5/3/2015 18 STAY CALM “I’m sorry.” Listenwithout judgment DEVISE KEEP PATIENT OUT OF HARM’S WAY Even if it means grabbing the patient or blocking him Learn caregiver protection techniques-MANDT • Blocking arm swings • Getting out of holds • Controlling patients’ hands DEVISE MAKE ENVIRONMENTAL CHANGES Temperature Noise level Providing comfortable clothes Decorating with familiar pictures Soothing aromas Enjoyable sounds DEVISE
- 19. 5/3/2015 19 Develop a TrustingRelationship Get to know her history DEVISE Provide activity and structure Examine communication techniques DEVISE COMMUNICATION Speak slowly in a low- pitched voice Enunciate your words Begin your conversations socially Use short, familiar words and simple sentences Talk in a warm, easy- going, pleasant manner Ask simple questions that require a choice of a yes/no answer Listen carefully Give positive instructions and avoid “don’t . . . can’t” or negative commands Avoid questions that require short-term memory; e.g., “Did your son come to see you today?” Communicate using the person’s long-term memory: “I hear you have a wonderful son.” Give simple instructions for one task at a time (the simple task of brushing teeth contains 11 steps) Keep talking to the person with dementia, even if he cannot talk back Focus on a word or phrase that makes sense Respond to the emotional tone of the statement, not the words Stay calm and be patient Ask family members about possible meanings for words, names, or phrases Respond as though you understand Try a hug and change the subject Simply say, “Wow! Whoa!”
- 20. 5/3/2015 20 Learn caregiver protection techniques– MANDT • Blocking arm swings • Getting out of holds • Controlling patients’ hands Hospitalization on Geri Psych may be indicated if patient is a danger to self or others Medication interventions may be necessary DEVISE DETERMINE May not reach complete resolution but minimize the behavior and its consequences as much as possible It may take several weeks so . . . BE CONSISTENT! Labeling behavior can hide the real problem.
- 21. 5/3/2015 21 In Conclusion .. . Person with problematic behavior can actually be: Defending himself Paying someone back Letting someone know that he has had enough Telling someone he is in pain Protecting something precious The solution is to identify and stop what the patient feels: Is attacking her Started it Is antagonizing her Is hurting her Is threatening her
- 22. 5/3/2015 22 Problematic behavior is generallynot a vindictive action, though it may feel like an attack. • Problematic behavior is reduced, improving the quality of life for the patient. • The caregiver-patient relationship improves, preventing compassion fatigue and caregiver burnout. THE ULTIMATE RESULT Rabbins, Peter V.; Lykestsos, Constance G.; Steele, Cynthia D. Practical Dementia Care. New York: Oxford University Press, 2006 Mace, Nancy L.; Rabbins, Peter V. The 36-Hour Day. New York: Wellness Central/ The Johns Hopkins Press, 1999 Brackey, Jolene. Creating Moments of Joy. West Lafayett: Perdue University Press, 2007 References
- 23. 5/3/2015 23 Cindy Mann, RN,BSN Unit Manager Centra Senior Psychiatric Program [email protected] Beth B. Ulrich, LCSW Community Liaison Centra Senior Psychiatric Program CONTACT [email protected]