Making Sense of Behavioral Symptoms in Nursing Home Residents:
Alternatives to Antipsychotic Drug Use
Joel E. Streim, M.D.Professor of Psychiatry
University of Pennsylvania Philadelphia VA Medical Center
Quality Insights Webinar 2.20.13
Disclosures
Dr. Streim is on the faculty of the Geriatric Education Center of Greater Philadelphia, which is funded by the Bureau of Health Professions, Health Resources and Services Administration (HRSA), Dept. of Health and Human Services (DHHS).
The content of this presentation is solely the responsibility of the presenters and does not necessarily represent the official views or policies of HRSA or the DHHS.
Objectives
1. Explain challenging behaviors among nursing home residents by recognizing common causal or contributing factors.
2. Identify non-pharmacological interventions that are likely to produce desired results in modifying behavior.
3. Give examples of the systemic barriers to implementing non-pharmacological interventions in nursing facilities
Overview
Three premises lead to the conclusion that:1Antipsychotic drug treatment is usually not the most appropriate response to most resident behaviors; and2Sensible, effective, non-pharmacological responses to behavior required a patient-centered approach to care.
Premise #1
Not all behavioral symptoms are problemsA behavior becomes a problem when it is associated with:— Distress (subjective experience of the resident)— Disability (observable functional impairment)— Disruption (interference with delivery of care, or
disturbance of the living environment)— Danger (to self or others)
Premise #2
Most problematic behaviors among nursing home residents are not likely to respond to antipsychotic drugsMost behaviors are not caused by psychotic illnesses. Only a small proportion of residents have conditions that can be appropriately treated with antipsychotic medication, such as:
• Schizophrenia• Bipolar disorder• Depression with psychosis• Dementia with psychosis, in selected cases
Premise #3
Behavior problems are commonly triggered by an approach to care that fails to incorporate the resident’s own experience
Care that is based solely on facility routines and caregivers’perceptions often causes the resident to become anxious, fearful, irritable, or angry.
Resultant behaviors may include — Restlessness— Yelling or verbal hostility— Rejection of care— Physical combativeness
Case Example
A very confused 83-yr-old female resident, Mrs. M, sees staff put on coats and get ready to leave at change of shift (3pm).
Resident heads to the exit door. A CNA runs after her, yelling “no, you can’t go out
there.” Resident pushes the CNA away. Note entered in chart
says “resident tried to elope, and was physically aggressive toward staff.”
Attending physician is called and gives an order for haloperidol 2 mg every day.
Alternative Patient-centered Approach When patient heads to exit door, CNA asks: “Can I
help you?” Resident says, “I have to go home to get a snack
ready for my daughter. She’ll be home from school any minute.”
CNA says, “OK, I’ll help. Let’s go to the kitchen and get some cookies for your daughter. I bet she’ll like them. What’s her name?”
The resident turns away from the exit door, and follows the CNA to the kitchen area.
What do we need to learn as caregivers?
How to make sense of behavioral changes associated with dementia and other conditions— 1. Understand and empathize with the resident’s experience— 2. Recognize factors that cause or contribute to behavioral
problems Once understood, interventions and management
strategies become apparent
Assessment informs approach to care
Making Sense of Resident Behavior
All behavior makes sense / has meaning Applies to residents with and without
dementia Looking for reasons behind behaviors by
“stepping into the resident’s world” enables us to identify person-centered solutions that— Are responsive to resident needs— Avoid using unnecessary medications
Person-centered Care: WHY?
Key to culture change in nursing homes Resident and staff become part of a
caregiver / care-recipient partnership Increases residents’ perception that staff is
“on their side”— Residents become less likely to experience
care as adversarial— Staff becomes less likely to experience
caregiving as a struggle
Person-centered Care: WHAT?
Focus on the resident’s experience— Try to imagine being in their world— Consider how things look from their
perspective Accept their reality— Their subjective experience is real to them— Doesn’t mean you actually adopt their point of
view for yourself
Person-centered Care: HOW?
Look for meaning in verbal and non-verbal communication
Ask, “what do you want? “how can I help?” Listen for clues to sources of distress or
unmet needs Avoid saying “no”, arguing or disagreeing Offer to help in ways that reduce distress or
meet needs, without compromising safety
Making Sense of Behaviors
A richer understanding of the resident’s experience also requires the identification of causal and contributing factors
Causal and Contributing Factors
Behavioral symptoms can be multiply determined by— Cognitive deficits — Unmet needs (physical and psychological)— Environmental / social irritants— Medical illness / physical discomfort— Psychiatric conditions— Adverse drug effects
Cognitive Domains Impaired in Dementia Memory loss (amnesia) Decline in other cognitive functions— Language (aphasia)— Visual-spatial function— Recognition (agnosia)— Performing motor activities (apraxia)— Initiating/executing sequential tasks
(apathy, abulia, executive dysfunction)
How does memory impairment lead to behavioral problems?
ExamplePatient can’t remember where his clothes are kept
Walks into hallway naked
How does language impairment (aphasia) lead to behavioral problems?
ExamplePatient who can’t verbally communicate that pills are hard to swallow
Spits medication at caregiver
How does impaired visual recognition (agnosia) lead to behavioral problems?
ExamplePatient can’t recognize a spoon as a utensil for eating
Throws the spoon on the floor
How does impairment in performance of motor tasks (apraxia) lead to behavioral problems?
ExamplePatient cannot manipulate zippers or buttons to unzip or unbutton his pants
Wets his clothing
Common misattributions for behaviors
Caregiver may assume resident is:Angry / BelligerentLazy / DependentManipulative
Often, a behavior that is interpreted as “uncooperative” is actually better explained by cognitive disability
Emphasize Resident Strengths
Recognize
areas of impaired function
and
areas of preserved function Help compensate for impairment Support and celebrate residual abilities
— Focus on something unique that person feels good about
— Express appreciation and admiration
Remember: There’s no one-size-fits-all response to behaviors Different residents have different situations
and needs Residents change over time; needs and
behaviors change, too Some responses work one day, not the next Some responses work for one caregiver, but
not another Responses must be tailored to the individual
and modified over time
Strategies for Communicating with Residents with Language Comprehension Deficits
Sit down; communicate at eye-level Connect with smiles, humor Reassure with simple words, comfort with touch Use visual and gestural cues Speak slowly, using short sentences, single words
— One idea, one direction at at time— Be patient; give adequate time to process and respond
Avoid using negative tone or words— Don’t scold or argue
When language comprehension is severely impaired, use other senses to communicate — Smell, touch, vision, taste
What modifiable factors may contribute to behavioral changes
in nursing home residents (with or without dementia)?
Unmet needs that can lead to behavioral disturbances
Physical needs— Nutrition, hydration, toileting, exercise, rest
Psychological needs—Security, autonomy, affection, self-worth
All residents—whether cognitively intact or impaired—have common, basic needs
Environmental irritants that can lead to behavioral disturbances Physical— Noise— Confusing visual stimuli— Physical barriers— Uncomfortable temperature— Unfamiliar surroundings
Social— Changes in routines— Caregiver interactions
Medical conditions and physical discomfort that can lead to behavioral disturbances
Physical discomfort— Pain— Constipation— Urinary urgency— Shortness of breath— Dizziness— Fatigue
Medical condition— Arthritis— Dehydration— Prostatic hypertrophy— COPD— Cerebrovascular disease— CHF
Psychiatric conditions that can cause behavioral disturbances Depression Delirium Psychosis— delusions— hallucinations
Anxiety Sleep disturbance
Adverse drug effects that can cause behavioral disturbances Nuisance symptoms Anticholinergic effects Antihistaminic effects Paradoxical excitation / disinhibition Intoxication or withdrawal states Akathisia (syndrome of motor restlessness)
Identification of any of these modifiable causes—unmet needsenvironmental and social irritantsmedical illness and physical discomfortpsychiatric conditionsadverse drug effects—
points the way to specific interventions
Institutional resources to promote non-pharmacological approaches Consistent staff assignments Assignment of staff across disciplines to
supervise everyday leisure activities — Group— Individual / solitary— Beyond structured recreation therapy
Space for exercise, outdoor activities
Barriers to Implementation of Non-pharmacological Approaches Ingrained culture of medical and nursing care Inadequate staff training Staff turnover Aversion to risk-taking— Need to accept that risks are part of normal,
everyday life— Need to change attitudes of families, staff,
administrators, regulators, surveyors, legal counsel
Resources for Training and Implementation CMS campaign website:http://www.nhqualitycampaign.org/star_index.aspx?controls=
dementiaCare Hand-in-Hand (person-centered dementia
care training materials):http://www.cms-handinhandtoolkit.info/
Index.aspx
Questions
&
Discussion
