Behavior Problems: Dementia and Mental Illness in Long Term Care and Assisted Living

Transcription

1 Behavior Problems: Dementia and Mental Illness in Long Term Care and Assisted Living Module II Dr. David A. Smith, M.D., FAAFP, CMD mmlearn.org is a program of Morningside Ministries

2 Cell Phones and Pagers Please turn your cell phones off or turn the ringer down during the session. If you must answer a call, please be considerate of other attendees and leave the room before you begin to have your conversation.

3 Presenter: Dr. David A. Smith, M.D., FAAFP, CMD

4 Approved for Contact Hours Participants must be present for the entire program Participants are required to sign in (or register online) Participants will be required to complete an evaluation form at conclusion of presentation (for learner-paced, completion of a post-test).

5 EVALUATION SHEET After viewing online, you are required to complete your post-test/evaluation form.

6 Disclosures No conflicts of interest were evident in the development of content for this activity by planning committee members or presenters. No commercial support was received by EMTI at Morningside Ministries for this activity.

7 Disclosures Non-Endorsement of Products No Off-Label Use is related to the content of this activity.

8 Want To Ask a Question or Make a Comment Click on the Ask bubble at the top of the presentation to ask a question.

9 What do you think? Your feedback is important to us. Click on SURVEY in the upper right of the presentation screen. It will take less than 5 minutes.

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12 Module II Pain Perception Cortex Limbic system ~ agitation, emotionality Thalamus Spinal cord Peripheral receptor

13 Anticholinergic drugs antihistamines antimuscarinics/urge incontinence drugs digoxin theophylline, ipatropium

14 Anticholinergic drugs cont d many psychotropics (e.g. anti psychotics, tricyclics, antidepressants) anti Parkinsonian medications many others anticholinergic load

15 Positive Consequences of Restraint Visible indication that something is being done Immediate effect Fairly inexpensive Reusable Has been the normative standard of care Administrative sanction

16 Negative Consequences of Restraint Physiologic: Immobilityloss of strength contractures decubiti loss of balance cardiovascular decompensation, decreased blood volume postural hypotension

17 Negative Consequences of Restraint Physiologic: Immobilitydependent edema incontinence of bowel and/or bladder decreased appetite and malnutrition decreased immune response to challenge decreased fluid intake decreased basal metabolic rate cont d

18 Negative Consequences of Restraint Physiologic: Abrasions and skin tears EEG changes Increased falls with injury Strangulation cont d

19 Negative Consequences of Restraint Psych-Social: Increased agitation Anger, aggression, verbal abusiveness Screaming Resignation and withdrawal cont d

20 Negative Consequences of Restraint Psych-Social: cont d Depression Decreased interaction with others Appearance of infirmity or lack of capacity

21 Marital Relationships Attachment Competing balance between intimacy and independence Negotiation (set balance of intimacy and independence)

22 Marital Relationships cont d Unconscious fears of connection and separation Power in negotiation Patterned or automatic maintenance of balance of power

23 Marital Relationships cont d Change and restoration of balance of power after conflict or crisis Health-facilitating balances which enhance personal mastery and growth

24 Marital Relationships cont d Balance which copes with external stressors (illness, loss) but also promotes intimacy and individuality Values, shared beliefs, attitudes

25 Dysfunctional Family Dynamics Loss of generational boundaries Rigidity or chaotic lifestyle Lack of privacy, individuality Triangulation or scapegoating

26 Dysfunctional Family Dynamics Abuse and victim / perpetrator issues

27 Conflicted Surrogate Syndrome A syndrome characterized by actual or potential negative outcomes of a LTC resident due to social, psychological or psychiatric problems in a responsible party, family member or the family system. Is there a Conflicted Surrogate Syndrome affecting quality of care in nursing homes? JAMDA, March 2006: 7; 3,

28 Summary: Some Reasons for Behavior Problems in Dementia Cognitive loss/misinterpretation of the environment Psychological/personality explanation Cultural/social systems explanation Unmet physical need Pain

29 Summary: Some Reasons for Behavior Problems in Dementia cont d Physical illness with functional deficit Physical illness with psychiatric symptom Medication side effect psychiatric symptom Mental illness comorbid with dementia Any combination of the above

30 Consequences of Behavior Problems in Long Term Care

31 Behavior in Nursing Facility BANG! BANG! BANG! HELP ME! HELP ME! Screaming, repetitious vocalization, banging in 11-30% Effect on staff, other residents and visitors

32 Behavior Problems in Dementia The single most common cause of nursing facility placement from home or assisted-living facilities

33 Behavior Problems in Dementia cont d The most important, potentially remedied time sink for staff

34 Behavior Problems in Dementia cont d Staffing is among the largest line items of expenses in the nursing facility

35 Impact of Behavioral Problems in the Nursing Facility Behaviors often require licensed nurse and certified nursing assistant (CNA) intervention Most frequently reported behaviors Physical agitation Refusal of care Requests for unneeded attention Kleinman L, et al. Consult Pharm. 2002;17:

36 Impact of Behavioral Problems in the Nursing Facility Behaviors often require licensed nurse and certified nursing assistant (CNA) intervention Most costly behaviors per occurrence Physical aggression Psychotic symptoms Sexual disinhibition Depressive symptoms cont d Kleinman L, et al. Consult Pharm. 2002;17:

37 Determining the Per Diem Resource Utilization Groups (RUGs) Special Rehabilitation (14) Extensive Services (3) Special Care (3) Clinically Complex (6)

38 Determining the Per Diem Impaired Cognition (4) Behavior Problems (4) Physical Function (10) MDS 3.0 Implemented Oct10 cont d

39 Motivations Under PPS Manage outcomes rather than expenses Look at value

40 Impact of Behavioral Problems on Nursing Home Staff Nursing home staff caring for the elderly with behavioral problems may» Feel frustrated, exhausted, and helpless» Withdraw from the patient, resulting in provision of minimal care» Overuse physical restraints Potts HW, et al. J Gerontol Nurs. 1996;22:11-16.

41 Caregiver expectations of patients Gratitude Acceptance Patience 41

42 Caregiver responses to aggression: Anger Retaliation Defensiveness Understanding

43 Behavior Problems in LTC: Interdisciplinary Teaming

44 Behavioral Problem Solving by Interdisciplinary Team Process What explains the resident s behavior? Is this intrinsic to the resident? Extrinsic to resident, a problem with environment/ system? A combination?

45 Behavioral Problem Solving by Interdisciplinary Team Process cont d -When does it occur? (Under what circumstances?) -What precedes the behavior? (Triggers?) -What exactly is the behavior? -What happens after the behavior? (Rewards? Consequences?) Worst Case Scenario?

46 Behavior Problem Solving by the Interdisciplinary Team Process Diagnosis review? Mental disease explains the behavior. Physical disease explains the behavior. Physical disease causes mental symptoms.

47 Behavior Problem Solving by the Interdisciplinary Team Process Drug review? Drug-induced mental symptoms. Inadequate or incorrect drug treatment of mental illness. cont d

48 Implementing Behavioral Approaches: Consistency most important David A Smith MD,CMD

49 Reasons Primary Care Physicians Should Do Much Nursing Home Mental Healthcare Logistics Ready made rapport Current elder cohort bias against psychiatry Nip It in the bud Common problem Biopsychosocial integration

50 Resources for Behavior Problems in LTC Psychiatrist/geriatric psychiatrists Geriatricians (CAQ, CMD, Fellowships) Pharmacists with Added Qualifications Psychologists Medical social workers Teaming

51 Barriers to Interdisciplinary Teaming Logistics, time Family involvement No specific reimbursement code for physicians CNA not involved or lacks skills Gap between care planning and implementation (naysayers)

52 Thank you!