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

Transcription

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

2 Disclosures to Participants mmlearn.org at Morningside Ministries mmlearn.org at Morningside Ministries is an approved provider of continuing nursing education by the Texas Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. Title of Activity: Behavior Problems: Dementia and Mental Illness in Long Term Care and Assisted Living (Module IV)

3 Disclosures to Participants mmlearn.org at Morningside Ministries Requirements for Successful Completion: The purpose of this education activity is to enhance the knowledge of the long-term care and assisted living Registered Nurse in the area of behavioral management of patients with dementia by addressing Strategies for mental illness prevention and non-pharmacologic therapies to address problem behaviors in an effort to prepare the RN to be able to guide the interdisciplinary team in preparing for and conducting activities that relate to mental illness prevention and to increase the nurse s confidence in utilizing and guiding the team in nonpharmacologic therapies for behavioral interventions as evidenced by the learner s achievement of all activity objectives and a passing score on the activity post-test.

4 Disclosures to Participants The objectives of this education activity are: 1. Describe activities that can be used as a form of primary and secondary mental illness prevention. 2. Discuss behavioral interventions that can be utilized as alternatives to drugs in the resident with dementia and/ or mental illness.

5 Disclosures to Participants To receive contact hours for this continuing education activity, the participant must:» Complete and submit an evaluation form» Achieve a passing score of 80% on the activity posttest Once successful completion has been verified, a Certificate of Successful Completion will be awarded for _1.2_ contact hours.

6 Disclosures to Participants Conflicts of Interest» Explanation: A conflict of interest occurs when an individual has an opportunity to affect or impact educational content with which he or she may have a commercial interest or a potentially biasing relationship of a financial nature. All planners and presenters/ authors/content reviewers must disclose the presence or absence of a conflict of interest relative to this activity. All potential conflicts are resolved prior to the planning, implementation, or evaluation of the continuing nursing education activity. All activity planning committee members and presenters/authors/content reviewers have submitted Conflict of Interest Disclosure forms. The planning committee members and presenters/authors/ content reviewers of this CNE activity have disclosed no relevant financial relationships related to the planning or implementation of this CNE activity.

7 Disclosures to Participants This activity expires: 3/9/2017 Reporting of Perceived Bias:» Bias is defined by the American Nurses Credentialing Center s Commission on Accreditation (ANCC COA) as preferential influence that causes a distortion of opinion or of facts. Commercial bias may occur when a CNE activity promotes one or more product(s) (drugs, devices, services, software, hardware, etc.). This definition is not all inclusive and participants may use their own interpretation in deciding if a presentation is biased.» The ANCC COA is interested in the opinions and perceptions of participants at approved CNE activities, especially in the presence of actual or perceived bias in continuing education. Therefore, ANCC invites participants to access their ANCC Accreditation Feedback Line to report any noted bias or conflict of interest in the education activity. The toll free number is 1(866)

8 History forms (res, family, staff) Psych tests (MMSE, GDS, Cornell, Ham A, etc ) Coding appropriately comprehensive, change in condition Document time between visits into visits Medically necessary f/u to evaluate titrations efficacy and side effects

9 Activities: Primary and Secondary Mental Illness Prevention Socialization to decrease loneliness, increase self-esteem and well-being. Integrating with family, community, intergenerational. Resident-to-resident centered, not always resident-to-staff.

10 Activities: Primary and Secondary Mental Illness Prevention When resident-to-staff break down dichotomy Exercise to increase strength and vigor, therefore, increase opportunities for more interaction Exercise to decrease depression, increase self-esteem and well-being cont d

11 Preventative Mental Health in Long Term care Staff attitudes/staff development Patient rights (privacy, personal belongings) Visitation by family and friends (inclusion in family events) Outings and activities Work therapy/community service projects Worship Funerals

12 Preventative Mental Health in Long Term Care Cocktail hour Pets Intergenerational activities Touching, one-on-one, TLC

13 Preventative Mental Health in Long Term Care cont d Including patient and family in developing Rx plan Minimizing drugs with potential CNS side effects Architecture, decoration, odor control, colors, sound

14 Non Pharmacologic Therapy

15 Behavioral Interventions: Alternatives to Drugs in the Nursing Home Resident Milieu and attitude therapy Distraction Validation Reminiscence and mile- stoning Reframing the problem Desensitization Relaxation training Hypnosis Group Therapy Reprinted with permission of Geriatrics from and article by the author published in Vol. 45(2),1990,p. 55.

16 Behavioral Interventions: Alternatives to Drugs in the Nursing Home Resident Family therapy Brief directive psychotherapy Behavior contracting Behavior modification and token systems Paradoxical therapy Time out Restrictive and aversion therapy cont d Reprinted with permission of Geriatrics from and article by the author published in Vol. 45(2),1990,p. 55.

17 Milieu Therapy Overall environment, formal and casual interactions with staff and other patients. Use: All pathologies

18 Activities: Primary and Secondary Mental Illness Prevention Exercise to fatigue elders, to decrease wandering, agitation, pestering, re-synchronize with nursing facility schedule. Variety of choices resident-centered. Fun or worthy or fostering reminiscence, or fostering relationships. Can change nursing facility from a place to die into a place to live!!!

19 Distraction Beginning with an interpretation of the patient s behavior, motives, feelings and then gradually shifting the conversation until the patient s thoughts are distracted away from their problematic train of thought. Use: Any pathology, but especially valuable for emotionally labile, organic, patients.

20 Validation To agree with the feelings expressed verbally or non-verbally by the patient. Use: Depressed patients

21 Reminiscence Encouraging memories that improve selfesteem, feelings of happiness or tranquility. Use: Depressed patients, mild to moderately demented patients.

22 Behavior Modification, Token Systems Systems of positive and negative reinforcement or punishment contingent on patient behavior. Use: An pathology. Patients with or without insight. Best for clearly definable behaviors that are under some volitional control of the patient.

23 Behavior Contracting Writing a formal contract for a desired behavior or against a problem behavior and providing rewards and/or negative consequences as appropriate. Use: Competent patients who do have some control of their behavior.

24 Reframing Interpreting a patient s emotions or the life circumstances responsible for their emotions in a different context. Use: Patients with some insight, especially depressed patients.

25 Prescribing Behaviors, Double Bind or Paradoxical Therapy Extinguishing a behavior or emotion by requiring a patient to voluntarily perform the behavior or experience the emotion in a new context. Use: Non-demented patients with little insight. Patients whose problems have been unresponsive to other approaches.

26 Brief Directive Psychotherapy A form of psychotherapy wherein the therapist is more directive and active; steering the conversation to elucidate the problems, giving guidance, information, and reassurance. Use: Transient situational disturbance, neuroses, depression, grief in elders.

27 Desensitization Gradual exposure to a noxious stimulus until its negative consequence is reduced. Use: Phobia

28 Relaxation Training Various modalities to promote relaxation / tranquility. Use: Anxiety disorders, anxiety associated with depression.

29 Family Therapy Collective and separate meetings with patient and family for therapeutic crisis intervention, restructuring pathological family dynamics or other strategies. Use: Any pathology where the recruitment of family resources, transfer of information, or changing of family dynamics will assist in recovery.

30 Group Therapy Collected groups of patients with similar or dissimilar problems for therapeutic conversation. Use: Any pathology especially those improved when patient gains a sense of not being unique or alone in their problem. Withdrawn patients. Situations where one to one therapy is too time intensive.

31 Hypnosis Inducing a hypnotic trance to obtain locked in information, or to place a post-hypnotic suggestion. Use: Depression from repressed guilt, differentiation of physiologic and psycho logic mutism or other conversion reaction, breaking habits.

32 Highly Restrictive Procedures & Aversive Therapy Behavior modification using physical restraint or punishment. Usually not appropriate or necessary. Usually not very effective. Sometimes needed if consequences of behaviors are extremely dangerous to self or others. BEWARE PATIENT RIGHTS

33 Behavioral Approaches Mutt & Jeff Maternal (Paternal) High Touch & Positive Available & Positive Kind Limit Setting Mechanical Giving Space Tender Loving Care

34 High Touch and Positive: Used with withdrawn patients and some depressed patients. Patient is actively sought out. This is used to build self-esteem and increase patient s socialization skills.

35 Available & Positive: Used with paranoid or suspicious patient. Caregiver available, but patient takes the first step.

36 KIND LIMIT SETTING: Used with the depressed, withdrawn patient. Caregiver takes control and sets up expectations. Doesn t take no for an answer.

37 Mechanical: Used for manipulative or seductive patients. Patient receives in an mechanical, nonemotional fashion, the natural consequences of their actions.

38 Maternal (Paternal): Use with mildly organic, childlike, or dependent patients. Staff with rapport lavish praise or scold the patient as appropriate with the implication of strengthening or weakening the bond of affection between them. CAUTION: May increase dependency if misused!

39 MUTT & JEFF: Use with antisocial patients or manipulative patients. One or more staff with whom patient has rapport encourage positive behavior or discourage problem behavior forming an alliance with the patient, while one or more staff without rapport with the patient take opposition. CAUTION: Borders on brainwashing if misused!

40 GIVING SPACE: Used for the patient who has lost control. No demand is placed on the patient until he/she regains some reason and deescalates.

41 TENDER LOVING CARE: Used for patients with no rehabilitation potential or terminal patients. Patient s needs are anticipated and met. Provides a sense of security for patient.

42 Implementing Behavioral Approaches: Consistency most important