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
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Presenter: Dr. David A. Smith, M.D., FAAFP, CMD
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Module II Pain Perception Cortex Limbic system ~ agitation, emotionality Thalamus Spinal cord Peripheral receptor
Anticholinergic drugs antihistamines antimuscarinics/urge incontinence drugs digoxin theophylline, ipatropium
Anticholinergic drugs cont d many psychotropics (e.g. anti psychotics, tricyclics, antidepressants) anti Parkinsonian medications many others anticholinergic load
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
Negative Consequences of Restraint Physiologic: Immobilityloss of strength contractures decubiti loss of balance cardiovascular decompensation, decreased blood volume postural hypotension
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
Negative Consequences of Restraint Physiologic: Abrasions and skin tears EEG changes Increased falls with injury Strangulation cont d
Negative Consequences of Restraint Psych-Social: Increased agitation Anger, aggression, verbal abusiveness Screaming Resignation and withdrawal cont d
Negative Consequences of Restraint Psych-Social: cont d Depression Decreased interaction with others Appearance of infirmity or lack of capacity
Marital Relationships Attachment Competing balance between intimacy and independence Negotiation (set balance of intimacy and independence)
Marital Relationships cont d Unconscious fears of connection and separation Power in negotiation Patterned or automatic maintenance of balance of power
Marital Relationships cont d Change and restoration of balance of power after conflict or crisis Health-facilitating balances which enhance personal mastery and growth
Marital Relationships cont d Balance which copes with external stressors (illness, loss) but also promotes intimacy and individuality Values, shared beliefs, attitudes
Dysfunctional Family Dynamics Loss of generational boundaries Rigidity or chaotic lifestyle Lack of privacy, individuality Triangulation or scapegoating
Dysfunctional Family Dynamics Abuse and victim / perpetrator issues
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; 3,168-172.
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
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
Consequences of Behavior Problems in Long Term Care
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
Behavior Problems in Dementia The single most common cause of nursing facility placement from home or assisted-living facilities
Behavior Problems in Dementia cont d The most important, potentially remedied time sink for staff
Behavior Problems in Dementia cont d Staffing is among the largest line items of expenses in the nursing facility
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;17:497-507.
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;17:497-507.
Determining the Per Diem Resource Utilization Groups (RUGs) Special Rehabilitation (14) Extensive Services (3) Special Care (3) Clinically Complex (6)
Determining the Per Diem Impaired Cognition (4) Behavior Problems (4) Physical Function (10) MDS 3.0 Implemented Oct10 cont d
Motivations Under PPS Manage outcomes rather than expenses Look at value
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.
Caregiver expectations of patients Gratitude Acceptance Patience 41
Caregiver responses to aggression: Anger Retaliation Defensiveness Understanding
Behavior Problems in LTC: Interdisciplinary Teaming
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?
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?
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.
Behavior Problem Solving by the Interdisciplinary Team Process Drug review? Drug-induced mental symptoms. Inadequate or incorrect drug treatment of mental illness. cont d
Implementing Behavioral Approaches: Consistency most important David A Smith MD,CMD
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
Resources for Behavior Problems in LTC Psychiatrist/geriatric psychiatrists Geriatricians (CAQ, CMD, Fellowships) Pharmacists with Added Qualifications Psychologists Medical social workers Teaming
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)
Thank you!