Making Sense of Behavioral Symptoms in Nursing Home Residents: Alternatives to Antipsychotic Drug Use

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Making Sense of Behavioral Symptoms in
Nursing Home ResidentsAlternatives to
Antipsychotic Drug Use
Quality Insights Webinar 2.20.13

• Joel E. Streim, M.D.
• Professor of Psychiatry
• University of Pennsylvania
• Philadelphia VA Medical Center

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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.

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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

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Overview

• Three premises lead to the conclusion that
• Antipsychotic drug treatment is usually not the
  most appropriate response to most resident
  behaviors and
• Sensible, effective, non-pharmacological
  responses to behavior required a patient-centered
  approach to care.

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Premise 1

• Not all behavioral symptoms are problems
• A 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)

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Premise 2

• Most problematic behaviors among nursing home
  residents are not likely to respond to
  antipsychotic drugs
• Most 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

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Premise 3

• Behavior problems are commonly triggered by an
  approach to care that fails to incorporate the
  residents own experience
• Care that is based solely on facility routines
  and caregiversperceptions 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

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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 cant 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.

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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. Shell be home from school
  any minute.
• CNA says, OK, Ill help. Lets go to the kitchen
  and get some cookies for your daughter. I bet
  shell like them. Whats her name?
• The resident turns away from the exit door, and
  follows the CNA to the kitchen area.

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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 residents
  experience
• 2. Recognize factors that cause or contribute to
  behavioral problems
• Once understood, interventions and management
  strategies become apparent
• Assessment informs approach to care

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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 residents world enables us to identify
  person-centered solutions that
• Are responsive to resident needs
• Avoid using unnecessary medications

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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

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Person-centered Care WHAT?

• Focus on the residents 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
• Doesnt mean you actually adopt their point of
  view for yourself

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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

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Making Sense of Behaviors

• A richer understanding of the residents
  experience also requires the identification of
  causal and contributing factors

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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

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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)

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How does memory impairment lead to behavioral
problems?

• Example
• Patient cant remember where his clothes are
  kept

Walks into hallway naked
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How does language impairment (aphasia) lead to
behavioral problems?

• Example
• Patient who cant verbally communicate that
  pills are hard to swallow

• Spits medication at caregiver

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How does impaired visual recognition (agnosia)
lead to behavioral problems?

• Example
• Patient cant recognize a spoon as a utensil for
  eating

• Throws the spoon on the floor

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How does impairment in performance of motor tasks
(apraxia) lead to behavioral problems?

• Example
• Patient cannot manipulate zippers or buttons to
  unzip or unbutton his pants

Wets his clothing
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Common misattributions for behaviors

• Caregiver may assume resident is
• Angry / Belligerent
• Lazy / Dependent
• Manipulative
• Often, a behavior that is interpreted as
  uncooperative is actually better explained by
  cognitive disability

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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

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Remember Theres 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

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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
• Dont scold or argue
• When language comprehension is severely impaired,
  use other senses to communicate
• Smell, touch, vision, taste

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What modifiable factors may contribute to
behavioral changes in nursing home residents
(with or without dementia)?
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Unmet needs that can lead to behavioral
disturbances
All residentswhether cognitively intact or
impairedhave common, basic needs

• Physical needs
• Nutrition, hydration, toileting, exercise, rest

• Psychological needs
• Security, autonomy, affection, self-worth

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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

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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

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Psychiatric conditions that can cause behavioral
disturbances

• Depression
• Delirium
• Psychosis
• delusions
• hallucinations
• Anxiety
• Sleep disturbance

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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)

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• Identification of any of these modifiable causes
• unmet needs
• environmental and social irritants
• medical illness and physical discomfort
• psychiatric conditions
• adverse drug effects
• points the way to specific interventions

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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

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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

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Resources for Training and Implementation

• CMS campaign website
• http//www.nhqualitycampaign.org/star_index.aspx?c
  ontrolsdementiaCare
• Hand-in-Hand (person-centered dementia care
  training materials)
• http//www.cms-handinhandtoolkit.info/Index.aspx

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Questions Discussion