behavior problems: dementia and mental illness in long term … · 2017. 10. 10. · nursing home...
TRANSCRIPT
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a program of Morningside Ministries
Behavior Problems: Dementia and Mental Illness
in Long Term Care and Assisted Living
Dr. David A. Smith, M.D., FAAFP, CMD
Module II
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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 II)
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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 geriatric/long-term care Registered Nurse in the area of behavioral management of patients with dementia by addressing anticholinergic drugs that may affect behavior, effects of family relationships on behavior, and barriers that affect a patient’s adaptability to a new environment in an effort to guide the interdisciplinary team to effectively care for residents with dementia who exhibit challenging behaviors as evidenced by the learner’s achievement of all activity objectives and a passing score on the activity post-test.
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Disclosures to Participants • The objectives of this education activity are:
1. Identify the anticholinergic drugs commonly used in long term care or assisted living facilities that may have an adverse effect on behaviors.
2. Discuss the benefits and risks of the use of restraints for patients in the long-term care setting.
3. Describe marital relationship issues that may affect behavioral concerns in Long Term Care or Assisted Living.
4. Recognize areas of noted dysfunctional family dynamics that affect staff, resident, and family relationships in Long Term Care or Assisted Living.
5. Identify the four (4) most costly behaviors per occurrence for Long Term Care and Assisted Living Facilities.
6. List four (4) barriers to interdisciplinary team success in behavioral problem solving 4. Discuss the Predictors of Violence.
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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 post-test
• Once successful completion has been verified, a “Certificate of Successful Completion” will be awarded for _1.1_ contact hours.
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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.
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Disclosures to Participants • This activity expires: 03/09/2017 • 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) 262-9730.
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Pain Perception
Cortex
Limbic system ~ agitation, emotionality
Thalamus
Spinal cord
Peripheral receptor
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Anticholinergic drugs
• antihistamines
• antimuscarinics/urge incontinence drugs
• digoxin
• theophylline, ipatropium
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Anticholinergic drugs
• many psychotropics (e.g. anti psychotics, tricyclics, antidepressants)
• anti Parkinsonian medications
• many others
• anticholinergic load
cont’d
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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
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Negative Consequences of Restraint
Physiologic: Immobility-
loss of strength contractures decubiti loss of balance cardiovascular decompensation, decreased blood
volume postural hypotension
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Negative Consequences of Restraint
Physiologic: Immobility-
dependent 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
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Negative Consequences of Restraint
Physiologic: Abrasions and skin tears EEG changes Increased falls with injury Strangulation
cont’d
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Negative Consequences of Restraint
Psych-Social: • Increased agitation
• Anger, aggression, verbal abusiveness
• Screaming
• Resignation and withdrawal
cont’d
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Negative Consequences of Restraint
Psych-Social: • Depression
• Decreased interaction with others
• Appearance of infirmity or lack of capacity
cont’d
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Marital Relationships
• Attachment
• Competing balance between intimacy and
independence
• Negotiation (set balance of intimacy and
independence)
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Marital Relationships
• Unconscious fears of connection and
separation
• Power in negotiation
• Patterned or automatic maintenance of
balance of power
cont’d
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Marital Relationships
• Change and restoration of balance of power after conflict or crisis
• Health-facilitating balances which enhance personal mastery and growth
cont’d
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Marital Relationships
• Balance which copes with external stressors (illness, loss) but also promotes intimacy and individuality
• Values, shared beliefs, attitudes
cont’d
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Dysfunctional Family Dynamics
• Loss of generational boundaries
• Rigidity or chaotic lifestyle
• Lack of privacy, individuality
• Triangulation or scapegoating
• Abuse and victim /
perpetrator issues
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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.
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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
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Summary: Some Reasons for Behavior Problems in Dementia
• 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
cont’d
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Consequences of Behavior Problems in Long Term Care
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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
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Behavior Problems in Dementia
• The single most common cause of nursing facility placement from home or assisted-living facilities
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Behavior Problems in Dementia
• The most important, potentially remedied “time sink” for staff
cont’d
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Behavior Problems in Dementia
• Staffing is among the largest line items of expenses in the nursing facility
cont’d
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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 frequently reported behaviors
– Physical agitation – Refusal of care – Requests for unneeded attention
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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
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Determining the Per Diem
• Resource Utilization Groups (RUGs)
• Special Rehabilitation (14)
• Extensive Services (3)
• Special Care (3)
• Clinically Complex (6)
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Determining the Per Diem
• Impaired Cognition (4)
• Behavior Problems (4)
• Physical Function (10)
ü MDS 3.0 Implemented Oct10
cont’d
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Motivations Under PPS
• Manage outcomes rather than expenses
• Look at value
*Adapted from Malcolm Fraser MD,CMD
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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.
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Caregiver expectations of patients
• Gratitude
• Acceptance
• Patience
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Caregiver responses to aggression: Anger
Retaliation
Defensiveness
Understanding
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Behavior Problems in LTC: Interdisciplinary Teaming
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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?
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Behavioral Problem Solving by Interdisciplinary Team Process
-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?
cont’d
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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.
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Behavior Problem Solving by the Interdisciplinary Team Process
Drug review? Drug-induced mental symptoms.
Inadequate or incorrect drug treatment of
mental illness.
cont’d
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David A Smith MD,CMD
Implementing Behavioral Approaches:
Consistency – most important
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Reasons Primary Care Physicians Should Do Much NH Mental Healthcare
• Logistics
• Ready made rapport
• Current elder cohort bias against psychiatry
• “Nip It…” in the bud
• Common problem
• Biopsychosocial integration
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Resources for Behavior Problems in LTC
• Psychiatrist/geriatric psychiatrists
• Geriatricians (CAQ, CMD, Fellowships)
• Pharmacists with Added Qualifications
• Psychologists
• Medical social workers
• Teaming
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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 (nay-sayers)