Geriatric Giants: Challenging/Difficult Behaviours in the Acutely Ill Older Adult
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Transcript of Geriatric Giants: Challenging/Difficult Behaviours in the Acutely Ill Older Adult
Geriatric Giants: Challenging/Difficult
Behaviours in the Acutely Ill Older Adult
Gerontological/Geriatric CNS of BC 2003
Who are we again?
THEIR STORY
• Married 52 years
• Doug has Alzheimer's
• Mary has heart failure
• Mary’s the “brain”
• Doug is the “brawn”
• They live in their home of 50 years.
THEIR FAMILY
• Meet Sue
• Meet her family
• She is a professional
• She works full-time
• She lives the closest to Mary and Doug
• Her brother lives in Nova Scotia with his family
The “Acute” Incidents
• Doug slipped while trying to help Mary get out of the bath tub.
• He fractured his hip and has many bruises.
• After one hour of struggling Mary managed to get to a phone and call 911
• Both Mary and Doug have been brought to hospital.
DOUG
• Doug keeps yelling and calling to Mary to save him from these robbers who have broken into their house
• He is thrashing about in the bed despite his fracture.
• He is to have surgery tonight and is awaiting a bed on the surgical unit.
Mary
• Mary is hypothermic; has a black eye and has high BP/P on admission
• She hears Doug calling & tries to go to him.
• She is SOB and weak
• She oriented x3 but is very anxious.
• She is to be admitted to a medical unit.
SUE: The Daughter
• Sue was called at work
• She has just arrived on the scene
The Care Providers
• You are to care for Doug and Mary
• What are your thoughts, feeling and body sensations?
• What do you think Sue is feeling?
The Challenges of Caring
The Goals
• Increase understanding related to what behaviours are: patient and care provider
• Gain added knowledge of mental health and psychiatric issues as they relate to behaviour and therapies
• Offer practical tips to increase your “toolbox” of approaches to care
Goals
• To “coach you in building positive outcome “habits and structures” to assure best practice and care of the older adult.
• Today to discuss the “Geriatric Giants” related to challenging/difficult behaviours, including the “D’s” and how they impact upon the older adult and care providers’ abilities.
“BEHAVIOUR”
• ALL meaningful - telling/sending message
• Observed “gut-brain” response to internal and external stimuli
• “Feeler” of the stimuli is asking the responder to “understand” what is being non-verbally and verbally said.
• “Receiver” interprets message leading to response - This is the real challenge!
“What is difficult/challenging behaviour?”
• Each person interprets actions by others and their own actions based upon their life experiences, knowledge and personal perceptions
• It is all in the EYE of the beholder - Mary, Doug, Sue and You.
Top 5 Challenges
1.
2.
3.
4.
5.
The Brain
• Central processor of all bodily and behavioural functions and activities
• Must always consider what is happening in the brain and nervous system.
• If only the brain was housed in a glass bubble so that we could see what is being activated and what is not.
AXIS…what?
• Psychiatry classifies abnormal behaviours into diagnosis as per the consensus guideline - DSM IV- R = 5 axis
• Continuum of adaptive to maladaptive
• Continuum of constructive to destructive
• Mental illness is no different than physical or social illness. It is biopsychosocial!
“The Label…”
• Once labeled, there for LIFE!• CAUTION: biases, discrimination and “…
isms” can lead to:– fear– shame– hopelessness– death by exclusion
The “D’s” ?
• Gero or geri-psychiatry
• D elirium
• D epression
• D ementia
• D elusions
• D rugs
Delirium
• Rapid onset with changes in sensorium
• inability to shift thoughts/inattentiveness
• fluctuation over the day/night
• visual hallucinations and/or illusions
• previous hx
• Drugs or Bugs
• REVERSIBLE : Find the cause and treat!
Delirium C.P.G.
• Require a baseline cognition and full physical work-up
• Preferable on admission; however, do screen if sudden change in cognition.
• MMSE - helpful or not?
• Doug has a dementia; therefore, he has a greater likelihood of developing a delirium
Withdrawal?
• Look for withdrawal from alcohol, drugs, nicotine, caffeine..
• CAGE, CIWA and protocol
• Harm reduction
• Fat storage and liver function
• Referral
Post-Op: Doug
• 10 days following his surgery, Doug suddenly becomes restless (physical movement) and is visually hallucinating
• He was on CIWA protocol following the admission CAGE score.
• He starts to seizure
• What could this be?
The Brain: Acquired Injury
• WHO 1996: Damage to the brain, which occurs after birth and is not related to a congenital or degenerative disease. These impairments may be either temporary or permanent and cause partial or total functional disability or psychological maladjustment.
Brain
• Developmental delay due to congenital birth defects (e.g. FAS, trisomy,)
• Anoxia, CVA, drugs• Cognition affected by the location and extent
of the damage.• Frontal lobe - disinhibition (increasing)• www.bcbia.org - website for BC Brain Injury
Association
Mary: LOS = 14 days
• Mary had a black eye initially. The ecchymosis spread to her forehead and into her hairline
• She has been observed to be increasingly agitated (verbalization ) in the past few days.
• What should you do?
Depression
• Persistent over 2 weeks or more
• Change in appetite and intake
• Change in sleep pattern
• Change in motor and functional level
• Hopelessness, helplessness - Suicidal
• Differentiate between grief and sadness
• REVERSIBLE - identify and treat!
Depression CPG
• Currently in last stages of development
• To be applied across the full continuum of care including acute care through to home care and residential services
• Geriatric Depression Scale – preferably self-scored
• Suicide assessment
Mary Declines
• Mary has been told that she and Doug will most likely have to go into a nursing home now.
• She says that she and Doug would be better off dead.
• Her appetite and sleep have been poor for several weeks.
• What to do?
Dementia
• Slow, insidious decline in cognition (memory marker) and executive function
• Vascular,mixed,Alzheimer type, Lewy body
• NOT reversible but can be slowed down if diagnosed early and monitored
• Complex partial seizure and sudden aggression with post-ictal sequelae
Doug: Alzheimer Type
• Doug has a foley; but he keeps pulling it out
• When up in the wheelchair, he is constantly heading for the door or going into other patients rooms and calling for Mary
• Evening’s finds him very restless and stripping off his clothing
• What to do?
Delusions
• Persistent mistaken thoughts
• Is seen in psychosis and also in dementing disorder like Lewy body or frontal/temporal dementia
• NB! Act upon their mistaken thoughts. Paranoia and suspicious
• Can treat to control paranoia; however, if dementing will decline oft times rapidly.
Mary
• Mary becomes increasingly restless and agitated.
• She accuses you of trying to poison her and is refusing her medications.
• She has phoned 911 to report you.
• She is constantly leaving the unit.
• What to do?
DRUGS
• Can be both the cure and the cause of adverse behavioural response
• psychotropics - antipsychotics; anxiolytics; sedatives; antidepressants; anticonvulsants
• in the elderly: Go LOW and GO SLOW!!!
• Too many, too much OR too few, too little =
Antipsychotics/Neuroleptics: Goal of Therapy - Psychosis– To control specific psychotic symptoms (e.g.
hallucinations, delusions, disordered thinking)– To reduce agitation in acute psychoses– To prevent relapse of chronic psychotic illness
– To reduce distress level in patients with dementing illness with cognitive and psychotic symptoms
Antipsychotics/Neuroleptics: Investigations
• Determine pre-existing psychiatric, medical and drugs from history
• Assure differentiation of diagnosis (e.g. delirium, schizophrenia, B.A.D., withdrawal) - Psychiatrist/Geropsych.
• Assure baseline labs - CBC, TSH, liver function tests, ECG in patients over 40 years.
Antipsychotics/Neuroleptics: Therapeutic Choices:Non-
Pharmacological
– Reduce environmental stressors/stimuli
– Educate family
– Hydrate and nourish
– Least restraints and freedom to move
– Support as symptoms come under control
– Refer to psychiatrist
Antipsychotics/Neuroleptics: Therapeutic Choices
• First generation block dopamine receptors– CPZ, haldol, loxapine– watch for EPS, TD, hypotension,tachycardia,– neuroleptic malignant syndrome
• Second generation selectively block dopamine and serotonin receptors– lower risk for EPS and TD– clozapine, olanzapine, resperidone,quetiapine,
clopixol
Anxiolytics: Anxiety DisordersGoal of Therapy
• To decrease symptomatic anxiety
• To decrease anxiety-based disability
• To prevent recurrence
• To treat comorbid conditions (e.g. addiction withdrawal, distressing medical condition, PTSD, panic disorders, phobias)
Anxiolytics: Anxiety DisordersInvestigations
• Thorough HX - nature & onset of symptoms• Comorbid mood disorders - treat first• Assure accurate diagnosis• Physical to exclude endocrine, cardiac,
substance abuse• Labs - CBC, liver function, GGT,TSH,ECG
Anxiolytics: Anxiety DisordersNon-pharmacological
• Decrease caffeine or other stimulants
• Minimize ETOH use
• Short-acting benzos only for prn x 4 days
• Stress reduction - relaxation, imagining
• Specific cognitive-behavioural (CBT)
• Psych consult if no improvement within 6-8 weeks with drug therapy
Anxiolytics: Anxiety Disorders:Pharmacological
• Benzodiazepines (BDZs) - ST vs LT use; NB! Withdrawal; paradoxical effect– clonazepam, lorazpam,alprazolam; atypical
buspirone
• Antidepressants - reduce frequency and severity of panic attacks– SSRIs– adjunctive - propanolol
Sedatives/Hypnotics:Goal of Therapy
• To treat sleep disorders
• To increase depth of sleep so that person identifies positive feelings of energy refreshment
• To return person to non-pharmacological sleep cycle
Sedatives/Hyponotics:Investigations
• Review sleep and rest HX
• Review drug and ETOH Hx as relates to use as a sleep inducer - NB! Effectiveness?
• Assess personal normal sleep pattern
• Differentiate diagnosis of depression or mood disorder
• Refer - Sleep Clinic at UBC
Sedatives/Hypnotics:Therapeutic Choices
• Dark, well ventilated, quiet & cool room
• COMFORT : Toilet before sleep time
• Do not give after 0100h or will produce day/night reversal
• Assess for nocturnal hypoxia - elevate head of bed
• Silent bed exit alarm
Sedatives/Hypnotics:Pharmacological
• Short acting with few metabolites preferable• Oxazepam, chloral hydrate, trazadone,
caution with TCAs; prefer non-benzo e.g. zoplicone
• May cause or worsen delirium• May contribute to falls• May contribute to incontinence
Antidepressants:Goals of Therapy
• To relieve depressive symptoms
• To prevent suicide
• To restore optimal functioning
• To prevent recurrence of depression
Antidepressants:Investigations
• Review past HX especially re: previous depression, suicide attempts, family Hx
• Differentiate Dx of type of mood/affective disorder from chronic dysthymia. SUICIDE
• Physical to r/o medical cause (e.g.thyroid)
• Labs - same as antipsychotics
• Referral to appropriate psychiatrist
Antidepressants:Non-Pharmacological
• Education
• Cognitive behavioural or interpersonal psychotherapies
• ECT
• Supportive
• Utilize clinical practice guidelines
Antidepressants:Pharmacological
• TCAs, SSRIs, NSSRIs, MAOIs, RMAIOI
• takes 4-6 weeks to titrate to effective treatment level
• observe for side effects - serotonin syndrome
• drugs cannot stand alone - require concurrent other therapies
Adjuncts:Goal of Therapy
• To treat the underlying psychiatric disorder in conjunction with usual drugs ( e.g. cholinesterase inhibitors, mood stabilizers, neurontin, anti-convulsants)
• To enhance or modulate other drug therapies
• To decrease distressful symptoms
Adjuncts:Investigations
• Review what is currently being used and the effectiveness
• Hx and physical
• Labs
Adjuncts:Pharmacological
• Have a pharmacist review for drug/drug interactions (e.g. aricept with loxapine; gingko with coumadin, paxil with coumadin; lithium with NSAID)
• More is not necessarily better
• Is the adjunct treating the side effects caused from the primary drug? (e.g Cogentin)
Summary for Drugs
• Psychotropic drugs require knowledge– targeted behaviours– appropriate for symptoms– side effects and contraindications– prn, ST, LT maintenance
• Elderly: Go LOW and go Slow
• OBSERVE AND DOCUMENT
Who is in charge?
• Is it…”Want to be in control?” or “Need to be in control?”
• Upon what is the locus of control based?
• Whose control is it? Patient or YOU?
• Conflict frequently is the outcome of control struggles.
• Power = Control? Control = Power!
“Fire,Ready,Aim!”
• What is wrong with this sequence?
• When approaching a patient whose gut-brain mix is causing them mental turmoil, decelerate yourself first or you may find you fire,ready,aim;therefore resulting in harm to either one or both of you.
• Timing,Proximity,Boundaries with TRUST
Your Stories
• What are the causes of the difficult/challenging behaviours?
• What do you now know that you would do next time?
• What one aspect of care can you nurture to change practice on your unit?
Current Abilities As a Cause
• Able to do the requested task?
• Able to communicate?
• Able to problem-solve?
Physical Causes
• Pain
• Medications
• Impaired senses (vision, hearing,smell..)
• Malnutrition/dehydration
• Constipation - Incontinence (CPG)
• Lack of sleep
• Acute and chronic illness
Emotional/Psychiatric Causes
• Depression (CPG)
• Delirium (CPG)
• Dementia
• Delusions
• Death
• Duty to protect
Communication
• Respectful
• Set the mood before it is set for you
• Simple and clear
• Focused and directed
• If appropriate offer two choices
• Do NOT argue, challenge, order, condescend, talk around
Outcomes?
Or the Story can go...
• Mary, Doug and Family
Question?
• Has your “eye” changed?
• Let’s get wisdom through foresight rather than hindsight!
Hope and Light!
• Better assessments including neuropsych.
• Treatment scope and variety is ever growing. More sustainable & effective
• Psychotherapy; group therapy; rehab
• ECT - excellent therapy
• Psychotropics (1955) - know the drug; be cautious; assess…assess…assess...
Take Home Message
• All behaviour has a reason and purpose
• By being a detective, solutions can be found
• Document and report sooner than later
• If you do not understand the behaviour, ask
• Safety of the client, caregivers and yourself are number ONE
• You make the difference!!!
Thank you for your CARING!
• Please complete – evaluation form