Kristina Morro, OTR/L Charlotte Rozycki, MSN, RN BEHAVIORAL CHALLENGES FOLLOWING STROKE: STRATEGIES FOR SUCCESSFUL PARTICIPATION

Transcription

1 Kristina Morro, OTR/L Charlotte Rozycki, MSN, RN BEHAVIORAL CHALLENGES FOLLOWING STROKE: STRATEGIES FOR SUCCESSFUL PARTICIPATION

2 Disclosures No conflicts of interest 2

3 Objectives Discuss the prevalence and potential predictors of agitation in stroke survivors Discuss common agitated behaviors seen after CVA Review Kessler Institute behavior management program Review the ABC method to identify and address internal and external triggers Participate in creating individualized behavior plans 3

4 Prevalence of Agitation Not just in TBI 15-35% of Stroke survivors within the first year Impacts participation, caregivers and discharge disposition (Tang et. al., 2017) 4

5 Predictors Previous Stroke Cognitive impairments Delirium Location Limbic regions, temporal lobes, inferior parietal lobes and occipital lobes Left vs Right (Caplan, C., 2010), (Choi-Kwan, K. et. al, 2013), (McManus, et. al. 2007), (Tang, W.K. et.al., 2017). 5

6 Left vs Right Brain Left Brain Stroke Cautious or compulsive Apraxia Aphasia Right Brain Stroke Emotional Short attention span Poor judgment Confusion Spatial- perceptual problems (Arnadottir, G., 2009) 6

7 Agitation Defined Distractibility Impulsivity Low frustration tolerance Violence or Threatening violence Explosive or unpredictable anger Rocking, rubbing, moaning Pulling at tubes or restraints Wandering Restless Repetitive behaviors or perseveration Rapid loud or excessive talking Sudden changes in mood Lability Self abusiveness (Bogner, Corrigan, Bode, & Heinemenn, 2000) 7

8 Insert video 8

9 Admission to Kessler Discussion with the nurse liaisons from various hospitals to determine the appropriateness of the admission and what kind of behavioral level of care they require. 9

10 Behavioral Screen 10

11 Behavioral Screen 11

12 Behavioral Screen Assessment for restraints, safety devices, Q15 rounding near the nurses station 1-to-1 observation or enclosure bed 12

13 Once the patient is admitted Proper safety mechanisms for the patient are put into place They become part of the behavioral team with a fall prevention strategy 13

14 KIR Behavior Management Process Safety wing TOP program Weekly rounds Daily supervision rounds 14

15 Creating a Behavior Plan Individualized Triggers Internal External 15

16 Another way to look at it 16

17 ABC Method Antecedent Prior to or surrounding a behavior Behavior Problem behavior Consequence What follows the behavior (Winkens, Ponds, Pouwels, Eilander, & Van Heugten, 2014) 17

18 Internal Trigers Pain, fatigue, hunger Disorientation, confusion, memory Lack of insight Communication deficits Disturbed sleep/wake cycle 18

19 Managing Internal Triggers Pain: Medical Intervention, modalities, pressure relief, repositioning Memory: Frequent re-orientation or environmental cues Awareness: Avoid arguing, performance rating, calmly redirect Communication: Gestures, timed voiding, non-verbal body language Sleep: Medical Intervention, stim during the day and low stim at night (Flanagan, et. al., 2009) 19

20 External Triggers Overstimulation Medical Interventions Frustrating tasks Change in environment or structure Restraints 20

21 Managing External Triggers Overstimulation: Reduce noise, visitors, clutter, communication Be flexible with medical intervention Demands: Provide just right challenge Limit change in structure Restraint Alternatives (Pryor, 2004) 21

22 Restraints Enclosure bed Mitts Posey sleeve Rear locking seatbelt Four side rails up in the bed 22

23 Enclosure Bed 23

24 RESTRAINT DEMONSTRATION 24

25 Safety Devices Wheelchair alarm Posey devices Wrap-around device Omni belt Floor mats Bed alarm Low bed Wander guard 25

26 Pharmacological Considerations No magic pill Minimize opioids and benzodiazepines Seizure medications Beers list (Seidel, 2017) 26

27 Medications Sleep Attention/ Memory Depression /Anxiety Restlessness Agitation/ Combative Melatonin Amantadine Effexor Gabapentin Risperdol Trazadone Ritalin Buspar Propranolol Seroquol Remeron Bromacryptine Zoloft Olanzepine Aricept Lexapro Ativan Exelon Seidel,

28 Case Study 1 Mrs. Smith is a 67 year old female admitted to Kessler s/p CVA with resulting R hemiparesis. She is aphasic and unable to verbalize her needs. When male RAs assist with her morning ADLs, she screams and becomes physically combative. She has fallen once at Kessler and continues to try to get up from her chair despite her physical limitations. 28

29 Case Study 2 Mr. Jones is 59 year old male s/p ruptured aneurysm. He is ambulating with close supervision however is impulsive and bumps into objects on the left when he walks. He is extremely distractible, wanders around the unit and sometimes into other patients rooms. He has also frequently attempts to leave the building and yells at staff for keeping him locked up in jail when they try to redirect him. 29

30 Questions? 30

31 References 1. Arnadottir, G. (2009). A-One training course. Columbia University. (p.39-51). 2. Bogner,J., Corrigan, J., Bode, R., Heinemann, A., (2000). Rating scale analysis of the agitated behavior scale. Journal of Head Trauma Rehabilitation. 15(1), Caplan, L. (2010). Delirium: A neurologist s view- The neurology of agitation and over activity. Reviews in Neurological Diseases. 7(4) Choi-Kwon, Han, K, Cho, KH, et.al. (2013), Factors associated with post stroke anger proneness in ischemic stroke patients. European Journal of Neurology. 20: Flanagan, S., Elovic, E., Sandel, M., (2009). Managing agitation associated with traumatic brain injury: Behavior versus pharmacologic interventions? American Academy of Physical Medicine and Rehabilitation. 1,

32 References 8. McManus, J. et.al. (2007). Delirium post-stroke. Age and Ageing. 36: Pryor, J, 2004). What environmental factors irritate people with acquired brain injury? Disability and Rehabilitation. 26 (16), Tang, W.K. et.al. (2017). Location of acute infarcts and agitation and aggression in stroke. The Journal of Neuropsychiatry and Clinical Neuroscience. 29: Seidel, B. (August 4, 2017). [Personal interview]. 12. Winkens et. al. (2014). Using single-case experimental design methodology to evaluate the effects of the ABS method for nursing staff on verbal aggressive behavior after acquired brain injury. Neuropsychological Rehabilitation. 24(3),

33 Thank you!

34 Right Choice. Right Setting. Right Outcome.

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