Behavior Problems: Dementia and Mental Illness in Long Term Care and Assisted Living Module III

Transcription

1 a program of Morningside Ministries Behavior Problems: Dementia and Mental Illness in Long Term Care and Assisted Living Module III Dr. David A. Smith, M.D., FAAFP, CMD

2 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 III)

3 Disclosures to Participants mmlearn.org at Morningside Ministries Requirements for Successful Completion: The purpose of this education activity is to enhance the knowledge and skills of the Registered Nurse in the area of geriatrics/long term care by addressing limitations in knowledge of testing instruments designed to address and quantify cognitive defects, depression, and anxiety; limitations in knowledge of medicines currently used for the treatment of psychiatric disorders; and assessment skills of resident behaviors following pharmacologic treatments for psychiatric disorders in an effort to allow the registered nurse to identify and utilize testing instruments designed to address and quantify cognitive defects, depression, and anxiety and facilitate the RN s understanding of current pharmacologic treatment for psychiatric disorders allowing for better assessment of behaviors as a result of these interventions. This will be evidenced by the RN achieving a passing score on the activity post-test and data from the evaluation tools that reflects that the activity was helpful in achieving the objectives.

4 Disclosures to Participants The objectives of this education activity are: 1. Describe the instruments utilized for assessing mental health disorders in elderly residents residing in Long Term Care Facilities or Assisted Living. 2. Identify current pharmacologic therapies and the risks associated with treatment for cognition problems, depression, delirium, psychosis, bipolar disorder, chronic anxiety and acute anxiety.

5 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 posttest Once successful completion has been verified, a Certificate of Successful Completion will be awarded for _1.2_ contact hours.

6 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.

7 Disclosures to Participants This activity expires: 04/30/2017 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)

8 Behavior Problems in LTC: Testing

9 Mental Capacity for: Decision Making» Personal» Medical» Financial Testamentary Capacity Capacity to Stand Trial

10 Quantifying and Following Cognitive Deficit Mini Mental Status Exam-MMSE (Dementia) St.Louis University Mental Status-SLUMS (MCI, Dementia) Confusion Assessment Method- CAM (Delirium)

11 Diagnosing & Following Major Depression Beck Depression Inventory» Beck AT, Ward CH, Mendelson M, et.al.(1961) An inventory for measuring depression. Archives of General Psychiatry 4:53-63 Hamilton Depression Scale» Hamilton M (1960) A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry 23: 56-62

12 Diagnosing & Following Major Depression Geriatric Depression Scale(short & long)» Yesavage JA, Brink TL, Rose TL, et. al.(1983)development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research 17: Cornell Scale» Alexopoulos GS, Abrams RC, Young RC et.al. (1998) Cornell Scale for Depression in Dementia. Biological Psychiatry 23: cont d

13 Mania Scale Others:» Bech P, Rafaelsen OJ, Kramp P. Bolwig TG (1978) The Mania Raing Scale: scale contruction and inter-observer agreement. Neuropharmacology 17: Functional Pain Scale Hamilton Anxiety Scale Assessment Scales in Old Age Psychiatry Burns A, Lawlor B, Craig S. Martin Dunitz Ltd.Distributed by: Blackwell Science Inc., Commerce Place, 350 Main St.,Malden MA 02148

14 Objectifying Nursing Assessment of Behavioral Problems (Meeting Goals) Each shift: Rate your pain as a caregiver in response to resident behavior of on a zero to 10 scale. Initial your score.

15 Minnie has delusions of worms crawling out of her skin and from under her fingernails. She is scratching herself raw and complains constantly to staff of worms. Before drug A 7,10,8,8,7,6,10 After drug A 10,7,8,6,8,10,7 (no ADR) After drug A increased- 7,8,10, 8,10, 6,7, (no ADR) After drug B 6,8,6,5,7,7,5,6 (no ADR) What Now?

16 Using Scales Trained interviewers/raters (but it s easy) Trigger from MDS items Trigger from identification of potential problem by team or team member

17 Using Scales Set time to retest to evaluate efficacy of therapy!! Objectification of what is poorly handled by subjective assessment Need a doctor s order or not?

18 Behavior Problems in LTC: Pharmacologic Therapy

19 Drugs for Dementia Cholinesterase Inhibitors» donepizil» rivastigmine» galantamine» tacrine NMDA Inhibitors» memantine

20 Grid for Treatment of Dementia and Psychiatric Disorders Causing Behavior Problems Cognition problems ChI and/or memantine Depression antidepressant Depression with psychosis antidepressant/aap Delirium rapid acting AAP or haloperidol Psychosis AAP

21 Grid for Treatment of Dementia and Psychiatric Disorders Causing Behavior Problems cont d Mania or Bipolar illness mood stabilizer Chronic Anxiety disorder SSRI, buspirone Acute or situational anxiety Bzd (short acting/only phase 2) Appropriate chemical restraint Bzd (short acting/ only phase 2)

22 Drug Treatment & Titration Issues Determine target symptom(s) Establish treatment goals prospectively Mandated Informed Consent Therapeutic Window

23 Drug Treatment & Titration Issues Time to steady state Objective symptom monitoring- efficacy Monitor for ADRs Set time for GDR/DC or plan life-long treatment consistent with CPG s cont d

24 Task Define appropriate and inappropriate chemical restraint (Hint: remember OBRA Guidelines)

25 Task : Chemical Restraint What s wrong with this? Haldol 0.5-1mg po or IM q 4 hrs PRN agitation. T.O. Dr. R. Jones/B. Bruse RN

26 To maximize the resident s physical and mental well-being or slow decline Behavior Diagnostic hypothesis Rx drug / non-drug Follow-up by objective symptom monitoring measure target behavior before & after treatment to steady state nullifies inter-rater variability Follow-up side effects, overall function, length of Rx

27 Evidence-based Pharmacologic Treatment of Dementia Cholinesterase inhibitors tacrine (Cognex) donepizil (Aricept) rivastigmine (Exelon) galantamine (Reminyl) Claims for improving behavior exaggerated Think of maximizing cognitive function as a requisite for most normal behavior

28 Evidence-based Pharmacologic Treatment of Dementia NMDA receptor antagonist memantine (Namenda) cont d Claims for improving behavior exaggerated Think of maximizing cognitive function as a requisite for most normal behavior

29 Pharmacologic Treatment of Dementia with Negative Evidence Ginko Vit. E Estrogen Selegiline NSAIDS Chelation