When Behaviors Become Difficult

Transcription

1 When Behaviors Become Difficult Help me! Help me! Help me! A Problem-Solving Approach Philomena Poole, RN, GNP-BC

2 Prevalence Alzheimer s Disease is the sixth leading cause of death in the US Will affect 1 in 8 Americans There is no cure Death from Alzheimer s is spiraling upward

3 As the Disease Progresses Dysphagic Motor Impairment Incontinent Gradual Loss of Touch With the World Increasingly more dependent on others for entire essential physiological, psychological, spiritual, social, and comfort needs

4 Behaviors Anger/Agitation Hallucinations/Paranoia Incontinence Problems with Bathing Problems with Dressing Problems with Eating Problems with Sleeping Wandering Repetitive Actions Screaming/Verbal Noises Wanting to go Home

5 My Behavior Is My Communication Behaviors become the conduit for needs, pleasures, frustrations Assess and manage behaviors as a symptom of discomfort Address the most primary needs: hunger, thirst, wet briefs, too hot, too cold, a need to move, etc.

6 Comfortable people do not hit, scream, pound on tables, or call out. If a behavior is present, the caregiver must assess for the cause and intervene.

7 I I am trying to tell you! Causes of Behavioral Problems Physical and Emotional Causes Environment The Task at Hand Communication

8 Physical and Emotional 1. Medications 2. Sensory Impairment 3. Acute Illness 4. Chronic Illness 5. Dehydration 6. Constipation 7. Depression 8. Fatigue 9. Physical Discomfort

9 Medications Persons with dementia are at increased risk of overmedication, drug interactions, and side effects If a behavior occurs what new drug was just started? Or discontinued? Many medications also affect bladder function (both incontinence and retention) May increase risk somnolence, falling and agitation

10 Where the heck are we? Environmental Causes Too Large Too Much Clutter Excessive Stimulation No environmental cues Poor Sensory Environment Unstructured Unfamiliar

11 You want me to do WHAT? Task Related Causes Too Complicated Too Many Steps Combined Increasing Impairments Unfamiliar Task

12 What Are You Saying? Communication Do not understand what is expected Are unable to make themselves understood

13 Please, Help Me! When does the behavior occur? Who was involved? Who was affected? What was the emotion being expressed? How did the caregiver respond? Review the 4 categories: Physical and emotional health Environment Task Communication

14 Personhood The state of being human Dementia robs an individual of personhood It is up to us to support and preserve personhood It is essential to really know the person

15 About Me My Life Story Physical Psychological Spiritual Social Routine Likes and Dislikes

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17 Person Directed Approach Warm, home-like environment Tactile, acoustic, olfactory, visual, and thermal stimulation Adequate lighting, temperature, noise control, appropriate music, effective color differentiation, and personal items These interventions have been shown to promote positive behaviors and decrease agitation---and promote caregiver satisfaction

18 I I just want to be comfortable. Pain Environmental temperature Need to go to the bathroom Hunger Thirst Need to move Fatigue

19 Problem Solving When does the behavior occur? Who was/is involved? What emotion was being expressed? How did others respond? Review physical/emotional; environment; task; communication

20 Possible Causes -Physical/Emotional Depression Physical Illness UTI/Pneumonia Impaired Vision Medications Different Sensation to stimuli Pain/Discomfort Hallucinations Fatigue/Change in Sleep Pattern Need to use the Bathroom Stress Boredom Frustration Feels Threatened

21 Possible Causes-- Environmental Sensory Overload Unfamiliar People or Surroundings Poor Lighting Lack of Privacy Too Hot or Too Cold Can t Find the Bathroom Too Many Distractions Odors Restraints

22 Possible Causes Task Too Complicated Does Not Understand Feels Rushed Caregiver is Tense or Frustrated Fearful or Anxious

23 Possible Causes-Communication Communication Attention span too short Hearing Impairment Language May refer to an object by another word Speaking too fast or pitch too high

24 Develop a Strategy Multidisciplinary team approach Develop a list of strategies Prioritize the strategies and then implement Don t worry if it doesn t work the first time you are still gathering information regarding the situation What works today, may not tomorrow

25 Strategies Music Massage Reminiscing Quiet Reading Aroma Therapy Going for a Walk Pets Do not communicate in juvenile manner

26 Get away from me! The individual may feel that they are losing control or are threatened Consistent Staffing One on One Activities Identify Stressful Situations or Tasks Approach avoid approach from behind. Be mindful of body language.

27 That nurse took my purse! Increase Lighting/Night Lights Keep a spare set of keys/purse, etc. Learn where the person s hiding places are Distraction Investigate the person s history---maybe they were a robbery or harassment victim Explain misinterpretation

28 It s s morning, I have to go to work! Blinds open in the daytime Avoid caffeine Snack at bedtime Avoid upsetting activities Distraction Rocking chair

29 I I don t t need a bath! Prepare the bath ahead of time Consider the personal preference for water depth Simple statement about what you are doing Consider a bath vs. shower Let the person touch the water before getting in Cover shoulders with towel and pin it with a clothespin Offer a reward Consider washing hair separately Give the person something to hold onto

30 I I don t t want to get dressed! Provide privacy Don t rush good time to socialize Offer 2 choices One step at a time dressing can be overwhelming Allow the individual to do as much as they are able Try clothes that are 1 size larger Loose fitting, easy on and easy off If they prefer to wear the same outfit day after day, purchase several

31 I m m not opening my mouth! Make sure dentures are fitting and dentition is in good repair Soft relaxing music Serve one food at a time Avoid distractions Use bowls rather than plates Try to offer familiar foods prepared in familiar ways Smaller groups of 4 to 6 persons in quiet environment Concentrate on the person Allow enough time

32 I m m looking for my mother. Provide areas safe for wandering Keep areas clear Put up stop signs on doorways to prevent from going into others rooms Camouflage doorways Distract with food and drink Wandering can relieve stress and tension Try to determine what the individual may be searching for

33 I I want to go home. I want to go home. I want to go home. home. I want to go home. Try audio or video tapes featuring a familiar person (consider that this may also be confusing) Remove coats, hats, etc. from view Are most likely trying to feel some sense of control are fearful, anxious Distraction Food and drink There may be some meaning in a repeated word Consider what home means

34 Delirium and Dementia Dementia is a risk factor for delirium The prevalence of delirium superimposed on dementia (DSD) ranges from 22% to 89% Persons with DSD have accelerated decline in both cognitive and physical function, greater need for institutionalization, and increased mortality

35 Delirium DSM-IV Definition Acute confusional state associated with: Acute onset and fluctuating course Inattention Disorganized Thinking Altered Level of Consciousness

36 Three Subtypes of Delirium Hyperactive restlessness, increased psychomotor activity, and irritability Hypoactive more passive, drowsy, withdrawn, or lethargic. Mixed---fluctuation between hyperactive and hypoactive

37 Under-recognition recognition Risk factors for not recognizing delirium Hypoactive delirium Age 80 and over Vision impairment Dementia

38 Assessment for DSD The most important aspect to assess for is change from baseline Enlist the help of family and caregivers to determine what baseline has been

39 Assessment Tools Mini-Cog Includes a Clock Draw, measures orientation, registration, and recall Easy to use Neecham Confusion Scale Correlates strongly with MMSE Mini-Mental State Examination (MMSE) Easy to administer and widely recognized Confusion Assessment Method (CAM) Most widely validated instrument for screening for delirium

40 CAM 4 Key Delirium Features Onset and fluctuation Inattention Disorganized thinking Altered level of consciousness

41 CAM

42 Who is at Risk for DSD Dementia Acute Medical Illness Advanced Age Alcohol Abuse Male Gender Depression Physical Restraints Foley Catheters Polypharmacy (more than 3 meds) Malnutrition Terminal Illness ICU

43 Workup Review Medications Labs---Na, K+, glucose, Ca+, BUN, creat Evaluate for infection (UTI, pneumonia) Evaluate for hypoxemia Neuroimaging usually low yield Evaluate for pain Consider myocardial ischemia Consider alcohol or benzodiazepine withdrawal Consider SSRI withdrawal

44 Medications Commonly Associated with Delirium with Delirium Benzodiazepines (esp. long acting) Anticholinergics Opioid Narcotics Antiparkinsonian drugs H2 Receptor Blockers Antibiotics Anticonvulsants Prednisone Cardiovascular Drugs Almost any drug can cause delirium This is a partial list

45 Strategies Goal is to prevent delirium Identify high risk persons Review medications Control pain Observe for infection; fluid and electrolyte imbalance Observe for urinary retention Implement nonpharmacological interdisciplinary interventions Involve family members Prepare the individual and family for possibility of delerium

46 Avoid Restraints Avoid Foley catheters Sensory hearing aides, glasses, dentures Promote adequate sleep Environmental cues open blinds during the day, calendars, explanation of procedures/activities

47 Delirium Marker for future bad outcomes Poor functional recovery Cognitive decline Increased mortality

48 Figure out who I am. Meet me where I am. Help me be me.

49 THANK YOU!