Behavioral Challenges in TBI Rehabilitation

Transcription

1 Behavioral Challenges in TBI Rehabilitation Michelle Tipton Burton MS, OTR/L Santa Clara Valley Medical Center Richard L. Delmonico, Ph.D. Chief, Neuropsychology Kaiser Foundation Rehabilitation Center

2 Objectives Understand how to conduct a comprehensive behavioral assessment Understand how to develop specific strategies/interventions to address common behavioral problems in rehabilitation Identify methods for ongoing education, assessment, and modification of behavioral interventions across the rehabilitation continuum of care Best practices to educate caregivers in using and modifying behavioral interventions Understand case examples

3 Philosophy of Our Approach Provide a safe environment that motivates patients to actively participate in their rehabilitation Reduce patient care workplace injuries related to behavioral disturbances To use the least restrictive methods of behavioral management and to discontinue interventions when appropriate Empower staff to use their experience and to encourage their ability to problem-solve Facilitate and coordinate appropriate family/caregiver involvement in behavior management Improve outcomes by maximizing patient rehabilitation potential

4 Interdisciplinary Approach to using Behavioral Interventions Respect, dignity, compassion Keep your cool - Take a couple deep breaths Focus attention on your behavior, feelings, verbal and non-verbal communication impact on patient Safety look and listen Consistency is the key Take responsibility Be Proactive Be direct and honest with patient/family Behavioral interventions are Everyone s Job!

5 Basics of Behavioral Interventions The Language of Behavior Management What is a problematic behavior Antecedents/Precipitating Factors Trying an intervention Patient s response to the intervention Modifying interventions

6 Behaviors that Require Intervention Active Behaviors Agitation and restlessness Combativeness/aggression Impulsivity Perseveration Disinhibition (including sexual) Impulsivity Wandering Refusals to participate

7 Behaviors that Require Intervention Passive Behaviors Poor initiation Poor participation General confusion

8 Case Study - AC Rehab 4 wks post injury. Trach change from cuffed to Jackson because good cough. Plugging started. Intermittently followed commands, which improved quickly to agitated, confused: pulls at PEG, paroxysmal tachycardia, hypertension, sweating; L hemiparesis, insomnia. Parents divorced. Lives w mother who speaks Spanish, divorced father bilingual and now concerned.

9 Behaviors that Require Intervention Other Issues Fatigue Impaired sleep wake cycle Pain Other Psychological Disturbances (depression, anxiety, psychosis)

10 Behavior Management Documentation Agitated Behavior Scale Behavior Log Sleep Log Behavior Management Pocket Card General Behavior Support Guidelines Therapeutic Interventions Information Behavior Management Plan of Care Behavioral Management Home Program

11 Agitated Behavior Scale

12 Agitated Behavior Scale Scoring / shift Total score = global measure 1 = behavior absent 2 = slight, self redirect, 3 s and 4 s indicate no interference level of supervision 3 = moderate, needed to achieve responds to redirection success, prevent by others disturbance of others 4 = extreme, redirection not successful

13 Behavior Log Please complete the log following each shift/therapy session (regardless if the problematic behaviors occurred or not) by identifying the following: Behavior (What did the patient do described the behavior in detail?) Precipitant (What happened right before the behavior took place? What were the conditions -- who was around, what was going on?) Intervention (What did you do when the behavior took place?) Outcome (How did the behavior change -- for better or worse?) NOTE: Please be sure to.sign (nr) the end of your entry (after "Outcome"). Thank you. Patient Name: MRN: Date: Time: Behavior: Precipitant: Intervention: Outcome:

14 Behavior Log for Coach

15 Behavior Management Pocket Card

16 General Guidelines Behavioral Guidelines: Observe, listen, and assess the situation Identify problematic behaviors Safety codes (Red, Yellow, Green) Communicate, document, and re-assess Family and staff communication and consistency

17 Behavior Management Meetings Behavior interferes with participation in treatment or with other patients Any team member can request! Facilitator Attended by all staff Targeted behaviors and interventions Family members: at team discretion

18 Meeting Objectives Specific guidelines and interventions Defensive techniques are reviewed Schedule videotaping as appropriate Monitor team follow through continued assessment

19 Development of Treatment Plan The behavior is analyzed with respect to: Antecedents Behavior in question Consequences

20 Development of Treatment Plan Attempted Solutions: What has been attempted to reduce the problematic behavior? Who is successful in working with this patient and what are they doing/not doing? What worked and What didn t work? Brainstorming alternative solutions Ask the family!

21 Aggression Management Quantify acceptable and problematic behavior Environment: special beds, time out, control stimuli Redirect behavior: physical activity with coach Minimize sedation Observe your position and patient s position Avoid sudden movements and touching patient Co-Treat for protection Written behavioral plan: staff/ family agreement

22 Agitation Management (Cont.) 1:1 Coaching Criteria Harmful to self: pulling vital tubes, suicidal Disruptive to other patients Does not follow weight bearing, helmet precautions Not manageable with cubicle bed / net bed High elopement risk, unable to care for self

23 Behavior Management Policies Restraint and Non-Restraint Policy Variety ranging from least to most restrictive (Limb restraints Wheelchair Alarms) Enclosure Bed Wander Guard (Signaling Device) GPS System Elopement Policy General Behavior Management Policy

24 Restraints and Non-Restraint Devices Enclosure Bed Signaling Device (Wanderguard) GPS System (EmFinder) Bed Alarm Wheelchair Alarm Safety Belt (XBelt) Sitter/Companion/Coach

25

26 Enclosure bed candidates Agitated/Confused Impulsively getting out of beds with siderails Risk of falling Patient can benefit from free mobility in safe area May have catheter, IV, or continuous feeds Regular hospital bed is unsafe Family consent Physician initial order and daily re-order

27 Progression to regular bed Determine safe transfers from regular bed Trials with behavior checklist: unsafe transfers Unzip Enclosure bed, open Cubicle bed door Start day shift Progress to evening and night shift Then 24 hrs Regular bed introduction with cubicle users

28 GPS/GSM Locator System

29 Behavioral Interventions: Environment Alter auditory and visual stimulation decrease distraction Limit visitors if necessary Provide privacy, quiet time for patient Provide consistency and structure

30 Behavioral Interventions: Behavioral Guiding Levels of Assist/ Graduated guidance Minimum Verbal/Guiding Moderate Verbal/Guiding Maximum Verbal/Guiding techniques

31 Behavioral Interventions: Communication / Interaction Model calm and appropriate behaviors Re-orient and provide simple cues Speak calmly, slowly, and in simple sentences Break down tasks/phrases into simple steps Use Yes/No questions Give praise for the desired behaviors

32 Behavioral Interventions: Communication / Interaction (cont.) Make eye contact before speaking with the patient Redirect undesirable behaviors Provide limited equal choices whenever possible

33 Pharmacological Management Meds can be a helpful part of a behavioral management plan Avoid impulse to react with a medication Rarely a quick fix Off-label uses common start low and go slow

34 Pharmacological Targets Delirium Anxiety Depression Insomnia Psychosis Aggression and agitation Impairments in arousal Attention Fatigue

35 Pharmacology More Acceptable: Trazodone Valproic Acid Propanolol Carbamazepine Atypical antipsychotics SSRI s Buspirone Dopamine agonists (amantadine, bromocriptine) Methylphenidate Limit Exposure to: Benzodiazepines Anticholinergics Antidopaminergics (haloperidol, typical antipsychotics, metoclopramide) Barbituates Antihistamines Phenytoin (decreased axonal sprouting) Lithium

36 AC video 3-4 days after rehab admit Behavioral baseline and medication intervention: insomnia-> Restlessness, hitting, biting-> Tachycardia, sweating-> Pulling at gastrostomy-> Communication w family Criteria for d/c coach Criteria for tapering meds

37 Case Study What Do You Do? Mr. X is a 27 year-old male who was intoxicated while driving four-wheel drive pick-up truck. He was unrestrained and had 2 restrained passengers with him. Injury resulted in a right brachial plexopathy, right orbital fracture with damage to his visual acuity/field, right subdural hematoma (evacuated), dense right UE hemiplegia, and left LE weakness. Transferred to KFRC for rehab from Modesto. They reported that he was agitated and combative.

38 Case Study: What Do You Do? Mr. Y is a 25 Year Old Male with a TBI. He is confused and agitated. Nursing attempts to give him his morning meds. He becomes very agitated, verbally abusive, trying to hit the nurse and as additional staff arrive he threatens to physically assault the nurse and other staff who have arrived.

39 Therapeutic Interventions: Conclusions Respect and Dignity Keep Your Cool Take a couple deep breaths Pay Attention to Your Reactions! Observations - Be Specific Take Responsibility: Everyone is Crucial to Success Review all policies that relate to behavioral management Documentation and consistency Educate and involve the family/caregivers early!

40 Bibliography Brain Injury Survivor and Caregiver Manual, J Marcus, E Irvin eds, Aspen Publishers, Inc, Gaithersberg, MD, Jacobs, HE, Behavior Analysis Guidelines and Brain Injury Rehabilitation: People, Principles, and Programs. Aspen Publishers, Inc. Mysiw JW and Sandel ME, The agitated brain injury patient, part 2: pathophysiology and treatment. Arch Phys Med Rehabil: :213 Northern California TBI Model Systems Website: tbi-sci.org; COMBI (Center for outcome measurement in brain injury) site for scales

41 Prigitano, GP, Disturbances of self-awareness of deficit after TBI in Prigitano GP and Schacter DL, Awareness of Deficit After Brain Injury: Clinical and Theoretical Issues. Oxford University Press, New York, 1991 Sandel, ME, Mysiw, WJ, The agitated brain injured patient. Part 1: Definitions, differential diagnosis, and assessment. Archives of Physical Medicine and Rehabilitation77:6: , Santa Clara Valley Medical Center (2003) Behavior management guidelines. Unpublished in-house reference. Zafonte RD, Elovic E, Mysiw J, O Dell M, Watanabe T, Pharmacology in TBI: fundamentals and treatment strategies in Rosenthal M et al eds, Rehabilitation of the Adult and Child with TBI. FA Davis Co, Philadelphia, 1999.