Cindy Mann, RN, BSN. Unit Manager. Centra Senior Psychiatric Program

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1 Cindy Mann, RN, BSN Unit Manager Centra Senior Psychiatric Program

2 Sundowning Physical aggression Wandering Identification of Problematic Behavior Verbal aggression Hiding possessions Combativeness with interaction

3 Type of dementia CONSIDER Area of brain affected Stage of disease

4 Is NOT a specific disease. Alzheimer's disease is the most common cause of a progressive dementia. Is a GROUP OF SYMPTOMS affecting intellectual and social abilities severely enough to interfere with daily functioning. Memory loss generally occurs in dementia, but memory loss alone does not imply you have dementia. E

5 Alzheimer s Disease Vascular Dementia Mixed Dementia Parkinson s Disease Dementia Dementia with Lewy Bodies Frontotemporal Dementia

6 ALZHEIMER S DISEASE Brain disorder, most common form of dementia Affects 5% of people at age 65 Increased Confusion Affects 50% of people age 85+ Increased Anxiety Late-onset (65+) is most common, slowestprogressing Increased Frustration Average course of DAT: 6-20 years

7 VASCULAR DEMENTIA 2nd most common dementia after Alzheimer's disease Result of a damage to the brain caused by problems with the arteries serving the brain or heart Poor Impulse Control ASSOCIATED SYMPTOMS: Confusion and agitation; depression Unsteady gait Problems with memory Urinary frequency, urgency, incontinence Night wandering Decline in ability to organize thoughts/actions, difficulty planning Poor attention/concentration Impaired Judgment Inability to Make Decisions Approx % of all dementias are VaD

8 LEWY BODY DEMENTIA Deposition of Lewy bodies in both, cortical and subcortical SYMPTOMS - Core criteria (must have two): Fluctuating attention and concentration Recurrent, well-formed visual hallucinations Newly emerged PD-type motor problems Visual Hallucinations Affects 1% of those age 65, 5% over age 85 Usually progresses more rapidly than DAT (average = 6 years)

9 FRONTOTEMPORAL DEMENTIA Group of diseases characterized by the degeneration of nerve cells in the F-T areas of the brain (Fronto-temporal areas of the brain are generally associated with personality, behavior and language). In these dementias, portions of these lobes atrophy. ASSOCIATED SYMPTOMS: socially inappropriate behaviors loss of mental flexibility decline in personal hygiene language problems, and movement disorders difficulty with concentration and thinking. Changes in personality Changes in temperament Begins earlier and progresses faster than AD Changes in demeanor Occurs at ages younger than AD, i.e.,

10 Comorbidities???

11 Physical Changes, Illness or Injury? Is the person responding to Changes in hearing/vision OR Delirium OR Pain

12 FALL RISKS Fall Risks Vision Changes Medications Sedation Orthostatic Hypotension Muscle Weakness Orthopedic changes

13 Is there an underlying Mood Disorder? Are they depressed? Are they anxious?

14 SUICIDE RISK History of depression, suicidal ideation/attempts Family history of suicide reduces the taboo Medical advances increase life expectancies Fear of institutionalization Financial stressors of growing older Grief (family, friends, career, autonomy, health, wealth)

15 Is there an Underlying Thought Disorder? Having Trouble Processing Psychotic Fearful

16 Identification of Triggers What precipitated the behavior?

17 Could it have been.. Over- Stimulation? Fatigue? Change of Residence or Caregiver? Misinterpretation of Situation? Receptive Aphasia?

18 Know the Person Know their Life Story To better understand WHY a person responds the way they do Understand WHO a person is and has been.

19 A traumatic or abusive history? The lifestyle or work history they led? Are their behaviors or responses related to. Their level of education? Relationships they ve had? Religious or Cultural backgrounds? Medical history?

20 Are their needs being met? Potty Positioning Pain Personal Items P.O. intake

21 Tools and measures have been developed to help predict aggression in acute inpatient psychiatric settings

22 BRØSET VIOLENCE CHECKLIST (BVC) HCR-20 CLINICAL SCALE DYNAMIC APPRAISAL of SITUATIONAL AGGRESSION (DASA)

23 IRRITABILITY IMPULSIVITY UNWILLINGNESS TO FOLLOW DIRECTIONS SENSITIVITY TO PERCEIVED PROVOCATION EASILY ANGERED WHEN REQUESTS ARE DENIED NEGATIVE ATTITUDE ANXIOUS OR FEARFUL LOW EMPATHY OR REMORSE PAST VICTIM OF SEXUAL OR PHYSICAL ABUSE PHYSICAL AGGRESSION TOWARD OBJECTS IN PAST 24 HOURS VERBAL AGGRESSION TOWARD A PERSON IN PAST 24 HOURS PHYSICAL AGGRESSION TOWARD A PERSON IN PAST 24 HOURS

24 Inform ALL Care Providers and Increase Monitoring Responses to Warning Signs Possible Changes in Medication Re-assess Behavioral Strategies

25 Remain Positive & Focus upon the feelings of the individual, not the facts. In most situations, their behaviors are telling you what the person no longer can.

26 Beth B. Ulrich, LCSW Community Liaison, Centra Senior Psychiatric Program

27 PREVENTION Affection Control Security Basic Needs Inclusion

28 PREVENTION Challenging behaviors, including aggression, are usually the person s search for security, control, identity, affection or a sense of purpose or achievement.

29 PREVENTION Goal of Prevention Not stopping the behavior but addressing the needs that lie behind it.

30 PREVENTION Fundamental Questions How do we perceive behaviors? Person s effort to cope/communicate a need NOT something that must be eliminated. The approach is to identify alternatives and increase understanding rather than imposing controls.

31 REWARDS AND CONSEQUENCES DO NOT WORK

32 PREVENTION Fundamental Questions How do we see our role with cognitively impaired patients? Paternalistic versus becoming her partner Paternalistic determining what she needs or what is best for her Becoming her partner entering her world

33 Get to know the patient It is important to engage with the patient. Life story Preferences Food Activities Values Identity Mother Husband Vocation How do we see our role with cognitively impaired patients? Paternalistic versus becoming her partner Paternalistic determining what she needs or what is best for her Becoming her partner entering her world

34 PREVENTION Fundamental Questions How do we understand the behavioral and functional manifestations of dementia? Caregiver must understand the disability in order to meet the needs of the patient. Apraxia Aphasia Amnesia Agnosia Executive dysfunction

35 PREVENTION Do we ask our patients to do things that are impossible for them to do?

36 PREVENTION Fundamental Questions How do we respond to an individual s needs? The need to meet physical & psycho-social needs Security or Restriction? Identify compensation measures to meet the needs of the patient i.e., providing specific activities and forms of assistance, addressing specific needs.

37 THE 4-D APPROACH Define Decode Devise Determine Observations, details, facts Where, when, how, with whom, after/ before what? What may be contributing to cause the problem? Treatment Plan: What are we going to do? What outcome is expected? Do the interventions work?

38 DEFINE DIFFICULT BEHAVIORS VERBAL yelling, screaming, threatening through body posture PHYSICAL hitting, pushing, shoving, kicking, spitting Focus on specific behavior e.g., hits while being bathed Usually a precipitant or provocation can be identified related to the behavior.

39 DEFINE Serious problem leading to injury, distress in patients & distress to others The form the behavior takes It is important to describe: Against whom it is directed The context in which it occurs Consequences, such as injury DIFFICULT BEHAVIORS Time of day Also to examine: Frequency What the patient says

40 Decode: HEAR Health & Medical Conditions Environment Approach Resident Factors

41 Decode: HEAR Health and Medical Conditions Psychiatric Disorder or History may be related to delusions, hallucinations, suspicious behavior or paranoia Medical Disorder/History Also depression, mania, sleep deprivation Delirium Pain Constipation Visual/Hearing Impairments Certain medications (steroids, etc.) Hydration and nutrition A thorough medical exam including consideration of psychiatric history should be conducted. Include a head CT.

42 Decode: HEAR Environment over stimulating or under stimulating? Is there a lack of structure and activity?

43 Decode: HEAR Approach being pushed, approached from behind, inadequate communication A supportive and attentive approach helps to prevent problematic behaviors.

44 Decode: HEAR Resident Factors Be aware of patients Needs Wants Habits Desires

45 Decode Aphasia patient may be frustrated by an inability to express himself or to understand something being said to him. Agnosia patient may not recognize a person who is approaching him and may strike out in self defense Consider the symptoms of dementia or other cognitive disorders Apraxia patient cannot identify an object so he throws it (i.e. TV or lamp) Amnesia patient tells the same story repeatedly or cannot remember what he had for breakfast Executive Disorder inhibitions related to aggressive urges no longer exist

46 Decode Could it be a catastrophic reaction?

47 Decode Catastrophic Reaction Sudden expression of negative emotion i.e., crying, yelling precipitated by an environmental event or a task failure Person behaves as if a catastrophe has happened even though the precipitant is minor.

48 DEVISE Change caregiver approach Remove the precipitant Use distraction Stay calm Keep patient out of harm s way even if it means grabbing the patient or blocking him Make environmental changes Pay attention and spend time with your patient develop a trusting relationship Know how to identify precipitants especially related to catastrophic reactions

49 DEVISE CHANGE CAREGIVER APPROACH Stop correcting Don t argue (delusions and hallucinations) The patient is always right Walk away and try again later with a different approach Show the person what you want him or her to do by demonstrating and praising nonverbally through hugs or a caring smile Don t talk about the person in front of him/her

50 DEVISE REMOVE THE PRECIPITANT Certain people Time of day Certain places Understand the task failure Reassure And use distraction

51 DEVISE USE DISTRACTION What does he/she like to do? Reminisce Favorite foods Favorite music Avoid TV, especially soaps and talk shows (old sit coms and old Westerns are better).

52 DEVISE STAY CALM I m sorry. Listen without judgment

53 DEVISE KEEP PATIENT OUT OF HARM S WAY Even if it means grabbing the patient or blocking him Learn caregiver protection techniques-mandt Blocking arm swings Getting out of holds Controlling patients hands

54 DEVISE MAKE ENVIRONMENTAL CHANGES Temperature Noise level Providing comfortable clothes Decorating with familiar pictures Soothing aromas Enjoyable sounds

55 DEVISE Develop a Trusting Relationship Get to know her history

56 DEVISE Provide activity and structure Examine communication techniques

57 COMMUNICATION Speak slowly in a lowpitched voice Enunciate your words Begin your conversations socially Use short, familiar words and simple sentences Talk in a warm, easygoing, pleasant manner Ask simple questions that require a choice of a yes/no answer Listen carefully Give positive instructions and avoid don t... can t or negative commands Avoid questions that require short-term memory; e.g., Did your son come to see you today? Communicate using the person s long-term memory: I hear you have a wonderful son. Give simple instructions for one task at a time (the simple task of brushing teeth contains 11 steps) Keep talking to the person with dementia, even if he cannot talk back Focus on a word or phrase that makes sense Respond to the emotional tone of the statement, not the words Stay calm and be patient Ask family members about possible meanings for words, names, or phrases Respond as though you understand Try a hug and change the subject Simply say, Wow! Whoa!

58 DEVISE Learn caregiver protection techniques MANDT Blocking arm swings Getting out of holds Controlling patients hands Hospitalization on Geri Psych may be indicated if patient is a danger to self or others Medication interventions may be necessary

59 DETERMINE May not reach complete resolution but minimize the behavior and its consequences as much as possible It may take several weeks so... BE CONSISTENT!

60 Labeling behavior can hide the real problem.

61 In Conclusion...

62 Person with problematic behavior can actually be: Defending himself Paying someone back Letting someone know that he has had enough Telling someone he is in pain Protecting something precious

63 Is attacking her Is threatening her The solution is to identify and stop what the patient feels: Started it Is hurting her Is antagonizing her

64 Problematic behavior is generally not a vindictive action, though it may feel like an attack.

65 THE ULTIMATE RESULT Problematic behavior is reduced, improving the quality of life for the patient. The caregiver-patient relationship improves, preventing compassion fatigue and caregiver burnout.

66 References Rabbins, Peter V.; Lykestsos, Constance G.; Steele, Cynthia D. Practical Dementia Care. New York: Oxford University Press, 2006 Mace, Nancy L.; Rabbins, Peter V. The 36-Hour Day. New York: Wellness Central/ The Johns Hopkins Press, 1999 Brackey, Jolene. Creating Moments of Joy. West Lafayett: Perdue University Press, 2007

67 CONTACT Cindy Mann, RN, BSN Unit Manager Centra Senior Psychiatric Program Beth B. Ulrich, LCSW Community Liaison Centra Senior Psychiatric Program

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