Geriatric Giants: Challenging/Difficult

Behaviours in the Acutely Ill Older Adult

Gerontological/Geriatric CNS of BC 2003

Who are we again?

THEIR STORY

• Married 52 years

• Doug has Alzheimer's

• Mary has heart failure

• Mary’s the “brain”

• Doug is the “brawn”

• They live in their home of 50 years.

THEIR FAMILY

• Meet Sue

• Meet her family

• She is a professional

• She works full-time

• She lives the closest to Mary and Doug

• Her brother lives in Nova Scotia with his family

The “Acute” Incidents

• Doug slipped while trying to help Mary get out of the bath tub.

• He fractured his hip and has many bruises.

• After one hour of struggling Mary managed to get to a phone and call 911

• Both Mary and Doug have been brought to hospital.

DOUG

• Doug keeps yelling and calling to Mary to save him from these robbers who have broken into their house

• He is thrashing about in the bed despite his fracture.

• He is to have surgery tonight and is awaiting a bed on the surgical unit.

Mary

• Mary is hypothermic; has a black eye and has high BP/P on admission

• She hears Doug calling & tries to go to him.

• She is SOB and weak

• She oriented x3 but is very anxious.

• She is to be admitted to a medical unit.

SUE: The Daughter

• Sue was called at work

• She has just arrived on the scene

The Care Providers

• You are to care for Doug and Mary

• What are your thoughts, feeling and body sensations?

• What do you think Sue is feeling?

The Challenges of Caring

The Goals

• Increase understanding related to what behaviours are: patient and care provider

• Gain added knowledge of mental health and psychiatric issues as they relate to behaviour and therapies

• Offer practical tips to increase your “toolbox” of approaches to care

Goals

• To “coach you in building positive outcome “habits and structures” to assure best practice and care of the older adult.

• Today to discuss the “Geriatric Giants” related to challenging/difficult behaviours, including the “D’s” and how they impact upon the older adult and care providers’ abilities.

“BEHAVIOUR”

• ALL meaningful - telling/sending message

• Observed “gut-brain” response to internal and external stimuli

• “Feeler” of the stimuli is asking the responder to “understand” what is being non-verbally and verbally said.

• “Receiver” interprets message leading to response - This is the real challenge!

“What is difficult/challenging behaviour?”

• Each person interprets actions by others and their own actions based upon their life experiences, knowledge and personal perceptions

• It is all in the EYE of the beholder - Mary, Doug, Sue and You.

Top 5 Challenges

1.

2.

3.

4.

5.

The Brain

• Central processor of all bodily and behavioural functions and activities

• Must always consider what is happening in the brain and nervous system.

• If only the brain was housed in a glass bubble so that we could see what is being activated and what is not.

AXIS…what?

• Psychiatry classifies abnormal behaviours into diagnosis as per the consensus guideline - DSM IV- R = 5 axis

• Continuum of adaptive to maladaptive

• Continuum of constructive to destructive

• Mental illness is no different than physical or social illness. It is biopsychosocial!

“The Label…”

• Once labeled, there for LIFE!• CAUTION: biases, discrimination and “…

isms” can lead to:– fear– shame– hopelessness– death by exclusion

The “D’s” ?

• Gero or geri-psychiatry

• D elirium

• D epression

• D ementia

• D elusions

• D rugs

Delirium

• Rapid onset with changes in sensorium

• inability to shift thoughts/inattentiveness

• fluctuation over the day/night

• visual hallucinations and/or illusions

• previous hx

• Drugs or Bugs

• REVERSIBLE : Find the cause and treat!

Delirium C.P.G.

• Require a baseline cognition and full physical work-up

• Preferable on admission; however, do screen if sudden change in cognition.

• MMSE - helpful or not?

• Doug has a dementia; therefore, he has a greater likelihood of developing a delirium

Withdrawal?

• Look for withdrawal from alcohol, drugs, nicotine, caffeine..

• CAGE, CIWA and protocol

• Harm reduction

• Fat storage and liver function

• Referral

Post-Op: Doug

• 10 days following his surgery, Doug suddenly becomes restless (physical movement) and is visually hallucinating

• He was on CIWA protocol following the admission CAGE score.

• He starts to seizure

• What could this be?

The Brain: Acquired Injury

• WHO 1996: Damage to the brain, which occurs after birth and is not related to a congenital or degenerative disease. These impairments may be either temporary or permanent and cause partial or total functional disability or psychological maladjustment.

Brain

• Developmental delay due to congenital birth defects (e.g. FAS, trisomy,)

• Anoxia, CVA, drugs• Cognition affected by the location and extent

of the damage.• Frontal lobe - disinhibition (increasing)• www.bcbia.org - website for BC Brain Injury

Association

Mary: LOS = 14 days

• Mary had a black eye initially. The ecchymosis spread to her forehead and into her hairline

• She has been observed to be increasingly agitated (verbalization ) in the past few days.

• What should you do?

Depression

• Persistent over 2 weeks or more

• Change in appetite and intake

• Change in sleep pattern

• Change in motor and functional level

• Hopelessness, helplessness - Suicidal

• Differentiate between grief and sadness

• REVERSIBLE - identify and treat!

Depression CPG

• Currently in last stages of development

• To be applied across the full continuum of care including acute care through to home care and residential services

• Geriatric Depression Scale – preferably self-scored

• Suicide assessment

Mary Declines

• Mary has been told that she and Doug will most likely have to go into a nursing home now.

• She says that she and Doug would be better off dead.

• Her appetite and sleep have been poor for several weeks.

• What to do?

Dementia

• Slow, insidious decline in cognition (memory marker) and executive function

• Vascular,mixed,Alzheimer type, Lewy body

• NOT reversible but can be slowed down if diagnosed early and monitored

• Complex partial seizure and sudden aggression with post-ictal sequelae

Doug: Alzheimer Type

• Doug has a foley; but he keeps pulling it out

• When up in the wheelchair, he is constantly heading for the door or going into other patients rooms and calling for Mary

• Evening’s finds him very restless and stripping off his clothing

• What to do?

Delusions

• Persistent mistaken thoughts

• Is seen in psychosis and also in dementing disorder like Lewy body or frontal/temporal dementia

• NB! Act upon their mistaken thoughts. Paranoia and suspicious

• Can treat to control paranoia; however, if dementing will decline oft times rapidly.

Mary

• Mary becomes increasingly restless and agitated.

• She accuses you of trying to poison her and is refusing her medications.

• She has phoned 911 to report you.

• She is constantly leaving the unit.

• What to do?

DRUGS

• Can be both the cure and the cause of adverse behavioural response

• psychotropics - antipsychotics; anxiolytics; sedatives; antidepressants; anticonvulsants

• in the elderly: Go LOW and GO SLOW!!!

• Too many, too much OR too few, too little =

Antipsychotics/Neuroleptics: Goal of Therapy - Psychosis– To control specific psychotic symptoms (e.g.

hallucinations, delusions, disordered thinking)– To reduce agitation in acute psychoses– To prevent relapse of chronic psychotic illness

– To reduce distress level in patients with dementing illness with cognitive and psychotic symptoms

Antipsychotics/Neuroleptics: Investigations

• Determine pre-existing psychiatric, medical and drugs from history

• Assure differentiation of diagnosis (e.g. delirium, schizophrenia, B.A.D., withdrawal) - Psychiatrist/Geropsych.

• Assure baseline labs - CBC, TSH, liver function tests, ECG in patients over 40 years.

Antipsychotics/Neuroleptics: Therapeutic Choices:Non-

Pharmacological

– Reduce environmental stressors/stimuli

– Educate family

– Hydrate and nourish

– Least restraints and freedom to move

– Support as symptoms come under control

– Refer to psychiatrist

Antipsychotics/Neuroleptics: Therapeutic Choices

• First generation block dopamine receptors– CPZ, haldol, loxapine– watch for EPS, TD, hypotension,tachycardia,– neuroleptic malignant syndrome

• Second generation selectively block dopamine and serotonin receptors– lower risk for EPS and TD– clozapine, olanzapine, resperidone,quetiapine,

clopixol

Anxiolytics: Anxiety DisordersGoal of Therapy

• To decrease symptomatic anxiety

• To decrease anxiety-based disability

• To prevent recurrence

• To treat comorbid conditions (e.g. addiction withdrawal, distressing medical condition, PTSD, panic disorders, phobias)

Anxiolytics: Anxiety DisordersInvestigations

• Thorough HX - nature & onset of symptoms• Comorbid mood disorders - treat first• Assure accurate diagnosis• Physical to exclude endocrine, cardiac,

substance abuse• Labs - CBC, liver function, GGT,TSH,ECG

Anxiolytics: Anxiety DisordersNon-pharmacological

• Decrease caffeine or other stimulants

• Minimize ETOH use

• Short-acting benzos only for prn x 4 days

• Stress reduction - relaxation, imagining

• Specific cognitive-behavioural (CBT)

• Psych consult if no improvement within 6-8 weeks with drug therapy

Anxiolytics: Anxiety Disorders:Pharmacological

• Benzodiazepines (BDZs) - ST vs LT use; NB! Withdrawal; paradoxical effect– clonazepam, lorazpam,alprazolam; atypical

buspirone

• Antidepressants - reduce frequency and severity of panic attacks– SSRIs– adjunctive - propanolol

Sedatives/Hypnotics:Goal of Therapy

• To treat sleep disorders

• To increase depth of sleep so that person identifies positive feelings of energy refreshment

• To return person to non-pharmacological sleep cycle

Sedatives/Hyponotics:Investigations

• Review sleep and rest HX

• Review drug and ETOH Hx as relates to use as a sleep inducer - NB! Effectiveness?

• Assess personal normal sleep pattern

• Differentiate diagnosis of depression or mood disorder

• Refer - Sleep Clinic at UBC

Sedatives/Hypnotics:Therapeutic Choices

• Dark, well ventilated, quiet & cool room

• COMFORT : Toilet before sleep time

• Do not give after 0100h or will produce day/night reversal

• Assess for nocturnal hypoxia - elevate head of bed

• Silent bed exit alarm

Sedatives/Hypnotics:Pharmacological

• Short acting with few metabolites preferable• Oxazepam, chloral hydrate, trazadone,

caution with TCAs; prefer non-benzo e.g. zoplicone

• May cause or worsen delirium• May contribute to falls• May contribute to incontinence

Antidepressants:Goals of Therapy

• To relieve depressive symptoms

• To prevent suicide

• To restore optimal functioning

• To prevent recurrence of depression

Antidepressants:Investigations

• Review past HX especially re: previous depression, suicide attempts, family Hx

• Differentiate Dx of type of mood/affective disorder from chronic dysthymia. SUICIDE

• Physical to r/o medical cause (e.g.thyroid)

• Labs - same as antipsychotics

• Referral to appropriate psychiatrist

Antidepressants:Non-Pharmacological

• Education

• Cognitive behavioural or interpersonal psychotherapies

• ECT

• Supportive

• Utilize clinical practice guidelines

Antidepressants:Pharmacological

• TCAs, SSRIs, NSSRIs, MAOIs, RMAIOI

• takes 4-6 weeks to titrate to effective treatment level

• observe for side effects - serotonin syndrome

• drugs cannot stand alone - require concurrent other therapies

Adjuncts:Goal of Therapy

• To treat the underlying psychiatric disorder in conjunction with usual drugs ( e.g. cholinesterase inhibitors, mood stabilizers, neurontin, anti-convulsants)

• To enhance or modulate other drug therapies

• To decrease distressful symptoms

Adjuncts:Investigations

• Review what is currently being used and the effectiveness

• Hx and physical

• Labs

Adjuncts:Pharmacological

• Have a pharmacist review for drug/drug interactions (e.g. aricept with loxapine; gingko with coumadin, paxil with coumadin; lithium with NSAID)

• More is not necessarily better

• Is the adjunct treating the side effects caused from the primary drug? (e.g Cogentin)

Summary for Drugs

• Psychotropic drugs require knowledge– targeted behaviours– appropriate for symptoms– side effects and contraindications– prn, ST, LT maintenance

• Elderly: Go LOW and go Slow

• OBSERVE AND DOCUMENT

Who is in charge?

• Is it…”Want to be in control?” or “Need to be in control?”

• Upon what is the locus of control based?

• Whose control is it? Patient or YOU?

• Conflict frequently is the outcome of control struggles.

• Power = Control? Control = Power!

“Fire,Ready,Aim!”

• What is wrong with this sequence?

• When approaching a patient whose gut-brain mix is causing them mental turmoil, decelerate yourself first or you may find you fire,ready,aim;therefore resulting in harm to either one or both of you.

• Timing,Proximity,Boundaries with TRUST

Your Stories

• What are the causes of the difficult/challenging behaviours?

• What do you now know that you would do next time?

• What one aspect of care can you nurture to change practice on your unit?

Current Abilities As a Cause

• Able to do the requested task?

• Able to communicate?

• Able to problem-solve?

Physical Causes

• Pain

• Medications

• Impaired senses (vision, hearing,smell..)

• Malnutrition/dehydration

• Constipation - Incontinence (CPG)

• Lack of sleep

• Acute and chronic illness

Emotional/Psychiatric Causes

• Depression (CPG)

• Delirium (CPG)

• Dementia

• Delusions

• Death

• Duty to protect

Communication

• Respectful

• Set the mood before it is set for you

• Simple and clear

• Focused and directed

• If appropriate offer two choices

• Do NOT argue, challenge, order, condescend, talk around

Outcomes?

Or the Story can go...

• Mary, Doug and Family

Question?

• Has your “eye” changed?

• Let’s get wisdom through foresight rather than hindsight!

Hope and Light!

• Better assessments including neuropsych.

• Treatment scope and variety is ever growing. More sustainable & effective

• Psychotherapy; group therapy; rehab

• ECT - excellent therapy

• Psychotropics (1955) - know the drug; be cautious; assess…assess…assess...

Take Home Message

• All behaviour has a reason and purpose

• By being a detective, solutions can be found

• Document and report sooner than later

• If you do not understand the behaviour, ask

• Safety of the client, caregivers and yourself are number ONE

• You make the difference!!!

Thank you for your CARING!

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