a program of Morningside Ministries

Behavior Problems: Dementia and Mental Illness

in Long Term Care and Assisted Living

Dr. David A. Smith, M.D., FAAFP, CMD

Module II

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 II)

Disclosures to Participants mmLearn.org at Morningside Ministries

Requirements for Successful Completion: The purpose of this education activity is to enhance the knowledge of the geriatric/long-term care Registered Nurse in the area of behavioral management of patients with dementia by addressing anticholinergic drugs that may affect behavior, effects of family relationships on behavior, and barriers that affect a patient’s adaptability to a new environment in an effort to guide the interdisciplinary team to effectively care for residents with dementia who exhibit challenging behaviors as evidenced by the learner’s achievement of all activity objectives and a passing score on the activity post-test.

Disclosures to Participants •  The objectives of this education activity are:

1.  Identify the anticholinergic drugs commonly used in long term care or assisted living facilities that may have an adverse effect on behaviors.

2.  Discuss the benefits and risks of the use of restraints for patients in the long-term care setting.

3.  Describe marital relationship issues that may affect behavioral concerns in Long Term Care or Assisted Living.

4.  Recognize areas of noted dysfunctional family dynamics that affect staff, resident, and family relationships in Long Term Care or Assisted Living.

5.  Identify the four (4) most costly behaviors per occurrence for Long Term Care and Assisted Living Facilities.

6.  List four (4) barriers to interdisciplinary team success in behavioral problem solving 4. Discuss the Predictors of Violence.

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 post-test

•  Once successful completion has been verified, a “Certificate of Successful Completion” will be awarded for _1.1_ contact hours.

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.

Disclosures to Participants •  This activity expires: 03/09/2017 •  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) 262-9730.

Pain Perception

Cortex

Limbic system ~ agitation, emotionality

Thalamus

Spinal cord

Peripheral receptor

Anticholinergic drugs

•  antihistamines

•  antimuscarinics/urge incontinence drugs

•  digoxin

•  theophylline, ipatropium

Anticholinergic drugs

•  many psychotropics (e.g. anti psychotics, tricyclics, antidepressants)

•  anti Parkinsonian medications

•  many others

•  anticholinergic load

cont’d

Positive Consequences of Restraint

•  Visible indication that something is being done

•  Immediate effect

•  Fairly inexpensive

•  Reusable

•  Has been the normative standard of care

•  Administrative sanction

Negative Consequences of Restraint

Physiologic: Immobility-

loss of strength contractures decubiti loss of balance cardiovascular decompensation, decreased blood

volume postural hypotension

Negative Consequences of Restraint

Physiologic: Immobility-

dependent edema incontinence of bowel and/or bladder decreased appetite and malnutrition decreased immune response to challenge decreased fluid intake decreased basal metabolic rate

cont’d

Negative Consequences of Restraint

Physiologic: Abrasions and skin tears EEG changes Increased falls with injury Strangulation

cont’d

Negative Consequences of Restraint

Psych-Social: •  Increased agitation

•  Anger, aggression, verbal abusiveness

•  Screaming

•  Resignation and withdrawal

cont’d

Negative Consequences of Restraint

Psych-Social: •  Depression

•  Decreased interaction with others

•  Appearance of infirmity or lack of capacity

cont’d

Marital Relationships

•  Attachment

•  Competing balance between intimacy and

independence

•  Negotiation (set balance of intimacy and

independence)

Marital Relationships

•  Unconscious fears of connection and

separation

•  Power in negotiation

•  Patterned or automatic maintenance of

balance of power

cont’d

Marital Relationships

•  Change and restoration of balance of power after conflict or crisis

•  Health-facilitating balances which enhance personal mastery and growth

cont’d

Marital Relationships

•  Balance which copes with external stressors (illness, loss) but also promotes intimacy and individuality

•  Values, shared beliefs, attitudes

cont’d

Dysfunctional Family Dynamics

•  Loss of generational boundaries

•  Rigidity or chaotic lifestyle

•  Lack of privacy, individuality

•  Triangulation or scapegoating

•  Abuse and victim /

perpetrator issues

Conflicted Surrogate Syndrome

•  A syndrome characterized by actual or potential negative outcomes of a LTC resident due to social, psychological or psychiatric problems in a responsible party, family member or the family system.

“Is there a Conflicted Surrogate Syndrome affecting quality of care in nursing homes?” JAMDA, March 2006: 7; 3,168-172.

Summary: Some Reasons for Behavior Problems in Dementia

•  Cognitive loss/misinterpretation of the environment

•  Psychological/personality explanation

•  Cultural/social systems explanation

•  Unmet physical need

•  Pain

Summary: Some Reasons for Behavior Problems in Dementia

•  Physical illness with functional deficit

•  Physical illness with psychiatric symptom

•  Medication side effect – psychiatric symptom

•  Mental illness comorbid with dementia

•  Any combination of the above

cont’d

Consequences of Behavior Problems in Long Term Care

Behavior in Nursing Facility

BANG ! BANG ! BANG ! HELP ME ! HELP ME !

Screaming, repetitious vocalization, banging in 11-30%

Effect on staff, other

residents and visitors

Behavior Problems in Dementia

•  The single most common cause of nursing facility placement from home or assisted-living facilities

Behavior Problems in Dementia

•  The most important, potentially remedied “time sink” for staff

cont’d

Behavior Problems in Dementia

•  Staffing is among the largest line items of expenses in the nursing facility

cont’d

Kleinman L, et al. Consult Pharm. 2002;17:497-507.

Impact of Behavioral Problems in the Nursing Facility

Behaviors often require licensed nurse and certified nursing assistant (CNA) intervention

•  Most frequently reported behaviors

–  Physical agitation –  Refusal of care –  Requests for unneeded attention

Kleinman L, et al. Consult Pharm. 2002;17:497-507.

Impact of Behavioral Problems in the Nursing Facility

Behaviors often require licensed nurse and certified nursing assistant (CNA) intervention

•  Most costly behaviors per occurrence

–  Physical aggression –  Psychotic symptoms –  Sexual disinhibition –  Depressive symptoms

cont’d

Determining the Per Diem

•  Resource Utilization Groups (RUGs)

•  Special Rehabilitation (14)

•  Extensive Services (3)

•  Special Care (3)

•  Clinically Complex (6)

Determining the Per Diem

•  Impaired Cognition (4)

•  Behavior Problems (4)

•  Physical Function (10)

ü  MDS 3.0 Implemented Oct10

cont’d

Motivations Under PPS

•  Manage outcomes rather than expenses

•  Look at value

*Adapted from Malcolm Fraser MD,CMD

Impact of Behavioral Problems on Nursing Home Staff

•  Nursing home staff caring for the elderly with behavioral problems may »  Feel frustrated, exhausted, and helpless

»  Withdraw from the patient, resulting in provision of minimal care

»  Overuse physical restraints

Potts HW, et al. J Gerontol Nurs. 1996;22:11-16.

36

Caregiver expectations of patients

•  Gratitude

•  Acceptance

•  Patience

Caregiver responses to aggression: Anger

Retaliation

Defensiveness

Understanding

Behavior Problems in LTC: Interdisciplinary Teaming

Behavioral Problem Solving by Interdisciplinary Team Process

•  What explains the resident’s behavior?

•  Is this intrinsic to the resident?

•  Extrinsic to resident, a problem with environment/ system? A combination?

Behavioral Problem Solving by Interdisciplinary Team Process

-When does it occur? (Under what circumstances?)

-What precedes the behavior? (Triggers?)

-What exactly is the behavior?

-What happens after the behavior?

(Rewards? Consequences?) Worst Case Scenario?

cont’d

Behavior Problem Solving by the Interdisciplinary Team Process

Diagnosis review? Mental disease explains the behavior.

Physical disease explains the behavior.

Physical disease causes mental symptoms.

Behavior Problem Solving by the Interdisciplinary Team Process

Drug review? Drug-induced mental symptoms.

Inadequate or incorrect drug treatment of

mental illness.

cont’d

David A Smith MD,CMD

Implementing Behavioral Approaches:

Consistency – most important

Reasons Primary Care Physicians Should Do Much NH Mental Healthcare

•  Logistics

•  Ready made rapport

•  Current elder cohort bias against psychiatry

•  “Nip It…” in the bud

•  Common problem

•  Biopsychosocial integration

Resources for Behavior Problems in LTC

•  Psychiatrist/geriatric psychiatrists

•  Geriatricians (CAQ, CMD, Fellowships)

•  Pharmacists with Added Qualifications

•  Psychologists

•  Medical social workers

•  Teaming

Barriers to Interdisciplinary Teaming

•  Logistics, time •  Family involvement

•  No specific reimbursement code for physicians

•  CNA not involved or lacks skills

•  Gap between care planning and implementation (nay-sayers)