Making Sense of Behavioral Symptoms in Nursing Home Residents: Alternatives to Antipsychotic Drug Use - PowerPoint PPT Presentation

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Making Sense of Behavioral Symptoms in Nursing Home Residents: Alternatives to Antipsychotic Drug Use


Objectives Explain challenging behaviors among nursing home residents by recognizing common causal or contributing factors. – PowerPoint PPT presentation

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Title: Making Sense of Behavioral Symptoms in Nursing Home Residents: Alternatives to Antipsychotic Drug Use

Making Sense of Behavioral Symptoms in
Nursing Home ResidentsAlternatives to
Antipsychotic Drug Use
Quality Insights Webinar 2.20.13
  • Joel E. Streim, M.D.
  • Professor of Psychiatry
  • University of Pennsylvania
  • Philadelphia VA Medical Center

  • Dr. Streim is on the faculty of the Geriatric
    Education Center of Greater Philadelphia, which
    is funded by the Bureau of Health Professions,
    Health Resources and Services Administration
    (HRSA), Dept. of Health and Human Services
  • The content of this presentation is solely the
    responsibility of the presenters and does not
    necessarily represent the official views or
    policies of HRSA or the DHHS.

  1. Explain challenging behaviors among nursing home
    residents by recognizing common causal or
    contributing factors.
  2. Identify non-pharmacological interventions that
    are likely to produce desired results in
    modifying behavior.
  3. Give examples of  the systemic barriers to
    implementing non-pharmacological interventions in
    nursing facilities

  • Three premises lead to the conclusion that
  • Antipsychotic drug treatment is usually not the
    most appropriate response to most resident
    behaviors and
  • Sensible, effective, non-pharmacological
    responses to behavior required a patient-centered
    approach to care.

Premise 1
  • Not all behavioral symptoms are problems
  • A behavior becomes a problem when it is
    associated with
  • Distress (subjective experience of the resident)
  • Disability (observable functional impairment)
  • Disruption (interference with delivery of care,
    or disturbance of the living
  • Danger (to self or others)

Premise 2
  • Most problematic behaviors among nursing home
    residents are not likely to respond to
    antipsychotic drugs
  • Most behaviors are not caused by psychotic
    illnesses. Only a small proportion of residents
    have conditions that can be appropriately treated
    with antipsychotic medication, such as
  • Schizophrenia
  • Bipolar disorder
  • Depression with psychosis
  • Dementia with psychosis, in selected cases

Premise 3
  • Behavior problems are commonly triggered by an
    approach to care that fails to incorporate the
    residents own experience
  • Care that is based solely on facility routines
    and caregiversperceptions often causes the
    resident to become anxious, fearful, irritable,
    or angry.
  • Resultant behaviors may include
  • Restlessness
  • Yelling or verbal hostility
  • Rejection of care
  • Physical combativeness

Case Example
  • A very confused 83-yr-old female resident, Mrs.
    M, sees staff put on coats and get ready to
    leave at change of shift (3pm).
  • Resident heads to the exit door.
  • A CNA runs after her, yelling no, you cant go
    out there.
  • Resident pushes the CNA away. Note entered in
    chart says resident tried to elope, and was
    physically aggressive toward staff.
  • Attending physician is called and gives an order
    for haloperidol 2 mg every day.

Alternative Patient-centered Approach
  • When patient heads to exit door, CNA asks Can I
    help you?
  • Resident says, I have to go home to get a snack
    ready for my daughter. Shell be home from school
    any minute.
  • CNA says, OK, Ill help. Lets go to the kitchen
    and get some cookies for your daughter. I bet
    shell like them. Whats her name?
  • The resident turns away from the exit door, and
    follows the CNA to the kitchen area.

What do we need to learn as caregivers?
  • How to make sense of behavioral changes
    associated with dementia and other conditions
  • 1. Understand and empathize with the residents
  • 2. Recognize factors that cause or contribute to
    behavioral problems
  • Once understood, interventions and management
    strategies become apparent
  • Assessment informs approach to care

Making Sense of Resident Behavior
  • All behavior makes sense / has meaning
  • Applies to residents with and without dementia
  • Looking for reasons behind behaviors by stepping
    into the residents world enables us to identify
    person-centered solutions that
  • Are responsive to resident needs
  • Avoid using unnecessary medications

Person-centered Care WHY?
  • Key to culture change in nursing homes
  • Resident and staff become part of a caregiver /
    care-recipient partnership
  • Increases residents perception that staff is on
    their side
  • Residents become less likely to experience care
    as adversarial
  • Staff becomes less likely to experience
    caregiving as a struggle

Person-centered Care WHAT?
  • Focus on the residents experience
  • Try to imagine being in their world
  • Consider how things look from their perspective
  • Accept their reality
  • Their subjective experience is real to them
  • Doesnt mean you actually adopt their point of
    view for yourself

Person-centered Care HOW?
  • Look for meaning in verbal and non-verbal
  • Ask, what do you want? how can I help?
  • Listen for clues to sources of distress or unmet
  • Avoid saying no, arguing or disagreeing
  • Offer to help in ways that reduce distress or
    meet needs, without compromising safety

Making Sense of Behaviors
  • A richer understanding of the residents
    experience also requires the identification of
    causal and contributing factors

Causal and Contributing Factors
  • Behavioral symptoms can be multiply determined by
  • Cognitive deficits
  • Unmet needs (physical and psychological)
  • Environmental / social irritants
  • Medical illness / physical discomfort
  • Psychiatric conditions
  • Adverse drug effects

Cognitive Domains Impaired in Dementia
  • Memory loss (amnesia)
  • Decline in other cognitive functions
  • Language (aphasia)
  • Visual-spatial function
  • Recognition (agnosia)
  • Performing motor activities (apraxia)
  • Initiating/executing sequential tasks (apathy,
    abulia, executive dysfunction)

How does memory impairment lead to behavioral
  • Example
  • Patient cant remember where his clothes are

Walks into hallway naked
How does language impairment (aphasia) lead to
behavioral problems?
  • Example
  • Patient who cant verbally communicate that
    pills are hard to swallow
  • Spits medication at caregiver

How does impaired visual recognition (agnosia)
lead to behavioral problems?
  • Example
  • Patient cant recognize a spoon as a utensil for
  • Throws the spoon on the floor

How does impairment in performance of motor tasks
(apraxia) lead to behavioral problems?
  • Example
  • Patient cannot manipulate zippers or buttons to
    unzip or unbutton his pants

Wets his clothing
Common misattributions for behaviors
  • Caregiver may assume resident is
  • Angry / Belligerent
  • Lazy / Dependent
  • Manipulative
  • Often, a behavior that is interpreted as
    uncooperative is actually better explained by
    cognitive disability

Emphasize Resident Strengths
  • Recognize
  • areas of impaired function
  • and
  • areas of preserved function
  • Help compensate for impairment
  • Support and celebrate residual abilities
  • Focus on something unique that person feels good
  • Express appreciation and admiration

Remember Theres no one-size-fits-all response
to behaviors
  • Different residents have different situations and
  • Residents change over time needs and behaviors
    change, too
  • Some responses work one day, not the next
  • Some responses work for one caregiver, but not
  • Responses must be tailored to the individual and
    modified over time

Strategies for Communicating with Residents with
Language Comprehension Deficits
  • Sit down communicate at eye-level
  • Connect with smiles, humor
  • Reassure with simple words, comfort with touch
  • Use visual and gestural cues
  • Speak slowly, using short sentences, single words
  • One idea, one direction at at time
  • Be patient give adequate time to process and
  • Avoid using negative tone or words
  • Dont scold or argue
  • When language comprehension is severely impaired,
    use other senses to communicate
  • Smell, touch, vision, taste

What modifiable factors may contribute to
behavioral changes in nursing home residents
(with or without dementia)?
Unmet needs that can lead to behavioral
All residentswhether cognitively intact or
impairedhave common, basic needs
  • Physical needs
  • Nutrition, hydration, toileting, exercise, rest
  • Psychological needs
  • Security, autonomy, affection, self-worth

Environmental irritants that can lead to
behavioral disturbances
  • Physical
  • Noise
  • Confusing visual stimuli
  • Physical barriers
  • Uncomfortable temperature
  • Unfamiliar surroundings
  • Social
  • Changes in routines
  • Caregiver interactions

Medical conditions and physical discomfort that
can lead to behavioral disturbances
  • Physical discomfort
  • Pain
  • Constipation
  • Urinary urgency
  • Shortness of breath
  • Dizziness
  • Fatigue
  • Medical condition
  • Arthritis
  • Dehydration
  • Prostatic hypertrophy
  • COPD
  • Cerebrovascular disease
  • CHF

Psychiatric conditions that can cause behavioral
  • Depression
  • Delirium
  • Psychosis
  • delusions
  • hallucinations
  • Anxiety
  • Sleep disturbance

Adverse drug effects that can cause behavioral
  • Nuisance symptoms
  • Anticholinergic effects
  • Antihistaminic effects
  • Paradoxical excitation / disinhibition
  • Intoxication or withdrawal states
  • Akathisia (syndrome of motor restlessness)

  • Identification of any of these modifiable causes
  • unmet needs
  • environmental and social irritants
  • medical illness and physical discomfort
  • psychiatric conditions
  • adverse drug effects
  • points the way to specific interventions

Institutional resources to promote
non-pharmacological approaches
  • Consistent staff assignments
  • Assignment of staff across disciplines to
    supervise everyday leisure activities
  • Group
  • Individual / solitary
  • Beyond structured recreation therapy
  • Space for exercise, outdoor activities

Barriers to Implementation of Non-pharmacological
  • Ingrained culture of medical and nursing care
  • Inadequate staff training
  • Staff turnover
  • Aversion to risk-taking
  • Need to accept that risks are part of normal,
    everyday life
  • Need to change attitudes of families, staff,
    administrators, regulators, surveyors, legal

Resources for Training and Implementation
  • CMS campaign website
  • http//
  • Hand-in-Hand (person-centered dementia care
    training materials)
  • http//

Questions Discussion
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