Quality Insights Webinar 2.20.13
Making Sense of Behavioral Symptoms
in Nursing Home Residents:
Alternatives to Antipsychotic Drug Use
Joel E. Streim, M.D.
Professor of Psychiatry
University of Pennsylvania
Philadelphia VA Medical Center
Disclosures
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 (DHHS).
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.
Objectives
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
Overview
Three premises lead to the conclusion that:
1
Antipsychotic drug treatment is usually not
the most appropriate response to most
resident behaviors; and
2
Sensible, effective, non-pharmacological
responses to behavior required a patientcentered 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 environment)
— 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 resident’s own experience

Care that is based solely on facility routines and
caregivers’perceptions 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 can’t 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. She’ll be home from school
any minute.”
CNA says, “OK, I’ll help. Let’s go to the kitchen and
get some cookies for your daughter. I bet she’ll like
them. What’s 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 resident’s experience
— 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 resident’s 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 resident’s 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
— Doesn’t mean you actually adopt their point of
view for yourself
Person-centered Care: HOW?





Look for meaning in verbal and non-verbal
communication
Ask, “what do you want? “how can I help?”
Listen for clues to sources of distress or
unmet needs
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 resident’s
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 problems?
Example
Patient can’t remember where his clothes
are kept
Walks into hallway naked
How does language impairment (aphasia)
lead to behavioral problems?
Example
Patient who can’t verbally communicate
that pills are hard to swallow
Spits medication at caregiver
How does impaired visual recognition
(agnosia) lead to behavioral problems?
Example
Patient can’t recognize a spoon as a
utensil for eating
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 about
— Express appreciation and admiration
Remember: There’s no one-size-fitsall response to behaviors

Different residents have different situations
and needs

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 another

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 respond

Avoid using negative tone or words
— Don’t 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 disturbances
All residents—whether cognitively intact or
impaired—have 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
Medical condition
Physical discomfort
— Arthritis
— Pain
— Dehydration
— Constipation
— Prostatic hypertrophy
— Urinary urgency
— COPD
— Shortness of breath
— Cerebrovascular disease — Dizziness
— CHF
— Fatigue
Psychiatric conditions that can cause
behavioral disturbances

Depression

Delirium

Psychosis
— delusions
— hallucinations

Anxiety

Sleep disturbance
Adverse drug effects that can cause
behavioral disturbances

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 Nonpharmacological Approaches

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
counsel
Resources for Training and
Implementation

CMS campaign website:
http://www.nhqualitycampaign.org/star_index
.aspx?controls=dementiaCare

Hand-in-Hand (person-centered dementia
care training materials):
http://www.cmshandinhandtoolkit.info/Index.aspx
Questions
&
Discussion