Geriatric Giants:
Challenging/Difficult
Behaviours in the Acutely Ill
Older Adult
Gerontological/Geriatric CNS of BC
2003
Who are we again?
THEIR STORY
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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
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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
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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:
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fear
shame
hopelessness
death by exclusion
The “D’s” ?
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Gero or geri-psychiatry
D elirium
D epression
D ementia
D elusions
D rugs
Delirium
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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
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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:NonPharmacological
– 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 Disorders
Goal of Therapy
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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 Disorders
Investigations
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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 Disorders
Non-pharmacological
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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
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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
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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 gutbrain 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
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Pain
Medications
Impaired senses (vision, hearing,smell..)
Malnutrition/dehydration
Constipation - Incontinence (CPG)
Lack of sleep
Acute and chronic illness
Emotional/Psychiatric Causes
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Depression (CPG)
Delirium (CPG)
Dementia
Delusions
Death
Duty to protect
Communication
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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
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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!
• Please complete
– evaluation form