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 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.
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 Disorders Goal 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 Disorders Investigations 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 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?
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!!!
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