October 2011

 Experience. Education. Excellence.  Harvest is a leading full-service behavioral health provider, specializing in the delivery of progressive and innovative consultative behavioral health services for patients and residents residing in skilled nursing, rehabilitation, and assisted living facilities. Our multidisciplinary team of highly skilled professionals work together to offer a broad menu of services including but not limited to 24-hour prescriber on- call services and hospitalization support, comprehensive cognitive assessments, documentation review, OBRA compliance support and customized educational programs designed for the individual needs of your facility.

 This presentation was developed for the continuing education of healthcare providers  At the conclusion of this presentation the audience will have a basic understanding of agitation and difficult behaviors associated with dementia and strategies for managing them.  A mental health professional should be consulted in the treatment of patients with mental illness.

 Agitation or aggression is reported to occur in 50% of patients with advanced dementia.  Agitation is an initial symptom of dementia in 36% of patients.  At least one form of agitation occurred in nearly 71% of institutionalized elderly.  Agitation is a complex phenomenon with no simple association between a singular cause and no singular treatment.  Residents with dementia have limited control of their environment and impaired ability to communicate with those who might act on their behalf.

 Agitation is correlated with emotional exhaustion in nurses.  Agitated patients can cause behavioral problems for lucid patients which in turn further aggravates the initially agitated person.  Aged care residents could be provoked by whatever would irritate anyone else, but with cognitive impairments it is difficult for them to communicate the frustrations/irritants.

 Agitation includes any aberrant behavior associated with dementia and mental illness.  In the literature the definition of agitation is varied.  Most authors describe agitation as excessive motor activity with inner tension and one or more of approximately 47 different disruptive behaviors.  This presentation will consider agitation to be disruptive or difficult behavior associated with dementia and other psychiatric illnesses (persons with cognitive impairment).

 Complaining  Cursing  Striking out  Verbal aggression  General restlessness  Repetitive sentences  Negativism  Constant calls for help  Wandering  Trying to escape  Pacing  Inappropriate dressing  Strange noises  Hoarding  Repetitive mannerisms  Screaming  Strange movements  Hiding things  Intrusion / invading personal space

 Disruptive behaviors are always evoked by either unmet needs or triggers.  You must assess and investigate in order to figure out if it’s an unmet need or a trigger.  Triggers are external and come from environment. Examples are noises, smells, temperature, and people.  Unmet needs are internal. The following slides will review Maslow’s Hierarchy of needs which will provide a basic understanding of human needs that need to be met on a continuous basis.

Self Actualization: Pursue Inner Talent, Creativity, Fulfillment Self Esteem: Achievement, Mastery, Recognition, Respect Belonging-Love: Friends, Family, Spouse, Partner, Lover Safety: Security, Stability, Freedom from fear Physiological: Food, Water, Shelter, Warmth

 Psychologist Abraham Maslow's ( ) need hierarchy suggests that unmet needs help explain difficult behavior patterns.  When a patient presents with a disruptive behavior it is helpful to assess the basic needs in an effort to discover potential unmet need which may be fueling the behavior.

 Physiological needs are the very basic needs such as air, water, food, sleep, sex. When unsatisfied we may feel sick, irritated, uncomfortable. These feelings motivate us to alleviate them as soon as possible to reestablish our equilibrium. Once alleviated, we are able to focus on other things.

 When physiological needs are largely satisfied, we become increasingly interested in finding safe circumstances, stability, and protection. We might develop a need for structure, order, some limits.  When safety needs are not met, we can't move to the next level. ◦ if deprived, can lead to neurosis, insecurity; ◦ if pathological, can develop phobias such as agoraphobia.

 Belonging - Love Needs When physiological needs and safety needs mostly are met, we begin to feel the need for friends, a partner, children, affectionate relationships, a sense of community. Humans have a desire to live and belong to groups including clubs, work groups, religious groups, family, gangs. We need to feel loved and accepted by others. if deprived, can lead to loneliness if pathological, can lead to antisocial behavior.

 Lower form needs are respect from others, for status, fame, glory, recognition, attention, reputation, appreciation, dignity, even dominance.  Higher form needs involves the need for self- respect, including such feelings as confidence, competence, achievement, mastery, independence, and freedom.  Low self-esteem and an inferiority complex are negative versions of these needs and are at the root of many, if not most, psychological problems. if deprived, can lead to feelings of inferiority; if pathological, can lead to depression.

 The need for self-actualization is "the desire to become more and more what one is, to become everything that one is capable of becoming." People can seek knowledge, peace, esthetic experiences, self-fulfillment.  Self-actualization needs: ◦ do not distort our perception as do other needs; when self- actualized, we more accurately perceive what exists; ◦ can never be satisfied -- when can you have enough truth, beauty, or justice? ◦ at work, focus on creativity, fulfillment; ways to increase employee enjoyment and satisfaction; ◦ if deprived, can cause feelings on lack of meaning in life, boredom; ◦ if pathological, metapathologies such as boredom, cynicism, alienation.

 The first four levels -- physiological, safety, belonging, self-esteem -- Maslow calls deficit needs, or D-needs. If you don’t have enough of something, i.e., you have a deficit -- you feel the need. But if needs are met, they are no longer salient and you feel nothing at all. Consequently, these needs don't motivate. As the old blues song goes, “you don’t miss your water 'til your well runs dry.”

 Under stressful conditions, or when survival is threatened, we can “regress” to a lower need level.  When a person can not verbalize their unmet need because of cognitive impairment, they will attempt to communicate their unmet need through behavior.  When this behavior is disruptive it is not always considered to be important, but it always is.

 In order to treat disruptive behaviors effectively we must identify the unmet need or environmental trigger that is likely behind the disruptive behavior.  Remember that the patient will not be able to communicate the need or trigger and investigative work is needed.  Is the behavior associated with just one patient or several?  If individual agitation ask yourself if the behavior is related to: ◦ hunger ◦ Hydration ◦ Hygiene ◦ Comfort ◦ Environmental over or under stimulation ◦ Fear ◦ Lack of social interaction ◦ Boredom ◦ Other basic needs of that individual

 Does the agitation/behavior warrant assessment and possible treatment? ◦ Is safety and/or dignity of the patient or others at risk?  (1) Identify and, where possible, treat any physical conditions causing the agitation. If staff and other residents can tolerate the behavior and it poses no threat to welfare, including the resident’s, then a more positive interpretation of the behavior may be sufficient, rather than active treatment. This is the most conservative option.  (2) If treatment is required and the behavior is common throughout the institution, consider a group or system-wide intervention because the same factor could be operating generally. Environmental causes should be suspected if agitation patterns are consistent across residents; there could also be systemic neglect of care. System wide interventions can be efficient if they are effective.  (3) If the agitation is unique to an individual and intervention is necessary for the welfare of the resident, staff, other residents, visitors and institutional viability, then individualized treatment will be required.

 (1) Removing the negative, to target the causes of agitation such as care deficiencies, unmet needs (e.g., need for social contact), excessive task demands and environmental stressors. Removing the negative is both preventative and curative, and can operate system-wide or be individually targeted. Removing the negative could include relocating the resident away from an aggravating influence, as the environment is incompletely controllable.  (2) Positive intervention, such as music or relaxation therapy, multi-sensory rooms, and verbal and diversionary therapies additional to everyday maintenance care. These strategies should be implemented as treatments for agitation when no negative causes can be identified or modified. This approach could be preventative or curative.

 (3) Negative intervention, such as physical restraint and pharmacological treatments. Such measures are controversial. They should be limited to when other options are exhausted and the agitation threatens the welfare of the agitated resident, other residents, staff or visitors, and the institution’s functioning despite reasonable allowances for the behavior. Negative intervention can involve risks to the resident, which should be considered against expected benefits. If negative interventions must be used, it should be sparingly, reluctantly, individually, only as a temporary expedient, with ongoing observation, not routinely, only curatively and never preventatively, punitively or as a substitute for positive measures and quality care.

 When agitation becomes extreme and safety is at imminent risk: ◦ Stay calm: If we are stressed then our patients behaviors will escalate as they will need to try harder to get their needs met ◦ Notify supervisor if you believe that there is a imminent risk for harm to self or others ◦ Use soft, soothing voice ◦ Use firm and directive statements ◦ Remove others that may be at risk for harm ◦ If appropriate, walk away and get help. Don’t become part of the problem, step back ◦ Supervisor will determine if patient needs to be transported to Emergency Room for assessment and if police need to be notified ◦ Refer to psychiatric services for follow up  Never force a patient to do anything. Use coercion, distraction, try at a later time or have someone else try.  Allow for "escape routes." We all have a "fight or flight" response to stressful situations. If the resident is not a danger to himself or others, allow that resident to "escape" from apparently stressful situations.

 Stay calm: If we are stressed then our patients will behaviors will escalate as they will need to try harder to get their needs met.  Don’t personalize the behaviors of patients  Determine if the behavior is unique to one or to many patients.  Define the behavior we wish to manage, and identify the unmet needs or triggers.  Create a plan of action to address the unmet need or trigger. There are 3 approaches: 1)remove the negative, 2) positive intervention or 3)negative intervention.  When dealing with residents be creative, be safe, and use common sense when difficult behavior occurs.  Review the plan's results to determine if it is working, and change it if necessary.  Communicate your assessment and results with staff in an effort to prevent the behaviors from re-occurring.

 If you encounter an agitated patient what is the first thing you should do?  What is the difference between agitated and aggressive?  When you believe safety for the patient(s) or staff is at risk, what should you do?  What are common causes of agitation?