11

Treatment Modalities for the Treatment Modalities for the Management of Distressed Management of Distressed

Behaviors in Elderly Behaviors in Elderly

Revised by Tony SetiabudhiRevised by Tony SetiabudhiDecember 2010December 2010

22

DefinitionsDefinitions ““Behavior” refers to an individual’s observable Behavior” refers to an individual’s observable

actions.actions.

“Cognition” refers to any personal activities related to organizing memory, sensation, and thinking

““Mental status” refers to an individual’s overall Mental status” refers to an individual’s overall level of alertness, activation, and responsiveness level of alertness, activation, and responsiveness to the outside world.to the outside world.

AMDA Dementia CPG 1998AMDA Dementia CPG 1998

33

Incidence of BehaviorsIncidence of Behaviors Apathy (72%)Apathy (72%) Agitation (60%)Agitation (60%) Anxiety (45%)Anxiety (45%) Irritability (42%)Irritability (42%) Motor restlessness (38%)Motor restlessness (38%) Disinhibition (36%)Disinhibition (36%) Sleep disturbance (24%)Sleep disturbance (24%) Depression (23%)Depression (23%) Delusions (22%)Delusions (22%) Hallucinations (10%)Hallucinations (10%)

44 1. Finkel SI et al. Int Psychogeriatr. 1996;8:497-500

Distressed Behaviors in Nursing HomesDistressed Behaviors in Nursing Homes Increases stress between patients and caregiversIncreases stress between patients and caregivers11

Create intensive and costly levels of treatmentCreate intensive and costly levels of treatment11

Increase morbidity and mortality Increase morbidity and mortality 11

Lead to public health problems that contribute to the Lead to public health problems that contribute to the enormous cost of treating dementiaenormous cost of treating dementia11

Increase risk of overmedication and restraintsIncrease risk of overmedication and restraints

55

““Agitation”Agitation” Excessive motor or verbal activity that is Excessive motor or verbal activity that is 11

1.1. One of the followingOne of the following Disruptive OR Unsafe OR Distressing to the patient

2.2. Interferes with care and Interferes with care and 3.3. Is not because of needIs not because of need

Generally, is a poor descriptor of behaviorGenerally, is a poor descriptor of behavior Appears similar despite great variety of causesAppears similar despite great variety of causes Need to make diagnosis, not focus only on symptomsNeed to make diagnosis, not focus only on symptoms When severe, may be the target for urgent intervention When severe, may be the target for urgent intervention

1. Cohen-Mansfield et al, 1996; Tariot et al, 1994 Cohen- Mansfield Agitation Inventory. www.medafile.com/zyweb/CMAI.htm

66

Agitation and Aggression in DementiaAgitation and Aggression in Dementia

Cohen-Mansfield et al, 1996; Tariot et al, 1994

PhysicalPhysical VerbalVerbalHittingHitting ThreatsThreatsPacingPacing AccusationsAccusationsKickingKicking Name-callingName-callingBitingBiting ObscenitiesObscenitiesPushingPushing ComplainingComplainingSpittingSpitting Attention-Attention-

seekingseekingScratchingScratching ScreamingScreaming

77

Behavior Diagnosis: PitfallsBehavior Diagnosis: Pitfalls

Many etiologies can present with the same Many etiologies can present with the same behaviors (Example of fever)behaviors (Example of fever)

Co-existence of multiple risk factors present Co-existence of multiple risk factors present in any one resident: disease, medications, in any one resident: disease, medications, changed environment, etc.changed environment, etc.

The key is to have a process to evaluate the The key is to have a process to evaluate the resident for the behaviorresident for the behavior

88

General Approach toGeneral Approach to BehaviorsBehaviors Clearly characterize Clearly characterize target symptomstarget symptoms

Standard Standard medical evaluationmedical evaluation to identify possible to identify possible medical disordermedical disorder

Differential diagnosisDifferential diagnosis of behavior cause of behavior cause

The The A,B,C’s of Behavior InterventionA,B,C’s of Behavior Intervention

– Antecedent, Behavior, ConsequencesAntecedent, Behavior, Consequences

Document, Document, DocumentDocument, Document, Document

Non-pharmacologic interventionNon-pharmacologic intervention

99

Good Target SymptomsGood Target Symptoms AnxietyAnxiety InsomniaInsomnia Delusions (stressful)Delusions (stressful) Hallucinations (stressful)Hallucinations (stressful) Dysphoria/DepressionDysphoria/Depression Compulsive behaviorsCompulsive behaviors Agitation/AggressivenessAgitation/Aggressiveness Motor restlessnessMotor restlessness PainPain

1010

Poor Target SymptomsPoor Target Symptoms Exit-seekingExit-seeking Pacing & WanderingPacing & Wandering Perseverant vocalizationsPerseverant vocalizations Hoarding/StealingHoarding/Stealing Inappropriate sexual touchingInappropriate sexual touching Non-stressful delusionsNon-stressful delusions DisrobingDisrobing

1111

Medical EvaluationMedical Evaluation Medical/Psychiatric HistoryMedical/Psychiatric History Medication: excess, withdrawal, ADRMedication: excess, withdrawal, ADR Physical evaluation: urinary retention, Physical evaluation: urinary retention,

fecal impaction (constipation), pain, fecal impaction (constipation), pain, dental problemsdental problems

Mental Status ExamMental Status Exam Lab studies/oximetryLab studies/oximetry Imaging StudiesImaging Studies

1212

Medical IllnessMedical Illness

Illnesses: GERD, angina, OA, etc.Illnesses: GERD, angina, OA, etc. Medication side effectsMedication side effects Chronic painChronic pain

ConstipationConstipation Hearing or vision impairmentHearing or vision impairment Sleep deprivationSleep deprivation Dental problemsDental problems

1313

Differential for Behavior Differential for Behavior CausesCauses

Dementing disordersDementing disorders

Frontal Lobe impairmentFrontal Lobe impairment

DeliriumDelirium

MedicationsMedications

Toxic personality syndromeToxic personality syndrome

PainPain

1414

Differential for Behaviors (cont.)Differential for Behaviors (cont.)

Primary psychiatric illnessPrimary psychiatric illness

- Affective disorder (Depression)- Affective disorder (Depression)

- Anxiety disorder- Anxiety disorder

- Psychotic disorder- Psychotic disorder

- Personality disorder- Personality disorder

Environment/StressorsEnvironment/Stressors

1515

Definition: DementiaDefinition: Dementia

A syndrome (a collection of signs & symptoms) of progressive decline in multiple areas of cognitive function which eventually produces significant deficits in self-care and social and occupational performance.

AMDA Dementia CPG 1998

1616

DementiaDementia Incidence of 1-2% at 65-70 years of age, Incidence of 1-2% at 65-70 years of age,

increasing to >30% after 85increasing to >30% after 85

Up to 80% of NF residents have some Up to 80% of NF residents have some degree of dementiadegree of dementia

The resultant decline in functional capacity The resultant decline in functional capacity is the chief cause of NF admissionis the chief cause of NF admission

1717

Dementia CategoriesDementia Categories Alzheimer’s disease (65%)Alzheimer’s disease (65%)

Lewy Body dementia (7%)Lewy Body dementia (7%)

AD w/vascular disease (10%)AD w/vascular disease (10%)

AD w/Lewy bodies (5%)AD w/Lewy bodies (5%)

Vascular dementia (5%)Vascular dementia (5%)

Other: Infectious, EtOH, etc. (8%)Other: Infectious, EtOH, etc. (8%)

1818

Definition: Dementia of the Definition: Dementia of the Alzheimer Type (DAT)Alzheimer Type (DAT)

A degenerative neurologic disease that results in impaired memory, thinking and behavior. It is characterized by a gradual onset of progressive symptoms that include memory loss, personality changes, and decline in ability to think and function. DAT is by far the most common from of dementia in the U.S., so it is generally used as the prototypical dementia in most guide to diagnosis and treatment.

“All DAT is dementia, but not all dementia is DAT”

1919

DATDAT 60-80% of dementia that occurs in those >65 60-80% of dementia that occurs in those >65

years oldyears old Slow, insidious decline in multiple cognitive skillsSlow, insidious decline in multiple cognitive skills Relatively well preserved motor function early in Relatively well preserved motor function early in

disease coursedisease course CT/MRI normal, or atrophy, perhaps with mild CT/MRI normal, or atrophy, perhaps with mild

white matter changeswhite matter changes No biological markers - diagnosed at autopsyNo biological markers - diagnosed at autopsy Etiology: genetics (APO e4) + ?Etiology: genetics (APO e4) + ?

Shiozaki et al:J Neurol Neurosurg Shiozaki et al:J Neurol Neurosurg Psych: V67:1999Psych: V67:1999

Dementia with Lewy BodiesDementia with Lewy Bodies (DLB)(DLB)

DLB more recently accounts for 15 - 20% of all dementiaDLB more recently accounts for 15 - 20% of all dementia

Hallmark feature: widespread Lewy bodies throughout Hallmark feature: widespread Lewy bodies throughout the neocortex with Lewy bodies and cell loss in the the neocortex with Lewy bodies and cell loss in the subcortical nucleii with subcortical nucleii with distinctive pattern of neuritic distinctive pattern of neuritic degeneration on autopsydegeneration on autopsy

More males than femalesMore males than females Age of onset: 50 – 83Age of onset: 50 – 83

Insidious onset progressing to profound dementia Insidious onset progressing to profound dementia

McKeith. I.G. Dementia with Lewy Bodies. British J of Psychiatry 2002, 180,144-147

2121

Required: Cognitive Decline with decreased social Required: Cognitive Decline with decreased social or occupational functioningor occupational functioning

A diagnosis of Probable DLB requires 2 of the A diagnosis of Probable DLB requires 2 of the following (Possible DLB requires only one of the following (Possible DLB requires only one of the following):following):– Fluctuating cognition with pronounced variation in Fluctuating cognition with pronounced variation in

attention and alertness attention and alertness 11

– Recurrent visual hallucinations that are typically well Recurrent visual hallucinations that are typically well formed and detailed  formed and detailed 

– Spontaneous motor features of parkinsonism Spontaneous motor features of parkinsonism 1. Quantification and Characterization of Fluctuating Cognition in Dementia with Lewy Bodies and Alzheimer's

Disease M.P. Walker, G.A. Ayre, E.K. Perry, K. Wesnes, I.G. McKeith, M. Tovee, J.A. Edwardson, C.G. Ballard Dementia and Geriatric Cognitive Disorders 2000;11:327-335 (DOI: 10.1159/000017262

2. McKeith. I.G. Dementia with Lewy Bodies. British J of Psychiatry 2002, 180,144-147

DLB DLB Core FeaturesCore Features

2222

Dementia with Lewy BodiesDementia with Lewy BodiesTreatment IssuesTreatment Issues

– Up to 80% of DLB patients have hypersensitivity Up to 80% of DLB patients have hypersensitivity to neuroleptics. to neuroleptics. Prescribe antipsychotics only Prescribe antipsychotics only when absolutely necessary and under strict when absolutely necessary and under strict monitoring monitoring

– Provisional evidence suggests that patients may Provisional evidence suggests that patients may respond more preferentially to AChI therapy respond more preferentially to AChI therapy

– Concomitant depression Concomitant depression 35% of DLB vs. 16% of AD35% of DLB vs. 16% of AD

McKeith. I.G. Dementia with Lewy Bodies. British J of Psychiatry 2002, 180,144-147

2323

Frontal Lobe Impairment: SxFrontal Lobe Impairment: Sx Mood lability or inappropriate affectMood lability or inappropriate affect Poor impulse controlPoor impulse control Verbally rude, caustic, bigoted, etc.Verbally rude, caustic, bigoted, etc. Episodically physically aggressiveEpisodically physically aggressive PerseverativePerseverative Restless/grabbing/reacts strongly to stimuliRestless/grabbing/reacts strongly to stimuli Difficult to redirectDifficult to redirect Sexually inappropriate/aggressiveSexually inappropriate/aggressive

2424

Frontal Lobe ImpairmentFrontal Lobe Impairment

Not psychotic behavior, but poor impulse Not psychotic behavior, but poor impulse controlcontrol

Seen in multiple types of disease processesSeen in multiple types of disease processes- SDAT- SDAT- Vascular dementia- Vascular dementia- Multiple sclerosis- Multiple sclerosis- EtOH disease- EtOH disease

2525

Frontal Lobe Impairment: Frontal Lobe Impairment: Non-Pharmacologic ManagementNon-Pharmacologic Management

Maintain professional distanceMaintain professional distance– Exaggerated manners, professional attireExaggerated manners, professional attire

– Emphasize courtesy, avoid overly friendlyEmphasize courtesy, avoid overly friendly

Communicate concretely, no open ended commentsCommunicate concretely, no open ended comments Define the activity, give few and clear choicesDefine the activity, give few and clear choices Shape the behavior, acknowledge improvementsShape the behavior, acknowledge improvements Medication when needed:Medication when needed:

– Safety concernsSafety concerns

– Not responsive to nonpharmacologic interventionsNot responsive to nonpharmacologic interventions

2626

Definition: DeliriumDefinition: Delirium

A state of acute confusion, inattention, and altered level of consciousness (LOC), usually abrupt in onset (over several hours to several days).

2727

Delirium: SymptomsDelirium: Symptoms Fluctuations in alertness & mental Fluctuations in alertness & mental

functioning manifested by inattentionfunctioning manifested by inattention AnxietyAnxiety HallucinationsHallucinations DisorientationDisorientation TremorsTremors DelusionsDelusions IncoherenceIncoherence

2828

Common Delirium TriggersCommon Delirium Triggers Acute illnessAcute illness Heart or lung diseaseHeart or lung disease InfectionsInfections Poor nutritionPoor nutrition Endocrine disordersEndocrine disorders MEDICATIONSMEDICATIONS Alcohol useAlcohol use

2929

DeliriumDelirium A syndrome, not a final diagnosis A syndrome, not a final diagnosis

Fluctuating level of alertness Fluctuating level of alertness

Difficult to assess with dementiaDifficult to assess with dementia Must identify etiology to treat Must identify etiology to treat

appropriately appropriately

If psychotic, If psychotic, time-limittime-limit use of use of antipsychoticsantipsychotics

3030

DeliriumDelirium 10% of all hospitalized patients10% of all hospitalized patients 22-38% of hospitalized patients >6522-38% of hospitalized patients >65 60% of hip fracture cases60% of hip fracture cases Up to 75% of hospitalized patients from SNF’sUp to 75% of hospitalized patients from SNF’s Associated with a 35% increase in hospital Associated with a 35% increase in hospital

mortalitymortality Physicians correctly diagnose delirium in Physicians correctly diagnose delirium in less thanless than

20% of cases20% of cases

3131

Distinguishing Delirium fromDistinguishing Delirium from DementiaDementiaDelirium•Acute onset, usually occurring over days or less•Global disorder of attention & cognition•Level Of Consciousness: Hypoactive, hyper-active or both•Generally lasts days to weeks •Usually reversible•Prominent physiologic changes

Dementia•Gradual onset that cannot be dated• Attention fairly normal initially•Level Of Consciousness: normal until final stages•Chronically progressive over months or years•Irreversible•Minimal physiologic changes

3232

Depression: DiagnosisDepression: Diagnosis Depressed mood for at least 2 weeksDepressed mood for at least 2 weeks

PlusPlus At least four of the following:At least four of the following:

- Insomnia or hypersomnia- Insomnia or hypersomnia- Significant weight loss or malnutrition- Significant weight loss or malnutrition- Fatigue or loss of energy- Fatigue or loss of energy- Decreased ability to concentrate- Decreased ability to concentrate- Psychomotor agitation or retardation- Psychomotor agitation or retardation- Excessive guilt or feelings of worthlessness- Excessive guilt or feelings of worthlessness- Thoughts of death, suicidal ideation, or a planned or- Thoughts of death, suicidal ideation, or a planned or attempted suicidal actattempted suicidal act- Loss of interest or pleasure in nearly all activities- Loss of interest or pleasure in nearly all activities

3333

Depression: DiagnosisDepression: Diagnosis

Geriatric Depression Scale (GDS)Geriatric Depression Scale (GDS)

Cornell Scale for Depression in DementiaCornell Scale for Depression in Dementia

Center for Epidemiologic Studies of Center for Epidemiologic Studies of Depression (especially for African-American Depression (especially for African-American and Native Americans)and Native Americans)

No direct biologic markerNo direct biologic marker

3434

Depression: Elder vs YoungerDepression: Elder vs Younger• Elders exhibit different symptomsElders exhibit different symptoms

• Multiple somatic complaintsMultiple somatic complaints

• FatigueFatigue

• InsomniaInsomnia

• Functional lossFunctional loss

• IrritabilityIrritability

• Younger: tearfulness, sadness and suicidal Younger: tearfulness, sadness and suicidal indicationsindications

3535

DepressionDepression The most common geriatric psychological disorderThe most common geriatric psychological disorder

Up to 1/3 of NF residentsUp to 1/3 of NF residents

Estimated that PCP’s fail to diagnose depression Estimated that PCP’s fail to diagnose depression up to half the time & fail to provide adequate up to half the time & fail to provide adequate treatment for half of those so diagnosed (Kroenke, treatment for half of those so diagnosed (Kroenke, AIM. AIM. 1997)1997)

Closely associated with functional decline & Closely associated with functional decline & triggering quality indicatorstriggering quality indicators

3636

DepressionDepression Often co-morbid with dementia Often co-morbid with dementia

Common post-stroke – up to 30%Common post-stroke – up to 30%

Beware “ageism” as a barrier to diagnosis/txBeware “ageism” as a barrier to diagnosis/tx

Look for underlying medical/medication Look for underlying medical/medication causescauses

3737

DepressionDepression May be mimicked/caused by ADRMay be mimicked/caused by ADR

- Carbidopa/levodopa- Carbidopa/levodopa

- Beta-blockers- Beta-blockers

- Clonidine- Clonidine

- Benzodiazepines- Benzodiazepines

- Barbituates- Barbituates

- Anticonvulsants- Anticonvulsants

- H2 blockers- H2 blockers

3838

Depression… or Dementia… (or Both?)Depression… or Dementia… (or Both?)DepressionDepression Clear, recent onsetClear, recent onset Shorter durationShorter duration Often previous psychiatric Often previous psychiatric

historyhistory Memory complaintsMemory complaints Fluctuating performanceFluctuating performance Recent and remote memory Recent and remote memory

equally badequally bad Depressed mood precedes Depressed mood precedes

memory complaintsmemory complaints

DementiaDementia Gradual onsetGradual onset Progression over yearsProgression over years May not have psychiatric May not have psychiatric

historyhistory Minimizes disabilitiesMinimizes disabilities Tries hard to performTries hard to perform Memory loss greater for Memory loss greater for

recent eventsrecent events Memory loss precedes Memory loss precedes

depressiondepression

3939

Anxiety: DefinitionAnxiety: Definition Awareness of the physiologic reactions of the Awareness of the physiologic reactions of the

“fight or flight” responses“fight or flight” responses

May be triggered by internal or external factorsMay be triggered by internal or external factors

May be triggered by issues considered May be triggered by issues considered “irrelevant” to others but are real to the sufferer“irrelevant” to others but are real to the sufferer

Anxiety symptoms are far more common than Anxiety symptoms are far more common than anxiety disorderanxiety disorder

4040

Anxiety DisordersAnxiety Disorders Think Differential Diagnosis:Think Differential Diagnosis:

– Psychosis/Depression/Delirium/Pain/GADPsychosis/Depression/Delirium/Pain/GAD Modify environmental triggers if possibleModify environmental triggers if possible Medications:Medications:

- Caffeine- Caffeine- Bronchodilators- Bronchodilators- Pseudoephedrine- Pseudoephedrine

Medical illnessMedical illness- Hyperthyroidism- Hyperthyroidism- Cardiac arrhythmias (Atrial fibrillation, PVC’s, etc)- Cardiac arrhythmias (Atrial fibrillation, PVC’s, etc)

4141

PsychosisPsychosis DefinitionDefinition

– Impaired connection to realityImpaired connection to reality

– Auditory or visual hallucinations or delusionsAuditory or visual hallucinations or delusions

Psychosis is a Psychosis is a symptomsymptom, , notnot a final diagnosis a final diagnosis Differential Diagnosis includes all types of Differential Diagnosis includes all types of

Dementia, Delirium, Drugs (both intoxication and Dementia, Delirium, Drugs (both intoxication and withdrawal), Schizophrenia, Bipolar Mania and withdrawal), Schizophrenia, Bipolar Mania and Psychotic DepressionPsychotic Depression

The The diagnosisdiagnosis indicates indicates durationduration of treatment of treatment

4242

Personality DisordersPersonality Disorders Easy to over-diagnose when elder Easy to over-diagnose when elder

patients decompensate due to patients decompensate due to dementia, depression, pain, etc. dementia, depression, pain, etc.

Consider empiric treatment with Consider empiric treatment with antidepressantantidepressant

Look for LIFELONG history of the Look for LIFELONG history of the personality disorderpersonality disorder

4343

Toxic Personality SyndromeToxic Personality Syndrome Not a disease, but a personality typeNot a disease, but a personality type

This personality type is often hypercritical, angry, This personality type is often hypercritical, angry, and accusatory in spite of every effort to give them and accusatory in spite of every effort to give them comfort and optimal care. (Take care not to judge comfort and optimal care. (Take care not to judge the care in a facility based solely on the behaviors the care in a facility based solely on the behaviors or statements of this personality)or statements of this personality)

Does not require (or respond to) any treatmentDoes not require (or respond to) any treatment

4444

The ABC’s of Behavior InterventionThe ABC’s of Behavior Intervention

““A” = The Antecedent EventsA” = The Antecedent Events

““B” = The Behavioral EventB” = The Behavioral Event

““C” = The ConsequencesC” = The Consequences

Slattery et al, Annals of Long Term Care 1999; 7[10]:385-391

4545

The Antecedent EventThe Antecedent Event(Behavior events are rarely unprovoked)(Behavior events are rarely unprovoked)

Triggers that occurred before or even caused Triggers that occurred before or even caused the behavioral event.the behavioral event.

Modifying triggers is best approach for Modifying triggers is best approach for cognitively impaired, because memory loss cognitively impaired, because memory loss interferes with learning consequencesinterferes with learning consequences..

4646

Five Categories of TriggersFive Categories of Triggers Physical Triggers::Physical Triggers:: pain, impaired sight orpain, impaired sight or hearing, hearing,

fecal impaction/constipation, needs changing or fecal impaction/constipation, needs changing or repositioning, etc. repositioning, etc.

Emotional Triggers:Emotional Triggers: worried, afraid, distressed, etc. worried, afraid, distressed, etc. Environmental Triggers:Environmental Triggers: too much or too littletoo much or too little

lighting, noise, temperature, activity levels, etc. lighting, noise, temperature, activity levels, etc. Task Triggers:Task Triggers: difficulty when challenged by a difficulty when challenged by a

specific task like bathing, dressing or eating, etc. specific task like bathing, dressing or eating, etc. Communication Triggers:Communication Triggers: difficulty understanding difficulty understanding

others or expressing self, etc. others or expressing self, etc.

4747

Environment/StressorsEnvironment/StressorsStressorsStressors LossesLosses

Decreased controlDecreased control

EnvironmentEnvironment CrowdingCrowdingLevel of stimulationLevel of stimulation

Premorbid personalityPremorbid personality IdentityIdentityActivitiesActivities

Caregiver issuesCaregiver issues Burnout, need for respiteBurnout, need for respiteEducation & expectationsEducation & expectations

ApproachApproach Concrete with flexibility Concrete with flexibility Respect, redirectionRespect, redirection

Areas to Consider Examples

4848

The Behavioral Event

Defined as any behavioral episode that is disruptive or adverse, or that jeopardizes the safety of the resident, other persons, or objects in the environment.

4949

Goals of Treating Behaviors in the Goals of Treating Behaviors in the NHNH

Reduce the risk of injuryReduce the risk of injury

Reduce patient distressReduce patient distress

Minimize adverse drug eventsMinimize adverse drug events

Maintain resident in most desirable Maintain resident in most desirable living settingliving setting

Define for WHOM it is a problemDefine for WHOM it is a problem

5050

Impact of Behavioral SymptomsImpact of Behavioral Symptoms 25% required no intervention.25% required no intervention.

0.8% resulted in injury to others.0.8% resulted in injury to others.

0.9% resulted in physical damage to the 0.9% resulted in physical damage to the environment.environment.

An average of 24 minutes of staff time An average of 24 minutes of staff time was required per intervention.was required per intervention.

Souder E, Heithoff K, O’Sullivan PS , et al, Aging and Mental Health, 1999; 3:54-68

5151

The ConsequencesThe Consequences

Includes all actions or occurrences Includes all actions or occurrences encountered after the episode or as an encountered after the episode or as an outcome of the event.outcome of the event.

A cognitively intact resident learns to repeat A cognitively intact resident learns to repeat behaviors that are “rewarded”, for example, if behaviors that are “rewarded”, for example, if they get attention from staff. Caregivers must they get attention from staff. Caregivers must consistently reward desired behavior.consistently reward desired behavior.

Cognitively impaired residents don’t remember Cognitively impaired residents don’t remember the “rewards”, so it’s best to focus on the “rewards”, so it’s best to focus on changing the antecedents or triggers.changing the antecedents or triggers.

5252

Documentation TipsDocumentation Tips Document all diagnosis being actively treated in monthly Document all diagnosis being actively treated in monthly

orders & progress notes orders & progress notes Document behavior in progress notes Document behavior in progress notes

– Summarize target symptoms Summarize target symptoms – Attempted nonpharmacologic interventionsAttempted nonpharmacologic interventions– PRN’s usedPRN’s used– onset, duration, frequency, associated factorsonset, duration, frequency, associated factors

Document medication efficacy re: target symptomsDocument medication efficacy re: target symptoms Look at behavior monitoring for accuracy and Look at behavior monitoring for accuracy and

completeness. Consider other ways to documentcompleteness. Consider other ways to document– GDS, Cornell, Behave AD, Cohen MansfieldGDS, Cornell, Behave AD, Cohen Mansfield

5353

Documentation ShortfallsDocumentation Shortfalls 108 bed community nursing home.108 bed community nursing home. 44 (41%) residents were on antidepressant therapy.44 (41%) residents were on antidepressant therapy. 14 residents were also on at least one antipsychotic 14 residents were also on at least one antipsychotic

medication for management of agitation.medication for management of agitation. Indication for use was documented in 42 cases Indication for use was documented in 42 cases

(95%).(95%). Outcome was documented in 25 cases (57%).Outcome was documented in 25 cases (57%). Adverse drug reaction monitoring was documented Adverse drug reaction monitoring was documented

in 9 cases (20%).in 9 cases (20%).

Annals of Long Term Care 1999, 7[10]:364-368

5454

Non-pharmacologic Interventions:Non-pharmacologic Interventions:Behavioral StrategiesBehavioral Strategies Behavioral ContractingBehavioral Contracting Positive ReinforcersPositive Reinforcers Written CommunicationsWritten Communications One-on-One InterventionOne-on-One Intervention RedirectionRedirection Distraction Distraction Traffic ControllersTraffic Controllers Signs/SymbolsSigns/Symbols Wander Prevention NetsWander Prevention Nets

5555

Urgent Action IssuesUrgent Action Issues

The immediacy and intensity of actiontaken should reflect the severity

and safety of the situation.

There may not be time to explore antecedents in an explosive situation

5656

The Prescribing CascadeThe Prescribing Cascade Important in behaviors as it is in other areas Important in behaviors as it is in other areas

of LTC issuesof LTC issues The continuing use of medications to The continuing use of medications to

address the adverse drug effects of prior address the adverse drug effects of prior drugsdrugs

On-call doctors and frequent staff changes On-call doctors and frequent staff changes in facilities can inadvertently accelerate the in facilities can inadvertently accelerate the cascadecascade