understanding behavioral issues in long term care patients. · • both are linked to higher...

Understanding Behavioral Issues in Long Term Care Patients.

Kansas Healthcare Association Annual Conference 2016.

Sosunmolu Shoyinka, M.D.

MedicalDirectorforBehavioralHealth,

SunflowerHealthPlan.

AdjunctProfessorofClinicalPsychiatry,

UniversityofMissouri,Columbia.

Disclosure

MedicalDirectorfor

Envolve PeopleCare,afor‐profit,publiclytradedcompany.

Objectives

Attheendofthistalk,participantswill

1. UnderstandthemanifestationsofcommonmentalhealthconditionsinLongTermCarepatients,includingaddictions.

2. UnderstandhowtocommunicatewithindividualswithmentalhealthconditionsinLongTermCare.

3. UnderstandhowtomanagecommonbehavioralissuesinindividualswithmentalillnesswholiveinLongTermCarefacilities.

Behavioral Health Conditions in Nursing Home Patients

Psychiatric Conditions in Long Term Care (LTC) Facility Patients.

• Increasingly,LTCfacilitiesarebeingusedforlongtermcareofindividualswithseverementalillness,intellectualdisabilityoracombinationofboth,inadditiontodementia.

• A2005studyshowedthattheproportionofthosebeingadmittedtoLTCfacilitiesformentalillness+dementiaisgreaterthandementiaalone.

• PrevalenceofmentalillnessinLTCfacilitypatientsrangefrom65‐91%.

• Increaseswithage.

• Dementia• commonlycomorbidwithotherpsychiatricconditions(30%to90%ofpatients)

Psychiatric Conditions in LTC facility Patients. DepressiveDisorder

• X3to5timesmoreprevalentthaninthecommunity.• Majordepressivedisorder[6‐26%]• 11‐50%haddepressivesymptoms

Otherconditionscommonlycomorbidwithdementiainclude• Anxiety• Psychosis,• Agitation• Aggression• Disinhibition• Sleepdisturbances.

Psychiatric Conditions in LTC facility Patients. • Schizophrenia(2.7‐ 7%)

• Intellectualdisability.

• Delirium

• Increasingly,SUD.

Why is this important?

• Mentalillnessisone,andsometimesthedecisive,factorcontributingtoplacementinaLTCfacility.

• Predictslongerstays

• MentalillnessinLTCfacilitypatientspredictstheuseofrestraintsandpsychotropicmedications.

• Botharelinkedtohighermorbidityandmortality,forpatients.

• Consumesmorenursingtime.

• Higherratesofstaffturnoverandinjury.

• Higheroverallcoststosystem,includingmorefrequentadmissions.

– LTCfacilityresidentswithdementiacomplicatedbymixedagitationanddepressionhavethehighestrateofacutehospitalizationcomparedwithothergroups(15.6%over3months),comparedwithonly9.4%forresidentswithoutadiagnosisofdementia(Bartels,Horn,etal.,2003).

Depression

• Amongthecommonestofmedicalconditionsworldwide

Depression: A Global Crisis

• Aspectrumofdisorders,rangingfrommild‐severe.

• Affectsover350millionpeopleworldwide.

• Theleadingcauseofdisabilityworldwideintermsoftotalyearslostduetodisability(DALY).

• Burdenofdiseaseis50%higherforfemalesthanmales(WHO,2008).

• Leadingcauseofdiseaseburdenforwomeninbothhigh‐incomeandlow‐ andmiddle‐incomecountries(WHO,2008).

• Maternaldepressionmaybeariskfactorfordevelopmentaldelaysinyoungchildren(Rahmanetal,2008).

• 12monthprevalenceintheUSis7%

DSM V Diagnostic Criteria5ormoreofthefollowingpresentdaily/nearlydailyfor>2weeks.

• Depressedmood(coresymptom)

• Anhedonia (coresymptom)

• Significantweightlossorgain(>5%)inamonth)

• Insomniaorhypersomnianearlydaily

• Psychomotoragitationorretardation

• Fatiguenearlydaily

• Feelingsofworthlessness/excessiveorinappropriategrief

• Inabilitytoconcentrate,indecisiveness

• Recurrentthoughtsofdeath/suicidalideationorplan.

• Inmanycultures(USincluded)primarycomplaintsarebesomatic(e.g.pain)ormaymanifestasanxietyorirritability.

Medical Complications of Depression

• Worsensoutcomesforvirtuallyallco‐morbidconditions.

• Chronicpain

• Apredictorofworseoutcomespost‐MI,post‐stroke.

• Worseoutcomesinnursinghomepatients

• Leadstopooradherencetotreatmentrecommendationsandpooroutcomes(diabetes,HTN,post‐MI)

• Stronglyassociatedwithalcoholabuse/dependenceandotherSUDs.

“Secondary” Depression

• Maybeduetothedirectpathophysiologicaleffectstheassociatedmedicalcondition (commonwithneurologicandendocrinedisorders)

• Maybeduetomedication/substanceadministration/intoxicationorwithdrawal

• Psychologicalstressassociatedwithmedialillnessesmayinduceorexacerbateanxiety.

Medications Associated with Depressive Symptoms

• AntiHTNdrugs:calciumchannelblockers,Alphamethyldopa,guanethidine,reserpine,clonidine)

• Retinoicacidderivatives

• Antidepressants,

• Anticonvulsants

• Antimigraine

• Hormonalpreparations

• Tamoxifen

• Propanolol

• Steroids

• IFalpha

• GnRh

• IL2

• LDopa

• Chemotherapeuticdrugs

• Steroids

Anxiety Disorders• Agroupofdisordersthatsharethefeaturesof

‐ excessivefear‐ anxiety‐ relatedbehavioraldisturbances

• Differfromnormativefearbybeing

– Excessive– Persistingbeyonddevelopmentallyappropriateperiods– >6months.

Prevalence

• 18%ofthegeneralpopulationsuffersfromananxietydisorderatanygivenpointintime.

• Frequentlyco‐morbidwithmedicalillness:e.g >1/3rd ofindividualswithchestpainandnormalcoronaryarterieshaveapanicdisorder.

• Commonerinfemales(2:1)

DSM V Anxiety Symptoms

Variousspecifiers forGAD,Panicdisorder,Socialanxiety,OCD,specificphobia.

Commonsymptomsinclude:

• Muscletension.• restlessness/feelingkeyedup/fidgetiness.• Inabilitytoconcentrate.• Insomnia.• Irritability.• Fatigue.• Symptomscauseclinicallysignificantimpairmentordistress

Anxiety Disorders

• SeparationAnxiety.

• SpecificPhobia(e.g.needles,blood)

• SocialPhobia.

• PanicDisorder.

• Panicattacks.

• Agoraphobia.

• GAD.

• Selectivemutism

• OCD

• Delirium

• Dementia

• Somatoformdisorder(e.ghypochondriasis)

• PTSD

• Mooddisorders

• Psychoticdisorders

Secondary Causes of AnxietyMedicalCauses

• Thyrotoxicosis

• Hypothyroidism

• Phaeochromocytoma.

• Carcinoidsyndrome.

• Hyperparathyroidism

• Vestibulardysfunction

• Seizuredisorders

• Cardiopulmonarydisease;arrhythmias,SVT,COPD,asthma.

• Parkinson’sdisease

• Poststroke

Medications

• Anesthetics

• Analgesics

• Sympathomimetics

• Bronchodilators

• Anticholinergics

• Insulin

• Thyroidmeds

• OCPs

• Antihistamines

• Antiparkinson meds

• Corticosteroids

Schizophrenia• SeverePersistentMentalIllness.

• Oftenprecededforyearsbyaprodrome,withattenuatedsymptoms.

• Characterizedbydelusions,hallucinations,disorganizedspeechandbehavior.

• Associatedwithneurocognitivedeficits,apathy,amotivation,impairedexecutivefunction disabling.

• Socialoroccupationaldysfunction.

• Symptomsmusthavebeenpresentforsixmonthsandincludeatleastonemonthofactivesymptoms.

• Outcomesarehighlyvariable.

• Someevidenceofheritability.

SubstanceUseDisorders:DSMV• Takingthedruginlargeramountsandfor

longerthanintended.

• Wantingtocutdownorquitbutnotbeingabletodoit

• Spendingalotoftimeobtainingthedrug

• Cravingorastrongdesiretouse(drug)

• Repeatedlyunabletocarryoutmajorobligationsatwork,school,orhomeduetodruguse

• Continuedusedespitepersistentorrecurringsocialorinterpersonalproblemscausedormadeworsebydruguse

• Stoppingorreducingimportantsocial,occupational,orrecreationalactivitiesduetodruguse

• Recurrentuseofdruginphysicallyhazardoussituations

• Consistentuseofdrugdespiteacknowledgmentofpersistentorrecurrentphysicalorpsychologicaldifficultiesfromusingdrug

• Tolerance

– asdefinedbyeitheraneedformarkedlyincreasedamountstoachieveintoxicationordesiredeffector

– markedlydiminishedeffectwithcontinueduseofthesameamount.

• Withdrawalmanifestingaseithercharacteristicsyndromeorthesubstanceisusedtoavoidwithdrawal(Doesnotapplywhenusedappropriatelyundermedicalsupervision)

Behavioral Issues

Abehaviorbecomesaproblemwhenitisassociatedwith:

– Distress(subjectiveexperienceoftheresident)

– Disability(observablefunctionalimpairment)

– Disruption(interferencewithdeliveryofcare,or disturbanceofthelivingenvironment)

– Danger(toselforothers)

MakingSenseofBehavioralSymptomsinNursingHomeResidents:AlternativestoAntipsychoticDrugUse.QualityInsightsWebinar2.20.13JoelE.Streim,M.D.

Common Behavioral Issues

Restlessness

Yellingorverbalhostility

Rejectionofcare

Apathy/lethargy.

Physicalcombativeness


Understanding Behavioral Issues

• Notallbehavioralsymptomsareproblems.

• Mostongoingproblematicbehaviorsamongnursinghomeresidentsarenotlikelytorespondtomedicationinthelongterm.

• Mostbehaviorsarenotcausedbypsychoticillnesses.

• Onlyasmallproportionofresidentshaveconditionsthatcanbeappropriatelytreatedwithantipsychoticmedication.

• Medicationsmayexacerbateproblems(e.g.akathisia,confusion)orleadtoharm.

• Behaviorproblemsareoftentriggeredbyanapproachtocarethatfailstoincorporatetheresident’sownexperience.

• E.g.carethatisbasedsolelyonfacilityroutinesandcaregivers’perceptionsoftencausestheresidenttobecomeanxious,fearful,irritable,orangry


Understanding Resident Behavior

• Allbehaviormakessense/hasmeaning

• Appliestoresidentswithandwithoutdementia

• Lookingforreasonsbehindbehaviorsby“steppingintotheresident’sworld”

• Thisfocusesontheproblem‐solvingtomeetthemember’sneedsandallowsteamstoidentifyperson‐centeredsolutions.

– Areresponsivetoresidentneeds– Mayavoidtheuseofmedications

Common misattributions for behaviors

Caregivermayassumeresidentis:•Angry/Belligerent•Lazy/Dependent•Manipulative

Often,abehaviorthatisinterpretedas“uncooperative”isactuallybetterexplainedbycognitivedisability

Causal and Contributing Factors

Cognitivedeficits

Unmetneeds(physicalandpsychological)

Environmental/socialirritants

Medicalillness/physicaldiscomfort

Psychiatricconditions

Adversedrugeffects


Cognitive Domains Impaired in Dementia

• Memoryloss(amnesia)

• Declineinothercognitivefunctions.

Language(aphasia)

Visual‐spatialfunction

Recognition(agnosia)

Performingmotoractivities(apraxia)

Initiating/executingsequentialtasks(apathy,abulia,executivedysfunction)

Unmet Needs Can Lead to Behavioral Disturbances

• SpiritualNeeds

• EmotionalNeeds

– Humaninteraction,emotionalconnection,recreation,agency,self‐direction,meaning.

• Physicalneeds– Nutrition,hydration,toileting,exercise,rest

Environmental irritants that can lead to behavioral disturbances• Physical

– Noise– Confusingvisualstimuli– Physicalbarriers– Uncomfortabletemperature– Unfamiliarsurroundings

• Social– Changesinroutines– Caregiverinteractions

Medical conditions and physical discomfort that can lead to behavioral disturbances

Physicaldiscomfort– Pain– Constipation– Urinaryurgency– Shortnessofbreath– Dizziness– Fatigue

Medical condition— Arthritis— Dehydration— Prostatic hypertrophy— COPD— Cerebrovascular disease— CHF

Psychiatric conditions that can cause behavioral disturbances

• Depression• Delirium• Psychosis

– delusions– hallucinations

• Anxiety• Sleepdisturbance

Adverse drug effects that can cause behavioral disturbances

• Nuisancesymptoms

• Anticholinergiceffects

• Antihistaminiceffects

• Paradoxicalexcitation/disinhibition

• Intoxicationorwithdrawalstates

• Akathisia(syndromeofmotorrestlessness)

Identificationofanyofthesemodifiablecauses—unmetneedsenvironmentalandsocialirritantsmedicalillnessandphysicaldiscomfortpsychiatricconditionsadversedrugeffects—

pointsthewaytospecificinterventions

Person-centered Care: HOW?

• Lookformeaninginverbalandnon‐verbalcommunication

• Ask,“whatdoyouwant?“howcanIhelp?”

• Listenforcluestosourcesofdistressorunmetneeds

• Avoidsaying“no”,arguingordisagreeing

• Offertohelpinwaysthatreducedistressormeetneeds,withoutcompromisingsafety

Remember: There’s no one-size-fits-all response to behaviors

• Differentresidentshavedifferentsituationsandneeds.

• Residentschangeovertime;needsandbehaviorschange,too.

• Someresponsesworkoneday,notthenext.

• Someresponsesworkforonecaregiver,butnotanother.

• Responsesmustbetailoredtotheindividualandmodifiedovertime.

Institutional Approaches

Consistentstaffassignments

Assignmentofstaffacrossdisciplinestosuperviseeverydayleisureactivities Group Individual/solitary Beyondstructuredrecreationtherapy

Spaceforexercise,outdooractivities

Aggression• Oftentheresultofamedicalcondition

suchasinfectionsorendocrineconditions

• Commonindementia.

• Canbeduetounderlying/untreatedmentalhealthconditionssuchasschizophrenia,PTSD,Anxiety,Depression

• Sundowning.

• Medications(mayconfuse/disinhibit)

• Interpersonaldiscordwithpeersandstaff.

Aggression ManagementPrevention/De‐escalation

• Activelistening• Verbalresponding• Redirection• “Fiblets“• Stance• Positioning• “Tincture"oftime• Notjumpingtoconclusions• Controllingtheenvironment• Teamwork

Strategies for Communicating with Residents with Mental IllnessDO•Minimizedistractions•Useactivelistening.•Mindnon‐verbals.Understandthateye‐contactmaybethreatening.•Simplifyandbestraightforward.Acknowledgewhattheotherpersonsaysandhowtheyfeel,evenifyoudon’tagree.•Engagebyaskingforopinionsandsuggestions.•Lookforcommonground.Avoidunnecessaryconfrontation.•Sticktopresentissues.•Usehumorineasysituations.•Askpermissionbeforephysicalcontact.

• DON’T•Don’ttakethingspersonally.•Don’tcriticize,accuseorblame.•Don’tmakeassumptions.Clarifybyaskingquestions.•Don’traiseyourvoiceorattempttointimidateor“discipline”theperson.•Don’tusesarcasmandavoidhumorindifficultsituations•Avoidsoundingpatronizingorcondescending.

Treatment:aBio‐Psycho‐Socialapproach

• Athorough,carefulreviewtoruleoutunderlyingcauses.

• ALWAYSruleoutdelirium.

• Investigatepersonalandfamilyhistory.

• Reviewmedications,especiallyifnew‐onsetandtemporallyrelatedtoaddition/discontinuationofmedication.

• Reviewdrug/addictionhistory.

• Physicalexamination:lookforstigmataofETOH/opioid/otherdruguse.

• Investigateforpotentialunderlyingetiologies:ABGs,EKG,ECHO,Holter,serumPTH,TSH,CMP,CBC,MRI,catecholamines.

• CheckserummarkersforETOHaddiction,suchasMCV,GGT,LFTs,CDT.

Medication Use in LTC facility Residents

• AppropriateuseofpsychiatricmedicationsinLTCfacilitiesisalong‐standingqualityofcareissue.

• Inappropriateprescribingincludesthataimedataddressingbehavioralsymptomsbyusingsedatingmedications,partlytocompensateforpoorstaffinglevels(Hughes&Lapane,2005).

• ConcernsaboutthepossiblemisuseofantipsychoticmedicationsinLTCfacilitiesledtothedevelopmentofaspecialsectionoftheOBRAregulationsinordertorestricttheiruse.

• Stevensonetal.(inpress)foundthat40%ofLTCfacilityresidentsusinganantipsychoticmedicationhadnoappropriateindicationforsuchuse,while42%ofresidentswhotookbenzodiazepineshadnoappropriateindication.

• Despitewidespreaduse,clinicaltrialsresearchstudiesshowmodesteffectivenessatbestandunderscoresignificantpotentialsideeffect

– Antipsychoticsaresomewhateffectivebutoveralleffectivenesswasoffsetbyadverseeventsresultinginphysiciansdiscontinuingthemedication(Karlawish,2006;Schneider,Dagerman,&Insel,2005

Medication Use in NH Residents

• Inonestudy,27.6%ofMedicarebeneficiariesinLTCfacilitiesreceivedanantipsychoticprescriptionduringthestudyperiod(Briesacher etal.,2005).

– Only41.8%receivedantipsychotictherapyinaccordancewithnursinghomeprescribingguidelines;

– 23.4%ofresidentshadnoappropriateindication,

– 17.2%haddailydosesexceedingrecommendedlevels,

– 17.6%hadbothinappropriateindicationsandhighdosing(Briesacher etal.,2005).

Psychotherapy

• Generallyunderutilized

• Fewersideeffectscomparedwithpsychiatricdrugregimens(Bharucha,Dew,Miller,Borson,&Reynolds,2006).

• Reminiscencegrouptherapies (Goldwasser,Auerbach,&Harkins,1987)

– Significantlydecreasedepressionscores,asmeasuredbytheGDSandtheBeckDepressionInventory(Cook,1991;Haight,Michel,&Hendrix,1998;E.D.Jones,2003).

– Documentedimprovementsinpsychologicalwell‐being,self‐esteem,andlifesatisfaction(Frey,Kelbley,Durham,&James,1992).

• Othernonpharmacologicaltherapeuticmodalitiesinclude– Improve/giveasenseofcontrol– Problemsolving– Cognitivebehavioraltherapies

• Showntodecreasedepressionsymptomsandimprovethequalityoflifeforresidentsinthenursinghome(Zerhusen,Boyle,&Wilson,1991)

Social Treatments

• Appropriatelyinvolvingfamily,friendswhomthepatientidentifies asbeingsupportivewith theirpermission.

• Helppt.withrealisticplanning:impartsasenseofcontrolanddirection.

• Pastoralcare/involvingreligiouscommunity.

• Socialwork:canbehelpfulinidentifyingadditionalresources

Addiction in LTC facilities .

– Agrowingproblemintheelderlypopulation

• Upto15%.

– Oftenunrecognized.

– Easilymissed/notscreenedforroutinely.

– Mostlyalcohol,OTCandprescriptionmeds(opioids,benzodiazepines,musclerelaxants,sedatives).

– Somepatientshavealifetimehistoryofdruguse.

• Mayhavesignificantmentalhealthandmedicalproblemsarisingfromdruguse.

– Maybelethalgivenchangesinbody’shandlingofmedicationwithage.

– Mayinvolveanaccomplice.

Recognizing Addiction in LTC facilities . – Moodchanges:depression,anxiety,andirritability.

– Memoryproblems.

– Fatigue

– Sleepproblems

– Confusion

– Sudden/new/recentonsetcognitiveproblems

• Difficultywithconcentration,lossofshort‐termmemory,andgenerallossofinterest.– Mayinvolveproblembehaviors

• Askingtogooutsideatunusualtimes• Withdrawalsymptomsforsomedrugs• Notablechangeincognition,moodorbehaviorfollowingoutings/visitsbycertainpersons.• Clearchangefrombaseline.

– Maybeadministeredinunusualways(ivlines/ports,feedingtubes).

• Canleadtomedicalcomplications(centrallineinfections,endocarditis)

Treating Addiction in LTC facilities.

– Recommendproactivelyplanningforanddevelopingpolicyinthisregard.

– Mayrequirereferraltotreatmentfacility/programifsufficientlysevere.

– Considermedication‐assistedtreatment.

Questions

understanding behavioral issues in long term care patients. · • both are linked to higher...

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