Management of Behaviour Disorders Strategies for management and optimal ustilization of resources

By Rosemarie Pavlakovic

Introduction

It is well known that acuity of care is increasing in long term care facilities. Up to 70% of new admissions to these facilities have some type of dementia, which is associated with behavioural problems up to 90% of the time. In fact, the reason for admission to a long term care facility is often due to problematic behaviour in cognitively impaired individuals, reported by a family member or caregiver. It has been estimated that by the year 2031, there will be almost 800,000 seniors with dementia in Canada.

There are several factors that can impact on the behaviours seen in these residents. Many factors are reversible, so it is crucial that staff is well-educated in this area. Issues such as poor pain management and inadequate sleep can exacerbate aggressive behaviours. It is important that facilities have a strategy in place for evaluation and management of behaviours, because each individual situation is unique.

The Implications

There are several implications, or costs associated with behaviour disturbances in the long term care facility, that must be considered. Some of these costs translate into a negative impact on resident quality of life. Other costs will impact on your facility and staff indirectly. Optimal management of these behavioural problems within a facility must be a priority, to minimize these significant costs. Implications of Behavioural Disturbances

Behaviour Management Approach

Evaluation of Behaviours

Many medical conditions and symptoms are common in long term care facility residents, including pain, constipation, heart failure, and sensory impairment. For a resident with dementia, behavioural disturbances are often aggravated by symptoms that indicate lack of control of a medical condition. Pain is an important consideration, because it is a subjective personal experience. Various tools are available to evaluate pain, however, because of the time involved and the lack of information provided by residents with dementia, this is often left unchecked. As part of the assessment of a new-onset behaviour or amplified behaviour, aggravation of long-standing conditions, and symptoms such as pain, hunger, and constipation must be considered.

Non-Pharmacologic Strategies

It may seem that staff will spend a significant amount of time evaluating behaviours, and instituting management strategies. There are two arguments to this point. Inappropriate use of psychotropic medications for the purpose of sedation is an ethical issue, thus it is important to ensure that all medication use is justified. A resident who is constantly walking around the unit and is non-threatening to others may be a nuisance to staff, however, this does not justify putting that resident at risk of medication side effects by starting a sedative-hypnotic such as lorazepam. It has been well-established that the regular use of benzodiazepines is associated with an increased risk of falls and fractures in the elderly. The second argument challenges that the time spent evaluating and managing behaviours without medications will be reduced as non-pharmacologic strategies become effective. In contrast, the potential complications of indiscriminate medication use, such as falls, increased confusion, and extrapyramidal effects, may require more nursing and caregiver intervention over the long term.

The interdisciplinary team must be educated about dementia and resulting behaviours. It is through education and experience that team members will overcome negative attitudes about dementia. Lack of the knowledge and skills required to manage these residents can contribute to significant job-related stress that must be addressed at a higher level within the facility. A team approach to care can help to decrease this burden on nursing staff.

All behaviours, even those that are difficult, have a purpose. Non-pharmacological techniques to manage behaviours require an understanding of the purpose of the behaviour. For example, upon investigation, staff find that a resident who enters other residents’ rooms on a regular basis was formerly a letter carrier. This behaviour has a purpose; there is a job to be done. If he were given a task that utilized this behaviour, this could be managed. Learning about the resident from family and other caregivers can provide information that can justify behaviours and identify triggers.

Residents who are non-communicative can become easily agitated if they are made to do things that are against their will. For example, a cold shower in the morning may not appeal to Mrs. Jones; however, she cannot express this verbally, and instead lashes out at staff each time she is bathed. In this case, removing Mrs. Jones from this situation, and changing the bathing pattern, may rectify this behaviour.

The environment can affect resident behaviours. Visual stimulation, light, and sound can serve as triggers to behaviours in a cognitively impaired resident. Restlessness as a result of inactivity may manifest as agitation. The key to management of environmental triggers is to know the residents, observe and document when behaviours occur, and take the time to implement simple individualized changes.

The Use of Medications

Facility staff should evaluate changes in behaviour by asking several questions of other healthcare team members, of family and caregivers, and residents if possible.

If the answer to any of the questions above is “yes”, medication therapy may need to be considered or reviewed. Although it may seem time consuming to go through this process, it is important, because it will save time, money, and improve resident quality of life over the long term. When medications are used unnecessarily, or as an initial option when other non-pharmacological options are available, the resident is subjected to a higher risk of medication adverse effects, and this is something that staff will ultimately need to handle.

Medications can play an important role in behaviour management, however, they are not a panacea. These therapies must be carefully evaluated, as they are not effective in many of the common behaviour manifestations seen in the long term care facility (e. g. wandering, nuisance behaviours). Table 3 summarizes various types of behaviours and their amenability to medication therapy.

Therapies

The pharmacist’s assessment of behavioural changes always includes a review of medication therapies and recent changes. There are several medications that can impact on behaviours, as seen in Table 2. Many of these medications are not recommended in elderly people for that very reason; however, many are commonly used medications that require close monitoring. For example, digoxin may be used in residents with heart failure for symptomatic control. If above-therapeutic levels of digoxin are present in the blood, toxicity may manifest as increased confusion in an elderly demented individual. This may not be suspected initially, but there are several potential medication interactions that may lead to increased digoxin levels, so it is necessary to evaluate these possibilities.

The use of medication therapy to treat behavioural disturbances associated with dementia must be accompanied by an interdisciplinary team approach. Assessment of the behaviour by various team members, including the physician, pharmacist, nursing staff, dietary staff, occupational therapist, social worker, and others will help to:

This detailed assessment has been referred to as the ABC technique.

A consensus guideline was recently published that addressed treatment of agitation in dementia. The key medication classes included in this summary were antipsychotics, benzodiazepines, and antidepressants. Other agents, such as beta-blockers and estrogens have been investigated, and are considered alternative therapies in some cases. There is some evidence that cognitive enhancing agents (donepezil and rivastigmine) may have positive effects on behaviours, in addition to slowing the rate of cognitive decline. Table 4 summarizes the guidelines for the use of medications in the treatment of agitation in dementia.

In situations where medication therapies are deemed appropriate for treatment of behavioural disturbances, it is important to consider age-related physiological changes. The use of psychotropic medications is limited by harmful adverse effects in elderly people, so choice of agent and close monitoring are important. Table 5 summarizes inappropriate use of psychotropic medications in the elderly.

Behaviour Management Teams

Since it is often difficult to decipher resident behaviours because of sensory deficits, concomitant medical conditions and medications, a behaviour management team at a long term care facility can work together to achieve a greater understanding of resident needs. All disciplines can contribute to discussions around assessment and management of difficult behaviours. Facilities should encourage interdisciplinary involvement to help meet the challenge of creating behaviour management care plans for cognitively impaired residents. If possible, family members should also have an opportunity to participate in such a group so that they can better appreciate the care needs of their spouse, sibling, or parent, and they can help by providing additional background information about the resident.

Summary

Difficult behaviours in cognitively impaired residents are often the reason for admission to the long term care facility. It is important that facilities are prepared to deal with these behaviours in a manner that minimizes risk to all residents and staff. The utilization of the interdisciplinary team expertise is critical for optimal assessment and management of aberrant behaviours. Medication use should be justified based on the type of behaviour and level of risk to all residents and staff. There is no “silver bullet” or quick fix for management of behaviours. Individualized care planning is necessary to manage this complex manifestation of cognitive decline.