Geriatric Giants: Challenging/Difficult Behaviours in the Acutely Ill Older Adult

1. Geriatric Giants: Challenging/Difficult Behaviours in the Acutely Ill Older Adult Gerontological/Geriatric CNS of BC 2003

2. Who are we again?

3. 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.

4. 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

5. 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.

6. 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.

7. 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.

8. SUE: The Daughter • Sue was called at work • She has just arrived on the scene

9. 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?

10. The Challenges of Caring

11. 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

12. 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.

13. “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!

14. “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.

15. Top 5 Challenges 1. 2. 3. 4. 5.

16. 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.

17. 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!

18. “The Label…” • Once labeled, there for LIFE! • CAUTION: biases, discrimination and “…isms” can lead to: • fear • shame • hopelessness • death by exclusion

19. The “D’s” ? • Gero or geri-psychiatry • D elirium • D epression • D ementia • D elusions • D rugs

20. 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!

21. 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

22. Withdrawal? • Look for withdrawal from alcohol, drugs, nicotine, caffeine.. • CAGE, CIWA and protocol • Harm reduction • Fat storage and liver function • Referral

23. 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?

24. 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.

25. 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

26. 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?

27. 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!

28. 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

29. 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?

30. 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

31. 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?

32. 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.

33. 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?

34. 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 =

35. 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

36. 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.

37. 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

38. 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

39. Anxiolytics: Anxiety DisordersGoal 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)

40. Anxiolytics: Anxiety DisordersInvestigations • 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

41. Anxiolytics: Anxiety DisordersNon-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

42. 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

43. 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

44. 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

45. 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

46. 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

47. Antidepressants:Goals of Therapy • To relieve depressive symptoms • To prevent suicide • To restore optimal functioning • To prevent recurrence of depression

48. 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

49. Antidepressants:Non-Pharmacological • Education • Cognitive behavioural or interpersonal psychotherapies • ECT • Supportive • Utilize clinical practice guidelines

50. 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