Second part of my lecture at Alice Salomon Hochschule (Berlin). Using flow-charts to take an important decision: which is the most suitable facility for old people relying on their main features.

1. “Behavioural Disorders and Decision Taking.
Choosing the best facilities for Psychogeriatric
patients”.
Assignment of Resources
Elena Lorente
Teacher. University Complutense of Madrid (Spain).
Psychologist and Staff Coordinator. Geriatel Nursing Home (Madrid, Spain).
Independent Consultant in Elderly Care.
Berlin 08.12.2010

2. Classifying global impairment in Elderly:
Global Deterioration Scale (Reisberg).
GDS-1: Normal.
GDS-2: Subjective memory complaints.
GDS-3: Mild Cognitive Impairment (preclinical). Little evidences of
memory impairment, difficulties at workplace, mild executive deficits.
Signs observed by relatives, coping with first symptoms, anxiety,
dysphoria, the patients feel insecure.
In a preclinical stage for Alzheimer’s it is frequently mistaken as a
Depression (by relatives!!!).
GDS-4: Mild Dementia. First cognitive deficits in all areas.
Disorganisation at IADL.
Coping with situations: negation and blaming others.
Emotional lability.
Tend to social isolation: not feeling capable to initiate a conversation.
A little portion of relatives still feel the patient is “good but a bit absent-
minded and forgetful”.

3. Classifying global impairment in Elderly:
Global Deterioration Scale (Reisberg).
GDS-5: Moderate Dementia. Important cognitive deficits.
Behavioural disorders: delusions, hallucinations, wandering, irritability,
opposition, aggressiveness.
Wandering mostly associated to freedom wishes (“I feel like a caged bird”) or
delusional content (“I’m leaving, I have to pick up my kids from school”).
Still remain verbal capacity to explain what they want.
Temporal and spatial disorientation.
Dependence in IADL and many BADL.
GDS-6: Severe Dementia. Important behavioural disorders.
Wide spectrum of behavioural disorders, with major trend to
aggressiveness, agitation, inadequate motor behaviours, or even apathy.
Wandering can be very difficult to handle (risk of falls).
Totally dependent in ADL.
Supervision needed.
GDS-7: Very Severe Dementia. Important health problems.

4. How to assess behavioural disorders:
Neuropsychiatric Inventory (NPI)
Behavioural disorders in neurological patients assessed by frequency,
severity and distress.
Held as a clinical interview with external observer: caregiver, relative, etc.
Main disorders assessed:
Delusions.
Hallucinations.
Agitation / aggression.
Dysphoria.
Anxiety.
Euphoria.
Apathy
Disinhibition.
Irritability / lability.
Aberrant and motor behaviour.
Sleep and nightime behaviour.
Appetite and eating behaviour.
Something missing:
Where can we classify “wandering”? Suggestion: both agitation and aberrant motor.
And for “insulting”? Suggestion: aggression, disinhibition and irritability.
For opposition, the suggestion is: irritability.

5. Reflection Exercise #1
How can these disorders interfere
with daily functioning?
Which disorders are more frequent
in early, middle or moderate stages
of Impairment or Dementia?

6. Behavioural disorders and
stages of involution
DISORDER GDS- GDS- GDS- GDS-7
4 5 6
Delusions + ++ ++ ?
Hallucinations + ++ ++ ?
Agitation + ++ +++ +
Dysphoria +++ ++ ++ ?
Anxiety ++ ++ ++ ?
Euphoria ++ ++ ++ ?
Apathy +++ + + +++
Disinhibition + +++ +++ +
Irritability / lability + +++ +++ ++
Aberrant motor behav. + +++ +++ +
Sleep and nighttime b. ++ +++ +++ +
Appetite and eating + +++ +++ ++

7. Global Impairment
and behavioural disorders
Disorders are linked to the stage of involution:
GDS-4: coping with symptoms and signs of involution,
depression, anxiety, apathy, etc.
GDS-5: disorders related to altered thinking, distorted
perception, frustration for miscomunication and
misunderstanding, and even disorientation.
GDS-6: in the same line but with less verbal abilities
to explain what really happens.
GDS-7: inactivity and severe global impairment make
many disorders invisible, but still remains irritability
and eating disorders are related to dysphagia.

8. Cue-recall: linking assessment of
behavioural disorders to assessment of
ADL
NPI does not inform about:
Family implications.
Caregiver strain = Zarit.
Real and factual difficulties to manage patients at home.
ADL + behavioural impairment:
First: Need for trained professionals.
Domiciliary Attention Services.
Next: Need for controlled environments + trained professionals.
Day Care Centers.
Nursing Homes.

9. Reflection exercise #2
•For how long can an elderly person live
alone at home?
•Can we choose the first resource we find
for a patient?
•Are behavioural disorders important for this
decision?

10. Resources and candidates
A resource is assigned considering:
Availability.
Localisation / “sectorisation”.
Legal requirements.
“Punctuation” and baremation of disability level.
Economical resources of the user.
Spain: Law of Personal Autonomy (a.k.a. “Law of
Dependence”) and its application in the 17
autonomous communities.
What about the candidates’ profile?

11. Candidates for Domiciliary
Attention Service
Absence of cognitive impairment but light mobility
problems to go out of home.
Total absence of affective or behavioural disorders.
Able to live alone but with little help.
Little functional impairment.
Only need help for:
IADL:
Walking, accompanying to medical visits.
Shopping.
Home duties.
BADL:
Only for bath or shower.

12. Candidates for Day Care Centres
Mild cognitive impairment or mild Dementia.
Slightly compromised mobility.
Needed and benefits of cognitive and physical
rehabilitation.
Not recommended staying alone at home all day.
Behavioral disorders for a GDS-4 or GDS-5.
Highly strained relatives.
Forgetfulness affecting home and personal security.
E.g.: leave the fridge open, switched on lights, taking double
dose of medication, heating a metallic recipient in
microwave, etc.
Lack of nighttime disorders, despite disorientation.

13. Candidates for Nursing Homes
From Mild cognitive impairment to very severe Dementia.
Inmovilism: space needed for wheelchairs, cranes, etc.
Benefits of integral attention and rehabilitation.
Evidence of health problems requiring careful treatment.
Behavioral disorders.
Highly strained relatives.
Consider ambivalence in relatives: strain and stress perception, but
also feeling guilty for “leaving” them in a nursing home.
Common in Spain (cultural).
Nighttime disorders, eating disorders, dependence in ADL.
Social risk.
Mental health.

14. When we have a patient, we must take a decision
Patient:
Health
Cognitive
Functional
Emotional
Behavioural Choosing
Social DECISION facilities or
TAKING resources
Environment
and living
conditions
FLOWCHART

15. Flowcharts
Diagrams representing algorithms and processes.
Step by step solution to a problem.
Symbols. Process
Helpful for taking decisions about a process or when
it is required considering many features.
Multidimensional = patient.
Mechanical? yes
In Health and Social Sciences 2+2 ≠ 4. conditional
Quick tool, but not all patients fit the taken decision by
A
algorithms.
First approach to a patient. no
Construction:
Less than 7 conditional steps. End
7 or more: separate by topics.

16. Useful flowchart
¿Candidate
I used this flowchart when I worked at the Alzheimer’s Association
for a Nursing to suggest which resource would be better for the patients when
Home? involution started.
Functionally and Functional
no no yes yes Strict yes
cognitively Dependence but Cognitive Behavioural Nursing
medical
Independent? preserved Impairment? Disorders? Home
treatment?
cognitive function?
yes yes no
no
Physical impairment, needed At home but with Day
Patient can physical attention. no Domiciliary Attention, Care
stay at home Suggestion: living in an adapted caring for avoiding Center
Home or Nursing Home social isolation.
with autonomy and
capability to take decisions.

17. Management of wandering: Brainstorm
Features related to wandering:
Getting rid of physical restraints.
Crawling out of bed at night.
Risk of falling and accidents.
Patient elopes and gets lost.
Verbalisation of freedom needs.
Feeling like a “caged bird”.
Patient becomes aggressive when it is not possible to get out.
Delusional content attaining wandering:
“I must go to Cordoba to visit my mother: she is dying”.
Disorientation.
Overlapped to aberrant motor behaviour:
Walks and takes off clothes at the same time.
Agitation.

18. Management of wandering: Weights
Features as light hazards.
Minimum risk of falling.
Verbalisation of freedom needs.
Patient can be managed when it is not possible to get out.
Disorientation.
Real hazards for wanderers.
Getting rid of physical restraints.
Risk of falling and accidents.
Patient elopes and gets lost.
Patient becomes aggressive when it is not possible to get out.
Delusional content attaining wandering.
Overlapped to aberrant motor behaviour.
Agitation.
Imantation (L’Hermitte Syndrome).

19. Wandering
Management of wandering
at home
yes Watch if the
patient is capable
Risk of Falls? to ask for help
when suffering a fall
no
Only verbalisations
of freedom needs Eloping +
yes yes yes
no Agitation? Nursing Home
delusional content? Agressive?
and Pharmacological
treatment
no no
no
yes
Disoriented:
needs for Gets rid of yes
Patient can walking in wide Physical
but controlled Restraints?
stay at home
spaces.
and caregiver
should be trained no
Day Care
Supervision Center
needed

20. Conclusions
We have different profiles in elderly,
requiring different resources.
We can make flowcharts for each area:
Concrete behavioural disorders.
Physical status.
Suggesting an area of living in a Nursing
Home.
Assignment to programmes.
Etc.

21. My suggestion:
constructing flowcharts to practise and test if they
work out in daily practice of Social Workers.
Comments to:
Elena.lorente@gmail.com
Elena.lorente@trs.ucm.es