Behavioural disorders and decision taking (Part II)
“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
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 ofmemory 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”.
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.
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.
Reflection Exercise #1 How can these disorders interferewith daily functioning? Which disorders are more frequentin early, middle or moderate stagesof Impairment or Dementia?
Global Impairment and behavioural disordersDisorders 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.
Cue-recall: linking assessment of behavioural disorders to assessment of ADLNPI 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.
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?
Resources and candidatesA 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?
Candidates for Domiciliary Attention ServiceAbsence of cognitive impairment but light mobilityproblems 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.
Candidates for Day Care CentresMild cognitive impairment or mild Dementia.Slightly compromised mobility.Needed and benefits of cognitive and physicalrehabilitation.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.
Candidates for Nursing HomesFrom 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.
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
FlowchartsDiagrams representing algorithms and processes. Step by step solution to a problem. Symbols. ProcessHelpful for taking decisions about a process or whenit 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. noConstruction: Less than 7 conditional steps. End 7 or more: separate by topics.
Useful flowchart ¿Candidate I used this flowchart when I worked at the Alzheimer’s Associationfor 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.
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.
Management of wandering: WeightsFeatures 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).
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 caregivershould be trained no Day Care Supervision Center needed
ConclusionsWe 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.
My suggestion:constructing flowcharts to practise and test if they work out in daily practice of Social Workers. Comments to: Elena.email@example.com Elena.firstname.lastname@example.org