Today, we hosted a workshop about behavior disorder in the emergency department for nurses. Although I was on the presenters panels, it was a great educating experience for me, I learned a lot.
Here are a few stats to situate this problem in its context. Dementia affects about 25% of patient in their seventies, 50% in their late eighties and about 60 to 90% of those will experience some neuropsychiatric symptoms that can include aggression, elopement, repetitive behavior, wandering, etc.
We call these behaviors, “responsive behaviors”. It is a reaction or response to something frustrating or confusing.
Responsive behaviors are not only a significative problem, but it is also challenging to manage because it is uncomfortable for us, their families, physicians are resistant to medication or physical restraints, we hesitate to call a code for an older adult, it is difficult to provide care and ultimately it affects our personal well-being. It is important to have some strategies to use while facing this issue.
First, those are the things that can exacerbate or contribute to responsive behaviors:
- Medical issues
- Vision/hearing uncompensated
- Bowels/bladder retention
- Cold room
- Noise levels
- Being left alone
- Hungry, Thirsty, having to pee.
Second, there is a general approach for all kind of behavior. Basics.
First, make sure that they can hear and understand you. Second, tell them what to do rather than what not to do and finally make sure that they agree before you start doing your things.
And address unmet needs: food, drink, bathroom, pain.
Then, lets review some of the more commun behavior disorder and how we can address them.
10-step approach to aggression/resistance to care.
- Introduce yourself and role
- Explanation (break down the steps)
- Slow down your care
- Body language and voice tone (respect personal space)
- Tell patient what to do (rather than what not to do)
- Review triggers (and unmet needs)
- Stop care and ensure safety
- Environmental safety
- Physical/chemical restraints
Elopement (leaving by design or mistake) strategic plan
- Consider who is at risk and level of risk (Mobile + cognitively impaired)
- Make person easier to find if they leave (Dress in hospital gown, note physical characteristics)
- Provide activities to keep the person occupied (Newspapers, etc.)
- Address unmet needs
- If holding a person against his/her will, under what authority
- Redirect person by asking them to walk with you and then attempt to engage them in another activity
Getting up inappropriately strategic plan
- Address unmet need
- Remind person of reason to stay on stretcher (can person be in chair near you instead of stretcher?)
- Falls risk strategies (try to avoid physical restraint)
Repeated questions strategic plan
- Answer and answer and answer
- Is there an unmet need?
- Can patient be engaged in some way (distraction like newspaper, coloring books, folding clothing, etc.)?
When everything fails, and it will in more than 50% of the case, it is the time to think about chemical and physical restraints. It is important to know their risks, their implication and the appropriate way to use them. Let’s talk about it in another post!