Hospital Resources - Behavioural Issues

Behavioural issues also known as responsive behaviours are generally characterized by challenging outbursts of aggression, agitation, repetitive or bizarre actions, shouting and/or disinhibited behaviours. They are generally associated with cognitive impairments due to complex mental health conditions and addictions (substance abuse), dementia or neurological conditions.

Why is it Important?

  • Challenging behaviours are a major source of distress both to the person experiencing them and those who experience them such as the caregiver and their family.
      • 34% of nurses have experienced physical assault from a patient and 47% reported emotional abuse (3)
      • Lack of community support and caregiver burnout may result in crisis admissions to hospital (3)
  • Hospital discharge may be delayed for persons experiencing responsive behaviours resulting in longer LOS and an increase in ALC designation (creating further burden on all sectors of the health care system)
      • ALC patients occupied 15% of all acute care beds in Ontario and 44% half of clients were waiting for long-term care (2)
  • Increased risk of iatrogenesis (unintended and untoward consequence of well-intended healthcare interventions) and functional decline contributing to client/patient morbidity and mortality

Common Causes:

May be precipitated by variety of triggers (follow P.I.E.C.E.S.™ acronym):
Physical: pain, constipation, polypharmacy, infections; especially UTI and pneumonia
Intellectual: Review Brain and Behaviour
Emotional: depression, anxiety
Capacity: miss match between functional ability and expectations
Environmental: changes in living environment, relocation, admission to hospital
Social: change or stress/illness of caregiver

Key Considerations

  • Responsive behaviours are not willful or intentional and represent an individual’s adaptive response to a negative stimulus in their physical, social, or psychological environment.
  • Responsive behaviours respond to appropriate and timely interventions: remain calm, empathetic, good communication techniques,distraction, build on their strengths, understand the causality and meaning behind the behaviour
  • Preventing responsive behaviours should inform the plan of care by recognizing and appropriately responding to the behaviour(s):
      • Creating a culture of safety and adapting the environment and care to meet client’s unmet needs; promoting the least restrictive and supportive physical and social environments whenever possible (i.e. reduce clutter, creating safe and accessible areas for ambulation, promote psychological safety)
      • Providing person centered care: getting to know the person as an individual, their likes, dislikes and background, fostering a “sense “of control and a collaborative approach to care model including the family, a knowledgeable care team
      • Utilization of informed clinical decision making to improve safety and quality of care through minimization of pharmacological interventions and use of the Beers criteria for potentially inappropriate medication use in older adults.
  • Identify conditions that may be responsive to medications and those which only respond to environmental or caregiving approaches.Pharmacological strategies should be carefully monitored and reviewed, time-limited and always combined with non-pharmacological strategies.
  • Facilitate good communication.

References

1. Dudgeon, S. & Reed, P. (2010). Older Adults Behaviour Support System. Retrieved Feb 19, 2014 from: 
    http://brainxchange.ca/Public/Resource-Centre-Topics-A-to-Z/Behavioural-Supports-Ontario.aspx

2. Ontario Hospital Association, (2012). Alternative Level of Care. Retrieved Feb. 2014 from:
    http://www.oha.com/currentissues/issues/eralc/Pages/eralc.aspx

3. Shields, M. & Wilkins, K. (2009). Factors related to on the job abuse of nurses by patients.
    Retrieved Feb. 2014 from:
    http://www.statcan.gc.ca/pub/82-003-x/2009002/article/10835-eng.pdf

4. The American Geriatrics Society. (2012). AGS Beers Criteria for Potentially Inappropriate Medication Use
    in Older Adults. Retrieved Feb. 2014 from:
    http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf