LTC 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. Symptoms generally include observable behaviours that are inappropriate or excessive within the situation and disturbing, disruptive or potentially harmful to the resident or others. (4)

Why is it Important?

  • 80-90% of nursing home residents live with some form of mental illness and/or cognitive impairment with more than 2/3 diagnosed with some form of dementia (5)
  • Individuals may have more severe symptoms in LTC with severe behavioural disturbances (3)
  • 12-21% of residents exhibit psychotic symptoms as a result of disorders such as schizophrenia, delusional disorders, mood disorders and delirium (4)
  • Neurological and vascular conditions such as Parkinson‘s disease (PD) can contribute to cognitive impairment and result in responsive behaviours.• 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 (5)
  • Prevalence and psychological symptoms include 44% global agitation, 24% verbal aggression and 14% physical aggression.(4) Responsive behaviours increase safety risks and disruption for individuals and others.
  • 47% of Registered Practical Nurses reported physical assault and 72% reporting emotional abuse (5)

Common Causes;

May be precipitated by variety of triggers (follow P.I.E.C.E.S.TM 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 emotional environment.  Health care providers (HCP) need to determine and understand the causality and meaning behind the behaviour.
  • Residents should receive individualized, self-directed person centered care.  Responsive behaviours respond to appropriate and timely interventions (4)
  • A culture of caring philosophy using empathy includes principles of psychosocial rehabilitation to maximize quality of life and build on resident and family strength while fostering a “sense’ of control”.
  • Utilization of informed clinical decision making assessment and screening tools based on evidence based practice.
  • Ongoing evaluation and modifications based upon resident, family and caregiver needs (4)
  • Minimization of pharmacological interventions and use of the BEERS criteria for potentially inappropriate medication use in older adults. Identify conditions that only respond to environmental or caregiving approaches. (6)   
  • Use of the P.I.E.C.E.S.TM framework and 3 question template:  
    1. What has changed?
    2. What are the RISKS and possible causes?    
    3. What is the action?

References

  1. Abbott-McNeil, D., Barber, D., Murphy. & Puxty, J. (2009).  Behavioral & Psychological Symptoms of Dementia (BPSD) in Long Term Care.   Bridges to Care Guide, The Centre for Studies in Aging and Health.
    www.sagelink.ca/bpsd_toolkit_full_pdf

  2. Conn, D., Gibson, M., Hirst, S., Leung, S., MacCourt, P., McGilton, K., Mihic, L., Cory, K., Le Clair, K., McLeary, L., Powell, S.,& Roberts, E.  (2006).  National guidelines for senior’s mental health. The assessment and treatment of mental health issues in long term care home.  Retrieved Feb. 2014 from:
    http://www.ccsmh.ca/en/natlGuidelines/ltc.cfm

  3. Dudgeon, S. & Reed, P. (2010).  Older Adults Behavioural Support System. Retrieved Dec 6, 2018 from: 
    http://brainxchange.ca/Public/Files/BSO/Older-Adults-Behavioural-Support-System.aspx

  4. Mental Health Commission of Canada. (2014). Retrieved Jan. 13, 2014 from: 
    http://www.mentalhealthcommission.ca/English

  5. 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

  6. 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