Managing behaviours in the nursing home setting can be exhausting for caregivers. It is estimated that up to 90 per cent of patients with dementia will be agitated at some point. Up to 72 per cent may be depressed. Often the nursing staff will request a psychiatric or psychological consultation in order to learn methods to decrease behaviors or obtain medication. How can this service be utilized in the most efficient manner for healthcare providers and patients? What do nurses need to know and do to maximize a positive response from the consultation and avoid needing frequent consultations in the future?
Case examples
During his morning care, Mr. Choudry, a patient with Parkinson’s disease, mentions matter of factually to his direct caregiver that he is seeing people in his room who are not there. He is not bothered by this and it is a chronic issue. He is easily distracted from this conversation and functions well during the day. Nurse Kiara, who is new to the unit, hears that the patient in Room 322 is hallucinating. She immediately requests a psychiatric consultation. She does not know the patient, or that hallucinations are a symptom of Parkinson’s. Mr. Bakshi tends to “isolate” in his room. He likes to lie down in the afternoon rather than play Pachisi with his friends.
Nursing feels he is depressed and a consultation is requested. A review of Mr. Jones’s record indicates he has COPD and chronic atrial fibrillation. He eats well, sleeps and has no other depressive symptoms. Many patients have disease processes that require frequent rest and limited activity. These diseases include rheumatoid arthritis, cardiac and respiratory conditions and infection. Staff members did not ask Mr. Jones if he was depressed, but based the referral on one observation.
Suggestions for Nurses
Here are some recommendations to minimize the use of psychiatric referrals:
1) Know the patient or consult with a staff member who does:
When there’s a shortage of staff members, caregivers often are assigned to patients they do not know. What may be seen as an unusual behaviour may be “normal” for the resident. His regular caregivers may be able to offer advice on dealing with his behaviours.
2) Know the diagnosis:
Hearing unusual thought content from a patient whose diagnosis is chronic schizophrenia would not be considered as worrisome as hearing it from a patient with no previous mental health history. Consults often are received on patients with chronic psychosis for actions that may be baseline behaviour.
3) Think “medical” first:
Ruling out medical causes in patients with a sudden change in mental status is the first step. Many medical conditions can create confusion and agitation. Treating the infection will clear the confusion. Rule out pain as a cause, and consider recent changes to the patient’s care plan.
4) Identify antecedents to the behaviour
What happened prior to the onset of the behaviour? Did the patient get anxious and agitated right after his visitors left? Does he get confused in the evening, but is oriented in the morning? Knowing what precipitates behavior may enable changes to be made to reduce it, or allow for medication to be given prior to the time when its effect is most needed.
5) Use time as a guide to behavioural change
Caregivers often complain of having a bad day, forgetting patients can have them too. One refusal of activity or one verbal altercation with another resident or caregiver does not require an immediate consultation. Also, remember that emotional issues and behaviours take time to resolve. Antidepressants take several weeks to work; Antipsychotic medications may require proper dosing.
6) Use available “As needed”(PRN) medication:
I often receive a medication referral for a patient described as aggressive or agitated. Upon reviewing the chart I find that the patient had medication already available that was not used. Often this PRN was suggested in a previous consultation. Using PRN meds at the first sign of anxiety or agitation will help control the behaviour and give the clinician an indication of whether a standing dose is needed based on the frequency of administration.
7) Educate the staff:
Teaching staff members about mental illness and what medication can and can’t do is important. Education on how to approach patients is very important to direct hands-on caregivers They are the front-line caregivers and are most likely to be injured by agitated patients. Changing staff behavior may be easier than the patient’s.
8) Brainstorm:
Using a team of people who interact daily with the patient can be a more effective way of devising a behaviour plan than relying on a single consultant. A regular staff member who works well with a patient may have better suggestions on how to interact with this problematic patient than a psychiatric consultant.
Productive Consultations Psychiatric consultation is an essential tool in providing care to residents in nursing home settings, but it can be overused. By implementing the steps above, patients and nurses will be better served by a more cohesive approach to patient management, making consultation a much more effective process when really needed.
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