NICHE Hospital Advances and Resources Update: Behavioral Health

Approximately 20% of adults ages 55 and over suffer from a mental disorder, the most common being anxiety disorders (e.g., generalize anxiety and panic disorders), severe cognitive impairment (e.g., Alzheimer's disease), and mood disorders (e.g., depression and bipolar disorder) (AOA, 2001). In 2005, nearly half of nursing home residents had dementia, and 20 percent had other psychological diagnoses (Houser et al., 2006). The following is an excerpt from Kathleen Fletcher, Dementia (2012). In: Boltz, M., Capezuti, E., Fulmer,T. & Zwicker, D. (eds.). Evidence-Based Geriatric Nursing Protocols For Best Practice (4th ed.). New York: Springer Publishing.

Behavioral and psycho-social symptoms of dementia are common with every form of progressive dementia particularly in the moderate stage. The three most troublesome symptoms are agitation, aggression and wandering. Problematic behaviors that occur during meals or bathing can be particularly challenging. It is important to recognize and realize that any new behavior could be a sign of an acute illness or an environmental influence. Unrecognized pain can cause disruptive behavior. The Progressively Lowered Stress Threshold (PLST) is a framework to optimize function, minimize disruption and help the caregiver (Smith et al., 2006). The PLST model increases the positive appraisal and decreases the negative appraisal of the caregiving situation (Stolley et al., 2002) and helps the caregiver manage the aggressive behaviors demonstrated in AD (Lindsey et al., 2009). By adapting the environment and routines, interventions are designed to help the patient with dementia use his/her functional skills and minimize potentially triggering reactions.

Following is an approach developed at a NICHE Hospital related to behavioral health.

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Innovations

Managing Behavioral Disturbances in Patients 

with Dementia

2013 NICHE Conference Poster Presentation. Authors: Kristine Todd, MSN, FNP-BC, RN-BC, and D'Anna Springer, BSN, RN-BC. Saint Mary's Health Care, Grand Rapids, Michigan.

In February of 2011 Saint Mary's Health Care opened a 32-bed acuity adaptable senior adult unit. Shortly after opening the unit began to see an increase in admissions of patients with behavioral disturbances related to dementia.

To help improve care for these older adult patients, an initiative was launched focused on the development of a dementia pathway to address all causes of behavioral disturbances that resulted in changes in behavior. The pathway was designed to address such issues as pain, bladder and bowel management and social/environmental needs. It was nurse-driven to allow early recognition and intervention.

As a result of the pathway implementation, length of stay decreased from baseline by 0.74 days. Also, the nursing staff felt more confident in providing care for patients with behavioral disturbances. Nurses were able to proceed through the pathway and assess patients for possible causes of the behavioral disturbances and proactively intervene by recommending changes in treatment. Examples included around-the-clock Tylenol dosing and suggesting appropriate medications for behavior control as recommended by the BEERS list and The American Geriatric Society.

NICHE-Related Resources 

Full access to some of the resources referenced here is only available to NICHE member hospitals.

NICHE Organizational Strategies

Resource: Behavioral Health Rapid Response

Describes a team of healthcare professionals who respond to patients experiencing behavioral changes or a mental health crisis.

A Crosswalk: Joint Commission Standards and NICHE Resources

The Crosswalk document details how NICHE resources comply with the Joint Commission Standards in terms of care of the older adult patient. The Provision of Care section deals with use of evidence-based assessment practices and individualized interventions to prevent and manage geriatric syndromes.

View the Crosswalk description.

NICHE Online Connect Webinars

Webinar: Rapid Response for Dementia and Behavioral Issues

Describes how the NICHE team at St. John Hospital and Medical Center assembled a team of specially trained professional associates to assist units with assessment and treatment of behavioral conditions.

Webinar: Patient Activity Cart (PAC) for Better Care

This webinar discusses how an interdisciplinary NICHE team at Saint Francis Hospital created an educational component outlining interventions for confusion/delirium. The interventions used equipment supplied in a Patient Activity Cart (PAC).

Webinar: Utilizing the Safety Bundle: A New Model for Patient Safety

The Safety Bundle is an assessment method that nurses can use for effective interventions in the care of the older patients with delirium.

View the webinar description.

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Webinar: Creating Smooth Transitions for Your Patients with Dementia

How do challenging transitions affect older adult patients? What can you do today to improve care for your older adult patients with dementia? This webinar details the answers and depicts several transitional care models.

Need to Know by NICHE

Title: Dementia Transition Series

This Need to Know series is presented in partnership with the St. Louis Chapter of the Alzheimer's Association. The patient and family education tool is designed and written to provide older adult patients with dementia and their families guidance to help them understand and cope with hospitalization and transitions. It consists of:

• Need To Know: Home to Hospital
• Need To Know: What to Communicate at the Hospital
• Need To Know: Hospital to LTC or Rehabilitation
• Need To Know: Hospital to Home

Evidence-Based Geriatric Nursing Protocols for Best Practice Book

Chapter 8: Assessing Cognitive Function

Compares and contrasts the clinical features of delirium, dementia and depression, and how to incorporate the assessment of cognitive function into daily practice.

Chapter 9: Depression

Discusses the major risk factors for late-life depression, nursing assessment for depression and strategies for older adults with depression.

Chapter 11: Delirium

Discusses the importance of early recognition of delirium and how to develop a plan to prevent or treat delirium.

View the Protocols book abstract.

Geriatric Patient Care Associate (GPCA) Curriculum

Module: Is Your Patient Confused?

Discusses the significance of delirium in hospitalized older adults and identifies care interventions to prevent and manage delirium.

View the course description.