Decreasing Agitation in Demented Patients Living in Nursing Home - Assignment Example

? Decreasing Agitation in Demented Patients Living in Nursing Home This paper discusses the major concern of agitation in patients with dementia living in nursing home care. The epidemiology and significance of the problem is presented as well as evidence based practices observed in several researches that will help decrease agitation in patients with dementia. In addition, the role of the nurse leader to enhance clinical outcomes according to the said evidence based practices is explained. Furthermore, a list of interventions and description of results is presented together with barriers and strategies used to overcome them. Keywords: agitation, dementia, nursing home, nurse leader, evidence based practice Decreasing Agitation in Demented Patients Living in Nursing Home Behavioral and emotional disturbances, particularly agitation, are the major problems commonly observed in impaired elderly people dwelling in nursing homes, particularly those who are suffering of dementia. According to Tariot, Daiello and Ismail (2002, p. 2), behavioral symptoms affect a large population of dementia patients in the United States, where “as many as 90% of patients with dementia develop significant behavioral disorders at some point.” Based on a clinical research conducted by Bartels, et al. (2003, p. 236), the condition of patients with dementia is “complicated by mixed agitation and depression accounts for over one-third of complicated dementia”. Compared with other subgroups, elderly patients with dementia which are also experiencing bouts of agitation have the “highest rate of hospitalization, the greatest number of medical diagnoses, and the greatest medical severity, and they receive the greatest number of psychiatric medications (Bartels, et. al. 2003, p. 234)”. As such, there is a great need to decrease agitation in dementia patients especially in the nursing home settings. Studies on psychiatric disorders recommend that agitation symptoms in patients with dementia should be efficiently treated through proper diagnosis and medication, together with the efficient management of the nurses and caregivers in enhancing the clinical outcomes according to evidence based practices (Salzman, et al., 2008). Cohen-Mansfield, Marx and Rosenthal (1990, p. 3) defined agitation as “inappropriate verbal, vocal, or motor activity that is not a necessary by-product of the needs or confusion of the agitated individual.” Agitated behavior may be manifested as an appropriate behavior executed with inappropriate rate of recurrence or it may be inappropriate based on social standards for the particular situation, as exemplified by the three syndromes such as aggressive behaviors, physically non-aggressive behaviors, and verbally agitated behaviors. The abusive or aggressive behavior of a patient may be directed towards him or others and are often apparent in the advanced stages of dementia. Physically non-aggressive behaviors are observed as adaptive to nursing home residents during their deteriorated stage of dementia, where their bodies need to be stimulated or undergo physical exercise. Verbally agitated behaviors are regarded as a form of help-seeking behaviors by patients that are experiencing depression and physical diseases (Cohen-Mansfield, Marx and Rosenthal, 1990). In addition, agitation may be brought by various physical and emotional factors like fears, insecurity, frustrations, and false beliefs brought about by impaired hearing, sight, or aphasia, most commonly observed in persons with cognitive impairment (Cohen-Mansfield, Marx and Rosenthal, 1990). There are also reports that nursing home staff frequently misapprehends symptoms of cognitive impairment as agitation instead of thoroughly checking if the said behavior stems from other reasons such as pain, hunger, boredom, fatigue, environmental chaos, or consequence of medical issues or medications. Sedatives and atypical antipsychotic drugs are usually administered to patients exhibiting dementia-associated agitation and aggression wherein the medications are used for short periods of time and in low doses. Although considered as a helpful approach in decreasing cases of agitation, Salzman, et al. (2008, p. 890) noted that “first-generation antipsychotic drugs sometimes produce substantial side effects, such as tardive dyskinesia, as well as extrapyramidal and anticholinergic symptoms.” There are also cases wherein the use of conventional neuroleptics has been linked with high mortality in older patients. Because of this, “precise description and categorization of agitated behavior in patients with dementia may assist practitioners in the selection of effective interventions” (Tariot, Daiello and Ismail 2002, p. 3). Physicians and nursing home staff should consider every possible cause of behavior disturbance in their assessment. As one of the key persons in charge in nursing homes, the nurse leader plays a significant role in enhancing the clinical outcomes according to evidence based practices. The nurse leader is responsible in ensuring that the nurse staff are providing sufficient care to the patients by addressing their needs and effectively assist them in reducing possible occurrence of agitation. Moreover, the nurse leader is accountable to the wellbeing of the patients, especially to the advanced stage of dementia where the patients can no longer complain verbally (Cohen-Mansfield, Marx and Rosenthal, 1990). Several evidence based practices are now utilized as an intervention to decrease agitation in patients with dementia that can be adopted by nursing home facilities. Australian On a medical research founded by the Australian government, Bidewell (2012), reported that residents with dementia are needed to be assessed for agitation each time that the individual experiences this behavioral disturbance which cannot be settled with simple interventions like serving of food or toileting the resident and when the resident is observed with a change in non-verbal behavior. In addition, the registered nurse is required to review the assessment tools several times until agitation is managed. When a number of residents are agitated at once, the patients are showing epidemic agitation so the nurse needs to identify the object or empathically interpret the situation that triggers the behavior. Since the ability to communicate is impaired to most of the residents and they have no control of their environment, they use agitation as the only available response. On the other hand, individual cases of agitation in residents can be handled by assessing the physiological causes of agitation which include observing the temperature, pulse, blood pressure and urinalysis of the patient, directing the care staff to complete a Confusion Assessment Method tool to screen for delirium, and reviewing the medication and medical history of the patient. Moreover, Tariot, Daiello and Ismail (2002, p. 4) recommended that “nonpharmacologic interventions should be part of a comprehensive treatment plan developed after appropriate medical and psychiatric evaluations and following treatment of any associated abnormalities”. The participation of the interdisciplinary health care team, family and nursing staff may be beneficial in formulating effective individualized nonpharmacologic methods to problem behaviors. The authors specifically cited the use of the A-B-C method, also known as the antecedent, resultant behavior, and consequences associated with behavioral symptoms, to characterize and create strategies to modify the environment, patient’s schedule, or the caregiver-patient interaction. However, it is difficult to keep agitated dementia patients from receiving sedatives and other medications considering their different levels of dementia. This is where the effective management of nurse leaders is measured, on how they can reduce the incidence of behavioral problems on dementia patient while ensuring their safety and the staff’s application of their training. Fossey, et al. (2012, p. 332), noted that the training and support intervention of the nursing home staff to promote a centered care and good practices “provides a viable alternative to neuroleptics for treating behavioral symptoms in patients with dementia”. In order to surpass the limitations of the evidence based practices listed above, Salzman, et al. (2008) proposed a series of strategies that nursing homes can follow in order to efficiently handle cases of behavioral disturbances. Upon admission, the physician and staff should talk about the needs of future care of the patient in the facility. Once agitation has occurred, the nursing staff should identify any reversible cause of the behavior and eliminate it. Salzman, et al. (2008, p. 890) noted that the “assessment of agitation should include: medication review emphasizing polypharmacy and drug interactions; intensive medical evaluation, including blood chemistries for liver, renal and cardiac functions, as well as metabolic lab values and a more complete neurologic exam”. The family members should be alerted with the potential benefits and risks of all clinical decisions and their consent must be secured. Furthermore, Cohen-Mansfield, Marx and Rosenthal (1990) suggested engaging nursing home residents with dementia in activities that can bring positive effects “such as marked increase in measured happiness, elevated interest and alertness, a decrease in boredom, improvement in the performance of activities of daily living and higher quality of life”. The increase in positive affect brought by engagement has significantly reduced agitation in the clinical trials the authors conducted. Few studies focus on searching for other alternative methods in decreasing agitation such as the use of aromatherapy persons with dementia. Since the patients have impaired olfactory abilities, cutaneous application of essential oils is preferred rather the mere smelling of the oils (Fossey, at. al., 2012) Still, it is critical for the nursing home staff to understand that the evidence based practices discussed are challenging to follow because of the different mental states of the residents. Cooperation, sensitivity to patient needs and open communication between the nurse leader and the nursing home staff is essential in effectively conveying the strategies in reducing agitation in patients with dementia. As such, it is necessary to apply the principles of Malcolm Knowles’ Principles of Andradogy or the theoretical framework of adult learning and Deming’s Theory or the PDSA Method in creating and implementing policy recommendations to reduce cases of agitation in patients with dementia in the nursing home care setting. Both Malcom’s Principles and Deming’s Theory can be used in successfully educating the staff and in measuring the outcome of the project at hand. The Principles of Andradogy deals with the concept that adult learners are direct learners that can understand instructions independently. It is better to give the nurses an invitation to participate in the formulation of the strategies in reducing cases of agitation in the home facility to make them feel that they are in control of their decision to participate or not (Bishop, 2012). Meanwhile, Deming Cycle or the PDSA method involves planning and analyzing its possible results, executing the plan, studying the results and taking action to standardize or improve the process. With the application of the Deming Cycle in implementing a particular project, the daily routine team management, project management and continuous development in terms of vendor and human resources can be well promoted by the management (Bishop, 2012). Nevertheless, the occurrence of agitation and other behavioral disturbances in patients with dementia in nursing homes is a critical concern that needs to be reduced, if not eliminated. With the capable management of the nurse leader, efficient strategies are needed to be implemented through the participation of the nursing home staff in order to successfully avoid, subdue and treat aggressive agitation in the individual and group levels of residents. The nursing staff should assess the object or situation that triggered the agitation, resolve the issue by eliminating the said cause and use medications only when needed. Various approaches that promote nonpharmacologic interventions are promoted as well as alternative methods that encourage engagement and activity with the residents. References Bartels, S. J., Horn, S. D., Smout, R. J., Dums, A. R., Flaherty, E., Jones, J. K., Moname, M., Taler, G. A. & Voss, A. C. “Agitation and Depression in Frail Nursing Home Elderly Patients with Dementia: Treatment Characteristics and Service Use.” American Journal Geriatric Psychiatry. 11.2 (2003): 231-238. Print. Bidewell, John. “Decision-Making Frameworks in Advanced Dementia: Links to Improve Care Project”. Agitation Framework Guidelines. University of Western Sydney. n.d. Web. 27 Web. 2012. Bishop, Dawn, L. “Nursing Knowledge and Attitudes Regarding the Pain Management of Cancer Patients”. Master of Science in Nursing Thesis. Florida State University. 2005. n.d. Web. 28 Nov. 2012. Cohen-Mansfield, Jiska, Marx, Marcia S. & Rosenthal, Alvin S. “Dementia and Agitation in Nursing Home Residents: How are they Related?” Psychology and Aging. 5.1 (1990): 3-8. Print. Fossey, J., Ballard, C., Juszczak, E., James, I., Alder, N., Jacoby, R. & Howard, R. “Effect of Enhanced Psychosocial Care on Antipsychotic Use in Nursing Home Residents with Severe Dementia: Cluster Randomized Trial”. British Medical Journal. BMJ (2006): 332-756. n.d. Web. 27 Nov. 2012. Salzman, C. Jeste, D., Meyer, R.E., Cohen-Mansfield, J., Cummings, J., Grossberg, G., Jarvik, L., Kraemer, H., Lebowitz, B., Maslow, K., Pollok, B., Raskind, M., Schultz, S., Wang, P., Zito, J. M. & Zubenko, G. S. “Aggression: Consensus Statement on Treatment Options, Clinical Trials, Methodology, and Policy.” Journal of Clinical Psychiatry. 69.6 (2008): 889-898. Print. Tariot, Pierre, N., Daiello, Lori A. & Ismail, Saleem. Agitation, Agression, and Behavioral Disturbances in Dementia: A Monograph for Continuing Medical Education Credit. ACCESS Medical Group, Department of Continuing Medical Education. 2002. Web. 28 Nov. 2012. Read More