Staff Key to Heading Off Psychiatric Emergencies

NEW ORLEANS – Educating staff to spot triggers for disruptive behavior in long-term care facility residents and to effectively prevent escalation is key to helping head off psychiatric emergencies, Dr. Amita Patel said at the annual meeting of the American Association for Geriatric Psychiatry.

In general, LTC staff–nurse's aides, in particular–are undereducated about dementia and the management of mental illnesses, said Dr. Patel, of the department of psychiatry at Wright State University, Dayton, Ohio. Given that staff members are “overburdened and underpaid,” she said, they often do not have the ability to manage these residents.

Agitated residents who have reached the crisis point are at a higher risk of falls and of injuring themselves and others. Such residents will also tend to be noncompliant, increasing the caregiver's burden, Dr. Patel said. There is already a 50%–70% turnover rate for licensed practical nurses and registered nurses; if they feel more burdened, turnover is likely to increase, she said. In addition, unmanaged psychiatric emergencies expose clinicians and facilities to potentially higher malpractice and workers' compensation premiums.

After she taught staffs at facilities in Ohio about ways to better manage residents, the workers' compensation premiums there went down, Dr. Patel said.

The first step is to prevent stress. The facility's environment is often an issue: Hallways are overcrowded; loud noises emanate from televisions or alarms; lighting is harsh; bathwater is too cold; exit signs act as a beacon for wandering residents seeking a way out. Instead, the environment should be made as soothing as possible, Dr. Patel said.

Alleviating boredom also can help. Activities and exercise are important, especially in the early evenings, when there are often no staff members available to provide activities. Residents may go to bed too early and wake up agitated, she said. Fenced areas can be maintained to allow higher-functioning residents to walk or get outside.

The staff also can make an environment more–or less–hospitable. Administrators should allow time for education on dementia and psychiatric illnesses, so that staff members know what to expect, Dr. Patel said. Staff members can also be taught to become less task oriented. For instance, if a resident is distressed and will not eat, the nurse should not continue shoveling food in just to complete that task, she said. The staff member can walk away and return at another time.

Residents also should be given eye contact, especially if they are hearing or vision impaired. Standing behind an impaired resident and barking out directions can be distressing, Dr. Patel noted.

Validation therapy is useful, particularly in paranoid or delusional residents. If residents are paranoid, don't try to tell them [their fears are] not true, she said. Instead, tell them that the situation will be investigated.

Staff members sometimes have a hard time coping with residents who may be stressed because they are grieving a loss of control or lack of attention from family. The staff can be trained in ways to help residents tolerate some of their distress and also to accept death as a reasonable outcome of living.

If residents do become agitated–exhibiting a change in voice; glaring; perspiring; or becoming restless, irritable and suspicious–“this is the state when you know they eventually are going to escalate,” she said.

At this point, the resident should be given empathetic support, encouraged to breathe, and asked to go to a quiet area. There, an assessment can be made, and–depending on the situation–oral medications might be offered.

An assessment should include an evaluation of what might have caused the episode–environment, a peer interaction, or a drug interaction. A complete blood count, toxicology screen, cognitive screen, and vital signs assessment can all help to get at the root cause. Substance abuse should be suspected if the patient has recently returned from a leave outside the facility, Dr. Patel said.

Once the etiology has been identified, treatment can begin. If the resident calms down, ongoing behavioral interventions and modifications of the environment should be considered. Continued agitation may require sedation or use of a geri-chair. Restraints should be used only as a last resort.

There are no medications approved by the Food and Drug Administration for the management of acute psychiatric emergencies in elderly people, Dr. Patel said. Most often, benzodiazepines are used.

Federal regulations require institutions to document that patients are being given medications for an adequate indication, and that they are given the appropriate dosage for the appropriate duration, Dr. Patel said. Documentation that therapeutic goals are being met must be provided.

The benefits of short-term medication use need to be weighed against the risks of chronic dosing. The benzodiazepines are not well studied in dementia or for long-term use, but are preferred for short-term episodes, despite side effects such as excessive sedation, ataxia, respiratory suppression, and the potential for abuse.

Newer antipsychotics may be useful, especially because several are available as orally disintegrating tablets, including risperidone (Risperdal) and olanzapine (Zyprexa). Residents cannot “cheek” those medications, she noted. Intramuscular olanzapine has been studied in agitated patients with schizophrenia. A 5-mg per injection dose has been recommended for geriatric patients. It should not be used in conjunction with benzodiazepines.

Dr. Patel is a speaker for Eli Lilly & Co., Wyeth Pharmaceuticals, Forest Pharmaceuticals Inc., and Sanofi Aventis.

NEW ORLEANS – Educating staff to spot triggers for disruptive behavior in long-term care facility residents and to effectively prevent escalation is key to helping head off psychiatric emergencies, Dr. Amita Patel said at the annual meeting of the American Association for Geriatric Psychiatry.

In general, LTC staff–nurse's aides, in particular–are undereducated about dementia and the management of mental illnesses, said Dr. Patel, of the department of psychiatry at Wright State University, Dayton, Ohio. Given that staff members are “overburdened and underpaid,” she said, they often do not have the ability to manage these residents.

Agitated residents who have reached the crisis point are at a higher risk of falls and of injuring themselves and others. Such residents will also tend to be noncompliant, increasing the caregiver's burden, Dr. Patel said. There is already a 50%–70% turnover rate for licensed practical nurses and registered nurses; if they feel more burdened, turnover is likely to increase, she said. In addition, unmanaged psychiatric emergencies expose clinicians and facilities to potentially higher malpractice and workers' compensation premiums.

After she taught staffs at facilities in Ohio about ways to better manage residents, the workers' compensation premiums there went down, Dr. Patel said.

The first step is to prevent stress. The facility's environment is often an issue: Hallways are overcrowded; loud noises emanate from televisions or alarms; lighting is harsh; bathwater is too cold; exit signs act as a beacon for wandering residents seeking a way out. Instead, the environment should be made as soothing as possible, Dr. Patel said.

Alleviating boredom also can help. Activities and exercise are important, especially in the early evenings, when there are often no staff members available to provide activities. Residents may go to bed too early and wake up agitated, she said. Fenced areas can be maintained to allow higher-functioning residents to walk or get outside.

The staff also can make an environment more–or less–hospitable. Administrators should allow time for education on dementia and psychiatric illnesses, so that staff members know what to expect, Dr. Patel said. Staff members can also be taught to become less task oriented. For instance, if a resident is distressed and will not eat, the nurse should not continue shoveling food in just to complete that task, she said. The staff member can walk away and return at another time.

Residents also should be given eye contact, especially if they are hearing or vision impaired. Standing behind an impaired resident and barking out directions can be distressing, Dr. Patel noted.

Validation therapy is useful, particularly in paranoid or delusional residents. If residents are paranoid, don't try to tell them [their fears are] not true, she said. Instead, tell them that the situation will be investigated.

Staff members sometimes have a hard time coping with residents who may be stressed because they are grieving a loss of control or lack of attention from family. The staff can be trained in ways to help residents tolerate some of their distress and also to accept death as a reasonable outcome of living.

If residents do become agitated–exhibiting a change in voice; glaring; perspiring; or becoming restless, irritable and suspicious–“this is the state when you know they eventually are going to escalate,” she said.

At this point, the resident should be given empathetic support, encouraged to breathe, and asked to go to a quiet area. There, an assessment can be made, and–depending on the situation–oral medications might be offered.

An assessment should include an evaluation of what might have caused the episode–environment, a peer interaction, or a drug interaction. A complete blood count, toxicology screen, cognitive screen, and vital signs assessment can all help to get at the root cause. Substance abuse should be suspected if the patient has recently returned from a leave outside the facility, Dr. Patel said.

Once the etiology has been identified, treatment can begin. If the resident calms down, ongoing behavioral interventions and modifications of the environment should be considered. Continued agitation may require sedation or use of a geri-chair. Restraints should be used only as a last resort.

There are no medications approved by the Food and Drug Administration for the management of acute psychiatric emergencies in elderly people, Dr. Patel said. Most often, benzodiazepines are used.

Federal regulations require institutions to document that patients are being given medications for an adequate indication, and that they are given the appropriate dosage for the appropriate duration, Dr. Patel said. Documentation that therapeutic goals are being met must be provided.

The benefits of short-term medication use need to be weighed against the risks of chronic dosing. The benzodiazepines are not well studied in dementia or for long-term use, but are preferred for short-term episodes, despite side effects such as excessive sedation, ataxia, respiratory suppression, and the potential for abuse.

Newer antipsychotics may be useful, especially because several are available as orally disintegrating tablets, including risperidone (Risperdal) and olanzapine (Zyprexa). Residents cannot “cheek” those medications, she noted. Intramuscular olanzapine has been studied in agitated patients with schizophrenia. A 5-mg per injection dose has been recommended for geriatric patients. It should not be used in conjunction with benzodiazepines.

Dr. Patel is a speaker for Eli Lilly & Co., Wyeth Pharmaceuticals, Forest Pharmaceuticals Inc., and Sanofi Aventis.

NEW ORLEANS – Educating staff to spot triggers for disruptive behavior in long-term care facility residents and to effectively prevent escalation is key to helping head off psychiatric emergencies, Dr. Amita Patel said at the annual meeting of the American Association for Geriatric Psychiatry.

In general, LTC staff–nurse's aides, in particular–are undereducated about dementia and the management of mental illnesses, said Dr. Patel, of the department of psychiatry at Wright State University, Dayton, Ohio. Given that staff members are “overburdened and underpaid,” she said, they often do not have the ability to manage these residents.

Agitated residents who have reached the crisis point are at a higher risk of falls and of injuring themselves and others. Such residents will also tend to be noncompliant, increasing the caregiver's burden, Dr. Patel said. There is already a 50%–70% turnover rate for licensed practical nurses and registered nurses; if they feel more burdened, turnover is likely to increase, she said. In addition, unmanaged psychiatric emergencies expose clinicians and facilities to potentially higher malpractice and workers' compensation premiums.

After she taught staffs at facilities in Ohio about ways to better manage residents, the workers' compensation premiums there went down, Dr. Patel said.

The first step is to prevent stress. The facility's environment is often an issue: Hallways are overcrowded; loud noises emanate from televisions or alarms; lighting is harsh; bathwater is too cold; exit signs act as a beacon for wandering residents seeking a way out. Instead, the environment should be made as soothing as possible, Dr. Patel said.

Alleviating boredom also can help. Activities and exercise are important, especially in the early evenings, when there are often no staff members available to provide activities. Residents may go to bed too early and wake up agitated, she said. Fenced areas can be maintained to allow higher-functioning residents to walk or get outside.

The staff also can make an environment more–or less–hospitable. Administrators should allow time for education on dementia and psychiatric illnesses, so that staff members know what to expect, Dr. Patel said. Staff members can also be taught to become less task oriented. For instance, if a resident is distressed and will not eat, the nurse should not continue shoveling food in just to complete that task, she said. The staff member can walk away and return at another time.

Residents also should be given eye contact, especially if they are hearing or vision impaired. Standing behind an impaired resident and barking out directions can be distressing, Dr. Patel noted.

Validation therapy is useful, particularly in paranoid or delusional residents. If residents are paranoid, don't try to tell them [their fears are] not true, she said. Instead, tell them that the situation will be investigated.

Staff members sometimes have a hard time coping with residents who may be stressed because they are grieving a loss of control or lack of attention from family. The staff can be trained in ways to help residents tolerate some of their distress and also to accept death as a reasonable outcome of living.

If residents do become agitated–exhibiting a change in voice; glaring; perspiring; or becoming restless, irritable and suspicious–“this is the state when you know they eventually are going to escalate,” she said.

At this point, the resident should be given empathetic support, encouraged to breathe, and asked to go to a quiet area. There, an assessment can be made, and–depending on the situation–oral medications might be offered.

An assessment should include an evaluation of what might have caused the episode–environment, a peer interaction, or a drug interaction. A complete blood count, toxicology screen, cognitive screen, and vital signs assessment can all help to get at the root cause. Substance abuse should be suspected if the patient has recently returned from a leave outside the facility, Dr. Patel said.

Once the etiology has been identified, treatment can begin. If the resident calms down, ongoing behavioral interventions and modifications of the environment should be considered. Continued agitation may require sedation or use of a geri-chair. Restraints should be used only as a last resort.

There are no medications approved by the Food and Drug Administration for the management of acute psychiatric emergencies in elderly people, Dr. Patel said. Most often, benzodiazepines are used.

Federal regulations require institutions to document that patients are being given medications for an adequate indication, and that they are given the appropriate dosage for the appropriate duration, Dr. Patel said. Documentation that therapeutic goals are being met must be provided.

The benefits of short-term medication use need to be weighed against the risks of chronic dosing. The benzodiazepines are not well studied in dementia or for long-term use, but are preferred for short-term episodes, despite side effects such as excessive sedation, ataxia, respiratory suppression, and the potential for abuse.

Newer antipsychotics may be useful, especially because several are available as orally disintegrating tablets, including risperidone (Risperdal) and olanzapine (Zyprexa). Residents cannot “cheek” those medications, she noted. Intramuscular olanzapine has been studied in agitated patients with schizophrenia. A 5-mg per injection dose has been recommended for geriatric patients. It should not be used in conjunction with benzodiazepines.

Dr. Patel is a speaker for Eli Lilly & Co., Wyeth Pharmaceuticals, Forest Pharmaceuticals Inc., and Sanofi Aventis.