Principles
  • Behaviours are a symptom of dementia
  • Behaviours are a response to interaction with physical and social environment
  • Behaviours are communication
  • Behaviours are an expression of need
  • A person is unique
A person-centered care approach involves looking beyond the brain damage occurring in dementia as the only cause of agitated behaviour. Agitation can also result from the person’s interaction with the physical and psycho-social environment. To reduce agitation, it is essential to pay attention to the uniqueness of individuals, their personality, their achievements and life history, their immediate environment and the care practices occurring.
(Loveday,B. and Kitwood, T. 1998)

Agitation

Inappropriate verbal, vocal or motor activity that is not judged by an outside observer to result directly from the needs or confusion of the person. (Cohen-Mansfield and Billig, 1988)
external image Angry+Old+Man.jpg


Symptoms of Agitation
Verbal
  • Negativism
  • Chanting
  • Repetitive sentences
  • Constant interruptions
  • Constant requests for attention
  • Verbal aggression

Physical
  • General restlessness
  • Repetitive mannerisms
  • Pacing
  • Hiding objects
  • Inappropriate handling
  • Shadowing
  • Trying to get away from protected environment
  • Inappropriate dressing/undressing
  • Physical aggression

Possible contributing factors
  • Pain/discomfort
  • Illness
  • Overstimulation (noise, people, activities)
  • Being stopped from what doing or what want to do
  • Altered routines
  • Strange environment
  • Reduced threshold

Responding to Agitation
1. Assess the Person
  • Presence of contributing factors
  • Health status
  • Medicines
  • Check vision and hearing

Please refer to the Cohen Mansfield Agitation Inventory (CMAI) – long form attached here.


2. Assess the Situation
  • Allow the person to express their needs
  • Ask other staff who know the older person well if they can assist in identifying the person’s needs, or the possible reasons for agitation
  • Consult the person’s behaviour and clinical charts for further information about the triggers for agitation
  • Assess the immediate environment for possible triggers for agitation
  • Consult close family members to identify possible triggers for agitation unknown to staff and not previously documented in behaviour and clinical charts.






Source : http://www.youtube.com/watch?v=EXoYaiqkV_I&feature=watch-vrec
3. Developing and consistently implementing an intervention plan
  • Once interventions are chosen these should be implemented consistently by all staff
  • Chosen interventions will be different depending on the person and the cause and should be tailored to the person
  • There are number of general interventions which can be applied

Delirium is described as : * Disturbance of consciousness (i.e. reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention
  • Change in cognition (e..g. memory deficit, disorientation, language disturbance and perceptual disturbance) that is not better accounted for by a pre-existing, established, or evolving dementia
  • Development over a short period of time (usually hours to days) and disturbance tends to fluctuate during the course of the day.
  • Development over a short period of time (usually hours to days) and disturbance tends to fluctuate during the course of the day.
American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders, (4th Ed.) Washington, DC

If agitation is related to delirium
Contact person’s doctor immediately requesting urgent advice /consultation
  • Rest the person, provide pain relief and fluids if needed, stay with the person and provide reassurance and comfort
  • Employ prescribed treatment as ordered by doctor
  • Re-assess the person’s cognitive status every half hour and chart any changes
  • Have medications reviewed and adjusted if needed





Source : http://www.youtube.com/watch?v=h-MP21WW4M0

If agitation is related to illness
Contact person’s doctor if required requesting treatment advice/consultation
  • Rest the person, provide necessary treatment
  • Regularly assess the person’s health status and levels of discomfort
  • Chart any changes to health status every two hours
  • Have medications reviewed and adjusted if needed

If agitation is related to emotional state
Attend to immediate causes of agitation
  • Employ social reinforcers to enable the person to feel less agitated
  • Reduce or eliminate, if possible, distressing or confusing environmental features
  • Respond proactively to further signs of agitated behaviour
  • Gain agreement from all staff to employ positive approached towards the person
  • Seek the support of family and friends, or volunteers, to spend time with the person in pleasant activities on a regular basis


Aggression
Aggressive behaviour can take the form of physical aggression against a person, verbal aggression, damaging property or a temper outburst.

external image angry-grumpy-fisheye-man-194x300.jpg

Possible contributing factors

  • Response to a perceived threat – invading personal space
  • Embarrassment
  • Feelings of incompetence arising from inability to perform tasks or to make self understood
  • Fear – insecurity
  • Fright – if approached from behind; unexpected physical contact – self-protection
  • Frustration arising from not being able to do what he/she wants; change in routine; lost items; inability to remember someone’s name
  • Misinterpreting events and situations
  • Environment – too much or too little stimulation; boredom; noise; lighting; chaos
  • Other people

Responding to Aggression

1. Prevention
  • Know the person







Source : http://www.youtube.com/watch?v=DZ0VMdxtYw4&feature=relmfu

  • Be respectful; maximise ability and independence
  • Minimise unexpected activity/noise
  • Involve the person in activities that are meaningful to them
  • Avoid excess stimulation
  • Provide attention when not aggressive to reinforce desired behaviour

2. Assess the behaviour

  • Explore the background to the aggression – what happened previously
  • Times/dates incidents occur
  • People involved
  • Identify if any pattern
  • Rating Scales for Aggressive Behaviour on the Elderly (RAGE)

* attach RAGE sample

General responses to aggression

  • Ensure safety of others – do not try to move the person who is being aggressive
  • Validate the person’s feelings – ask what is wrong; listen to the person; do not contradict or argue
  • Review each incident seeking causes and examining responses






Please refer to the Decision Tree for Determining Risk Level and Post-Admission Surveillance in Persons with Dementia relocating to Long Term Care sample attached here.


Code Grey Process
The “Huddle” used to defuse behaviours
The huddle is an ad hoc approach to touch base to regain awareness and discuss critical issues and emerging events during an emergency situation. It is a time to anticipate outcomes and likely contingencies assign resources, express concerns and allocate roles to those involved.



The code grey process at BECC:

  • Emergency Controller/AHC/Nurse in charge attends the emergency and initiates a Huddle.
  • With appropriate staff/area warden to establish safest possible outcome for all parties involved.
  • Consider is the disturbed person at risk to him/herself?
  • Is there any need to immediately do anything?
  • Ensure adequate numbers of personnel are available to mange the situation before taking action
  • Ensure that others are safe, away form the area of risk and their needs are being met.
  • Allow the staff member with best negotiation skills and existing rapport to interact with the disturbed person
  • Once the all clear code grey is announced a debrief should take place as soon as possible
  • RISKMAN report to be completed including reference to a huddle/debrief having occurred.

Please read the code grey policy under PROMPT Northern Health Intranet

Watch video clip of the Mental Health scenario “The Huddle" from the Team STEPPS toolkit 2010














Attend ISTA defence techniques training session annually

Please review the defence techniques by ISTA Via the BECC SHARED S Drive/Education/Behavioural Management Techniques Manual

Debrief

Is a process of improvement. You can provide brief informal information exchange and feedback. Should occur after and event or shift and designed to improve teamwork skills and outcomes. An over view of an accurate reconstruction of key events and analysis of why the event occurred and what should be done differently next time should be discussed.
Debrief Checklist
  • Communication clear?
  • Roles and responsibilities understood?
  • Situation awareness maintained?
  • Workload distributed?
  • Did we ask for or offer assistance?
  • Were errors made or avoided?
  • What went well, what should change, what can improve?

Watch video clip of debrief from the Team STEPPS toolkit 2010














Compiled by Mayla Villamin CNE and Angela Ruzzene CNE BECC 2012