Geriatric Mental Health Services

Geriatric Guide - Section B

For Assessing Changes in Behavior in Residents of Long Term Care Facilities and.......
Getting Help When Needed

Preparing for Changes in Behavior Ahead of Time

Each facility should establish an internal intervention team to address behavioral changes. The core team should include:

The director of nursing,
The social worker, and,
it is very important for the facility's medical director to be on the team

In addition to the above individuals there will be others joining the core team who work with the individual resident for whom the team is meeting, such as:

The resident in question,
His or her family member or other informal support network member,
Direct care staff.

The facility's core intervention team should develop a working relationship with Crisis Intervention staff so that when a crisis occurs, it will be easier for the two groups to work together.

In conjunction with Crisis Intervention staff, the facility's team should develop a general plan for when a call to Crisis Intervention is desirable.

When an individual arrives at the facility with a history of difficult behaviors, the intervention team should develop a plan specifically for that individual. Such advance planning gives both the facility and Crisis Intervention the means to provide quality service to the individual in need, and to the other residents and the staff. In addition advance planning will make later contacts easier and more effective. As with other plans, the resident and people who know him/her should be involved, along with the facility's Intervention Team and the Crisis Intervention staff.

General Plan to Handle Difficult Behavioral Changes

When a crisis occurs, the facility's Intervention Team will take the following steps:

1. Determine if this is an emergency.

team should quickly gather information for Crisis Intervention and contact them. If the changes in behavior are causing danger to the resident or to others, see, “Information for Crisis Intervention.”

2. Determine if this is a gradual change in behavior.

If it is, the Intervention Team will develop a plan to deal with the matter internally. See “Handling Difficult Behavior Internally”
If that doesn't work, the team will call an outside consultant. See “Gathering Information for a Consultant”.

3. Determine if this is an abrupt change in behavior.

If so, a medical evaluation should be the first step, including an assessment of medications. See, 'Medical Evaluation,” and “Gathering Information for a Consultant” .
If no medical or physical cause is found, the Intervention Team will develop a plan to deal with the matter internally. See, 'Handling Difficult Behavior Internally”.
If that doesn’t work, the team will call an outside consultant. See “Gathering Information for a Consultant”.

Handling Difficult Behavior Internally

If an abrupt change in behavior is not found to have a medical or physical cause, or if the change in behavior has been gradual, it is best to try to address the matter with existing staff, within the facility. The team should develop and implement an intervention plan, including ways to measure whether or not the plan has succeeded.
      1. Define the problem – see Appendix 1
      2. Measure the problem – see Appendix 2
      3. Review all this information as a team, and decide what is needed. The team now determines that

There is no longer a problem (please document that), or
Only internal actions are needed at this time, in which case a plan for those actions needs to be drawn up. The plan should state clearly who is going to do what, should include measures to determine if the plan has been successful, and should include a date for review.* Suggested elements of a plan:
Modify the environment - reduce noise, eliminate clutter, allow clutter, reduce/increase lighting.
Keep the furniture in the same place at all times. (unless change requested by resident.)
Be aware of the possible need to change roommate arrangements (often this should be one of the last options).
Assess and address the needs of the individual as stated by the individual, especially comfort needs.
An example of a situation that could cause difficulty for a facility is an older gentleman who has worked on the third shift all of his life - he is used to being up during the night and sleeping during the day. This type of situation could cause some problems for everyone especially if he cannot verbally communicate with staff.
Keep daily routines as consistent as possible as established by the resident's choices, not the institution's.
Internal actions are not sufficient; outside assistance is needed. See 'Gathering Information for a Consultant' .

Gathering Information for a Consultant

Have the following ready for the primary physician and/or consultant:

The reason for the consultation as defined by the team.
A record of behaviors (you might use the worksheets 'Defining the Problem' and 'Measuring Behavior' in the section on 'Handling Difficult Behavior Internally.')
A recent set of postural vital signs and an older set for comparison.
Information about the client's compliance with medications.
A list of medications currently being taken and any recently changed.
A list of PRN meds used during the past week.
Recent laboratory data. (especially information on infections, blood sugar level, electrolytes, UA and blood pressure).
Results of the mini-mental status exam.

* When an intervention has been in place for a while, repeat the worksheets and see how the person is doing. Be consistent, communicate regularly both within each shift and between shifts and with family/guardians and members of the informal network. Be patient when making changes. Give them enough time to work.