Elder Care In Hospital

Getting Started

Before using a medication solution for the behaviour, healthcare providers should be able to answer the following questions:

  1. Who is this person? Life story, likes, dislikes - knowing this information helps to select appropriate interventions in the care plan. Complete All About Me form.
  2. What is the behaviour? Be specific. Avoid the word agitation as that is too vague.
  3. When did the behaviour begin? How often is it occurring? This is answered by Behaviour Tracking.
  4. Why do you think the behaviour is happening? What are the triggers? This is usually the most difficult question to answer.

Use the acronym DO CARE PLAN to help you figure out the answer to Why:

How can we make life better for these individuals? Write a behavioural care plan that addresses the Who, What, When & Why that is unique to that person.

D Delirium, depression, dementia, delusions/hallucinations?
O Overstimulation?
 
C Constipation / need to toilet?
A My or our approach?
R Right or wrong medication?
E Environment? Too much clutter or no space to wander safely?
 
P Pain? Underlying physical cause (undiagnosed malignancy)?
L Loneliness? Boredom?
A Anxiety? Fear? Always try non-pharmacological approach first.
N Other unique needs like those we may see in individuals with frontal temporal lobe problems?

Behaviour Tracking

Instructions for Completing the Behaviour Tracking Form

  1. Fill in the patient’s name at top of page.

  2. Fill in the behaviour you plan to track. Do NOT say “agitation” because this is not specific enough. You must put in a very specific behaviour like “wandering” or “verbal aggression” or “calling out”, etc.

  3. Fill in your name or the name of the person who has agreed to review and analyze the tracking form. Do NOT leave this blank. If it is left blank, the form will sit unattended and collect information indefinitely. Staff get frustrated that nobody is looking at the form.

  4. Be sure to fill in the dates you want to track the behaviour between. If the behaviour is severe you likely will only have to track it for about 4 days. If it is less severe you may need to track it for 2 weeks. 

How Do I Analyze the Information on the Behaviour Tracking Form?

  1. Anyone can analyze the information.

  2. At the end date of the designated Tracking time period, it is important that the information be reviewed and a summary written in the Progress Notes on the patient’s chart.

  3. Begin by making a list of 2-hour time frames for the 24-hour clock on a piece of blank paper (8-10 a.m.; 10-12 noon; 12 noon-2 p.m.; 2-4 p.m.; 4-6 p.m.; 6-8 p.m.; 8-10 p.m.; 10-12 midnight; 12 midnight-2 a.m.; 2-4 a.m.; 4-6 a.m.; and 6-8 a.m.).

  4.  Next count the total number of entries on the form. How many times did the behaviour occur? How many times was the entry saying the behaviour did not occur?

  5.  Look at each individual behaviour entry and look at exactly what time it occurred. Put a tick (✔) on your clock list next to the time frame that the behaviour occurred in. For example, if Behaviour Tracking said that John was wandering at 9:15 a.m. and again at 3:20 p.m. then put a ✔ next to the 8-10 a.m. time slot and a ✔ next to the 2-4 p.m. time slot.

  6.  Total up the total number of ticks in each 2-hour time slot.

  7. The time slot that has the greatest number of ticks is when the behaviour is occurring the most often. It does not mean that it never occurs at another time, but we want to see when it is occurring the most. For example, in the time slot for 8-10 a.m. the behaviour “wandering” may have occurred 3 times. For 2-4 p.m. it occurred 7 times. For the time slot 6-8 p.m. it occurred 2 times. The time when the wandering behaviour is occurring the most is between 2-4 p.m.

  8.  What interventions worked to stop the behaviour? What interventions did not work? Why do you think the behaviour is happening? Look at triggers.

  9.  In the Progress Notes you would write something like: “Behaviour Tracking for Mr. Jones’ wandering behaviour took place between April 4-20th, 2015. There were a total of 14 entries on the Tracking Form. Most of the wandering occurred between 2-4 p.m. with a total of 7 out of 14 incidents happening at this time. Interventions that were successful in stopping the behaviour were 1:1 x 20 minutes, taking him to the toilet. An intervention that did not seem to work was giving Ativan. Behaviour seems to be triggered by a sense of loneliness when his wife leaves. We will review the care plan to ensure that the interventions are implemented between 2-4 p.m.”

  10.  Next have a care planning meeting with your colleagues. Discuss the Tracking Form’s information. Brain storm for ideas that will help address the behaviour. When did the group notice a change in behaviour? What interventions have worked for them? Why do you think the behaviour is happening? What are the triggers? Is it boredom? Is the patient looking for companionship? Looking for a toilet? Are they hungry, cold, etc.? What is the patient’s Life Story? Are there things we could put in the care plan that reflect what they like to do?

  11. Try to keep the care plan for behaviour to one page maximum. Revise the care plan as needed and leave a visible copy for all staff to see. Share the information. Remind staff of the updated care plan at shift change. Everyone must be on board to trial the care plan.

  12. Be sure to set a date to evaluate the care plan. Are the interventions making a difference? If not, revise the plan.

Clinical Vignettes (Case Studies)

Case Study

      Mrs. Jones is 78 years old and recently lost her husband Bob. She has 3 children: Sue, Bob Junior, and Janet. Sue found Mrs. Jones alone in her apartment crying after she called the police because someone stole her purse. Sue later found the purse in Mrs. Jones’ closet. She was noticeably more confused than 2 weeks ago and, according to the neighbours, had not come to the building’s afternoon tea parties or choir practice for a week. She always enjoyed sleeping in but the neighbours told Sue that she wasn’t sleeping much now. They could hear her out in the hall at 4 a.m.

      She was admitted to your unit 2 days ago with increased confusion and falls. Mrs. Jones is lying in bed under the blankets and wearing a Johnny shirt. The over bed light is off and her IV is infusing in her right arm. The room is quiet and she appears to be asleep. The window curtains are closed.

      A nurse rushes into the room with towels, a basin of water, and a facecloth and places them on the over bed table beside Mrs. Jones’ bed.

      “Time to get up, Mrs. Jones,” the nurse says quickly.

      She turns on the over bed light and tells her, “Mrs. Jones, I’m going to bathe you now. Come on, wake up. Wake up.” Mrs. Jones sleepily opens her eyes and turns to look at the nurse. She says nothing.

      The nurse repeats this louder to ensure Mrs. Jones hears her. She reaches for the bed sheets and tries to pull them down but Mrs. Jones holds onto them and says “No.”

      The nurse says loudly, “Mrs. Jones, I need to give you a bath now. Let go of the sheets.” Mrs. Jones just stares at the nurse and says “No,” while tightly holding the sheets.

      The nurse sighs and says, “You’re not going to fight me on this now are you? I’m going to get some help.”

      She returns with a male nurse saying to him, “It’s the same thing every time!”

      He pries Mrs. Jones’ hands off the sheets and then holds her wrists. Mrs. Jones struggles and says repeatedly “No, no!”

      The first nurse proceeds to wash Mrs. Jones’ face. Meanwhile both nurses are talking about Mrs. Jones and how difficult she is to wash.

      “Yes, we need to give her something to calm her down!” says the male nurse.

Questions

  1. How did this situation make you feel?
  2. Was this approach successful to meet the needs of Mrs. Jones?
  3. What could have been done that would be less upsetting for Mrs. Jones and the nurses?
  4. Review the steps of Who, What, When & Why document, also refer to acronym DO CARE PLAN (http://goo.gl/pXyQsF)
  5. Develop a short care plan that identifies who Mrs. Jones is, what the behaviour is, and when it is happening. Suggest more appropriate interventions using the Non-Pharmacological Interventions document (http://goo.gl/4uuEDn) for helping patients bathe and best approach based on why you think the behaviour is happening and who she is

Dementia/Cognition Care Tips to reflect on before writing a care plan

  • Physically restraining patients increases risk of aggression
  • “No,” usually means “No, I don’t want a bath now”. Try again in another hour or perhaps a different time of day
  • Increasing numbers of care providers at bath time does not mean success without resistance and in fact often makes the patient more upset
  • Nobody ever died from not being bathed for a day
  • Understanding why Mrs. Jones is resisting and who she is may help us to use a different approach. What is her Life Story? Check her All About Me Form
  • What is her current MMSE? Ask her daughter what she was like 3 weeks ago. Does Mrs. Jones usually bathe every day? Did she resist a bed bath before being in hospital? Have other nurses had success?
  • What is the difference between delirium/dementia and depression? Refer to the unit’s Resource Manual or this on-line section: https://bit.ly/2MMWNSo
  • When is it appropriate/not appropriate to use medications in a situation like this?
  • How would you educate her daughter Sue about dementia versus delirium?

Case Study

      Frank is 82 years old, married, and from Lunenburg. Many years ago he was a supervisor at Zellers. He and his wife Edith have five children. He was diagnosed with vascular dementia six years ago and his most recent MMSE a year ago when he was seen by Geriatrics was 22/30. Edith is his primary caregiver. Frank fell and broke his hip five weeks ago and is still in the hospital. He tends to like to walk, especially late in the afternoon.

      Frank walks in the doorway of another patient’s room wearing a Johnny shirt. He has no shoes on and his catheter bag is dragging on the floor.

      The male patient lying in bed in the room starts to shout, “Get out of here you fool! Get out!”

      The social worker walks by the room, hears the commotion and goes to find a nurse.

      A nurse runs into the room and grabs Frank’s arm.

      “Come on Frank. Come with me!” she says.

      Frank raises his fist and pulls away from the nurse. The patient in bed keeps yelling, “Get him out of here! He always comes in here. You need to lock him up!”

      The nurse says to Frank, “Come on Frank! I told you to stay out of here. Come on…come out of here”. Frank resists and tries to shake off the nurse’s grip on his arm. She lets go and calls for help at the door.

      A second staff member appears at the door. They both grab Frank’s arms and lead him out of the room toward his own room. Frank protests by trying to pull away.

      One staff says to another, “We need to give him some Ativan so he’ll stop wandering. I have to call the doctor about something else anyway so I’ll ask for that. We don’t have time to chase him all over the place.”

Questions

  1. How did this situation make you feel?
  2. Was this approach successful to meet the needs of Frank and the other patient? Recall that Frank resisted and raised his fist when grabbed by his arm. Recall that the other patient was shouting
  3. Is there anything else the social worker walking by could have done?
  4. What could have been done that would be less upsetting for Frank and the nurses? What may have been a better approach to use?
  5. What other information do you need to know about who Frank is (Life Story)?
  6. Review the steps of Who, What, When & Why document, also refer to acronym DO CARE PLAN (http://goo.gl/pXyQsF)
  7. Reflect on who Frank is, what the behaviour is, when it is happening, and why it is happening. Write a short care plan and suggest more appropriate interventions using the Non-Pharmacological Interventions document (http://goo.gl/4uuEDn) for patients who wander and best approach based on why you think the behaviour is happening and who he is

Dementia Care Tips to reflect on before writing a care plan

  • Avoid using words that wither such as “Stop that!” or “Get out of here!” This approach usually increases the defenses of the person with dementia
  • Avoid grabbing a patient by the arm. First, try to get their attention by stepping into their field of vision, smiling and using a calm, quiet voice. Extend your hand and ask him to come with you, say “I will help you.” Use hand gestures and beckon him by saying, “Come with me Frank, I want to show you something” or even shorter, "Follow me, Frank".
  • Think of wandering as exploring. Why is he exploring? Is he looking for a familiar face, a bathroom, or his room? Is he bored?
  • Usually for someone with dementia, their MMSE score may drop by 2-3 points per year. What is his MMSE now?
  • What time does his family come to visit? How might they be involved in a care plan?
  • Would allied health team members be able to contribute to the care plan (specifically Occupational Therapy, Physiotherapy or Recreation Therapy) and offer to do interventions with that patient at a particular time when wandering is worse?

Case Study

      Mrs. Grant is 84 years old and widowed. She has 2 children who rarely visit. She came to the hospital 3 weeks ago after she fell at home and became more confused. She was found to have pneumonia. When her son Jim did come to visit, he told the nurses that his mother hates to be cold and has quite a bit of arthritis in her shoulders and hips. She used to enjoy listening to Frank Sinatra music.

      After being off for 2 weeks on vacation, you come off the elevator and head towards your unit for an evening shift at 2:45 p.m.

      A female voice is calling, “Help me, please help me… help me… help me…” repeatedly.

      It’s Mrs. Grant. She is sitting in a Geri-chair with a lap tray securely in place. She’s banging her fist on the table, shaking it and calling out. She is on 1 mg of Lorazepam b.i.d. for her behaviour

      A nurse with her hands full of supplies stops by Mrs. Grant’s chair, bends over and gently tells her, “Mrs. Grant, just give me a minute. I’m busy right now. I’ll be back to help you ok?” and then she rushes away.

      Within 10 seconds the unit Occupational Therapist comes down the hall. She stops and says, “Oh, Mrs. Grant, you’re having a bad day today aren’t you? What’s wrong?”

      Mrs. Grant continues to say, “Help me… help me…” and does not seem to focus on the Occupational Therapist. The Therapist says she’ll get Mrs. Grant’s nurse and leaves.

      There is a housekeeping staff cleaning the floor nearby who doesn’t seem to notice Mrs. Grant. Two more staff members walk by deep in conversation and don’t acknowledge Mrs. Grant as she continues to call out and shake her head.

      Other residents and their family members walk by and say, “She does that all day and night. They need to give her something or move her to another floor.”

Questions

  1. How did this situation make you feel?
  2. Was this approach successful to meet the needs of Mrs. Grant?
  3. What might have been a better approach to use?
  4. What other information do you need to learn about who she is?
  5. Review the steps of Who, What, When & Why document, also refer to acronym DO CARE PLAN (http://goo.gl/pXyQsF)
  6. Reflect on who Mrs. Grant is, what the behaviour is, when it is happening, and why it is happening. Write a short care plan and suggest more appropriate interventions using the Non-Pharmacological Interventions document (http://goo.gl/4uuEDn) for patients who are calling out based on why you think the behaviour is happening and who she is

Dementia/Cognition Care Tips to reflect on before writing a care plan

  • Remember that calling out will never be stopped by using medications unless the patient is heavily sedated (which we don’t do)
  • Review her current medications. Are they appropriate for older adults?
  • Has she been screened for delirium? Depression? What is her MMSE?
  • What do you know from what her son said about her Life Story that may be making Mrs. Grant feel worse?

Medication Tips for Appropriate Use

A meta-analysis that examined efficacy of pharmacotherapy with AD patients found that only 20% of the patients responded favourably.
Garand, Backwater & Hall, 2000

Evidence has also demonstrated that the behavioural approach (non-pharmacological) has a success rate of about 60%. This, in addition to the known side effects of psychotropic medications in older adults, is why the non-pharmacological approach is preferred to be trialed first.

 

Helpful Resources

Articles on Reserve

The following article(s) are on reserve at the Health Sciences Library, Dickson Building. Contact asklibrary@nshealth.ca for details.

  • Murphy, C.A., Freterm S., Chisholm, T. (2003). The mini-mental status exam: as easy as 1 - 2 - 30. Dal Med Journal, 30 (2).