Managing difficult behaviors in head trauma patients.

How one long-term care facility's staff learned to cope with a major post-acute care challenge

Rehabilitating head trauma patients - and managing their care - presents a particular challenge to the staff of long-term care facilities. Frequently compounding the physical debilitations associated with brain injuries are numerous psychiatric and behavioral handicaps. Of these, reduced attention span, inability to concentrate, poor recall and general confusion are the most frequently encountered, often leading to difficult-to-manage behaviors - indeed, these may be the reasons for head trauma victims being placed in a long-term care facility.

In a sense, this is the classic long-term care admission: Family members have made heroic attempts to care for the patient at home, but the challenges have proven too difficult. After much soul searching and frustration, they are "forced" to place their loved one in a facility where he/she will receive the round-the-clock care they can't provide.

This, of course, transfers the challenges of caring for this individual to facility staff. But, once the patient is admitted, can the facility's staff accurately assess and meet his/her needs? How will they provide individualized care? Who will provide compassion and understanding? What measures will be taken to ensure that the patient's care plan will maximize his/her quality of life and allow him or her to live at the highest functional level?

In truth, dealing with the difficult behaviors of a head trauma victim is more than some long-term care facilities are prepared to address. In general, with the growth of managed care and the increase in early hospital discharges, the acuity level of long-term care has skyrocketed over the past 10 to 15 years, in many instances rising faster than the clinical capabilities of the staff. Add to this the effect of declining reimbursement, and it becomes obvious that many facilities find themselves racing to just keep up with routine tasks, much less care for residents with particularly challenging needs. On top of this, facilities' staff often lack the training needed to handle the patients their facilities must accept in order to survive in today's long-term care market.

As a result, brain-injured patients often are bounced from one facility to another without being appropriately assessed or having their behavioral healthcare needs met. Many facilities admit such patients "seeing only dollar signs," never comprehending what they are getting into or realizing the extent of their responsibility and moral obligation to the resident. They do not consider whether they are equipped to handle the resident's needs, and commonly, after a short and frustrating period, the resident is transferred to another facility and labeled as unmanageable. In this passing-the-buck scenario, it is ultimately the resident who loses.

The following case history highlights the success of Miller Memorial Rehabilitation Center in dealing with a brain-injured resident and the lessons staff there have learned about the challenges and rewards of managing the behaviors of such individuals. This patient's behavior was a challenge from the time of his arrival at the facility, but caring, devotion, ingenuity and teamwork ultimately led to improving his quality of life. Staff members benefited, as well, reaping the rewards of pride, success and accomplishment. This case, in our opinion, shows how long-term care was meant to be, and perhaps can serve as an example to other long-term care facilities that struggle with caring for residents with hard-to-manage behaviors.

Case:

SD is a 41-year-old white male who was admitted to the Miller Memorial Rehabilitation Center from a Pittsburgh area hospital in May 1996. He had experienced severe brain injuries from a fall down a staircase. At the time of his admission, SD was verbally and physically abusive, nondirectable, unmanageable, confused and disoriented. He exhibited explosive, violent outbursts and inappropriate verbal responses, as well as having poor short- and long-term memory. From the start, SD was fixated on leaving the facility and returning to his home in the Pittsburgh area. He also was preoccupied with comments about drug abuse and drug testing, and made frequent references to "Section 8," the specific meaning of which eluded the staff. In addition to his multiple cognitive and behavioral problems, SD suffered from poorly controlled diabetes mellitus, further complicating his health needs.

The first step in improving SD's quality of life involved readjusting his medication regimen. Initial efforts to get his diabetes under control were successful, eliminating one complicating factor. The next step was addressing his psychiatric needs. This was where the staff learned their first lesson in behavioral management: the old adage "more is better" does not always hold true, especially with psychotropic medications.

SD's medication regimen upon admission included no psychotropic medications, as is the case with many head trauma patients with behavioral problems. After several hospital visits for psychotic episodes, SD was put on a drug regimen that included various straight and prn orders for lorazepam (Ativan), chlorpromazine (Thorazine) and risperidone (Risperdal), but he continued to be difficult to manage. Although his diagnosis and assessment indicated that an antipsychotic would be beneficial, SD continued to be frequently agitated, with violent and unpredictable verbal and physical outbursts. His behaviors often endangered him and other residents.

Some course of action needed to be taken - but in what direction?

Continuous observation and careful care planning revealed that the antipsychotics SD received, with their extensive adverse effect profiles, tended to exacerbate his agitation rather than diminishing it. Furthermore, SD was experiencing considerable drowsiness, an effect that seemed most prevalent during daylight hours. Obviously, this did not enhance SD's manageability. In fact, it aggravated his agitated state to the point of combativeness and physical abuse. He was responding to his psychiatric medication regimen in much the same way that a child in need of a nap behaves - agitated or "cranky," to the point of defiance. This was a key point identified by staff.

Once this problem was identified, numerous trials were made with various drug therapy regimens in an attempt to fine-tune SD's therapy. The staff tried reducing the amounts of psychotropic medication SD received, while searching for that elusive point where the benefits of drug therapy would outweigh the risk of adverse effects. Over time, the staff learned to which psychotropics he responded favorably and what dosages were optimal for him.

These pharmacologic interventions, along with a mood-stabilizing agent, gave SD new freedoms. He was now more psychologically stable than at any previous time since his injury. Although he continued to experience confusion, inappropriate responses, disorganized thought and impaired memory, he came to experience fewer periods of agitation, abusive behavior and outbursts of profanity. Nevertheless, another problem remained: SD continued his wandering practices, endangering his own well-being and placing added stress on staff.

In the search for solutions, the staff tried using many standard behavioral management techniques. Initially, attempts were made to reorient SD to his current surroundings, but with little success. He continued to insist, many times daily, that he was leaving the facility and was on his way to Pittsburgh: In response, the staff attempted to make SD feel welcome. They continually reinforced that his current home was at the facility and that he was not permitted to leave.

This course of action proved only to worsen his agitation and make him even more difficult to manage. He did not want to be restricted in his movements or confined to the facility by those he saw as strangers, nor did he want to be told what to do. He continued trying to leave.

At times of limited staffing, this was particularly risky. SD was a resident who needed to be watched constantly for his own safety. This is not always an easy task with wandering residents, and it is not made any easier by local fire code requirements. But had SD left the facility without the staff's knowledge and made it to the nearby highway, the result could have been disastrous.

It was in dealing with this problem that the staff learned their second lesson in managing head trauma patients: Innovative ideas are called for. The staff decided to attempt an alternative approach. They knew, from experience, the manner in which SD responded to conflict, and this observation led to a new idea: Instead of trying to reorient SD to his current surroundings, they began to use validation therapy. Rather than correcting him and stressing that he was now living in Ohio, the staff validated SD's story by going along with it.

As time passed, staff began seeing success with this approach. When SD stated he was going to Pittsburgh and they responded with "Have a nice trip - we'll see you later," or "Okay, but the bus won't be leaving for another hour," he typically replied "OK, see ya!" and walked back down the hallway to his room or to another nurse's station. With this approach over time, SD came to accept his new home, and made a few friends with staff members along the way.

Observation and intervention were also the sources of the third lesson learned by facility start. SD's wandering was particularly a problem during the warm summer months. Like most of us, he wanted to go outside when the weather was nice - but how could staff members keep an eye on him at all times when he was outside?

The decision was made to give a departure alert system (in this case, the WanderGuard) a trial. The wandering resident wears a bracelet with a sensor in it and terminals are installed at all facility exits. When he/she attempts to leave, an alarm sounds to notify staff. In SD's case this proved very effective. In fact, it worked so well that he learned what the sound of the alarm meant. He came to understand that when the alarm sounded, something was wrong, and he would stop right where he was. After this system was used for several months, the staff would respond to the alarm, only to find SD waiting on the other side of the door. As the staff member approached, he would simply comment with a grin, "I was wondering how long it would take you to get here!"

SD became more enjoyable to be around and care for. He was a different person from the one who had entered the facility. He still had episodes of agitation at times and still presented a behavioral management challenge, but much less frequently than before. It is now possible to get SD to smile on most occasions, and there is a pleasant humor about him.

Once SD became more manageable, the staff learned the next lesson in SD's care: Keep him occupied. Since he had experienced significant cognitive impairment, SD was not always able to take part in planned activities within the facility, such as group games. He was able to go outside the facility to play ball occasionally, but what he really seemed to enjoy most was interacting with staff. Realizing this, all departments took it upon themselves to take SD under their wings and help him stay occupied.

It began to be a common sight within the facility to see SD tagging along with staff while they tended to their daily responsibilities. In fact, he was often able to offer some assistance, such as pushing a cart or helping to deliver interoffice memos or mail. He liked being helpful and always looked for some way to be involved. Like most of us, SD simply wanted to be included.

Checking into his background, the facility found that SD had been a very helpful individual prior to his accident. He had enjoyed working odd jobs, which is reflected in his current activities of interest. In fact, SD has grown so accustomed to being involved and having the staff give him something to do, it is now obvious when he's bored. He tends to wander the halls and become slightly agitated and boisterous. But once he's given an activity, he becomes calmer and easier to manage. Even something as simple as taking him for a walk or giving him some papers to carry puts him at ease. Realizing this reinforced our knowledge that identifying sources of agitation is half the battle.

Conclusion

SD's case is just one example of facility staff's success in improving our residents' quality of life. These caregivers have proven that it is possible to rehabilitate residents with head trauma injuries, or at least take the steps that will significantly improve their quality of life over a longer stay. With dedication comes success, through well-thought-out medical and behavioral interventions. In SD's case, he appears to be enjoying himself once again, and with the help of the entire Miller Memorial staff, he has reached his maximum functioning capacity and is living life to the best of his ability.

The more general lesson is that it takes a well-organized team approach to solve behavioral problems. As the old saying goes, "There is no 'I' in team." Every department of a long-term care facility has something to contribute toward rehabilitation and improving residents' quality of life - including the medical director, nursing, administration, consultant pharmacy services, respiratory therapy, dietary, social services, nursing aides, housekeeping and maintenance. based upon our own efforts and subsequent successes, we suggest the following points for anyone dealing with difficult behaviors in brain-injured residents:

1. Perform accurate assessments of the resident's needs.

2. Observe resident behaviors closely and on a daily basis.

3. When observing behaviors, make note of the resident's environment, the time of day, setting, etc.

4. Accurately document findings.

5. Utilize a team problem-solving approach.

6. Include all departments in the solutions.

7. Individualize interventions.

8. Identify and document risk factors for agitation.

9. Remember that persistence will eventually pay off.

10. Always care enough to go the extra mile.

In the case described above, dedication made a difference. And isn't that why we are all here - to make a difference?

Michael P. Slyk, PharmD, FASCP, is president, Pharmacotherapy Associates, Inc., Cortland, OH; Holly Durso, RN, is RN supervisor, Miller Memorial Rehabilitation Center, Andover, OH.