Mrs. B is a 100-year-old white female with a history of dementia, squamous cell carcinoma to the bilateral lower extremities, and venous insufficiency. She is no longer able to verbally express her opinions or desires, although she recognizes familiar faces and engages with others. She requires minimal assistance with transfers and ambulates with a front-wheeled walker. She is resistant and combative with care (usually hitting staff), especially during dressing, bathing, and transferring.
The staff has implemented care-plan interventions, including a known and consistent caregiver to work with her at all times and to reapproach her if she becomes resistant to care. The regular caregiver was working with Mrs. B one morning when she became resistant during the transfer from her bed; she swung at the caregiver, lost her balance, fell, and fractured her hip. Mrs. B underwent an open reduction and internal fixation surgery, and the postoperative course of events was uncomplicated. She was started on an anticoagulant for deep-vein thrombosis prophylaxis and treated with oral acetaminophen at 1,000 mg three times a day for pain. Her other medications include quetiapine, 12.5 mg in the morning and 50 mg in the afternoon, for “nonredirectional dementia.”
During her physical and occupational therapy sessions, Mrs. B is resistant to participation and will pinch and hit the therapists. She can take a few steps and transfer to a chair with the help of two people and verbal cues. Her family is very concerned and upset by her persistent resistance to care and their perception that she seems afraid and anxious. They wonder whether more medication could help her with these symptoms.
Elizabeth Galik, PhD, CRNP
Dr. Galik is a professor at the University of Maryland School of Nursing and a nurse practitioner at the Sheppard Pratt Neuropsychiatry Program. She is also a coeditor in chief of Caring for the Ages.Mrs. B appears to have a moderate to advanced stage of dementia. It may be that her pain level has been exacerbated by the recent fracture and surgery, and this could be interfering with her cooperation with rehabilitation. If the rehabilitative efforts are not deemed to be effective, the team should consider speaking with her family about the option of a palliative care or hospice consult, particularly a program that has dementia expertise.
Mrs. B likely could benefit from all staff employing a comfort care approach and using sensory activities to engage her as well as make her care easier. For example, she may find lavender scents calming, and soft music and small bites of chocolate also could be used to help soothe her anger, frustration, and agitation. Sponge baths and no rinse soap also could be used, taking care to keep her covered with large towels or a towel-poncho to help her feel less vulnerable. Also consider trying massage techniques to minimize her distress. To facilitate easier dressing, keep her clothes loose, simple, and comfortable; ask her family to purchase items that have buttons or Velcro to simplify and expedite her dressing.
Should the nonpharmacological approaches to care be unsuccessful, and if she tolerates the quetiapine well and it has resulted in some reduction in her physically aggressive behaviors, the next step may be to discuss an increase in dosage with the medical provider. If the quetiapine has been ineffective in treating her physically aggressive behaviors or has been poorly tolerated, then treatment with a selective serotonin uptake inhibitor such as citalopram could be considered.
Robin Ingram, GNA
Ms. Ingram is a geriatric nursing assistant at Roland Park Place in Baltimore, MD.
From a nursing perspective, we would make sure that Mrs. B has the same caregivers as often as possible and that they are individuals that she has seemed to be the most comfortable with. We would talk with her before providing any hands-on care about the things she enjoys to help engage her in the interaction. This requires having the nursing staff sit on her bed, hold her hand, and just talk. If Mrs. B still seems to be resistant to care, we would simply reschedule her bathing and dressing and attempt her care at another time.
Bathing would focus on minimizing her discomfort: making the room warm, using pleasant-smelling bath products, and engaging her in the bathing activities through role modeling — showing her how to wash her face, for example. We believe it is helpful to have her do as much as she can herself both to maintain her function and to help her feel less vulnerable.
During the day we would take Mrs. B to activities, particularly the activities that she enjoys. In addition, we would give her an afternoon/early evening rest period before dinner to avoid agitation and excessive fatigue. For transfers, we would give her time to adjust to the individual(s) working with her and then initiate the transfer.
Tonya Haynes, MSPT
Ms. Haynes holds a master’s degree from Thomas Jefferson University and has 24 years of experience as a physical therapist working with the geriatric population. She is the director of rehabilitation at Mountain View Care Center in Tucson, AZ.
Therapists would continue to work with Mrs. B. as she allows. We would schedule treatment sessions after she has received her pain medication in order to maximize her ability to participate. Many times a resident is resistant to therapy because of feeling pain but cannot express the discomfort verbally. Scheduling therapy sessions with a consistent therapist as well as with a favorite or known caregiver might also facilitate Mrs. B’s participation. Perhaps getting her family involved in the therapy sessions also could help. For residents with communication difficulty such as Mrs. B, the therapy should be focused on functional tasks — movements that are familiar and easier — in conjunction with tactile and visual cues to assist with communication.
Conduct a thorough assessment that incorporates a trauma-informed and strengths-based approach to identify the possible reasons for and precipitators of Mrs. B’s expressions of distress.
Ross Brantner, OTR/L
Mr. Brantner has worked in skilled nursing and long-term care for over five years. He currently manages the rehab department in a skilled nursing facility in Tucson, AZ.
Mrs. B. appears to be moving into the late stage of dementia. In light of her recent injury, it is critical that the team implements an approach that will facilitate her tolerance for engagement in therapeutic interventions. Otherwise, her current diminished level of function is unlikely to improve.
To maintain Mrs. B’s engagement, managing her expressions of distress will be essential. One of the primary characteristics of a person in Mrs. B’s situation is difficulty assimilating the new information she needs to function successfully in an unfamiliar situation. If the team can modify her therapeutic interventions (such as gait training, therapeutic exercise, or transfer training) in such a way as to make them appear to be part of a meaningful, familiar activity for her, the likelihood of her active participation in those interventions will increase exponentially. In short, the unfamiliar must become familiar.
One way to promote familiarity is to link her therapy sessions to something she is interested in doing. For example, Mrs. B probably won’t want to sit at the edge of a mat table, performing repetition after repetition of abdominal contractions to increase her core strength. If, however, she is sitting in a chair, reaching for pictures of family members, and placing them in an album, she is more likely to tolerate the activity, and it will produce the same physiological result.
The occupational therapist should also help train her other caregivers, help in establishing her routines, and adapt her environment to make her activities of daily living and transfers safer and less burdensome for her caregivers.
Melvin Hector, MD, FAAFP, CAQ Geriatrics, CMD
Dr. Hector is a Tucson-based physician with over 30 years of medical director experience.
As the medical director, I only have a few concerns, but they are interesting, common issues. Mrs. B was ambulatory before, and the assumption has been made that she would like to preserve that option — thus, her surgery. I would discourage the use of antipsychotics with Mrs. B: not only do the data show them to be of no use in treating the condition for which they are being prescribed, but they can be deleterious to the health of patients such as Mrs. B.
I would ask, What is the intent of physical therapy and occupational therapy at this juncture? What are realistic goals for this 100-year-old woman? Palliative treatment of her injury might simply be, to coin a term, PTAT (physical therapy as tolerated). If she is telling us by her “resistance” it is not tolerated, then we don’t do it — we wait until it is. (If it hurts when you do that, don’t do that, right?) When the therapy hurts her less, we can ease into gradually doing more, and accept what life and her tolerance allow us as the eventual best outcome.
This approach, of course, flies in the face of documenting progress in order to justify reimbursement, but perhaps “recovery days” can be allowed before the “work days” begin in earnest.
Michele Bellantoni, MD, CMD
Dr. Bellantoni is an associate professor in the Department of Medicine at the Johns Hopkins University School of Medicine. She is also the clinical director of the Division of Geriatric Medicine and Gerontology, and medical director of the Specialty Hospital Programs at Johns Hopkins Bayview Medical Center.
Anxiety is a common behavioral disturbance associated with dementia. The recent fall, hip fracture, and hospitalization have understandably contributed to Mrs. B’s new anxiety. Reassurance and cognitive behavioral therapies — first approaches for older adults — may not be effective in her setting of moderate dementia. Anxiolytic medication is appropriate. I would begin with a selective serotonin reuptake inhibitor with the least anticholinergic effect: citalopram, escitalopram, or sertraline. If her appetite or sleep are disordered, I would consider mirtazapine. I would monitor her closely for the common adverse effects of hyponatremia, constipation, and confusion.
Director of Nursing
Judi Kulus, MSN, MAT, RN, NHA, RAC-MT, DNS-CT
Ms. Kulus has been a certified AANAC RAC-CT Master Teacher since 2004 and currently serves as the vice president of curriculum development for AANAC and AADNS where she oversees and coordinates the associations’ certification and educational content.
From the nursing perspective, I recommend the following actions:
Before increasing Mrs. B’s antipsychotic medication, it is critical to work with the physician and family to rule out other causes of Mrs. B’s distress (manifesting as hitting, fear, and anxiety). Pain, trauma, or caregiver interactions may be contributing to her unease or inadvertently violating her choices/preferences. Are there opportunities for in-the-moment coaching? We would consider involving her family during her care sessions to work collaboratively to provide care in a way that mitigates Mrs. B’s fear and anxiety. We would engage the staff and family in discussions to determine any possible underlying reasons for her indicators of distress. One useful technique is to ask “Why?” multiple times to help uncover the possible reasons for her reactions.
We also would assess Mrs. B for pain and maximize her pain management, especially if pain is a barrier to her participation in her care and therapy. Also we would assess the other factors that could be influencing her resistance to care: sleep hygiene, hunger or thirst, the time of therapy in the resident’s daily schedule, and so on. We would evaluate the past 24 to 48 hours to determine whether there have been other variables contributing to her indicators of distress — such as hunger, constipation, a change in her schedule, or a chaotic environment.
From a regulatory perspective, the staff and providers are expected to help each individual attain and maintain her highest physical, mental, and psychosocial well-being. However, there is no requirement that the facility or provider must agree to specific medical interventions or treatments requested by the resident, family, or resident’s representative if the provider believes the request is inappropriate relative to the resident’s condition.
Increasing a psychotropic medication may not be the best option, and the provider and pharmacist should be in communication. Should they decide to initiate a trial increase for Mrs. B, her family must be informed of the potential negative side effects, such as restlessness, shakiness, mood changes, swallowing difficulty, constipation, nausea, vomiting, and poor appetite. There should be a clearly defined plan to reevaluate her situation to determine whether the medication has been efficacious and whether the family is willing to continue it, given the potential side effects.
Nicole Brandt, PharmD, MBA
Dr. Brandt is a professor and the executive director of the Lamy Center on Drug Therapy and Aging at the University of Maryland School of Pharmacy.
I would recommend a comprehensive assessment of the efficacy of the antipsychotic and whether it has decreased Mrs. B’s target symptoms of aggression toward the staff. Other potential reasons for Mrs. B’s demonstrated aggression toward the staff also should be investigated.
Mechanistically, quetiapine involves the antagonism of multiple receptors, two of which include histamine-1 receptors and alpha-1 adrenergic receptors. The antagonism of alpha-1 adrenergic receptors and histamine-1-receptors may result in orthostatic hypotension and drowsiness, respectively. In fact, according to a systematic review of the available literature on the tolerability and safety of quetiapine, both orthostatic hypotension and somnolence were the two of the common adverse effects experienced among older adults taking the drug (J Clin Pharm Ther 2016;41:7–18). Either of these adverse effects — or a combination of them — can increase the risk of falls in older adults.
Antipsychotic use has been shown to increase the risk of deep-vein thrombosis, pulmonary embolism, stroke, and hip fracture (Neurol Ther 2017;6:57–77); the risk of hip fracture may even be higher in older adults without dementia (BMC Geriatr 2016;16:204). Antipsychotic use also has been shown to be associated with long-term care dependence and nursing home admissions (J Gerontol A Biol Sci Med Sci 2018;73:1396–1402). Additionally, there is the possibility that randomized controlled trials have been overestimating the efficacy of antipsychotics while underestimating the risk of extrapyramidal symptoms due to the trials’ imbalances in baseline characteristics (Int J Methods Psychiatr Res 2018:e1757). This notion is further highlighted by a recent network meta-analysis that suggested atypical antipsychotics offer only a modest benefit over placebo but are associated with significant safety risks (JAMA Netw Open 2019;2:e190828).
If Mrs. B is past 35 postoperative days, I recommend discontinuing the anticoagulant for deep-vein thrombosis prophylaxis, given the risk of falls and bleeding (EFORT Open Rev 2018;3:136–148). Mrs. B also should be assessed to determine whether her pain is being adequately managed with the acetaminophen or if additional pharmacologic or nonpharmacologic modalities should be explored.
Paige Hector, LMSW
Ms. Hector has over 25 years’ experience in post-acute and long-term care settings as a social worker and clinical educator.
From a social work perspective, I would facilitate advance care planning discussions with the family to identify their goals of care and identify strategies to enhance Mrs. B’s quality of life. I would ascertain the family’s level of understanding about the disease progression of dementia, especially in light of Mrs. B’s recent hip fracture.
I would try to learn more about Mrs. B as a person, not as a diagnosis. I would ask her family questions such as “What was important to her?” “How did she occupy her time?” “How did she display frustration? And if she was upset, how did she soothe herself?” “What gave her life meaning before she moved into the facility and before she experienced dementia?” Shifting from “What’s the matter with our patients?” to “What matters to our patients?” demonstrates our movement toward person-centered care (HealthAffairs
, Jan. 24, 2012; http://bit.ly/31ZAcbM
Emphasizing a strengths perspective, no matter the diagnoses or situation, is paramount. Consider questions such as “What makes a good day for her?” and “What kinds of things did she used to do well?” with a goal of replicating those in a modified and meaningful way. I would engage staff and family in discussion to figure out what Mrs. B. is capable of, and I would try to shift the focus to her abilities instead of her limitations. I would make sure that her care plan emphasizes positive goals that maximize her quality of life — such as displaying signs of pleasure in life, receptivity to touch, smiling, and engaging in her own care — rather than traditional goals such as “frequency of hitting will be reduced.”
Recognize the importance of an interdisciplinary approach by combining each discipline’s unique perspective in a balanced set of recommendations.
Conduct a thorough assessment that incorporates a trauma-informed and strengths-based approach to identify the possible reasons for and precipitators of Mrs. B’s expressions of distress. Identify her unmet needs and welcome creative ideas for the staff to meet those needs. Involve her family at all junctures so they feel ownership of the plan of care and are supportive of the staff’s efforts to take wonderful care of Mrs. B.
Ensure that a comprehensive assessment informs the person-centered care plan and that the staff consistently carry out Mrs. B’s interventions.
Approach changes in antipsychotic medications conservatively and incorporate a risk/benefit analysis before making any changes.
Engage in frequent advance care planning discussions with Mrs. B’s family to identify goals and expectations as well as opportunities to provide additional information regarding disease progression and a realistic prognosis.
Regarding Mrs. B’s expressions of distress, I would like to see more emphasis on the assessment aspect and the incorporation a trauma-informed perspective. Did something happen in her past that is informing her current situation? Investigating the underlying cause of a symptom such as aggression or resistance is key (Greenwald, Social Work Policies, Procedures and Guidelines for Long-Term Care [Glenview, IL: SWCG, 2002]). Often when an individual demonstrates agitation, anxiety, or aggression, it is helpful to determine if there is an unmet need that, if met, may minimize the symptom and allow the individual to become more settled and more comfortable. What is the unmet need for Mrs. B at this point in time? Is she trying, in her own way, to be understood, to be cared for, to be involved, or to be safe? She might hit at staff because of a perception of danger, despite their displays of kindness and compassion.
Also consider the opposite point of view by asking, “When is the problem not happening?” So often in health care we are problem focused, so we miss opportunities to maximize desirable interactions because we only “see” the undesirable. If Mrs. B is more engaged and cooperative with the staff at certain times of the day, what is happening differently at those times? Can we replicate those circumstances?
This is also a wonderful opportunity to get her family involved right alongside staff as everyone works hard to figure out the best, most compassionate ways to work with Mrs. B. I would encourage frequent updates (in person and via phone) to the family, especially with positive news. Mostly families receive phone calls only when something unwanted or undesirable has occurred, not something positive. Surprise them!
The interdisciplinary team came up with some very helpful suggestions and approaches. Although there were contradictions, such is the value of an interdisciplinary approach: everyone’s opinion is heard, and then the team creates a plan of care with the voice of the resident leading the way. The overall theme was to avoid the use of medications, particularly antipsychotics, and to focus on identifying the underlying cause(s) for Mrs. B’s indicators of distress and implement therapeutic interventions. The cost/benefit analysis of medications, particularly antipsychotics, provided strong support to avoid these medications.
The team contributed to a comprehensive assessment that included asking the important question, “When is the problem not happening?” Different options were presented in terms of a rehabilitative focus versus a palliative care or even hospice approach, with emphasis on collaborating with her family. The staff maximized her pain management, especially before and during therapy, and used innovative approaches to engage Mrs. B in her therapy by focusing on familiar and meaningful activities. The nursing staff engaged her in personal care by maintaining consistent caregivers, role modeling, establishing rapport before initiating care, and using calming interventions during bathing. The staff also maintained regular communication with her family, including calling them with good news.
Dr. Resnick is the Sonya Ziporkin Gershowitz Chair in Gerontology at the University of Maryland School of Nursing in Baltimore. She is also a member of the Editorial Advisory Board for Caring for the Ages.
Ms. Hector is a clinical educator and professional speaker specializing in clinical operations for the interdisciplinary team, process improvement and statistical theory, risk management, and end-of-life and palliative care, among other topics. She is a member of the Editorial Advisory Board for Caring for the Ages. She is passionate about nursing homes and supporting staff to care for the most vulnerable people in their communities.