3/20/2019
Mental Health Disorders: Strategies for Approach & Treatment Transform 2019: OPTA Annual Conference Columbus, Ohio April 6th, 2019
Dawn Bookshar, PT, DPT, GCS Ian Kilbride, PT Marcia Zeiger, OTRL
Objectives
Participants will:
• Understand the prevalence and impact of mental health disorders in client populations • Understand clinical conditions, and associated characteristics of common mental health diagnoses • Apply effective treatment approaches for clients with mental illness. • Produce effective clinical documentation to support intervention for clients with mental illness
Mental Illness (MI)
www.schizophrenia.com
1 3/20/2019
Mental Illness (MI)
The term mental illness refers collectively to all diagnosable mental disorders defined as sustained abnormal alterations in thinking, mood, or behavior associated with distress and impaired functioning which substantially interferes with or limits one or more major life activities.
National Institute of Mental Health
Prevalence of MI
• More than 50% will be diagnosed with a mental illness or disorder at some point in their lifetime. • 1 in 5 Americans will experience a mental illness in a given year. • 1 in 25 Americans lives with a serious mental illness, such as schizophrenia, bipolar disorder, or major depression.
Centers for Disease Control & Prevention
Prevalence of MI in LTC
• 2/3 of people in nursing homes have a mental illness. • Nursing home residents with a primary diagnosis of mental illness range from 18.7% among those aged 65-74 years to 23.5% among those aged 85+ years. • Dementia, Alzheimer disease, and mood disorders are the most common diagnoses of mental illness in long-term care settings.
Centers for Disease Control & Prevention
2 3/20/2019
Prevalence of MI in LTC Ohio
• Residents with a diagnosis of schizophrenia and bipolar disorder increased from 9% to 16% between 2001 to 2016. • Ohio’s long-stay Medicaid population with a severe mental illness: o 47.5% age 0-64 o 26% age 65+
Shaping of Long Term Care in America Project at Brown University; Scripps Gerontology Center at Miami University
Complicating Psychosocial Factors
• Homelessness o 30% of people experiencing chronic homelessness have a serious mental illness o Up to 2/3 may have a substance use disorder o 48% have a history of mental illness o Different set of life skills: meaning to the individual
Complicating Psychosocial Factors
• Substance Use/Abuse o 260 million o Often co-occurs with mental health disorders o Prolonged substance abuse permanently alters activation of the brain
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Definition of Behavior
• The manner of conducting oneself • Anything that an organism does involving action & response to stimulation • The response of an individual to its environment • The way in which something functions or operates
Merriam-webster.com
Definition of Behavior
• Behavior to the actions or reactions of an object or organism, usually in relation to the environment. • Behavior can be: o Conscious or Unconscious o Voluntary or Involuntary
Maladaptive Behavior
The actions or reactions of persons in response to external or internal stimuli that is considered noxious to staff, other residents, the resident himself, or family.
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Maladaptive Behavior
• Inhibit a person’s ability to adjust to particular situations or are inappropriate or disruptive in nature. • Used to reduce one’s anxiety related to their perceptions of the situation, but the result is dysfunctional and non-productive. • Not a synonym for bad behavior, rather, it is behavior that is inadequate, inappropriate or excessive in a given situation.
Maladaptive Behavior
• Staff intervene more when: o Physical behaviors are directed towards self or others o Offensive verbalizations are directed towards others
• Staff intervene less when: o The resident talks all the time but never raises their voice o The resident sleeps too much o The resident is too weak to hurt anyone when they are aggressive
Understanding the Maladaptive Behavior
• What is the behavior? • When is it occurring? • Where is it occurring? • What happens before the behavior? VS • What happens as a result of the behavior?
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Causes of Maladaptive Behavior
Internal Triggers External Triggers • Emotion (despair, anxiety, fear) • Lack of meaningful activity • Medication • Unpleasant events or actions of • Illness (physical or mental) others • Confusion • Demands of others • Pain or discomfort • Too bright or too dim lighting • Lifelong perceptions • Too much noise • Being misunderstood by others
Common Behaviors
• Aggression • Anxiety • Confusion • Mania • Manipulation (self injurious or suicidal) • Psychotic (hallucinations and delusions)
Aggression
Definition: a forceful, attacking action which may be physical, verbal, or symbolic.
• Manifested behaviors: o Violence toward self, others, and/or property o Inability to control inappropriate behavior o Anxiety o Hostility o Hyperactivity o Restlessness o Decreased attention span o Impulsive and quick to escalate
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Anxiety
Definition: a state in which an individual feels vague discomfort, nervousness, restlessness, dread, helplessness, and self doubt, in response to a perceived threat to their physical, emotional, or social security • Manifested behaviors o Shortness of breath o Insomnia o Heart palpitations Rigidity o Chest pressure o o Pacing and rocking o Choking sensation o Localized sweating o Nausea o Weakness o Rapid breathing o Paranoia and confusion o Increase in blood pressure
Confusion
Definition: a mental state characterized by a lack of clear and orderly thought and behavior. • Manifested behaviors o Memory deficits o Disruptive behavior o Failure to perform ADL o Restlessness or anxiety o Combativeness or belligerence o Rambling speech and confabulation o Disorientation (person, place, time, or situation)
Mania
Definition: extreme sense of excitement and euphoria with a loss of reality testing. • Manifested behaviors o Hyperactivity and excessive involvement in activities without thought of consequence, o Pressured speech, tangential thoughts, o Inflated self-esteem, o Decreased need for sleep or food, o Distractibility, o Impulsivity
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Manipulation
Definition: the process of influencing others or the environment by passive or aggressive behavior in order to meet one’s own needs and desires. • Manifested behaviors o Threatening or actual harm to self or others o Drug seeking /substance Abuse o Impulsive and destructive o Lack of respect o Passive or refusal o Exaggerated self confidence, seductive
Psychotic Behaviors
Definition: characterized by a distorted or diminished sense of objective reality (delusions and hallucinations), psychomotor dysfunction, a radical change in personality, and impaired functioning.
• Manifested behaviors o Flat affect o Loose associations o Depersonalization o Loss of interest in self care o Disorganized thoughts and speech o Poor impulse control and poor judgment o Suicidal or homicidal behavior (thoughts or actions)
Selected Assessment Tools
• Allen Cognitive Levels • SLUMS* • Global Deterioration Scale • PSFS* • Agitated Behavior Scale* • BCAT • Geriatric Depression Scale* • PainAD • Apathy Evaluation Scale* • DS-DAT
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Common Mental Health Conditions
Schizophrenia, Bipolar Disorder, Anxiety Disorders Depression, Dementia, Delirium
Levels of Brain Activation
http://learn.genetics.utah.edu/content/neuroscience/brainimaging
Schizophrenia
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Schizophrenia: Symptoms Impacting Function
Positive Symptoms • Hallucinations o Visual, auditory, tactile, olfactory, gustatory. o "Voices" are the most common type of hallucination. • Delusions o False beliefs that are not part of the person's culture and do not change. o The person believes delusions even after other people prove that the beliefs are not true or logical. • Thought Disorders Unusual or dysfunctional thinking o Disorganized thinking o Thought blocking o Neologisms (new, meaningless words)
Schizophrenia: Symptoms Impacting Function
Negative Symptoms • Flat affect (emotions, feelings) • Lack of pleasure in everyday life • Lack of ability to begin and sustain planned activities • Speaking little, even when forced to interact. Cognitive Symptoms • Poor executive function (problem solving everyday tasks) • Trouble focusing or paying attention • Problems with memory
Schizophrenia: Medication
• Drowsiness • Skin rashes • Dizziness when changing • Rigidity positions • Persistent muscle spasms • Blurred vision • Tremors • Rapid heartbeat • Restlessness • Sensitivity to the sun
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Schizophrenia: Rehab Challenges
• Sensory Disruption: visual, tactile, olfactory, auditory, gustatory • Cognitive Deficits: attention, concentration, communication, information processing, learning • Physical Impairment: uncomfortable sensations, vestibular impairment, vision impairment, fatigue • Psychosocial Impairment: anxiety/fear, anhedonia, distrust, no meaning/purpose, difficulty performing daily self-care
Schizophrenia: Intervention Strategies
• Build trust and rapport • Engage in meaningful, • Reduce distractions of positive purposeful, concrete activity symptoms • Be mindful of the environment • Present information simply and and alter as needed concisely • Consider minimizing sensory • Use patience and unconditional input support (empathy) • Consider progressive activities: from in room to more public areas
Schizophrenia Research: Benefits of PT Intervention
• Aerobic exercise, strength training, and yoga reduce psychiatric symptoms, anxiety, and psychological distress.
• Aerobic exercise reduces negative and positive symptomatology and alleviates secondary symptoms
• Improves overall fitness and cardiopulmonary health.
(Vancampfort, 2012)
11 3/20/2019
Depression
Depression: Symptoms Impacting Function
• Persistent sad, anxious, or "empty" • Difficulty concentrating feelings remembering details, making • Feelings of hopelessness or decisions, pessimism, guilt, worthlessness, or • Insomnia, early-morning helplessness wakefulness, or excessive sleeping • Irritability, restlessness • Overeating, or appetite loss • Loss of interest in activities or • Aches or pains, headaches, cramps, hobbies once pleasurable or digestive problems that do not • Fatigue and decreased energy ease even with treatment.
Depression: Medication
Tricyclic SSRI • Dry mouth • Headache • Constipation • Nausea • Bladder problems • Nervousness • Blurred vision • Insomnia • Dizziness • Agitation/jittery • Drowsiness • Falls Risk • Increased heart rate
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Depression: Intervention Strategies
• Offer emotional support, • Encourage gradual activity and understanding, patience, and exercise once enjoyed encouragement • Break large activities into smaller • Talk to him or her, and listen ones carefully • Encourage the patient to make • Never dismiss feelings, but point choices and set priorities out realities and offer hope and • Try to facilitate spending time options with other people • Never ignore comments about • Offer activities as an ‘escape’ suicide option
Depression Research: Benefits of PT Intervention
• Evidence supports exercise as a front line treatment or to supplement conventional psychotherapy and pharmacological. o Small to moderate effective of exercise in reduction of symptoms. • General recommendations o 30-60 min day; 3-5 times week o 10-16 weeks o 60-80% HR max
(Trinh et. al., 2017)
Depression Research: Benefits of PT Intervention
• Those with depression and schizophrenia are less likely to stop exercising when supported by physical therapy. (World Confederation of PT)
• Exercise Is associated with a reduction in depressive symptoms compared with other approaches. (Cooney et. al., 2014)
• Exercise beneficial in reducing mortality and treatment of symptoms in major depression. (Murri et. al., 2019)
13 3/20/2019
Bipolar Disorder
Bipolar Disorder: Symptoms Impacting Function Mood Changes Manic Depressive • A long period of feeling ‘high’, or • An overly long period of feeling an overly happy or outgoing sad or hopeless. mood. • Loss of interest in activities once • Extreme irritability enjoyed.
Bipolar Disorder: Symptoms Impacting Function Behavioral Changes Manic Depressive • Talking very fast, jumping from one idea to • Feeling tired or ‘slowed down’ another, racing thoughts. • Problems concentrating, remembering, • Easily distracted and making decisions. • Increasing activities • Restless or irritable • Overly restless • Change in eating, sleeping, or other • Sleeping little habits. • Unrealistic belief in one’s abilities • Thinking of death or suicide or • Impulsivity and engaging in pleasurable, attempting suicide. high-risk behavior
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Bipolar: Medication
• Diarrhea • Dizziness. • Drowsiness • Headache. • Muscle weakness • Diarrhea, constipation. • Cognitive Impairment • Nausea, bloating or indigestion. • Slurred speech • Blurred vision. • Extrapyramidal symptoms • Rapid heartbeat. • Obesity • Skin rash.
Bipolar Disorder: Intervention Strategies
• Break up large tasks into small ones • Encourage the patient to make choices and set priorities • Encourage a consistent, regular routine or schedule • Promote exercise • Provide pleasurable, meaningful activities • Recommend journaling to track moods, identify triggers
Bipolar Research: Benefits of PT Intervention
• Interventions may impact the conditions associated with the diagnosis and side effects of medications. (Bauer et. al., 2015)
• Exercise may be ‘double edge sword’ for those with bipolar disorder. • Regular exercise may lead to improved sleep patterns. • Exercise with a rhythm or cadence may provide a somewhat calming effect. (Thomson, Turner et. al., 2015)
15 3/20/2019
Anxiety Disorders
• Post-traumatic stress disorder (PTSD) • Obsessive-compulsive disorder • Panic disorder • Social phobia • Generalized Anxiety Disorder
Anxiety Disorders: Symptoms Impacting Function
• Cannot relax • Startles easily • Difficulty concentrating • Trouble falling asleep/staying asleep • May have difficulty swallowing • Irritability • May exhibit sweating, nausea • May complain of lightheadedness • May have to go to the bathroom frequently • Complains of feeling out of breath, and having hot flashes • Experiences fatigue, headaches, muscle tension, muscle aches
Anxiety: Medication
• Drowsiness • Loss of coordination • Fatigue • Mental slowing • Confusion
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Anxiety Disorders: Intervention Strategies
• Calm, supportive approach • Use aerobic exercise • Listen to concerns • Foster choices, empowerment, • Select environments that reduce sense of control anxiety, minimize exposure to • Train in therapeutic breath triggers • Explore stress management techniques
Anxiety Research: Benefits of PT Intervention
• 6 week aerobic and anaerobic program shown to reduce anxiety and irritability • Aerobic and anaerobic exercise similarly effective as cognitive- behavioral therapy • Aerobic and anaerobic more effective than other anxiety reducing activities • Positive effects of aerobic exercise on PTSD symptom severity and associated depressive and anxious symptoms
(Zschucke et. al., 2013)
Dementia
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Dementia: Symptoms Impacting Function
• Paranoia • Sundowning • Delusions • Anger/agitation • Hallucinations • Rummaging • Wandering • Changes in personality • Catastrophic reactions • Repetitive questions or actions • Incontinence • Incorrect or inaccurate statements
Dementia: Medication
• donepezil (Aricept) • rivastigmine (Exelon) • galantamine (Razadyne) • memantine (Namenda)
Dementia: Intervention Strategies
• Modify the environment, • Ensure safety, including the focusing on maximizing stability provision of safe places for • Ensure that caregivers use a behaviors to occur consistent approach that is in • Have several diversional activities line with the patient’s abilities available (food, music, activity) • Utilize active listening
18 3/20/2019
Dementia Research: Benefits of PT Intervention
• Moderate intensity physical exercise improves memory, attention and executive function. (Kirk-Sanchez and McGough, 2014)
• Exercise promotes neuroplasticity in the hippocampus. (Karim and Kneiss, 2017)
• Following 6-12 months of structured exercise programming, improved cognitive scores observed. (Ahskog et. al., 2011)
• Aerobic exercise demonstrated a significant improvement in memory and executive function. (multiple sources)
Delirium
Delirium: Symptoms Impacting Function
• Memory deficit • Confusion • Disorientation • Fluctuating awareness • Language disturbance • Hallucinations • Perceptual disturbance
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Delirium: Intervention Strategies
Eliminate or minimize risk factors Provide a therapeutic environment • Prevent dehydration (offer H2O • Reassure & reorient patient in therapy) (unless pt. becomes agitated) • Provide adequate pain control • Communicate clearly and explain • Monitor vitals to maximize all activities oxygen delivery • Provide appropriate sensory • Use sensory aids as appropriate stimulation
Depression, Dementia, & Delirium
Characteristic Depression Dementia Delirium Onset Rapid mental decline Gradual Abrupt
Disorientation Oriented Late Early Disease state Chronic illness Acute illness Variability More stable More stable Moment to moment
Sleep wake cycle Difficulty falling asleep or Disturbed with day-night Disturbed, variable staying asleep, reversal, not as variable oversleeping
Hallucinations Rare Late Common early Level of Consciousness N/A No change until late stage Altered
Psychomotor changes Slowed movement Hyper or hypo late Hyper or hypo early
Additional Considerations
• Nonverbal Behavior o Personal Space ▪ Where you feel comfortable in relationship to the resident ▪ Respect the resident’s personal space needs ▪ Announce when and why you need to invade an individual's personal space o Body Language ▪ Facial, eye contact, stance, arms crossed, standing over a resident ▪ Gestures
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Additional Considerations
• Paraverbal Behavior (how we say what we say) o Tone (inflection, emphasis, bored, annoyed attitude) o Volume (too loud, too soft) o Speed (rushed, slow, angry)
• “I didn’t say you were wrong.” (Implying it wasn’t me) • “I didn’t say you were wrong.” (Implying I communicated it in another way) • “I didn’t say you were wrong.” (Implying I said something else)
Additional Considerations
• Setting & Environment o The conditions of an environment can have a significant impact on behavior. ▪ Keep it simple ▪ Organize the activity setting ▪ Carefully plan your approach to increase opportunities for successful participation and decrease the chances of a behavioral episode.
Additional Considerations
• One of the most important things to remember is, you are PART of the caregiving team • Recognize that an approach that works for one resident may not work for another who exhibits the same behavior • Be aware of your environment to assure safety for yourself, your resident, and others • It is vital that you build a rapport with the resident, otherwise your interaction may not result in the desired outcomes
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Additional Techniques
Validation Grounding Therapeutic Breath De-escalation
Validation
• Be present • Provide an accurate reflection with acceptance • Summarize findings
Grounding
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Grounding: 5-4-3-2-1
5: Vision 4: Touch 3: Hearing 2: Smell 1: Taste
Therapeutic Breath
1. Breathe in for 4 seconds 2. Hold your breath for 7 seconds 3. Exhale breath for 8 seconds 4. Repeat once or twice more
This can help reduce the ‘fight or flight’ reaction
De-escalation
• Listen – don’t judge • Respect personal space • Body language • Stay calm and rationale • Avoid challenging questions • Set limits
23 3/20/2019
Skilled Documentation
Documentation
• Affect • Flight of Ideas • Aggression • Grandiosity • Agitation • Hallucinations • Anxiety • Impulsiveness • Attention to task • Manipulation • Avoidance • Motivation • Compliance • Phobias • Compulsiveness • Poor Insight • Confusion • Self-esteem • Delusion • Withdrawn • Disorientation
Sample Goals
• Patient will demonstrate increased participation in functional transfers, evidenced by score of 28 in Agitated Behavior Scale, to increase safety of patient and caregiver in completion of functional tasks.
• Patient will complete functional ambulation using rolling walker with supervision visual cues in environment to increase sequencing and safety in task completion.
• Patient will identify unsafe household situations with 75% accuracy with min verbal cuing to increase safety in functional mobility and ambulation within her home.
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Daily Documentation
Describe behaviors and resulting techniques/approaches to intervention • Behaviors may include: apathy, hopelessness, paranoia, delusions, hallucinations, anxiety, racing thoughts/poor attention/focus/concentration, fearfulness, • Techniques may include strategies to orient, redirect, calm, increase alertness, reduce anxiety, build trust, determine most therapeutic environment or intervention
Negative vs Positive Documentation
Barriers to gaining any further Resident requiring maximal encouragement for safety during improvement include lack of functional tasks. Res tends to be challenged by poor insight motivation, lack of initiation, into deficits, and sitting abruptly during standing tasks not performing to max capable without regard for own safety or caregiver safety. Needs level, quitting abruptly during mod encouragement to participate fully in treatment due to gait activities. STM deficits and Allen’s level of 3 which is defined as …..
Barriers include impaired Resident is challenged by decrease in cognition including cognitive skills. alertness, attention and initiation, however with sensory stimulation and tactile facilitation techniques, is able to participate with therapy.
Pt shows little motivation during Pt requires mod encouragement to attend to task due to treatment. internal distractions.
Negative vs Positive Documentation Pt refusing to get OOB on a Pt exhibiting challenges with consistency in OOB due to regular basis. fatigue and decreased insight into limitations/purpose of therapy, needs max encouragement for consistent participation in treatment however with education will participate. Demonstrates minimal carry Pt demonstrating minimal carry over with current skills; will over. modify techniques and incorporate more of pt learning style to increase carry over of techniques.
Pt hitting, kicking, spitting. Pt displaying aggressive behaviors including verbal and physical outbursts during tx, redirected thru multimodal sensory techniques to allow participation with tasks.
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Sample Daily Note
Upon initiation of treatment session, patient demonstrated significant agitation and paranoia due to schizophrenia. Pt could not initially engage in skilled intervention, and required redirection and orienting techniques. Progressive sensory regulation principles were applied, with success as patient demonstrated reduced agitation and then tolerated focused intervention addressing bed mobility and sit- to-stand and stand-pivot transfers with mod vc and min assist.
Sample Daily Note
Due to patient’s depressed affect, decreased alertness and significant fatigue, significant treatment time was spent using sensory and neuro-reed techniques to increase stimulation and response, and in observation to determine most therapeutic environment/ intervention to facilitate engagement in treatment.
Pt responded best to casual personal conversation to initiate session, olfactory and tactile stimulation to regulate sensory response, and time to build rapport prior to initiation of gait training.
Takeaways
Complexity of Behaviors My Behavior My Skills
26 3/20/2019
THANK QUESTIONS? YOU!
27 Mental Health Disorders: Strategies for Approach & Treatment
Reference List
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Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, Waugh FR, McMurdo M, Mead GE. Exercise for depression. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD004366. DOI: 10.1002/14651858.CD004366.pub6
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Runnels p. Recent Advances in the Treatment of Schizophrenia: Increasing Adherence to Improve Outcomes. Journal of Managed Care Medicine. 2016; 21:49-52. Thomson D, Turner A, Lauder S, et al. A brief review of exercise, bipolar disorder, and mechanistic pathways. Front Psychol. 2015;6:147. Published 2015 Mar 4. doi:10.3389/fpsyg.2015.00147
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Zschucke E, Gaudlitz K, Ströhle A. Exercise and physical activity in mental disorders: clinical and experimental evidence. J Prev Med Public Health. 2013;46 Suppl 1(Suppl 1):S12-21
Websites:
ACN Latitudes (Sample Behavior Charts and Behavior Contract) - www.latitudes.org/behavioral_charts.html
Centers for Disease Control and Prevention: Mental Health https://www.cdc.gov/mentalhealth/index.htm
Crisis Prevention Institute www.crisisprevention.com
National Institute of Mental Health - www.nimh.nih.gov/index.shtml
Schizophrenia.com - www.schizophrenia.com
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