Principles of treatment of older adults: Non-pharmacological management (NPM)

Dr Rakesh Kumar TripathiAssistant Professor cum Clinical Psychologist

Department of Geriatric Mental Health,King Georg’s Medical University, Lucknow, UP, India

Principles of treatment of older adults in psychogeriatric setupMultidisciplinary approach1. Pharmacological Management

˃ Psycho-geriatrician (Psychiatrist)˃ Physician

2. Non-pharmacological Management (NPM)˃ Clinical Psychologist (trained Psychologist)˃ Trained Social Worker (Psychiatric/Geriatric Mental Health)˃ Physiotherapist˃ Occupational therapist˃ Dietician ˃ Yoga therapist˃ Care by Nurses˃ Care by carers

Why non-pharmacological management ?» Some limitations of pharmacological treatment» Drugs give only modest symptomatic improvement in cognition» Always risk of adverse effects» Patients in the older age groups vary in their response» Age is associated with decreased renal clearance and slowed

hepatic metabolism» Older patients often take several medications so drug interactions

and side effect are likely» Anti-cholinergic side effect may worsen cognitive impairment and

lead to delirium» Age also is associated with diminished vascular tone, which

increases susceptibility to orthostasis and falls» Involvement of other available resources in the management plan

NPM: What it does? Enhance quality of life, maximize functional performance by

improving cognition, mood, and behavior. Enhance coping skills, solving interpersonal conflicts,

develop insight NPM rely on a person-centered approach, respecting the

individual, and should be used irrespective of whether medication is also required

Focuses on social support, recreational therapy, physical exercise, mental stimulation and a variety of other non-medical treatment options as a means to improving the well being of older adults with mental health problems

Reduces caregiver’s burden and maintains strength & dignity

To take care of legal, financial and other such issues

Base line assessment for NPM» Activities of Daily living » Cognitive functions» Behavioural and psychological abnormalities» Premorbid functioning/personality» Conflicts» Interpersonal relationship» Stressors» Family dynamics » Physical environment» Diet pattern» Caregiver burden

Communication with older adults» Calm, reassuring tone of voice» Explain what you are going to do prior to moving into the patient’s

personal space to implement care/assessment» Use a non-threating posture» Do not approach the patient from behind» Touch and care should be in a respectful, careful and unhurried manner» Use short words and simple sentences» Ask one question at a time» Don’t ask ‘why’» Give adequate time for response» Repeat questions and instructions if necessary» Speak slowly and clearly » Use of aids (hearing, vision, physical) by the patient

Sing I & Tripathi SM (2013). Management of BPSD. In Tiwari SC & Pandey NM (eds.) Geriatric Mental Health at a Glance ,pp 81-95. Ahuja Publishing House , New Delhi , India.

Types of Non-pharmacological management» Psycho-social management/Psychotherapy» Physiotherapy» Occupational therapy» Diet therapy » Nursing care» Care by caregivers» Other

Psychosocial management/Psychotherapy» Supportive psychotherapy» Psychodynamic and psychoanalysis» Humanistic and Existential Therapies» Cognitive therapy» Behaviour therapy» Family therapy» Group therapy

Reconstructive

Re-educative

Supportive psychotherapyDeals with external factors of the problem, strengthening of existing defences, elaboration of new and better mechanisms of maintaining control» Guidance» Suggestion» Emotional catharsis» Reassurance» Environmental manipulation

Psychodynamic psychotherapy

Unravelling the dynamics of problem behaviour and helping the client achieve insight into those dynamics» Psychoanalysis (Free association, Resistance transference,

dream interpretation, working through, insight , termination)

» Contemporary psychoanalysis» Jung, Adler and Horney: focus on a underlying causes of a

disorder and strive for insight (self development in social context)˃ Analytical therapy (need for ‘individuation’, self realization)˃ Individual therapy (social and interpersonal factors, personal freedom and a fulfilling

‘style of life’)˃ Horney’s approach (help to identify maladaptive interpersonal strategies,

constructive interpersonal styles and greater self reliance)

Humanistic & Existential Therapies(Carl Rogers & Abraham Maslow)Special emphasis on sharpening the individual’s self awareness and self acceptanceShaping one’s own existence» Humane client therapist relationship

1. Empathy, 2. sensitive, unconditional positive regard, 3. never criticizing, always accepting , 4. do not judge, probe or disapprove, 5. be genuine, open, spontaneous and caring

» Client-centered therapy: ˃ discrepancies between “ideal” and “real” selves˃ Aim to reduce these discrepancies and associated pain

» Gestalt Therapy: (Fritz Perls)“The past is no more and the future is not yet”; thus “to me nothing exist except the now”-To make people ‘whole’ by encouraging them- Accepting responsibility , focus on “here and now”

» Existential therapy: (Viktor Frankl & Rollo May)˃ To emphasize that the client can have control over the problem and is thus responsible for

overcoming it.

Cognitive therapyMaladaptive behaviours comes from maladaptive ideas, or cognitions, and therapy focuses on modifying these cognitions- ‘cognitive restructuring’» Ellis’s Rational Emotive therapy (1950)

˃ Reveal and breakdown irrational beliefs that leads to stress˃ Reciprocal interactions among cognition, emotion and behaviour: ‘cause-effect

relationship’ (REBT,1993)

» Beck’s Cognitive Therapy» Meichenbaum’s self instructional training

˃ Self instructional training to replace maladaptive cognitions with rational, positive thoughts in stressful situation

Cognitive therapy (contd.)Aron T. Beck’s Cognitive Therapy» Recognizing and changing negative thoughts and

maladaptive beliefs» “Automatic thoughts”- personalized notions that are

triggered by particular stimuli that leads to a emotional responses

» Cognitive distortions:˃ Arbitrary inferences (without evidence)˃ Selective abstraction (conclusions from isolated detail of an event)˃ Overgeneralization˃ Magnification or minimization˃ Personalization˃ Labelling and mislabelling˃ Polarized thinking (all or none)

Behavioural therapiesAssumptions:» Psychological problems that come about through

learning or conditioning can be undone via the same processes

» Measurement of behaviour and behaviour change» Do not believe “unconscious conflicts” or “mental

illness”» They view their clients as suffering from acquired

behaviour patterns – and need to be unlearned» Learn more adaptive alternatives

Behavioural therapies (contd.)

» Instrumental or operant conditioning˃ Functional analysis of behaviour (A-B-C)˃ Identifying positive and negative reinforcers˃ Extinction˃ Differential reinforcement˃ Shaping˃ Token economy˃ Punishment˃ Covert sensitization

» Classical conditioning˃ Systematic desensitization˃ Flooding˃ Aversion therapy

» Social learning

Why Family Therapy?

To address:» Inability to resolve conflicts, make decisions or solve

problems» Chaotic family organization and lack of agreed upon

responsibilities» Too rigid an organization resulting in an ability to respond

the changing circumstances and stress» Over closeness to the point that individual family

members may lose a sense of individuality» Lack of emotional ties and communication among family

members» Failure of the parents to agree on child rearing practices

Group therapyFeatures: » Self disclosure

˃ In front of group members

» Acceptance and support˃ From the group members

» Norm clarification˃ One’s problem is neither unique nor serious

» Social learning˃ Being able to relate constructively and adaptively within the group

» Vicarious learning˃ Learning about oneself by observation of group members and therapist

» Self understanding˃ Finding out one’s behaviour in the group setting and the motivations

contributing the behaviour

Needs of Elderly persons for management

Behavioural and Psychological Symptoms of Dementia)(

BPSD (contd.)• Rule out delirium• Search for the treatable common cause:

– Constipation– pain/ discomfort– infection (UTI/pneumonia)/ other medical cause– Side-effects of medications– Sleep disturbances– Change in routine schedule/ environment– Lack of meaningful activity/stimulus– bad-mannered behaviour of staff/caregiver

BPSD (Contd.)Cohen-Mansfield (2000) model for agitation

‘Unmet needs model for agitation’» Behaviours to obtain or meet a need…» Behaviours to communicate a need…» Behaviours that result from an unmet need…

Non-pharmacological management of BPSD

» Identify trigger & remove it» Establish a routine» Familiar atmosphere » Clear & simple

communication» Involve in useful activities» Regular exercise» Distraction» Avoid punishment» Be consistent with a strategy» Be realistic about the goals» Avoid creating discomfort

Small changes can result in major gains!

•Medications

•Foot wear

•Walking aides

•Surface heights

•Chairs/bed

•Wall bars

•Lighting

•Flooring/mats

Alternative / complementary therapy for BPSD

Standard therapies» Behavioural therapy» Reality orientation» Validation therapy» Reminiscence therapyAlternative therapies Art therapy Music therapy Activity therapy Aromatherapy Bright-light therapy Multi sensory therapy Spiritual therapy

Psychotherapeutic Intervention modules to improve quality of life of urban elderlies with cognitive deficits (Tripathi and Tiwari, 2009)

Cognitive deficit Psychotherapeutic Intervention Approaches

Aggression, screaming, incontinence, wandering, stereotypical behaviours, and agitation

Behaviour oriented approach

Wandering Stimulus Control Disruptive vocalization

Differential reinforcement of other

behaviours Disruptive vocalization

Non-contingent Reinforcement

(NCR) Disruptive behaviours

Differential reinforcement of low

rates of behaviour intervention (DRL)

Personal care Token economy Problems in Dressing, Bathing, Fooding Contingency management

Coping skills, memory & mood, insight, isolation Emotion oriented approaches: enhance the strengths and coping skills of both patients

and caregivers Supportive psychotherapy

stimulates memory & mood in the context of the patients’

life history Reminiscence therapy

contentment, negative affect and behavioural

disturbance, insight, external reality Validation therapy

Social Isolation Simulated presence therapy

Redress cognitive deficits disorientation & confusion, verbal orientation

Cognition oriented approaches: Reality orientation

Agitation, social isolation, and mood, Stimulation oriented approaches: Behavioural problems i.e. agitation, social isolation and

mood Recreational therapy (Music &

Dance) Behavioural problems i.e. agitation, social isolation and

mood Art therapy

Memory, Orientation & executive functions (Cognitive decline)

Cognitive stimulation therapy:

Safety measures in all respect Environmental intervention: stressed, unsafe, unfriendly, uncomfortable, inconstant,

unfamiliar, unlighted and obstacle physical environment Physical

daily living activity schedule, adequate exposure to light & sleep hygiene

Temporal

Hearing and vision checkups Sensory consideration Helping at meal time Nutritional consideration

Helping entire family to cope, to plan, to participate in the management of elderly dementia patients at home as well as in institutional setup

Family therapy

Reality orientation» People are oriented to their environment using a range of

materials and activities

» Involves consistent use of orientation devices such as

signposts, notices and other memory aids

» debate regarding the efficacy of the approach

» Favorable review of the six randomised controlled trials of this

therapy (Spector et al’s 2002a)

Validation therapy» Attempt to communicate

by empathizing with the feelings and meanings hidden behind their confused speech and behavior.

» It is the emotional content of what is being said that is more important than the person’s orientation to the present.

What is Validation from Naomi Feil.webm

Reminiscence therapy

» A way of increasing levels of well-being and providing pleasure & cognitive stimulation.

» Involves helping a person to relive past experiences, especially those that might be positive and personally significant.

» Improvements in behaviour, well-being, social interaction, self-care and motivation

Environmental Intervention Physical Environment

Good Ideas:» Places to wander, Digital or hidden locks» Electronic bracelets/wander guards» Double bolts on doors, Half doors» Stage appropriate toys, books, puzzles, TV shows» Give meals in a style that suits ability- ie may need to

use finger foods» Flexible routine, Things to do!!!, MusicNot a good idea:» Highly patterned wallpaper» Mirrors» Loud call bells/paging systems» Frequent room changes/redesign

The ABC’s of Behavioral Intervention» A-Antecedent:» B-Behavior:» C-Consequence: the response to behavior.

What happened? Who did what to whom?Very important to document both successful

and unsuccessful interventions.

Behavioral Challenges… WanderingCheck :» akathesia (which increases need to pace), Was this

person a habitual walker/runner/doer? Is this behavior really a “problem”, Who’s problem?

At home: » Double locks on doors/move lock out of sight,

Wandering Registry, Adequate daytime physical activity, Things to do/distraction, If planning a move involve the less demented pt.

» In a more impaired pt you want to move the person quickly with little fuss

Behavioural Challenges….Repetitive Questions» Where’s my wife? What do I do now? Etc Etc….

˃ Consistently ignoring repeated questions works for some

˃ Distraction with food, presence, activity˃ React/respond to the emotional content rather than

the words˃ Controversy over the “therapeutic use of lies”

Behavioral Challenges….Screaming» Screaming usually occurs in the later stages of dementia » Broken brain» Careful assessment if new onset» May result from lack of/excess of environmental stimulation» Little efficacy of medication

Non-pharmacological management:» Increase socialization if appropriate» Increase auditory stimulation (if decrease is suspect)—music

works well» Monitor behavior carefully for triggers and rectify accordingly

Behaviour Challenges….Verbal & Physical Aggression

» Try to intervene early» Try to avoid situations that are known to

be provoking for the individual» Use a calm and reassuring voice» Avoid arguing or confrontation when agitated» Approach slowly, from the front

» Use touch judiciously-can be perceived as comforting or provoking

» Use non-threatening stance-should be at eye level

» Use distraction» Avoid the use of physical restraints

Behaviour Challenges….Verbal & Physical Aggression

Sexually Inappropriate Behavior» 4-6% in dementia» Consider etiology:

˃ Uncomfortable clothing˃ Need to toilet˃ UTI/Rash˃ Soiled

» If found undressed calmly bring a robe or blanket

» If found masturbating˃ Do not react with upset or ridicule˃ Gently lead to a private place˃ You may (or may not) wish to distract with a tactile object

May not be sexually related

Snoezelen or controlled multisensory environment (1970s Netherlands)

» Snoezelen or controlled multisensory environment (MSE) is a therapy for people with autism or developmental disabilities.

» It consists of placing the person in a soothing and stimulating environment, called the "Snoezelen room".

» These rooms are specially designed to deliver stimuli to various senses, using lighting effects, color, sounds, music, scents, etc.

» Snoezelen therapy is used for people with autism and other developmental disabilities, dementia, brain injury and even toddlers.

» However, research on the benefits of treatment is scarce, based on variable clinical study designs.

Geriatric PhysiotherapyThe ultimate aim of physiotherapy is the restoration of fullest functional activity as possible.and 1) To reduce pain by using heat therapy (I.R., S.W.D. Hot pack’s , Wax

bath and TENS )

2) To increase local metabolic activities (Ultrasonic therapy, U.V.R., Therapeutic Laser)

3) To increase or to maintain joint mobility by exercise

4) To maintain or increase muscle power by using resisted exercises (weight cuffs , dumbbells , thera bands , roll , balls ) 5)To reduce Complication, contracture and deformity

6) To enhance the vital capacity of the patient (breathing exercises , chest physiotherapy)

Physiotherapy in Various Geriatric Medical Condition» Fall's» Incontinences» Osteoporosis» Muscle wasting» Lack of concentration» Gait disturbance » In co-ordination » Pain» Constipation

• Mal nutrition• Forget to eat• Vitamin B12, D3• Nuts, fruits, vegetables• Milk and milk product• Avoid tobacco and

alcohol• Coffee and tea• Supplements on advice

Diet Therapy

Mental Exercises through Activities

Caregiver

C compassionate A affectionate R reliable E energetic

------------------------- G goal directed I involves others V variety in approaches E enjoys his work R relaxes the milieu

Who is a Caregiver?

» Spouse» Daughter- in – law» Son / Daughter» Other family members» Servant» Nurse» Trained / Skilled caregiver personnel

Caregiver Burden Depression Exacerbation of existing physical disease Marital Disharmony Social withdrawal Isolation Financial distress High rate of psychological morbidity Anxiety Insomnia Exhaustion Reduced concentration Poor relation with other family members

1) Although I cannot control the disease process, I need to remember I can control many aspects of it

2) I need to take care of my self, so that I can continue doing the things that are most important

3) I need to simplify my lifestyle so that my tine and energy are available for things that are really import at this time

4) I need to cultivate the gift of allowing others to help me because caring for my relative is too big a job done by one person

5) I need to take one day at a time rather than worry about what may or may not happen in future

6) I need to structure my day because a consistent schedule makes like easier for me and my relative.

12 Steps for Care-givers

12 Steps for Care-givers (Contd…)

7) I need to have a sense of humor because laughter helps to put things in a more positive perspective

8) I need to remember that my relative is not being difficult on purpose; rather that his behavior an emotions are distorted by illness

9) I need to focus on and enjoy what my relatives can still do rather than constantly lament over what is gone

10) I need to increasingly depend upon other relationship for love and support

11) I need to frequently remind myself that I am doing the best that I can at this very moment

12) I need to draw upon higher power, which I Believe is available to me

Overview of problems of an Elderly and management strategies

Conclusion• Person centered approach • Work with systems

– families– professionals– Caregivers– organizations

• Think of Underlying unmet needs• Underlying co-morbid conditions often un-recognized: treat them» Need research to know effectiveness of NPM• Involve culture appropriate methods» Many are simple, inexpensive and easy to implement, both in the

home and institutional setting, and can do much to improve the quality of life and possibly even reduce the need for medications

Thank you

Contact:Dr R.K. Tripathirastripathi@gmail.com91+9454202905