Download Suicide in the Elderly

The Elephant in the Room:
How to care for those with
Emotional Dysregulation
Disorders
RMHC Discharge Liaison Team
Carrie Howard, RN
Pauline Barton, RN
Hideko Saito-Dufton RN, CPMHN(c)
Learning Objectives
 To further define what constitutes Emotional
Regulation disorders
 To identify common responsive behaviors and
challenges associated with providing care to this
population.
 To discuss care approaches related to responsive
behaviours and communication: do’s and don’ts
 To apply these principles to a case study using
P.I.E.C.E.S framework.
Case Mrs. J
Mrs. J refused her BG monitoring this am. She came late for her
meal again, and staff went to her room three times to remind her.
After the meal had been cleared, Mrs. J approached a PSW to
complain that she “did not get anything to eat” and she will be
telling the doctor that the “nurses are trying to starve me”. Mrs. J
is offered toast and cereal for breakfast. She also continues to
refuse her medications. Shortly after, she requested a prn for her
anxiety and reported that “that girl that gets me up doesn’t know
anything, she shouldn’t work here, she got me all upset”. Staff try
and encourage her to take her regular medications, as she is to
receive her antidepressant and staff know that missing a dose
can make her feel awful. Staff were not able to re-direct her to
take her meds “you don’t really care if I take them or not”. Mrs. J
was given a prn of Ativan for her anxiety.
Case Mrs. J (cont’d)
After breakfast, Mrs. J was asked to go to group exercise. During
the activity, Mrs. J displayed several disruptive and attention
seeking behaviours. She raised her voice over that of others,
made rude comments to the other ladies in the class about their
weight and elicited several responsive behaviours from her
peers. When this happened, staff had to stop the group and
diffuse the altercations. Mrs. J was asked to leave the group
early, which often occurs. Others in the home often comment on
how awful Mrs. J can be and so they avoid speaking with her.
Later in the day, Mrs. J is found to be weepy in the hallway.
Several staff walk by Mrs. J, as they often see this behaviour. It is
usually unfounded complaints, or complaints of other staff and
they would rather not enter into those types of conversations.
Case Mrs. J cont’d
Mrs. J yells out “I wish I was dead” and begins to wail loudly.
The RN asks Mrs. J “what is the problem?”. “ I’m going to die and
no-one cares!!” . Mrs. J then asks staff for a prn for her bowels.
Staff know that this is a frequent request and that often Mrs. J will
overuse the laxatives, resulting in episodes of loose stools. The
RN told Mrs. J “no you can’t have anything for your bowels right
now”. Re-direction from these requests were often ineffective, as
Mrs. J responds to staff loudly that “my cousin died of
constipation, you don’t know anything, get me the pill”.
After about 30 minutes, staff received a call from Mrs. J’s
daughter. She was critical of staff not giving her mother a
laxative as requested. She demanded that staff give her mother
what she asks for. She called back after an hour to check that
staff had followed through with the request. She visited that night
and spoke with her mother. Mrs. J is now reporting that her
daughter is in the process of lodging a formal compliant to the
DOC.
Emotional Dysregulation
Defined
Associated with ways of thinking and
feeling about oneself and others that
significantly and adversely affect how an
individual functions in many aspects of
life.
Definition Cont’d
• Long-term, unchanging patterns of
dysfunction.
• Patterns forms and develop over long
period of time.
• Evident by early adulthood and usually
persists throughout the person’s
lifetime.
• Patterns are reinforced and then
becomes fixed and unrelenting.
• Influenced by: physical and emotional
abuse.
• Family interactions of neglect,
emotional over or under-involvement or
invalidation.
• Biological or genetics
• Difficulty regulating emotions
Emotional regulation is a process by
which individuals influence their
emotions, specifically when they have
them and how they experience and
express these emotions
Expression of
Emotional Dysregulation
Vulnerability to negative emotion
• Highly sensitive to their thoughts; causes emotional
arousal.
• Highly reactive with a slow return to baseline.*
• Recurrent suicidal behaviour: gestures/threats, self
mutilation.
• Chronic feelings of boredom
• Excessive fear of abandonment (real/imagined)
• In periods of extreme stress can present with transient
psychotic symptoms*
Expression of Emotional
Dysregulation
Poor coping skills
• Inability to manage social interactions.
• Inability to identify and label emotional experiences.
• Poor arousal management*
• Excessive need state
• Constant state of crisis
• Impulsivity with regards to spending, sex,
drug/alcohol abuse
Expression of Emotional
Dysregulation
Poor coping cont’d
• Disturbances in identity, sexual orientation, valuebelief system
• Poor choices in career goals, friends and romantic
partners
• Make unattainable goals.
Expression of emotional
Dysregulation
Maladaptive responses to other’s
emotions
• Others responses often trigger emotional arousal.
• Manipulate environment to satisfy needs/soothe
fears.
• View things/people as all good or all bad.
• Utilize passive aggressive behaviours*
• Black and white thinking can cause a defense
mechanism called “splitting”
Types
•
•
•
•
•
•
•
•
•
•
Paranoid
Schizoid
Schizotypal *
Antisocial *
Borderline *
Histrionic
Narcissistic *
Avoidant *
Dependent
OCD *
Cluster A
Cluster B
Cluster C
Behaviors and Challenges
• The client will often test the limits of the
treatment team.
• They will have angry or agitated periods.
• They will attempt to deviate from the
treatment plan: late for care or meals, will only
let a certain staff do care. *
• They will attempt to split staff: good nurse/
bad nurse.
• They often make caregivers feel
helpless/incompetent or less effective than
other peers. “Splitting”
Approaches:
Communication
Prior To Approach:
• Consider what is your agenda, multiple options and how much
time you have.
• Know strengths and limitations of yourself and your resident
• Focus on the person, not the disease
During The Approach:
• Be an active listener by being physically and mentally present
and showing interest
• Validate underlying emotions
• Avoid listening to stack or repetitive complaints
• Focus on his/her feelings
Approaches (cont’d)
During the Approach:
• Change vague complaints into specific problem statement
–
–
–
–
Problematic situations
Uncomfortable emotions (feelings/symptoms)
Dysfunctional behaviour
Troubling, re-current thoughts
• Focus on assisting the process of problem solving, NOT
“recue” or “cure”
• Direct to distraction of negative thoughts
• Keep the time!!
Approaches (cont’d)
The Plan:
• Create a plan of care with specific goals and routines, with
client involvement.
• Consistency is the key: All staff should be familiar with
routines and directives.
• Client should be assigned a consistent staff member for
continuity, if at all possible, to establish a trust relationship.
• Inform client of their assigned staff, whom they can go to for
requests and care. Other staff to re-direct to this staff when
approached.
• Care conference on a scheduled or as needed basis to stay
consistent and to see behaviour based on current situations
• Keep yourself in mind!!
Pro-attention Plan
• This is an efficient and objective way to provide the
person with needed attention at a more convenient time
for the care providers and other team members.
• It gives attention to the individual before they seek it out
in negative ways
• It is important that this attention is separate from
providing care, administering medications and meals
Back to Case Study…
Mrs. J is 81 years old, and has resided in LTCH for 10 years.
Dx: Emotional Dysregulation disorder, Major Depression, anxiety
disorder, somatization disorder, CHF, HTN, hypothyroid,
hyponatremia, pain, OA knees, recurrent UTI’s, Hx hip #.
Mrs. J often presents as lethargic and disinterested. She has
multiple somatic complaints with regards to her GI system, pain,
as well as subjective sleeplessness. She refuses care at times
from certain staff, so hygiene is often poor. She seeks out
medications to “help her”(has difficulty identifying her needs), is
hyper-vigilant of other residents in the home and how care is
provided to them, often citing that they get “preferred treatment”.
MMSE done by new graduate, first time 29/30.
Back to Case Study
Medications:
Cymbalta 60mg po once a day
Gabapentin 200mg po tid
Mirtazapine 45mg qhs
Trazodone 50mg tid
Hydromorph contin ER 6mg bid
Fentanyl patch 50 mcg/72hrs.
Clonazepam 0.5 mg bid
Seroquel XR 50mg once a day
Metformin 100 mg tid
Lasix 40 mg once a day
Coversyl 4 mg once a day
Ramipril 2.5 mg po once a day
HCTZ 25 mg po once a day
Synthroid 0.05 po once a day
PRN:
Trazodone 25 mg po q 6h for
anxiety/sleeplessness
Ativan 0.5 mg po q 6h
Seroquel 25mg po for agitation
Hydromorphone 2 mg po q4h
Tylenol 650 mg po q4h
Maalox 30 ml q2h
Ventolin 2 puffs q4h
Back to Case Study
History of trauma
Spent time in foster care as a young child. Remote report of
physical and sexual abuse, Mrs. J does not talk about this. Mood
is euthymic and often she c/o depression and wanting to die.
Mrs. J lost her husband 11 years ago(hx alcohol abuse), # of hip
10 years ago prompted the admission to LTCH. Has few
relationships in the home, as she can be critical and demanding
of her peers. Mrs. J is estranged from two of her children. Her
oldest daughter is overly involved with her mother’s care (codependent relationship).
Back to Case Study
•
Mrs. J loves to read, she attend programs of interest if asked
and encouraged to go (BINGO, exercise). She is very mobile
and can easily get around the home.
• Lives in a ward room with three other ladies. 2 of the women
have severe dementia and are full care. The third is a well
liked lady in the home, who is very active with resident’s
council.
• Daughter visits every other day for 4 hours, participates in
assisting with her mothers care, requests meetings with the
ADOC at each visit to talk about her mother. Daughter can be
very critical of the staff, as can her mother. Recreation staff
have a good idea of Mrs. J likes and dislikes but find it hard
when she is disruptive in programs, so they often wait until the
last minute to invite her. She attends church.
Take Home!!!
• Do not take behaviour personally
• Don’t get sucked in
• Do NOT take behaviour personally
Questions ???
References
• health.discovery.com/encyclopedias/
2871.html
• www.intelihealth.com
• mentalhelp.net
• www.surgeongeneral.gov/library/mentalheal
th/chapter4/sec2_1.htmal
• Sort, N.P., Kitchiner, N.J., & Curran, J.
(2004). Unreliable Evidence, Journal of
Psychiatric and Mental Health Nursing, 11;
106-111.
References (cont.)
• Dada, F., Sethi, S., & Grossberg, G.
(2001). Generalized anxiety disorder in
the elderly. The Psychiatric Clinics of
North America 24(1); 155-162.
• Antai-Otang, D. (2003). Current
treatment of generalized anxiety
disorder. Journal of Psychosocial
Nursing 41(12); 20-29.
References
Mosby,2007,Psychiatric Nursing Care
Plans
References—Gentle Persuasive
Approaches in Dementia Care
Strategies to enhance communication,
CME program, Dr. Orange UWO Nov.
2010.
References
• 2008, DSM-IV
• 2006, Borderline Personality Disorder,
Dr. Anne Dietrich, PhD, Adler Clinic,
Vancouver, B.C.
• 2007, Psychiatric Nursing Care Plans,
Mosby