As many clinicians are aware, clinical practice these days in a geriatric psych setting can be quite challenging. However, we have found that practicing with a strong theoretical base, one which includes cognitive assessment, can often assist in organizing and planning effective treatment and outcomes. Hopefully, this can also alleviate much of the stress care staff may feel in caring for many of these challenging individuals.
There may be multiple reasons for geriatric psychiatric admissions such as, depression, psychosis, bipolar illness, etc. However, admissions of individuals who suffer from Alzheimer's disease and related dementias have grown a great deal. A large majority of individuals who are deemed as having "behavior problems" are being admitted from home, assisted and supportive living facilities, and long-term care settings. Dr. Renaldo DeLosSantos, a geriatric psychiatrist and medical director at Alexian Brother's Behavioral Health Hospital's older adult unit, reports that in the past 20 years of his practice, there has been a tremendous increase in the admissions of Alzheimer's and dementia related cases. He believes these numbers will continue to grow.
The following information consists of guidelines and steps for how the Allen Theory is being implemented and used from the occupational therapy perspective on a geriatric psych unit; however, many of the principles can be adapted to working with these individuals in other practice settings, as well as adapting for discipline-specific treatment methods.
First of all, admissions need to start with good assessments. At our facility the case managers (social services) and occupational therapist are the primary team members carrying out the cognitive assessments. Case managers will administer the MMSE within the first 72 hours and the O.T. is responsible for administering the LACLS and adapted placemat assessment. One of the benefits of using the adapted placemat is that it can be administered in a group setting, provided the patients are not extremely distracted. You need to use good, sound clinical judgment to determine if you are identifying best ability to function. After the assessments are completed, both disciplines will discuss their results during the patient's first care plan conference to ensure consistent and accurate treatment interventions and goals. It's extremely important to find an arena to share interdisciplinary findings. It's probably an even better suggestion to make sure inservices occur to ensure that all team members understand the cognitive findings that are being presented to them. (Quick tip: We have found that our nurses are especially fascinated and eager to attempt the LACLS on an informal basis!).
Much of O.T. treatment in psychiatry is performed within groups, although occasional one-to-one treatments can occur. Once the cognitive assessment has been performed and the accurate Allen Cognitive Level of the individual has been identified, the patients on our unit are placed in higher functioning or lower functioning groups. On our unit the delineation is made with persons functioning in level 4 as higher functioning and level 3 as lower functioning. One-to-one treatments may be done with higher level 4s, especially for IADL intervention, and then with level 2s for more sensory stimulation activities. This is the best-case scenario; however, in the real world this is not always realistic due to time constraints and/or staffing shortages. You may need to adapt depending on the cognitive levels of the patients. We have been able to have larger groups if a) we have many high-functioning patients, or b) we have a co-leader available to work with the low-functioning patients. If we have a significant number of low-functioning patients and no co-leader, we will try to have two separate groups with a smaller number of patients in each group.
An example of using Allen theory and treatment in a group setting is our "grooming" group. In this group we provide highly familiar, safe self-care items available for the patients. (We try to keep patient "kits" in order to properly maintain infection control procedures). Remember, even at Allen Level Low 3, the patient may be able to engage in the activity for brief periods of time. Higher level 3s may require less assistance, sometimes only verbal cues, but still need to be supervised closely depending on the products, (especially make-up!), and low 4s may only require assistance to set up the self-care items, open unfamiliar containers, or assist with use of unfamiliar products. This group allows us to integrate aspects of the Routine Task Inventory to validate cognitive findings, as well as determine effectiveness of medication through improved functional performance.
When using Allen theory, remember we always emphasize, "Evaluation and treatment occur simultaneously." This is especially true in acute psychiatry in which our role is to also provide information on the effectiveness or ineffectiveness of the medications being administered to our patients.
We use our treatment groups to:
- Validate cognitive level from initial admission through discharge.
- Monitor effectiveness (or ineffectiveness) of medications and/or ECT treatments and impact on functional performance (including behaviors and safety).
- Engage patients in meaningful activities.
- Decrease anxiety, agitation, and behavioral outbursts.
- Assist case managers in determining appropriate discharge environments.
As we have stated in our courses, all of us play a key role in engaging patients in activities. Whether those activities are ADLs, leisure, or mobility, it is critical that we provide the best possible environment and caregiver approaches to allow the patients to engage in meaningful actions or activities to the best of their ability.
There are many benefits to engagement in valued activity. In fact, quality activity can be acknowledged as a non-pharmacologic treatment intervention. On our unit we have found that when patients are engaged in activities that match their cognitive level, they are far less aggressive compared to when there are no structured, modified activities occurring. This benefits the patient and family members who are our primary customers. Also by engaging patients in non-pharmacological treatment interventions, we are able to keep the need for PRN medications to a minimum, as well as assess and communicate with nursing as to when the PRN medications are absolutely needed. This one aspect alone has been a major factor in fall reductions on our unit as many of the psychotropic medications are known to negatively impact balance. Sleep cycle problems are another issue that can occur due to using these types of medications. We all know the care challenge and client frustrations that accompany the cycle disturbance of sleeping during the day due to the meds and being up all night. Once again, it becomes an imperative interdisciplinary goal to limit the use of psych meds through delivery of non-pharmacological interventions, such as meaningful activity.
Using the Allen Model on our geriatric psych unit has had a great impact on our multidisciplinary team and their perspective on patient care. Nursing and CNAs are grateful when patients are engaged in activity and not exhibiting aggressive, anxious, combative behaviors, which minimizes the need for chemical interventions and reduces resistive behavior during ADL care. Physical Therapy has used the Allen cognitive information to determine correct communication strategies, goals, and treatment interventions that are appropriate for the patients on our unit. Expressive therapy has used the information to grade/adapt their activities as needed. In addition, both the physicians and case managers seek assistance from our staff in determining safe and appropriate discharge environments for our patients to match their level of physical and cognitive function.
We hope this article will help guide clinicians, spark some new ideas, and provide additional tools to current practice models being used in this arena, as well as other practice settings. Please share your feedback and thoughts in our Instructor Community.
Good luck as you continue to serve this most worthy (and loved!) group of individuals.