Managing Hypersexuality in the Nursing Home – Where to Begin?

On March 18, 2010, In Behavior Management, Clinical / Nursing, Social Services, By Mark

"Won't you protect me?"

Today, we’ll talk about hypersexuality of the nursing home resident when there is no 2 –party consent for sexual advances, and what to do to manage this behavior.

In the nursing home industry, you’ll run across it sooner or later.  A little male resident who goes from female resident to female resident attempting to touch, kiss, and grope them inappropriately.  He disrobes in public… or worse.  He tries to go into their rooms.  He is sneaky and waits until staff are busy and no one is visible in the area.  He preys on the most vulnerable of our residents – the ones who are confused, demented, and who usually can’t report the incident.  He may also get brave and begin this behavior with your staff as they are attempting to shower or dress the resident.  This can set you up for worlds of trouble.

What we must do is stop the inappropriate behavior and safeguard our residents as well as our staff.  There is no sweeping this under the rug hoping it will go away!

If not, not only do we put our residents and staff at risk for sexual abuse, you almost definitely set yourself and your facility up for an immediate jeopardy tag(s).

You need to evaluate the initial inappropriate behavior by the resident and address it immediately.  If not, it only gets worse.  Some residents start off with trying to grope the CNAs.  You must educate your CNAs to report this sexual aggression and you must take interventions at that time.

We have to attempt to find the source of the behavior.  Is there a new medication the resident is taking?  Is it related to the patient’s dementia?  Is there a history of sexual abuse or sexual inappropriate behavior? Is there a UTI or psychiatric disorder?  Does the resident have delusions?

Is it actually sexual behavior?  For example, removing clothes or inappropriately touching the staff when hugged or assisted with baths may not necessarily be sexual aggression.  It could be disorientation or confusion on what is actually going on related to their dementia.  If the resident has targeted one specific female, it may very well be likely that he is confusing that resident/staff member with a spouse or significant other.

Obviously, we would attempt non-pharmocological interventions at first to redirect the resident but we’d also consider a medication regimen if unsuccessful.  Collaboration with appropriate mental health professionals can produce excellent non-pharmocological interventions.

A cognitive screen and lab work-ups should be completed for the resident.  Labs may include a blood glucose level, BUN, CBC, PSA, LH, Testosterone level, urinalysis, and liver function.  For aggressive hypersexualism, you should make use of your resources.  Keep your primary physician and medical director in the know.  Bring in your pharmacy consultant for medication review.  Bring in mental health professionals for geri-psyche as appropriate.  Room changes, frequent or even temporary 1-to-1 monitoring may be necessary to manage the behavior.  The family should be kept in the loop and they’re also a source for historical information on the resident to see if these behaviors have occurred in the past.  Staff education is a necessity and must be ongoing.

No medication, as far as I know, is currently approved for the treatment of sexually inappropriate behavior.  That being said, there are a number of medications that are commonly used for the purpose of managing these behaviors (or at least allowing the drug’s side effects to kick in effectively reducing sexual desire).  Let me tell you, it is usually a game of trial and error.  The local primary physician may not be well-versed with hypersexuality in long term care, so it is of utmost importance to make sure they are discussing options with your pharmacist and mental health provider.  Many times, it may take a combination drug therapy approach to effectively reduce or eliminate the undesirable behavior.

Common types of drugs used for the management of hypersexuality and sexual inappropriate behaviors in the long term care setting:

  • Chols (cholinesterase inhibitors) – may decrease libido, may help cognitive and behavioral issues – examples –  Aricept, Exelon, Razadyne
  • SSRIs – may decrease libido and offer better impulse control – Celexa, Paxil, Zoloft, Prozac, Androcur
  • Mood Stabilizers and Antipsychotics – (limited usefulness) may help calm aggressive behaviors – Risperdal, Lithium, Depakote
  • Antiandrogen agents – may decrease sexual aggression and misbehavior in men as well as decrease fantasies and urges – Provera, Depo-Provera
  • Leuprolide/LHRH agonists – may inhibit gonadotropin release and suppress testosterone production – Lupron, Zoladex
  • Estradiol – may increase estrogen levels and decrease sexual behavior.
  • Cimetidine (Tagamet) – may decrease hypersexual behaviors.

I am not a physician, nor a pharmacist.  I am not advising you to use any of the drugs listed above for your residents or for the treatment of any disease or condition.  However, one needs to know what options are available when attempting to manage the sexually inappropriate and sexually aggressive  resident in the LTC setting.

Every drug has side effects that must be monitored and many of the ones listed must have labs ordered with them.  Depo-Provera is a great drug for use with these behaviors, but I have seen residents swell after a few months on it.  There are also ethical considerations of altering the balance of a resident’s hormones for the purpose of behavior management.  Choose wisely, keep the family and physician in close conversation.  Update the care plans and monitor the resident closely for effectiveness of the drug as an intervention and for potential drug side effects.

Even with a combination of these drugs in place, it still may be impossible to manage the resident’s hypersexual behavior.  Don’t be afraid to utilize a short-stay geri-psyche facility or to discharge the resident altogether (to a safe environment).  I would much rather take a tag on inappropriate discharge than an IJ on sexual abuse in the facility.

I would love to hear your opinion on this and if you’ve had success with other measures.

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Using Your Relationships – A Little-Known Nursing Home Marketing Trick

On January 15, 2010, In Best Practices, Clinical / Nursing, Marketing, Admissions, and Census, Skin and Woundcare Management, By Mark

One of the tricks I came across in marketing nursing homes is to partner with other vendors and providers in the industry.  “Well, that’s not a big secret, Mark.  Everyone knows this,” you might think.  But, do you know how to utilize these relationships?

For example, one of the areas my facilities specialize in (because I make sure they specialize in it.  I make sure we get tons of the education, the right supplies, and the proper equipment and that we are successful in managing these types of residents) is woundcare.  Specifically negative pressure -- wound vacs. I will take a resident with terrible wounds, infected wounds, still on their IV Vancomycin, with an order for negative pressure. I like those types of residents.  I like to heal wounds everyone else is afraid of.  I ask for those types of residents when I’m marketing and other nursing homes are denying admission for the referral citing how they cost too much, etc.  Have they ever actually done a cost-out?  Most likely not.  Vancomycin is not a deal breaker.  Cubicin, maybe; but Vanc, Zosyn, etc. are fine.

It also doesn’t matter what type of negative pressure product (“Wound vac“ is the term commonly used when referring to a negative pressure product; however, KCI owns the patent on the actual wound vac and has the rights on the term “v.a.c.“).  Blue Sky, KCI, Medela, it doesn’t matter.  You can make arguments all day long about the subtle differences in how these products function.  One uses a sponge that may leave particles in the wound bed, the other uses an antimicrobial gauze which actually may do the same thing.  On one you have to use a higher pressure setting, on another a lower.  At a higher setting, there may be more pain to the patient.  One has an alarm, one doesn’t.  One has a smaller, portable size.  One has a larger size, but also a larger canister. 

Guess what?  I have gotten positive results with each of these products and didn’t see a huge difference either way in comparison.  If your wound isn’t healing with negative pressure, it may not be just the pump due to the fact that the pump itself is not a total solution.  It doesn’t relieve you of ensuring proper nutrition and supplementation, proper turning and repositioning, proper skincare and incontinence care.  The list goes on and on.

So, we’ve established I like wounds.  Here’s the part most facilities don’t do.  I like to partner with the provider of my negative pressure product and take them on a sales call with me.  I let them bring a medical model that most of their sales reps have and they will demonstrate negative pressure therapy on the sales call. 

The medical model is a lifelike rubberized mold of an actual patient’s backside that has examples of different types of wounds.

From Vatainc.com:

“ Displaying the following pressure ulcers* (NPUAP 2007 -- National Pressure Ulcer Advisory Panel): Stage I, Stage II, Stage III with undermining, tunneling, subcutaneous fat and slough, deep Stage IV with exposed bones, undermining, tunneling, subcutaneous fat, eschar and slough. Also shown are a suspected DTI (Deep Tissue Injury), unstageable full eschar/slough wound, and a 5 1/2” dehisced wound. The Stage III and Stage IV are positioned so that a “bridging” dressing for use with a vacuum assisted closure and negative pressure wound therapy devices can be demonstrated and practiced.”

Pretty neat, huh?

I will allow the negative pressure representative to do an actual dressing in front of the group I’m marketing to -- usually a room full of discharge planners, sometimes physicians - and hook up the negative pressure pump to the mold.  It makes for a very interesting demo and leaves a visual in the minds of my audience.  I follow up this demo with my own presentation for my nursing facility and our success with wound patients.  I inform them of how my facility is able to assist them with receiving and providing top care for those difficult-to-place wound patients.  I usually get several referrals with this technique as the hospitals generally have patients with wounds that other nursing homes are not excited about accepting.  Some of the other nursing homes actually deny readmission to their own patient if they have orders for a wound vac or are still on IV antibiotics.  The negative pressure representative is also usually happy to help because it helps them place a product if I get a patient needing this type of wound therapy.

Here are some places you can get your own “butt model” in case your rep’s company doesn’t offer this:

VATA

Health Edco

Laerdal

As we talked about, it’s about using your relationships to your advantage.  I just used negative pressure and wounds as an example.  You can use the same concept by partnering with your therapy company, your DME supplier, your hospice provider, etc. 

There you have one of the little secrets in nursing home marketing that actually works.  Stay tuned for more to come!

P.S.  Here’s a little bonus -- a video courtesy of YouTube that actually shows a negative pressure dressing change if you’re interested:

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Snoezelen Rooms – A New Tool for Alzheimers?

On December 21, 2009, In Behavior Management, Clinical / Nursing, Social Services, By Mark

Do you Snoezel? If not, you might need to start!

The word “Snoezelen” comes from 2 Dutch words, “snuffelen” (to seek out or explore, or to sniff) and “doezelen” (to relax, doze, or snooze).  The Snoezelen experience offers sensory stimulation and relaxation through lights, sounds, smells, and textures, and it appears that it can be a beneficial tool in the treatment of individuals with mental health issues.

While not exactly new, Snoezelen is catching on.  The Snoezelen concept was actually developed in the late 1970’s by two Dutch therapists from the De Hartenberg Institute in Holland, a center for individuals with intellectual disabilities.  Jan Hulsegge and Ad Verheul set up a sensory environment in a tent at one of their annual summer fairs and generated impressive results with challenged clients, both verbal and nonverbal.

Since that time the Snoezelen concept has evolved into multi-sensory stimulation rooms in many different types of settings.  A Snoezelen Room offers a safe, client-based, pressure-free environment enhanced for interpersonal interactions.

Some common Snoezelen Room settings include:

  • Developmental Disability
  • Children with Special Needs
  • Autism
  • Mental Health
  • Post Traumatic Stress Disorder
  • Stroke & Traumatic Brain Injury
  • Pain Control
  • Dementia, Alzheimers, “Sundowners”

Snoezelen can be used in a variety of ways.  It is used primarily to educate, stimulate, relax, calm, or energize individuals through a multi-sensory or a single sensory experience.  The lighting, atmosphere, sounds, textures, etc. are all adapted specific to the needs of the resident. Whereas we normally think of only 5 senses, Snoezelen targets 7:

  1. Vision
  2. Touch
  3. Smell
  4. Hearing
  5. Taste
  6. Vestibular -- Balance, your body’s feedback on gravity, movement, and changing head positions.
  7. Proprioception -- Feedback from muscles, joints, and other parts of the body to provide an awareness of positioning.

 Although there are various items that can be incorporated, some common pieces of equipment that might be found in a Snoezelen room might include:

  • Aromatherapy
  • Blacklights, dimmed lighting
  • Music
  • Videos
  • Positioning & seating items, bean bag chairs
  • Bubble tubes
  • Projectors
  • Cushions
  • Fiber optics
  • Water fountains
  • Massage pillows
  • Tactile panels
  • Vibrating music products
  • Interactive panels, switches, buttons
  • Murals
  • Even puddings or candies

FlagHouse  has signed an exclusive distribution agreement for North America for Snoezelen equipment with ROMPA International who own the Snoezelen trademark.

The nursing home industry is increasingly adopting this innovative approach to dealing with behaviors.  Sensory therapy has proven an effective treatment in calming aggressive behaviors and improving mood.  A number of nursing home professionals have come to realize that this type of treatment can be fun while being an effective dementia intervention, even being used for “Sundowners” and various other Alzheimers behaviors.  Would this benefit your facility?

A couple of Snoezelen Room examples can be found below -- courtesy of YouTube:

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How to Run a Care Plan Meeting

On December 18, 2009, In Best Practices, Clinical / Nursing, By Mark

 

high angle view of medical personnel seated around a table

Care Plan Meetings, also called Care Conferences or IDT Meetings with the Resident and/or Family are an important part of your resident’s stay at the facility.  They are necessary to ensure that no communication has been lost and that we are answering all questions and addressing all concerns raised by the resident and/or family.  Also, getting resident and family input into the plan of care is extremely important in order to optimize clinical outcomes.

Different individuals and even companies run the care plan meetings in different ways.  In some facilities, the MDS Coordinator leads the meeting.  At others, the Social Services Director or even the DON may lead it.  Regardless of who leads the meeting, there are several key components you should ensure are included:

  • Your invitations should go out to the family at least 10 days in advance.  One thing many facilities don’t do consistently is invite the resident.  Let’s make sure we don’t forget that.  After all, it is a meeting on the resident’s plan of care.
  • Make sure the resident’s medical record, care plans, ADL sheets, and current therapy progress notes are brought to the care plan.  You will need to refer to these documents at different points during your conversation.  Have them ready.
  • You should introduce yourself to the attendees as well as introduce all the IDT members.
  • Ask if there are any concerns, questions, or complaints they wish to discuss before reviewing the chart and care plans.
  • Your MDS should match your care plans and you should ensure the CNA ADL sheets have been updated to reflect the resident’s current status.  I always instruct my staff to review the care plan interventions for things the CNAs would need to know and then bring those interventions to the CNA ADL sheet so we are sharing it with the people who need it the most.
  • You should review the diagnoses and explain if the resident or family does not understand.
  • You should go over the current physician’s orders and explain what each medication is for.  Include any recent changes of medications.
  • You should review any significant changes with the resident – any improvements or any declines – since the last assessment.
  • Review the nursing care plan, reading the problem, goals, and interventions and discussing with the team, family, and resident.
  • Each IDT member should review their own department’s care plans and answer any questions that may come up.
  • Discuss if additions or changes need to be made to any of the care plans, goals, or interventions.  It is important to ensure the resident, facility, and family have similar goals for the resident’s best outcome.
  • Explain the facility’s regulatory requirements as necessary to indicate why we must attempt restraint reductions or attempt dose reductions on medications.
  • The QI/QM report should be reviewed for any flags and discuss those as well.   
  • The communication during the meeting should be focused and stay on the subject.  If an individual tends to drift out on a tangent, reel them back in.
  • If issues come up that need to be addressed by other staff (ie- grievances, work orders), ensure proper follow-up.
  • Take the opportunity to remind residents or family of any specific rules or issues that may violate the facility’s policies to ensure everyone is on the same page. (ie-smoking in room, or keeping uncovered snacks in room, family bringing in food that is not in compliance with physician-prescribed diet, etc.).
  • Reinforce that good communication is required between all parties to get the best outcomes. 
  • The resident and family should leave the meeting feeling like all their questions have been answered and that their input was appreciated and considered for any further care plan adjustments.
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