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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 5: In elderly patients known to have dementia, do not attribute behavioural problems to dementia without assessing for other possible factors (ex: medication side effects or interactions, treatable medical conditions such as sepsis or depression). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis This week I will be starting my first week of being on call for a nursing home, where many of the residents have a diagnosis of dementia. One of the many challenges for caregivers of patients with dementia arise from the behavioural (i.e., neuropsychiatric) disturbances that can frequently accompany this disease process. I expect to be called regarding the management of these issues. The first step in addressing behavioural concerns in a patient with dementia is to consider a differential diagnosis. Sure, the behavioural concerns may just be a manifestation of this disease process as it affects behavioural regulatory centres in the brain, but they may also be an adaptive physiological response to some sort of noxious trigger. UpToDate provides a comprehensive table that lists common reasons for behavioural disturbance in patients with dementia that I will no doubt be referring to: Sometimes it can take some time to figure out what the reason for a behavioural disturbance is. Other times, it's idiopathic. Regardless, in the moment the patient may be at risk of harming themselves or others, or caregivers are just having a hard time coping. In these cases, the best strategy is to apply behavioural techniques, such as ones that calm or distract, but these don't always work well enough. If a good effort at such techniques is made, or for whatever reason it's simply not feasible, then chemical or physical restraints may, unfortunately, be a last resort. Methotrimeprazine is a common agent used for agitation in the elderly in British Columbia, and haloperidol is also commonly used for acute agitation. Atypical antipsychotics are more commonly used on a chronic basis, but we know there is an association between antipsychotic medication use in dementia and greater mortality. While I hesitate to prescribe these unless absolutely necessary, sometimes it just is, in the interest of preventing the greatest harm. Physical restraints may be necessary while awaiting the calming effects of medications to kick in, but are even less desirable usually and they can stir up even more distress for the individual being physically restrained.
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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Behavioural Problems Key Feature 1: Because behavioural problems in children are often multifactorial, maintain a broad differential diagnosis and assess all factors when concern has been raised about a child’s behaviour:
Phase: Hypothesis generation, Diagnosis Key Feature 2: When obtaining a history about behavioural problems in a child:
Phase: History Key Feature 3: When treating behavioural problems in children for whom medication is indicated, do not limit treatment to medication; address other dimensions (ex: do not just use amphetamines to treat ADD, but add social skills teaching, time management, etc.). Skill: Clinical Reasoning Phase: Treatment Key Feature 4: In assessing behavioural problems in adolescents, use a systematic, structured approach to make an appropriate diagnosis:
Phase: Hypothesis generation, Diagnosis Learning (Patients) Key Feature 2: In children with school problems, take a thorough history to assist in making a specific diagnosis of the problem (ex: mental health problem, learning disability, hearing). Skill: Clinical Reasoning Phase: History, Hypothesis generation Key Feature 3: When caring for a child with a learning disability, regularly assess the impact of the learning disability on the child and the family. Skill: Patient Centered, Communication Phase: Hypothesis generation, Follow-up Key Feature 4: When caring for a child with a learning disability, ensure the patient and family have access to available community resources to assist them. Skill: Patient Centered, Clinical Reasoning Phase: Treatment, Referral Periodic Health Assessment/Screening Key Feature 1: Do a periodic health assessment in a proactive or opportunistic manner (i.e., address health maintenance even when patients present with unrelated concerns). Skill: Clinical Reasoning Phase: Treatment Today I saw three 4 year old kids who came into clinic with their parents for their routine vaccinations before entering kindergarten. These kids were impressive too - not a single one cried when I gave them their immunizations! Needless to say I was having a great day. All kids were healthy and without any history of significant medical concerns. During the last 4 year old visit, per my routine pediatric health check-up, I asked the patient's mom if she had any concerns. She described an odd tapping/pinching behaviour the child would do almost compulsively, which didn't sound so concerning but that was certainly out of the ordinary. I wasn't quite sure what to make of it, but I felt it was significant enough to warrant an assessment by a general pediatrician. At every pediatric check-up, I use either the Rourke Baby Record (ages 0-5 years old) or the Greig Health Record (ages 6-18 years old) to screen for any developmental or behavioural concerns, to promote wellness as opposed to just treating illness, and to obtain any screening investigations if indicated. These templates assess for medical conditions, psychosocial factors, and other developmental issues. I always make sure to include the child or adolescent's perspective as well, and in the latter case I always kick the parent/guardian out of the room to increase my ability to screen for certain issues such as domestic violence or sexually risky behaviours. When concerns are raised I also seek collateral information from other adults who look over the child or adolescent during the day, such as a main daycare or school instructor, as indicated. The reason for the comprehensive screening assessment is to be able to glance over the multitude of risk factors that may be contributing to behavioural concerns, which are more often than not a product of several interacting factors. That being said, it is important that treatments also focus on the multifactorial nature of behavioural concerns; it is rare if not impossible to find a pediatric behavioural concern that is best treated by medication exclusively. It is important to refer these children and adolescents for comprehensive assessments from specialised medical professionals and to build a team of interdisciplinary supports around them, as is feasible and available regionally, and as is tailored to the child's and family's values and interests. Although a small degree of difficult behaviour may be part of the natural development of children as they learn to explore boundaries and create an independent sense of identity, which is particularly true in adolescence, behavioural issues can also be very real manifestations of psychosocial precipitants or medical illness. Any behavioural concerns deserved to be explored and warrant some sort of intervention, whether it be parental reassurance or getting a whole team of community supports in place. As the primary care physician, it is important for me to recognize that issues that affect a child can really be affecting a whole family (not that this isn't true when adults have issues), and to check-in with how the rest of the family is impacted and how they are coping. It is also my job to ensure they have access to useful community resources that may help given their particular set of circumstances. |
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