Behavior Modification of Pica in a Geriatric Patient

Abstract

To the Editor:—The geriatrician is likely to be unfamiliar with pica, the eating of non-food items such as dirt, leaves, or cigarettes, since it is usually considered to occur only in children who are malnourished or developmentally delayed.1,2,3 In contradiction to the notion that pica is a disorder of childhood, recent data on the prevalence of pica in the mentally retarded shows the highest rate with geriatric patients; 39% in age 71 and older compared to 14% in ages 41 to 60; and 29% in ages 11 to 40.2 Pica is also more frequently encountered as the level of cognitive ability decreases.2 Significant medical complications secondary to pica frequently occur, including reduction in vitamin intake, presence of gastrointestinal parasites, and intestinal obstruction. This report presents what is believed to be the first report of the diagnosis and management of this disorder in a geriatric nonmentally retarded patient. Our patient was a 70-year-old white male with the diagnoses of organic brain syndrome, chronic undifferentiated schizophrenia in remission, a history of alcohol abuse, tardive dyskensia, plus several other nonpsychiatric medical disorders. His disorder involved eating styrofoam coffee cups, paper, and cigarette butts. The patient proved unresponsive to psychopharmacology, substitutions with appropriate chewing materials, ie, gum, candy, or a pipe, and instructions to stop. In the month preceding our treatment program the patient's ingestion of nonfood articles resulted in an upper gastrointestinal bleed requiring transfer from a long-term care ward to an acute care medical ward for several weeks. The treatment plan developed for this patient, centered around the behavior modification technique of brief physical restraint.4,5 While this procedure has been shown effective and without negative side effects when used in a developmentally delayed population, this is the first known application of the procedure to a geriatric nonretarded patient. Treatment occurred during three ten-minute sessions randomly spaced throughout the day. During these sessions a registered nurse and nursing assistant worked in pairs; the registered nurse supervised the treatment and kept behavioral records while the nursing assistant administered the brief physical restraint. When pica was observed, the following plan was used: (1) ask patient to remove nonfood items from his mouth, manually if necessary; (2) tell patient in matter-of-fact tone “(Patient's name) you can't eat (object name)”; (3) nursing assistant holds patient's arms at his sides for ten seconds; and (4) patient is released from restraint. The procedure is instituted immediately after the next incident of pica is observed. In order to determine the efficacy of this treatment, levels of pica and aggression were monitored using a procedure modified from Winton and Singh5 within a single subject experimental design with the following components; baseline, treatment, baseline, one month no treatment, baseline, and one month later a treatment fading condition using one ten-minute session daily. The results of our case study suggest that brief physical restraint may be as effective a treatment approach for geriatric cognitively impaired patients as it is for mentally retarded patients. The reductions in time spent in pica, 88% at second baseline, 99% at third baseline and 98% during the fading procedure, are equivalent to the success rates reported in the retardation literature. An additional measure of the success and clinical utility of the treatment program is that the patient has not required acute care hospitalization for pica-related complications since the brief physical restraint procedure was initiated. Monitoring the patient's level of aggression gave no indication of increased levels of aggression as a long-term side effect. Rather predictably, a minimal increase in aggression was noted only during the first treatment condition rising from an initial baseline level of 1% to 11%, falling back to 1% during all subsequent sessions. Several other positive changes were anecdotally noted by ward staff. The most striking of these is the patient's increased compliance with requests to remove nonfood objects from his mouth. The patient was also noted to show a posttreatment increase in appropriate interpersonal behavior such as saying “please” and “thank you.” In summary, the results of this study parallel those of brief physical restraint treatment of mentally retarded patients in terms of effectiveness and lack of negative side effects. While this disorder can appear baffling and untreatable, by using a behaviorally oriented conceptual approach it becomes a more manageable disorder.