Event ID:2840643
Event Started:1/12/2016 1:45:34 PM ET
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Good afternoon. We will go ahead and get started. Happy New Year, welcome back. Use made it through the midway point of dementia antipsychotic in the Long Term Care Setting quality improvement initiative. This is a partnership between University Medical Center, Vanderbilt University Medical Center, Center for Quality Aging and [Indiscernible] in Tennessee. This is Shasta number four co-principal's of non-pharmacologic management and the formulation of Behavioral Care Plans. If you have missed the earlier presentations, those are available on our website. There is a look at the upcoming presentations. You should be seeing our projects website pop-up in chat pane which depending on how you're screen is set-up will either be on the right-hand side or the top of your screen. We will have our phone lines are needed during presentation. It provides a better listening environment. If you have questions or comments for our presenters, please use the chat feature to connect with us and brick will be monitoring that today. -- Britt Kuertz will monitor to Bay -- today. Type in facility name and how many people at your facility are viewing this webinar to check out the chat pane. As you type that end, Britt Kuertz will feed helpful information and links during the presentation. Also, have a few more Polling Question's. A attention for those to pop-up on your screen as well. -- pay attention for those to POP up on your screen as well. Today's presentation has a lot of examples and good in-depth information. We have back with us today Dr. Jim Powers, who is a lot of things. In most importantly is a geriatrician at Vanderbilt University Medical Center and overseas the residents on their geriatric rotation. He is a fabulous position and we are lucky to have him with us today.
Thank you, Emilee. I'd like to introduce my callee, Carrie Plummer, who helped to produce this session. She is not able to be with us today but one of four colleagues, Anna Cook, Nurse Practitioner will comment on the slides. This is our fourth transportation, principles of non-pharmacologic management of behavioral disturbance in dementia and the formulation of Behavioral Care Plans. I hope that as we present you will think of patients, residents that you care for that have had behavioral problems in not only the difficult patients but your success stories. We would like to hear from you in future presentations to discuss some of these cases. We think having experiences that our authentic and alive from the field will be very helpful for our colleagues. This would be the identified of course but we have a team of experts that will be reviewing the submissions. We have [Indiscernible] physicians. To our geriatric and to practitioners, psychiatric practitioners who will be reviewing these cases. I will come back to that. The objectives of this session are to review the contexts, causes and consequences of behavioral disturbances in dementia. Yes, we will go into depth looking at these behaviors. Both the [Indiscernible] and consequences of the behavior's as well as approaches to the behaviors. Number two, we will discuss the basic principles of non-pharmacologic interventions. There are many of them and we will refer you to good resources that will also be posted on our website for you to think about and individualized in making patient-centred care plans. Number three, how to create a behavioral care plan. We know that the surveyors are going to be looking for evidence of expertise, as well as competency in using Behavioral Care Plans and modifying them. We will discuss that in cases we present. This is a very rich slide talking about the context, causes and consequences of behavior. Think about the context. Most people with dementia will suffer from some form of behavioral disturbances. This probably increases as the resident progresses from mild to severe Alzheimer's disease but it may be self-limited. The duration and intensity will be very individual. There are going to be personal and environmental and chronological, maybe even psychological component to the context. We will give examples for all of these categories because I know you are experiencing them in the field. The consequences of the behavior is also very complex. There is a lot of distress not only for the care provider but, yes, for the resident as well. They are distressed and behaviors are manifestations of that distress. We know difficult behaviors create a burden for care givers and liabilities. We are very much aware of that. The fact there are so many patients who are prescribed antipsychotics means that these are very difficult behaviors sometimes to control. We also know from previous presentations that antipsychotics can have many negative side effects and that we, as a country, prescribed them to frequently for dementia patients in long-term care. The causes of the behavior take a lot of understanding on the part of all of us as Providers. Will we know our patients will, when we are patient-centred, we try to find specific reasons for behaviors. It can take a lot of creativity, sometimes a lot of teamwork and information from the family to really understand the behavior. Paying is a very common cause. It can start with physical causes. The patient may not be able to Express the pain verbally. It may be non-verbal cues. In fact cues that pain is ongoing and you have to suspect something might be a problem. This can be a problem related to an infection, perhaps constipation, perhaps due to medication. Perhaps to be due to a fall. You can see you have to be very creative and very good diagnostician to come up with the answer. Also in terms of psychological causes. Loneliness and boredom are easy to understand but how about the loss of intimacy? Patient does not remember their widow or, perhaps, haven't seen their family for a file or maybe it is a new admission to the facility, and they are adjusting to that. This can take many weeks and months, as many of you know. Think also about environmental causes. Overstimulation or perhaps lack of a new environment being indoors, not having a real awareness of the passage of the day, this season can be very difficult for patients. Overstimulation as well. Being in a room of other individuals who have their own needs or, perhaps, to much noise. These are all things that can be detrimental to a patient dementia. Disorientation is also very common. Particularly, with new locations, the room changes, the roommates and personnel. Perhaps institutional routines can conflict with time valued routines care the individual may have, self-care and sticking to a timeclock sometimes does not always jive for a dementia patient. There can be emotional psychiatric in terms of the major you can also have depression, anxiety. And with a new medical probable pain, delirium can also be a component. Approaching the patient or resident with behavioral disturbance really takes a well-rounded approach and can include some or all of the issues of the causes we have discussed. The principles of non-pharmacologic management are inherently person-centered. Tailored to each patient specific behaviors and the to, including causes and situations involved. It often involves a team approach to understand the behavior itself and to come up with creative solutions. This includes the resident to the extent they can participate in expressing their needs and desires and preferences, as well as the family. This staff as well. This includes direct care staff, of course, our very important. They are up bedside but also social services, activities, nurses, nursing directors too really come up with an approach that's going to work for that individual. This Person-centered approach should be attempted before using medications. It is, obviously, something that requires reassessment. We recommend strongly the act, plan, do and study cycle, continuous process of quality improvement. Did it work? Do we have new information that makes the plan different now? Can we be Institute back next, we update are care plans. All critical factors involving a Person-centered approach of behavioral problems. We would recommend using stepwise approach to developing non-pharmacologic management strategy for the individual behavior that is expressed. First of all, ask the right question. Pick out the behavior that is of concern. The fine that problem behavior. This might be a frequency. It might be the time. Very important to describe behavior accurately to answer that question. What is the specific problem going on with that individual? Assess the behavior. Look and see if it has been expressed before. Perhaps it is a new behavior in response to new environmental challenges. Institute environmental modification if at all possible. Think of that. It might be a room changes necessary. Might be a roommate is -- we may change is necessary. We will have examples as we go along. Implement your treatment strategy. Identify which may be best approach for this individual. Implement it, studied the response and make adjustments as needed. Stepwise land times from University of Iowa adapt program. We will be talking about other tools they have developed. These will be appended to our website for all to access after this presentation. The University of Iowa adapt program is a Non-Drug Management Pocket Guide for improving antipsychotic appropriateness in dementia patients. This also is a complicated slide. However, it does in a very thumbnail sketch fashion show you a lot of different strategies to evaluate to treat and to monitor patients behaviors. This again well be on the website. We will go into detail on certain parts of it but I thought you would like to see this, even though it's on a small slide. Thank you.
It has three steps. Step one: Identify, assess, treat contributing factors to the behavior. Step two: Select and apply non-pharmacological interventions. Step three: Monitor outcomes and adjust course as needed. Yes, we will give examples of these. That is the basic strategy. How do we identify, assess and treat the behavior? Step one. First of all, focus on one behavior at a time. Determine the behavior that needs to be assessed. What does it look like? Provide details so that others will be able to recognize the behavior. How long does it happen, the duration? How often? What is the frequency? How severe is this behavior, the intensity of the behavior. Very important to really describe the behavior that is of concern. The next step is identify what triggers the problem. Others call this the antecedent to the behavior. Antecedents can be viewed as predictors of the behavior. If we know when the behavior will occur and we can prevent it from happening, hopefully, what preceded the behavior? What precipitated it? Was it an individual? With the different people? Who? Where? Was at a certain place or environment? Maybe the dining room. The time of day. When? Activities that not be taking place at the same time -- activities that might be taking place at the same time. The next step is reduced/eliminate the triggers. Look at the consequence of the behavior's. Consequences are not always negative but they lead to maintaining behavior. Is there reinforcement? Is there something being taken away that increases the behavior? Person specific in terms of looking for the reinforcement. Our there any punishers? Anything that's given or taken away that increases the behavior? This can also be very person-centered. Also look at any consequences that start a behavior that may not be the consequences, situation specific. These are all very important strategies to hold down on that. And of course, document outcomes and make changes as necessary. We focus on one behavior at a time such as frequency. Is it once a day are many times a day. For duration, is it a few minutes or throughout the entire process like taking a bath or getting dressed. And the intensity. Is it mild or really bad today? Describe the specific details and characteristics of the behavior in your charting as well as you're care plan. To identify, assess and treat, ask the team what is causing the problem behavior. Does anybody know what is making it worse? It may be the nurses aide who has the key information. Is it time of day? Perhaps the type of care being provided? Are some staff better able to resolve the issue and calm the resident? If so, what do they go? What strategies are they using? All very important to share with the colleagues to take better care of the patient. Yes, we have an example. We have a table that can be used. We are going take a generic, Mrs. Smith, with a targeted behavior of screaming. We will look at the duration of the behavior, thankfully, just a brief episode here but very disturbing to all, including Mrs. Smith when it does happen. Let's look at the frequency. My word, it's happening many times a day, and they're doesn't seem to be a real predominance, does it. It seems to be all of the time and the intensity is all over the map. This is helpful, perhaps in terms of describing may not be in terms of addressing it. It's going to take creative strategies them all of the staff thinking about what's going on in the day shift, the Evening Shift, to try to get through all of this. Constancy may [Indiscernible] there is a constancy going on even though screaming goes on throughout the day. Identify what leads to these trigger problems. Others, interventions -- assess the tools here to use. Back to what we talked about before. Physical, could it be playing? Could it be a new infection or illness? Could it be medication side effects or sleep disturbances? Incontinent can do this throughout the day as we saw in Mrs. Smith chart. It can occur many times throughout the day. It can be only one trigger. Certainly, the solution is more straightforward. Environment, can it be the type of stimulation such as noise, lighting or, perhaps, lack of lighting? Maybe it is the approach certain staff have toward this individual. Some be able to approach the patient in a caring way that does not stimulate resistance and others, well-meaning, might just have a different approach not acceptable to this individual. Could be routines and expectations of the institution. It's time to get dressed. It's time to have breakfast. It's time to take a bath. Maybe lack of cues or prompts to warn the patient that it's time to go to lunch. It's time to go to bed. Also look at the triggers that lead to these problems in terms of psychological or psychiatric components. Could it be loneliness? Could this be a new submission? That there be some fears or worries that maybe there would be no visits from the family member? Family, perhaps other staff through the day make it more information and putting that information together in a team approach may make solutions are reasonable explanations for the behavior. It could also be co- depression or anxiety or mental illness superimposed on the dementia.