COMPASSIONATE CARE IN RESIDENTIAL AGED CARE FACILITIES IN A COVID 19 - - PowerPoint PPT Presentation

COMPASSIONATE CARE IN RESIDENTIAL AGED CARE FACILITIES IN A COVID 19 WORLD

S U S AN KU RRLE

G E R I A T R I C I A N

H O R N S B Y K U - R I N G - G A I A N D E U R O B O D A L L A H E A L T H S E R V I C E S C U R R A N P R O F E S S O R I N H E A L T H C A R E O F O L D E R P E O P L E , F A C U L T Y O F M E D I C I N E , U N I V E R S I T Y O F S Y D N E Y

S U S A N . K U R R L E @ S Y D N E Y. E D U . A U 26th May 2020

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ROYAL COMMISSION INTO AGED CARE QUALITY AND SAFETY

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ROYAL COMMISSION INTERIM REPORT 2019

“A Shocking Tale of Neglect”:

• ‘Dreadful’ food, nutrition and hydration
• Inadequate wound care
• Poor continence care
• High use of physical restraints
• Overprescribing of psychotropic medications
• Low availability of palliative care
• Aged care is built around funding mechanisms, process

and procedures….not care needs

The antithesis of compassionate care

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COMPASSIONATE CARE

• ‘noticing, feeling, and responding to suffering’
• ‘intelligent kindness’
• care based on empathy, respect and dignity
• pity and concern for the misfortunes of others
• compassion underpins caring:
• understanding what is important to the other person
• understanding what the other person is going through
• acting to alleviate suffering in a selfless way

Florence Nightingale:

• “Gentleness, kindness, courtesy, compassion”

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COMPASSIONATE CARE IN A COVID WORLD

• Lack of compassionate care towards RACFs:
• acute hospitals planning to decline admissions from RACFs
• acute hospitals providing ‘hospital in the home’ to residents with Covid 19 to

prevent ‘unnecessary admissions’ when residents may have benefitted from hospital care

• Lack of compassionate care within RACFs
• RACFs refusing access to family members of dying residents
• RACFs not prioritising residents’ emotional needs above general
• rganisational safety and not allowing close family members to visit despite

government guidelines

• Tale of 2 mothers

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COMPASSIONATE CARE IN A COVID WORLD

• Communication and connection
• The importance of physical presence

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COMPASSIONATE CARE IN A COVID WORLD

• Communication and connection
• The importance of celebration and remembering

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COMPASSIONATE CARE IN A COVID WORLD

• Animal Assisted Therapy
• There is no evidence that domestic dogs (or chicks or alpacas) spread COVID19

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COMPASSIONATE CARE IN A COVID WORLD

• Getting some fresh air

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INTERGENERATIONAL PRACTICE IN AUSTRALIA

• Programs bring people from different generations together to participate in

purposeful activities that are beneficial to all involved

• Aim is to reconnect generations that may have lost touch
• Research has shown that for older people, the programs have had a positive

impact on their health and well-being; the programs have sparked enjoyment and improved mood, and have given them a sense of purpose, all of which may contribute to delaying the cognitive decline.

• For children, there has been an increase in confidence and communication skills
• Can implement in many different models:
• Colocated child care/pre-schools and aged care
• Visiting models
• Playgroups visiting aged care facilities
• Baby groups visiting aged care facilities
• Day care – children and adults together

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COMPASSIONATE CARE IN A PRE-COVID WORLD

• Concept of Intergenerational Care
• The ABC documentary series ‘Old People’s Home for 4 Year Olds’ was an example
• f an intergenerational program which aimed to improve well being, physical

activity, and socialisation amongst older people living isolated lives in residential care, and to improve confidence, and communication and speech skills in pre- school children

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COMPASSIONATE CARE IN A PRE-COVID WORLD

• During the series we witnessed the effect of the intergenerational program on

participants old and young

• Increased mood and feelings of pleasure, and physical activity in older participants
• Increased confidence to interact with older people, and improved language skills,

and awareness of older people in the pre-schoolers

• The benefits of cooperation when doing things together such as painting or cooking
• r counting

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COMPASSIONATE CARE IN A PRE-COVID WORLD Effect on physical frailty:

• A pre-post interventional study of frail and pre-frail older people living in a

retirement village in supported accommodation

• N = 11, mean age 87.3 years (range 78-95)
• Primary outcome: walking speed, HGS, tandem stance
• Intervention over 7 weeks: interaction with 10 4 year olds
• Clinically and statistically significant improvement in all primary outcome measures

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ABC 2019

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AWARD WINNING COMPASSIONATE CARE

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COMPASSIONATE CARE IN A POST-COVID WORLD

• Intergenerational care through playgroups meeting in aged care

facilities

• Need adequate space and tables and chairs
• (Physical distancing may be difficult)
• Need coordinator at aged care facility
• Benefits to all participants – children, parents, older residents
• See: agelessplay.com.au

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COMPASSIONATE CARE IN A COVID WORLD

Management of Behaviours and Psychological Symptoms of Dementia (BPSD)

Aged Care Royal Commission noted that this was a major area of concern, with physical restraint and high doses of psychotropic medication being widely used

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COMPASSIONATE CARE IN A COVID WORLD

BPSD occurs in around 95% of people with dementia – agitation, aggression, wandering, hallucinations, delusions, apathy, elation, disinhibition, sleep changes

Compassionate care underpins management of these distressing symptoms:

• ‘noticing, feeling, and responding to suffering’
• ‘intelligent kindness’
• care based on empathy, respect and dignity
• Understanding what sits behind the behaviours, and what are the causes
• Knowing the person and their background is key to appropriate management

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COMPASSIONATE CARE IN A COVID WORLD

An approach to management of behaviours:

• 1. look at acute medical factors – delirium, UTI, RTI, drugs, hypoxia,

constipation, pain

• 2. look at chronic medical factors – pain and discomfort, heat, cold (most people

get grumpy when they are in pain)

• 3. ask what is happening in the brain – the worse the dementia, the more severe

the behaviours eg frontotemporal dementia often results in apathy or disinhibition

• 4. ask what is the person trying to tell you with the behaviours – resistive

behaviour with personal care may be due to embarrassment, misinterpretation

• f staff intentions, self defence
• 5. look at environment – noisy, boring, hard to navigate, confusing

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COMPASSIONATE CARE IN A COVID WORLD

Environmental interventions:

1. Provide a predictable routine 2. Separate noisy and disruptive persons for quieter persons 3. Provide a safe environment - use security doors, etc 4. Use a night light 5. Provide orienting stimuli 6. Provide bright enough daytime lighting

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COMPASSIONATE CARE IN A COVID WORLD

Behaviour interventions:

1. Reduce isolation, talk to patient to distract from frustration 2. Identify specific precipitants 3. Experiment with targeted changes to schedule and environment 4. Provide reassurance 5. Allow patient to wander if secure environment 6. Encourage pleasant experiences

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COMPASSIONATE CARE IN A COVID WORLD

Recommended therapy alternatives for BPSD:

a) Only after a reasonable trial without medication b) Consider a trial of analgesia in a stepped approach if pain is an issue c) Consider using SSRI (e.g. citalopram 10-20mg) first for 6-8 weeks d) Risperidone is the only oral antipsychotic approved for use in BPSD (in Australia) – aggression and psychotic symptoms 0.5-1.5 mg/day e) Use should be restricted to 3 month trial (as per PBS) and then reviewed and possibly discontinued Always gain consent from the resident, or the substitute decision maker

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COMPASSIONATE CARE IN A COVID WORLD

Understanding the person and treating the cause:

• Treatments focused on understanding the cause of BPSD seem as effective

as those relying on drugs and are associated with reduction in psychotropic usage

• Person-centred care strategies are more effective than usual care in reducing

agitation

• Always consider undiagnosed pain as a cause of agitation or aggression

24 DBMAS 18 1800 699 799

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COMPASSIONATE CARE IN A COVID WORLD

MR GREEN

• 82 year old man, moderately severe mixed dementia, resident in aged care facility

for 3 years

• Minimal language, not recognising family, required assistance with all ADLs,

unable to mobilise independently

• Would often call out ‘help me’ when he was thirsty or uncomfortable and needed

repositioning, staff usually able to respond to his needs

• Began calling out constantly every few minutes and was given extra analgesia as

staff thought he was in pain from arthritis

• Calling out continued for several days, developed diarrhoea, not eating or

drinking much, not responding to attention from family or staff

• Rectal examination indicating faecal impaction with overflow diarrhoea
• Analgesics ceased, aperients and fluids started, good response to Fleet enemas

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COMPASSIONATE CARE IN A COVID WORLD

RESIDENTIAL AGED CARE FOR PEOPLE WITH DEMENTIA What is the best model of residential care for people with dementia?

• Traditional institution style or domestic homelike style?
• In a study of 541 older people (most with cognitive impairment or dementia)

across 17 facilities in 3 Australian states, the homelike model of care (aka cottage model) showed significantly higher quality of life and quality of care, lower hospitalisations (particularly presentations to ED), and lower psychotropic medication use, and cost less than the traditional institutional model

https://cdpc.sydney.edu.au/research/care-environment-and-quality-

• f-life/models-of-care

versus sus

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COMPASSIONATE CARE IN A COVID WORLD

WHAT WAS IMPORTANT TO RESIDENTS?

• Small unit size (< 15 residents)
• Access to outside areas independent of staff
• Staff member allocated to resident to provide continuity
• f care
• Meals prepared in the unit kitchen
• Residents assist in meal preparation and other household

tasks such as clothes washing, sweeping

Dyer et al (2018) Med J Aust 208 (10): 433-438. doi: 10.5694/mja17.00861

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COMPASSIONATE CARE IN A COVID WORLD

EVERYDAY DECISION MAKING

• We all make choices every day, some

independently, some with advice or assistance from others, some simple, some complex

• Currently concept of substitute decision

making when we have difficulty making decisions – power of attorney, guardianship

• Need to move to concept of supported

decision making 31

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SUPPORTED DECISION MAKING VS SUBSTITUTE DECISION MAKING

• Australia is a signatory to the UN Convention on Rights of Persons with

Disabilities which promotes supported decision making, defined as:

• “The process whereby a person with a disability is enabled to make

and communicate decisions with respect to personal or legal matters”

• Aims to maintain a person’s decision making ability, and create enabling

contexts to allow supported decision making to occur

• Commonwealth and state/territory legislation covers substitute decision

making (other than Victoria) not supported decision making

• Australian Law Reform Commission has provided guidance

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DECISION MAKING IN DEMENTIA

Mrs L, aged 82

2009: early dementia diagnosed, living independently on country property, driving, cooking, shopping, organised will and power of attorney with some advice from family solicitor, bought and sold property with input from accountant and stock and station agent, and from family 2012: some difficulties with major financial decisions, had forgotten some properties had been previously sold, family reported some forgetting of appointments, but generally making day to day decisions with minimal assistance and encouragement. 33

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DECISION MAKING IN DEMENTIA

2015: getting lost driving and licence revoked, family and farm manager supporting her to make decisions about buying and selling stock, planting crops etc, able to decide what to wear and eat, some assistance with daily activities, declined any assistance other than from family members 2017: needed to move into residential aged care which she chose (reluctantly) with advice from family and close friends 2019: very impaired short term memory, difficulty with day to day activities without assistance, but able to consent to minor knee surgery when explained by doctor, financial decisions made by daughters (power of attorney) respecting mother’s previously stated wishes 34

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THE REALITY

In CDPC Supported Decision Making in Dementia research project: “We’ve just been told that they haven’t got capacity, so they don’t get involved with any of their decision making. We don’t ever ask them, we always ask the next of kin.” (RACF Care manager) BUT the environment is changing:

• Consumer directed care with choice as a central tenet
• New single quality framework for aged care
• Availability of guidance on supported decision making for aged

care providers 35

SUPPORTED DECISION-MAKING

“…the process whereby a person with a disability is enabled to make and communicate decisions with respect to personal or legal matters” (United Nations, 2006)

A volun unta tary process ess About the person’s own decision Assisti isting ng person

• n to underst

stand nd Assisti isting ng person

• n to weigh

gh options

• ns

Assisti isting ng person

• n to commun

munica icate e choice ce Maintaining or building person’s decision- making ing abilit ity Cre reati ting ng enabl blin ing g contexts xts

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Australian Law Reform Commission, 2014

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SUBSTITUTE DECISION-MAKING: A LAST RESORT

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adapted with permission NSW Public Guardian, 2018

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HANDBOOK FOR CONSUMERS

https://cdpc.sydney.edu.au/research/planning-decision-making-and- risk/supported-decision-making/

Thank you

“Dear Nanna I hope you can go outside and see the birds again soon” Charlott tte e aged d 5

Thank you Cogn gnit itiv ive e Dec ecli line e Par Partner ershi ship p Cen entre cdp dpc.sydne .sydney.edu.au .edu.au