Vanderbilt & atom Alliance Webinar Series
Vanderbilt University Medical Center Vanderbilt University Center for Quality Aging atom Alliance
Session #1: Introduction to Dementia Care & QAPI Session #2: Dementia & Behavioral Disturbances Session #3: Psychopharmacology in the Nursing Home Session #4: Principles of Non-pharmacologic Management & the Formulation of Behavioral Care Plans Session #5: The Implementation of Behavioral Strategies & the Management of Pharmacologic Interventions Session #6: Addressing Barriers to Change: the Perspective of Psychiatry, Nursing, and Medical Directors
Chat Monitor: Emily Long, BS Emily.a.long@vanderbilt.edu Moderator: Emily Hollingsworth, MSW Emily.k.hollingsworth@vanderbilt.edu 615-936-2718
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Ralf Habermann, MD Jennifer Kim, DNP Paul Newhouse, MD James Powers, MD David Schlundt, PhD Warren Taylor, MD
Focus Group Facilitator David Schlundt, PhD
Psychiatry Nursing Medical Directors Warren Taylor, MD Jim Powers, MD Jennifer Kim, DNP Ralf Habermann, MD Paul Newhouse, MD
Review challenges described by focus group participants Identify and address barriers from each professional perspective Series Summary
What is the most common barrier to reducing antipsychotic medications in your facility? A. Family reluctance B. Lack of staff or resources C. Severity of behaviors D. Staff resistance E. Lack of knowledge about problem behaviors & behavioral techniques
Participants' Professional Background Focus groups at 3 nursing homes Other 2 Homes had successful strategies for managing antipsychotic Administrator 2 medications Certified Nurse Aide 2 Average Star Rating: 4.3 Nurse Practitioner 2 Average prevalence rate: 19.4% RN 3 DON 3 Total of 29 participants including full time employees, contract Social Worker 4 employees, and intern LVN/ LPN 11
Medication Reduction Management Prescribing Pathways Evaluation/ Differential Diagnosis Benefits • Rule out delirium • Improved quality of life • Underlying physical causes • Admitted on Prevent falls and injuries • Social isolation • Eat and sleep better antipsychotics • Dementia • Quality indicator improved • Validating need for meds • Happier families • Medication review Disruptive and Dangerous Behaviors Barriers • Family resistance • Changes in eating, sleep Behavior Management • Agitation, anxiety, mania Strategies • Psychosis, delusions, • Redirection hallucinations • Increased social contact • Violent disruptive behavior • Specific tasks Psychiatric • Withdrawal symptoms • Staff collaboration • diagnosis Disturbs other residents • Shift transition • Staff risk averse • Behavior tracking • Repeated failures • Family consultation • Lack of staff and resources • Intensified caregiving
Improved quality of life Prevent falls & injuries Eat and sleep better Quality indicator improved Happier families
“ Her behavior was erratic, sometimes obscene. [Since we took her off Seroquel], it took a while but it's been a turnaround. She's responsive, she'll say hello when you walk in, she acknowledges your presence there. She's not as lethargic anymore, she's actually more engaged.”
“ Did you talk about the difference [in falls] now that she's off of [the antipsychotic medication] it ?”
“ There's a lot of pros. The pharmacy stops breathing down your neck. Administration is happy because the numbers look better.”
‘Usually the families are a really good indicator … They’ll usually be the first to tell you like, “I stopped in to see mother, and she is a totally different person.” They’re a really good source, because they know the patient better than we do.’
Family resistance Changes in eating, sleep Agitation, anxiety, mania Psychosis, delusions, hallucinations Violent disruptive behavior Withdrawal symptoms Disturbs other residents Staff risk averse Repeated failures Lack of staff & resources
Family resistance Withdrawal symptoms “…. sometimes families are a barrier to not wanting their family members to come off of a med, because they’ve been on something for so long. They don’t want to upset the apple cart, so to speak.”
Family resistance “ We found a lot of family dynamics, sometimes with the families and how they react to what you're doing or what needs to be done, that they're unrealistic of the problems that's happening at that time .” “A lot of times I hear Dr. so and so said never let anyone take your Mom off that drug. I've had families often tell me that. Oh, okay, well.”
Changes in eating, sleep Agitation, anxiety, mania Psychosis, delusions, hallucinations “Not sleeping, not eating.” “Suspicious of everybody and everything.” “She had been tapered off and her delusions or hallucinations returned and they were even worse.”
Agitation, anxiety, mania Withdrawal symptoms Repeated failures “They’ve been on it so long, and you take them off, and once you bother that medication they get manic and it takes a while to get them back stable.”
Violent disruptive behavior Repeated failures Disturbs other residents Lack of staff & resources Staff risk averse “How much can you tolerate behaviors? How much does it put the facility at risk? Are the residents at risk? Is the resident themselves that's taking the medication at risk? I get a lot of pressure at some facilities about how much they can tolerate reducing them.”
Disturbs other residents Lack of staff & resources “ When somebody yells at night, and you've been through everything, and antipsychotics is the only thing that's left. You've got a whole hallway full of people that can't sleep because one person is up and yelling, you run out of options pretty quick and you get a lot of pressure that's provided from some facilities .”
Family resistance Staff risk averse “In our practitioner role it is sometimes difficult for me as a contract worker because I'm not their doctor. I'm making recommendations, ultimately maybe the doctor is comfortable with me making that change myself. If the family fights it I don't really have a choice. I have to defer back to the doctor.”
“Don’t they all do that?” : Lack of knowledge about behavioral problems in dementia. “ That’s psych” : Staff/MD show unwillingness to manage behavioral problems except with sedative medication. “If it ain’t broke, don’t fix it” : Inertia to change the approach, especially use of older antipsychotic medication.
“We know how to manage this” : Overconfidence in outdated approaches managing behavioral disturbances (restraint, sedation, etc.). “ These approaches are too complex/take too much time” : Over-reliance on medication to treat problems that can be ameliorated with non-medical approaches. “But that’s what they came in on” : Staff must feel able/empowered to reassess need for psychiatric medication following admission/re-admission.
Mrs. S is an 83 year old woman with dementia is transferred to your nursing home from home. She is taking an antipsychotic medication several times per day as well as an antidepressant and an anti-anxiety drug. She's very quiet and needs to be helped to walk and with most activities of daily living and feeding. Family reports that she was very agitated at home. What management strategies should be considered (best answer)? No need to change management, she's doing fine. A. She is clearly over treated and thus all psychotropic medication should B. be immediately stopped and she should be monitored. Her antipsychotic medication should be gradually tapered and her C. behavior monitored. Anti-dementia medication such as donepezil should be added now. D.
How long can it take to see the effects of medication changes in older dementia patients? A. 3 days B. 1 week C. 4 weeks D. 3 months
When antipsychotics reduce behaviors why are they “bad”? No continuing education about risks of antipsychotic medications Not invited to patient care discussions & planning Burdensome patient assignments Care can become reactive
Blame culture Safety concerns with agitation & aggressive behaviors Staffing shortages Busy shift, working with unpredictable population fear of interruption in routine
Family concerns: If behavior is not controlled, then resident may be transferred to another facility That medication reduction may cause the return of problem behaviors Transition from Hospital to SNF Unclear discharge orders Family/ Staff reluctance to change the “specialist hospital” orders
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