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Vanderbilt & atom Alliance Webinar Series Vanderbilt University - - PowerPoint PPT Presentation
Vanderbilt & atom Alliance Webinar Series Vanderbilt University - - PowerPoint PPT Presentation
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 &
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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
- f Psychiatry, Nursing, and Medical Directors
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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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How many people are in the room with you to
view this webinar? (Please answer in the chat pane, and be sure to include your full facility name)
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Ralf Habermann, MD Jennifer Kim, DNP Paul Newhouse, MD James Powers, MD David Schlundt, PhD Warren Taylor, MD
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David Schlundt, PhD
Focus Group Facilitator
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Psychiatry Nursing Medical Directors
Jennifer Kim, DNP Warren Taylor, MD Paul Newhouse, MD Jim Powers, MD Ralf Habermann, MD
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Review challenges described by focus group
participants
Identify and address barriers from each
professional perspective
Series Summary
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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
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Focus groups at 3 nursing homes Homes had successful strategies
for managing antipsychotic medications
Average Star Rating: 4.3 Average prevalence rate: 19.4% Total of 29 participants including
full time employees, contract employees, and intern
11 4 3 3 2 2 2 2 LVN/ LPN Social Worker DON RN Nurse Practitioner Certified Nurse Aide Administrator Other
Participants' Professional Background
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Prescribing Pathways
Admitted on antipsychotics Disruptive and Dangerous Behaviors Psychiatric diagnosis
Evaluation/ Differential Diagnosis
- Rule out delirium
- Underlying physical causes
- Social isolation
- Dementia
- Validating need for meds
- Medication review
Management
Behavior Management Strategies
- Redirection
- Increased social contact
- Specific tasks
- Staff collaboration
- Shift transition
- Behavior tracking
- Family consultation
- Intensified caregiving
Medication Reduction
Benefits
- Improved quality of life
- Prevent falls and injuries
- Eat and sleep better
- Quality indicator improved
- Happier families
Barriers
- 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 and resources
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Improved quality of life Prevent falls & injuries Eat and sleep better Quality indicator improved Happier families
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“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.”
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“Did you talk about the difference [in falls] now that she's off of [the antipsychotic medication] it?”
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“There's a lot of pros. The pharmacy stops breathing down your neck. Administration is happy because the numbers look better.”
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‘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.’
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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
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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.”
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“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.”
Family resistance
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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.”
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Agitation, anxiety, mania Withdrawal symptoms Repeated failures
“They’ve been on it so long, and you take them
- ff, and once you bother that medication they
get manic and it takes a while to get them back stable.”
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Violent disruptive behavior Disturbs other residents Staff risk averse Repeated failures Lack of staff & resources
“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.”
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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.”
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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.”
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“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.
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“We know how to manage this”: Overconfidence in
- utdated 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.
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- 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)?
A.
No need to change management, she's doing fine.
B.
She is clearly over treated and thus all psychotropic medication should be immediately stopped and she should be monitored.
C.
Her antipsychotic medication should be gradually tapered and her behavior monitored.
D.
Anti-dementia medication such as donepezil should be added now.
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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
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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
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Blame culture Safety concerns with agitation & aggressive
behaviors
Staffing shortages Busy shift, working with unpredictable
population fear of interruption in routine
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Family concerns:
- If behavior is not controlled, then resident may be
transferred to another facility
- That medication reduction may cause the return
- f problem behaviors
Transition from Hospital to SNF
- Unclear discharge orders
- Family/ Staff reluctance to change the “specialist
hospital” orders
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When a patient arrives at your facility already taking an antipsychotic medication, what is a reasonable first step to evaluate whether that medication should be reduced?
A.
Get history of psychiatric illnesses from family
B.
Review hospital discharge paperwork
C.
Monitor behavior to determine whether there appears to be a need
D.
All of the above
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On-going staff education/ training Include family and staff in care planning Good communication between all members
- f the care team
Assess and adjust staffing as needed (charge
nurses and CNAs)
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Behavioral disturbances are a common feature of
dementia
- Context often determines how behavioral disturbances are
expressed
Psychotropic medications may play role in managing
behavioral disturbances
- These medications all have risks
- It is important to have ongoing re-evaluations of their
continuing need in each patient
- Medication should be used after or in concurrence with
behavioral interventions
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Step 1: Identify, Assess, Treat Contributing Factors Step 2: Select & Apply Non- Pharmacological Interventions Step 3: Monitor Outcomes & Adjust Course as Needed
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