Vanderbilt & Qsource Webinar Series
Vanderbilt University Medical Center Vanderbilt University Center for Quality Aging Qsource
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 Paul Newhouse, MD Ralf Habermann, 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
Focus groups at 3 nursing homes Participants' Professional Background Homes had successful strategies for managing antipsychotic medications Average Star Rating: 4.3 Other Administrator Certified Nurse Aide Nurse Practitioner 2 2 2 2 Average prevalence rate: 19.4% RN 3 Total of 29 participants including full time employees, contract employees, and intern DON Social Worker LVN/ LPN 3 4 11
Prescribing Pathways Admitted on antipsychotics Management Evaluation/ Differential Diagnosis Rule out delirium Underlying physical causes Social isolation Dementia Validating need for meds Medication review Medication Reduction Benefits Improved quality of life Prevent falls and injuries Eat and sleep better Quality indicator improved Happier families Disruptive and Dangerous Behaviors Psychiatric diagnosis Behavior Management Strategies Redirection Increased social contact Specific tasks Staff collaboration Shift transition Behavior tracking Family consultation Intensified caregiving 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
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 Disturbs other residents Repeated failures 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)? 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.
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
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
On-going staff education/ training Include family and staff in care planning Good communication between all members of the care team Assess and adjust staffing as needed (charge nurses and CNAs)
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
Step 1: Identify, Assess, Treat Contributing Factors Step 2: Select & Apply Non- Pharmacological Interventions Step 3: Monitor Outcomes & Adjust Course as Needed
Emily Hollingsworth Emily.K.Hollingsworth@vanderbilt.edu Project Website: www.vanderbiltantipsychoticreduction.org Vanderbilt Center for Quality Aging www.vanderbiltcqa.org 615-936-1499