An Evaluation of a Training Program in Restraint-Free Care for Individuals

with Dementia Christina Garrison-Diehn, Clair Rummel, & Jane E. Fisher

Background

Disease. (Xu, Kochanek & Tejada-Vera, 2009)

Dementia is the leading cause of nursing home admission (Eaker, Vierkant, & Mickel, 2002).

70% of individuals with dementia are living in a nursing home at the end of their life (Mitchell, Kiely & Hamel, 2005)

Top reasons for nursing home placement: (Buhr, Kuchibhatla & Clipp, 2006)

Need for more skilled care

Dementia related behaviors

Background

Behavioral challenges:Agitation Repetitive vocalizationsAggression WanderingDelusional speech Depressed affectHallucinations Social withdrawal

Prevalence rates = over 60% (Lyketsos, et al. 2002).

Traditional Model of Dementia

Behavioral challenges = symptoms of neuropathology

Attribution of behavioral disturbances as a symptoms of dementia increases the risk of excess disability

Impairment in function beyond that which can be accounted for by the disease. (Dawson, Wells & Kline, 1993)

Frequency of adaptive behavior is diminished prematurely. (Fisher et al.,2007)

First line of treatment: antipsychotic medications

Antipsychotics

Most common treatment = antipsychotic medicationsPrescribed off-label

32-58% of nursing home residents are prescribed antipsychotics (Ronchon et al., 2007; Margallo-Lana et al., 2001; Kamble et al., 2009)

Typical: haloperidol, thorazineAtypical: risperidone, olanzapine

Moderate evidence of efficacy (Agency of Healthcare Research and Quality, 2007)

Antipsychotics

Adverse effects offset the advantages (Ballard et al., 2009; Schneider et al., 2006; Ballard & Waite, 2006).

Increased risk of:MortalityCerebrovascular adverse eventsExtrapyramidal symptomsUpper respiratory infectionsSedation & confusion

Premature reduction of adaptive functioningDecreased quality of life (Ballard & Margallo-Lana, 2004)

Contextual Model of Dementia

Behavioral challenges = inability to report private events & have needs met (Fisher et al., 2007)

Behavior communicates what words cannot

Intervention = medical assessment + environmental assessment

Evidence for contextual model: modification of the social and physical environment results in a reduction of these problems and a reduction in excess disability (Yury & Fisher, 2007; Burgio & Stevens, 1999; Buchanan & Fisher, 2002; Cohen-Mansfield & Werner, 1998).

Restraint Free Care Training Program Development

Quality and ComplianceGoals:

1. Increase staff knowledge of evidence-based practices for dementia care.

2. Reduce the use of psychotropic medications to manage behavioral challenges in residents with dementia.

3. Increase facilities ability to keep challenging residents.4. Improve quality of life for residents with dementia by

reducing excess disability and preserving adaptive functioning.

Restraint Free Care Training Program Development

Program characteristicsAvailable to long-term care facilities on a voluntary basisNo cost to the facilityNeeds assessment conducted pre-trainingTrain-the-trainer model10 hours of trainingConsultation services post-training

Aid in providing trainings to full staffBehavioral consultation for challenging cases

Satisfied state requirement for dementia training

Restraint Free Care Training Program Overview

Topics Covered:Stress of Dementia CareCommunication TechniquesExcess DisabilityAssessing PainDelirium

DepressionPromoting ChoiceDelusions and HallucinationsSexualityBehavioral Interventions

Structured trainings designed to include idiographic examples from each specific facility throughout the trainings

Program Timeline

Development & Recruitment

January 2010 April2010

Trainings Conducted

May 2010 November 2010

Data Collection Through April 2011

Facility Characteristics

FacilityType

N Residents on AntipsychoticMedication Pre Training

Residents on Anti-anxiety medication

Pre Training

Skilled Nursing

8 <10% - 60% 10% - 50%

Group Home

12 <10% - 100% <10% - 80%

Participant Demographics

N = 64Gender: 85% FemaleEducation:

High School: 5%Some College: 17%AA: 17%BA: 38%Masters/Professional: 15%

30%

5%3%

6%

47%

9%

Asian

African American

Hispanic

Native Islander

Caucasian

Unreported

Outcome Measures: Trainers

Pre & Post- Training Measures- Modified (ADKS;

Carpenter et al., 2009)

Approaches to Dementia Questionnaire (ADQ; Lintern et al., 2000 )

Vignette79-year-old woman

Facility resident: 2 years. Recently Mrs. Hansen has been less talkative to her fellow residents and less

more frequently and she is refusing to let staff give her a shower.

Outcome MeasuresObservational Data Collection

Two skilled-nursing facilities in Reno, NVResident criteria

Dementia diagnosisStaff report of challenging behaviors

Systematic observation of residents

Staff behavior and affect when interacting with observed residents

Pre- and post-training & post-facility wide trainingChart review

PRN administration, behavioral incidents, assessments, consults, illness, hospitalizationsMedication Administration Records, nursing notes, behavioral reports, incident reports

Outcome Measures

3- Month Follow UpFacility characteristics

Antipsychotic medication useStaff turnover

Evaluation and feedback formRate specific training objectivesRoom for comments

Status of facility wide trainings

Pre & Post ResultsMeasure N Pre Post P-value

ADKS 40 24.95 25.95 .002*

ADKS - Contextual 40 4.8 5.13 .02*ADQ 30 72.2 73.4 .058Vignette 34 3.21 3.62 .12Vignette - Communication Strategies

34 .56 .26 .02*

Vignette Assessment 34 1.01 1.53 .005*

Vignette - Consultation 34 .71 .56 .08

Vignette Environmental Strategies

34 .91 1.26 .06

Data Analysis underway

Resident behavior + Chart review (staff behavior)Systematic review of impact of training on staff behavior

Examining observed changes in adaptive behavior and

Versus staff charted behavior Pain assessmentMedical assessmentMedication administration

Aggregate Observational Data of Staff

Facility IIRR trials = 15%

Trials PositiveStaff Behavior

Negative Staff Behavior

Positive Affect

Negative Affect

Neutral Affect

Pre 38 84% 12% 87% 5% 16%

Post 63 86% 6% 68% 1% 7%

3 month follow-up 48 72% 13% 48% 10% 69%

Facility IIIRR trials = 45%

Trials PositiveStaff Behavior

Negative Staff Behavior

Positive Affect

Negative Affect

Neutral Affect

Pre 84 81% 4% 50% 4% 74%

Post 123 84% 16% 49% 3% 49%

3 month follow-up 83 87% 11% 43% 4% 69%

Agreement

Facility  II Mean Range.815 .688 - .958

% agreement .93 .89 - .98

Facility  I Mean Range.885 .722 1.0

% agreement .96 .90 1.0

Status of Trainings at 3 month follow-up (9 forms received)

Modules given to full staff

Managing the stress of dementia care 5

Knowing the facts about dementia 5

Communicating the facts about dementia 5

Knowing about excess disability 5

Assessing pain 4

Promoting choice 4

Making sense of delusions and hallucinations 3

Sexuality in long-term care 3

Ruling out excess disability 3

Ruling out delirium and depression 3

The contextual ABCs of dementia care 2

Searching for clues Part 1: Antecedent interventions 3

Searching for clues Part 2: Consequent Interventions 2

3-Month Follow-up Feedback (9 respondents)

Criteria ExcellentRatings

Very GoodRatings

GoodRatings

AverageRatings

Poor Ratings

Articulation of training program objectives

3 4 1 0 0

Meeting of training program objectives

3 4 1 0 0

Effectiveness of teaching methods

4 3 1 0 0

Flow and style of presentation

3 4 1 0 0

Relevance of information to your situation

3 4 1 0 0

Usefulness of handouts &/or training material

4 3 1 0 0

Usefulness of examples

3 4 1 0 0

3-Month Follow-up Feedback

Reported psychotropic medication useNo significant changes

Anti-psychoticAnti-anxiety

Responders commentsHelpfulness of the training programSuggested improvementsTrainings impact on staff ability to manage challenging behaviors

manage challenging behaviors

Discussion

Observational data does not indicate that the training program had an impact on staff interactions with residents

Chart review data will indicate if there was an impact on other staff behavior

Staff reported enjoying content and delivery of the training

Especially the use of in-facility examples

Discussion

Model based on identifying idiosyncratic barriers to effective caregiving and guided practice

More intense intervention may be needed

Limited use of follow-up consultationBuy-in from administration

Contact:christinagarrisondiehn@gmail.com

ReferencesAgency of Healthcare Research and Quality (2007). Efficacy and comparative effectiveness of off-label

use of atypical anti-psychotics [publication no. 07-EHC003-EF]. Rockville (MD): Agency of Healthcare Research and Quality.

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Buchanan, J.A., & Fisher, J.E. (2002). Functional assessment and noncontingent reinforcement in the treatment of disruptive vocalization in elderly dementia patients. Journal of Applied Behavior Analysis, 35, 68-72

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Dawson, P., Wells, D.L., & Kline, K. (1993). related dementias. New York: Springer.

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Mitchell, S.L., Kiely, D.K., Hamel, M.B. (2004). Dying with advanced dementia in the nursing home. Archives of Internal Medicine, 164, 321-3

Ronchon, P.A., Stukel, T.A., Bronskill, S.E., Gomes, T., Sykora, K. et al. (2008). Variation in nursing home antipsychotic prescribing rates. Archives of Internal Medicine, 167(7), 676-683.

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