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Management of Challenging Behaviors in Dementia;

Non pharmacological Approach

Presented by

Deepa Vinoo, RN

Milana Leviyev, RN

2018 NICHE CONFERENCE

Management of Challenging Behaviors in Dementia;

Non pharmacological Approach

Memory Care Unit Team

NYC Health+ Hospitals | Coler

Objectives

Implement National partnership’s goals and CMS regulatory standards to improve Dementia Care

Improve the quality of care of residents with diagnosis of Dementia by providing person centered comfort care

Reduce the usage of Antipsychotics by implementing non pharmacological approach

Reduce falls and physical altercations by implementing person centered care

Key elements and outcomes of successful Memory Care program

Management of Challenging Behaviors in Dementia;

Non pharmacological Approach

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Management of Challenging Behaviors in Dementia;

Non pharmacological Approach

Behavioral disturbances among patients with dementia,

including agitation, aggression, and psychosis, form a

constellation of symptoms referred to as behavioral and

psychological symptoms of dementia (BPSD).

BPSD impacts heavily on resident’s

Quality of life

Caregiver stress

Management options for the team

Manifestations of BPSD

Wandering

Impulsive: Pulling, pushing, grabbing

Verbal: Disinhibited language

Hallucinations and Delusions

Sleep and appetite disturbance

Apathy/Withdrawn/Depression

Sun downing

Anxiety/Pacing

Antipsychotic medications for BPSD

Not FDA approved for BPSD

Antipsychotic use peaked in 1990s to a high of nearly 1 in 3 dementia

residents receiving an antipsychotic.

Despite a federal ‘black box warning’ starting 2006 regarding risks,

antipsychotic use remained high

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Antipsychotic medications for BPSD

In 2011Q4: 23.9 percent of long-stay nursing home residents were receiving

an antipsychotic medication

Since then, there has been a decrease of 27 percent

2015Q3 :17.4 percent of long-stay nursing home residents were receiving an

antipsychotic medication

In 2016 Q4: 16% percent of long stay nursing home residents were receiving

an antipsychotic medication-

Prevalence of Alzheimer’s disease in the US

5 million people with Alzheimer’s disease in US

2 million people with Alzheimer’s disease live in a nursing home in USA

Over 60 % of Nursing home residents with dementia present with behavioral

problems

CMS standards:

F-329: Drug regimen is free from unnecessary drugs

Unnecessary drug: any of the following

1. Excessive dose

2. Excessive duration

3. Without adequate monitoring

4. Any combination of the above

The facility must ensure that:

1. Residents on antipsychotic receive gradual dose

reduction, and behavioral interventions, unless clinically

contraindicated, in an effort to discontinue these drugs

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CMS standards: F-248: Activities

F-248: Activities

The facility must provide ongoing program of activities

designed to meet the physical, mental and psychosocial

well-being

Behavior interventions are individualized

One-to-one programming for patients who will not or

cannot plan their own activity pursuits

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CMS standards: F-309 Quality of Care

F-309: Quality of Care

The facility must provide care and services to attain or maintain highest physical, mental and psychosocial wellbeing

Ensure that the resident obtains optimal improvement or does not deteriorate within the limits of the recognized pathology and normal aging

Coler Medication Guideline for BPSD:

Start: A, B and C – all 3 required

A. Non-medication interventions -unmet needs, comfort care,

meaningful engagement

B. Behavior results in distress or potential for harm to self or

others

C. Target behavior well defined, may include:

verbal

- physical

- resistance or aggression during care that impedes

daily care 12

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Assessment of Behaviors

Antecedent ↔ Behavior ↔ Consequence

Unmet needs Understand/attend (more attention, lonely) (How often?) (distracting) (pain, hunger) (when?) (redirecting)

(wet, soiled) (around who?) (stay calm) (constipation, UTI) (where?) (reassurance)

(new medical problems) (observation!) (close ended Q’s)

(perception of being (communicate differently)forced) (understand pt’s needs)

(dehydration)

Record behaviors and look for patterns

Change A or C in order to change B

Management of Challenging Behaviors in Dementia;

Non pharmacological Approach

Background

Using Lean Methodology, a “Memory Care” Project team came together in October 2014 to review current dementia care practices

“Identified” the gaps and created a structured Memory Care Program

Management of Challenging Behaviors in Dementia;

Non pharmacological Approach

Methods/Interventions

This study was conducted in four Memory care units with108 residents at an

815-bed long-term nursing care facility.

All admitted residents in Memory Care Units from last quarter of 2014 to last

quarter of 2017 were individually assessed for person centered care, usage of

antipsychotics, falls and physical altercations.

Baseline data collected from residents included demographics, diagnoses,

preexisting mental illness, and presence of concurrent mood symptoms

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Demographics of Memory Care Units N-108

AGE

<6565-7475-84

≥ 85

243428

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Male (Mean age 71.26)Female (Mean age 78.1)

5850

Diagnosis

Primary PsychosisAlzheimer’s Dementia

Vascular DementiaDementia Secondary to TBI

Dementia Secondary to Chronic Alcohol Use

Lewy Body Dementia

Dementia Secondary to HIV

1153

7112

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Memory Care Programs

Consistent staffing

Created a Memory Care “Neighborhood” and a Coordinator to integrate the

services

Modified Job Functions of interdisciplinary staff to improve meaningful

engagement

Cross Training

Consistent huddle with interdisciplinary staff

Memory Care Programs

Resident-centered structured program

Meaningful activities for short duration and multiple activities in different

stations

Snack on Demand

Music and Memory program around the clock

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Memory Care Programs

90% of residents are on liberalized diet

Developed I-Glance and I-Care Plan as a resident-centered

communication tool

90% of Interdisciplinary staff are Certified Dementia Practitioners by

NCCDP

Structure standardized in vivo training

Partner with NCCDP and Caring Kind to provide standardize training

to staff

Memory Care Programs

Live musical performances by interdisciplinary staff and residents

Weekly cooking programs in the unit

Weekly bread and coffee program

Weekly religious programs

Monthly outdoor barbeque

Memory Care Programs

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Memory Care Programs

Memory Care Garden

Daily therapeutic walk in the garden

Enhancement of student volunteer participation in Memory Care

“Adopt a Resident” Program

Daily Nursing Rehab

Memory Care Activities

Memory Care Programs

Chair Zumba

Doll Therapy

Pet Therapy

Sensory Room/Quiet Room

Bathing without Battle

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Comfort Care

Memory Care Programs: RESULTS

Residents-

Improved quality and safety of 108 residents with the diagnosis of Dementia

Family-

Improved family involvement

Verbalized high level of satisfaction

Memory Care Programs: RESULTS

30%

27%25%

22%

18%20%

22% 22% 22%20% 19% 19% 18%

Q2014 1Q2015 2Q2015 3Q2015 4Q2015 1Q2016 2Q2016 3Q2016 4Q2016 1Q2017 2Q2017 3Q2017 4Q2017

% of Residents on Antipsychotic Medications 4Q14-4Q17

% OF RESIDENTS ON ANTIPSYCHOTIC MEDS LINEAR (% OF RESIDENTS ON ANTIPSYCHOTIC MEDS)

30%

27%25%

22%

18%20%

22% 22% 22%20% 19% 19% 18%

Q2014 1Q2015 2Q2015 3Q2015 4Q2015 1Q2016 2Q2016 3Q2016 4Q2016 1Q2017 2Q2017 3Q2017 4Q2017

% of Residents on Antipsychotic Medications 4Q14-4Q17

% OF RESIDENTS ON ANTIPSYCHOTIC MEDS LINEAR (% OF RESIDENTS ON ANTIPSYCHOTIC MEDS)

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Memory Care Programs: RESULTS

0%

2%

4%

6%

8%

10%

12%

14%

4Q2014 1Q2015 2Q2015 3Q2015 4Q2015 1Q2016 2Q2016 3Q2016 4Q2016 1Q2017 2Q2017 3Q2017 4Q2017

% of Residents that had a Fall 4Q14-4Q17

% of Residents that had a Fall Linear (% of Residents that had a Fall)

Linear (% of Residents that had a Fall)

4%

20%

55%60%

78%

70% 70%

80% 80%

88%85%

80%

40%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

4Q2014 1Q2015 2Q2015 3Q2015 4Q2015 1Q2016 2Q2016 3Q2016 4Q2016 1Q2017 2Q2017 3Q2017 4Q2017

% of Residents on Music Memory Program 4Q14-4Q17

% of Residents on Music & Memory Program

Memory Care Programs: RESULTS

Staff Verbalized-

Increased level of satisfaction

Decreased level of stress

Increased staff morale

Enhanced bonding between staff, residents and family members

Enhanced team work

Provided an opportunity for more meaningful, personal connections with individuals in their care

Memory Care Programs: RESULTS

“Happy Staff = Happy Residents”

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RESULTS: Cost Effectiveness

Significant Reduction in transfer to Psych ER for dementia related behavior

Reduction of falls and altercations resulted in reduced transfer to acute hospital

for further fall related management

Reduction of 1:1 from 6 to 1

Flow of Patients; we accept Dementia patients with challenging behavior from

our acute hospitals, we save an average of $2500 /day

Case Study 1

A 60 year old male resident with Dementia due to HIV/AIDS, with wound and

drainage, has the behavior of masturbating in public .Verbally aggressive to

the staff and peers, refuses care, refuses medication, multiple attempts to

elope the facility, verbalized the desire to smoke. CDC count was low and Viral

load was high, Clonazepam and Risperidone were started

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Case Study 1

Actions:

Person Centered Care

Placed him in a single room with an attached bathroom ,provided privacy

Allowed him to smoke twice daily in a safe area under supervision

Engaged him in his favorite activities like bingo, dominos, etc.

Provided him a personalized ipod with his favorite Spanish music

Interdisciplinary staff started to engage him in meaningful ways like gardening, outdoor walk, etc.

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Case Study 1

Outcome:

Clonazepam and Risperidone were discontinued. The Resident’s behavior

changed dramatically, pleasant, socialized with staff and peers, did not attempt to

elope, Started to take medication, Received shower daily without any resistance,

stopped masturbating in the public, had significant improvement in his medical

condition. Safely discharged to the community.

Case study 2

Music & Memory in End of Life Care

An 84 year old Asian resident with moderate Dementia stood by the nurses’

station, tapping her fingers on the counter in time to music playing on her

iPod. Curious about what the resident might be trying to communicate, staff

found a portable piano keyboard and placed it before her. To everyone’s

astonishment, the resident began to play the piano, had never before indicated

to anyone that she was a musician, commenced playing for her fellow residents.

Everyone sang along.

Music and Memory in End of Life Care

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Case study 2

Music & Memory in End of Life Care

Eventually her Dementia advanced, she deteriorated medically and

functionally, had a stroke and was on palliative care. Resident was at end of

life care, she stopped eating, stopped responding, at her death bed the unit

team stood around and sang her favorite songs, she moved her hand, keeping

time with the music, and had a peaceful death in the presence of the unit team

listening to her favorite music

Case Study 3

Ms. T. has successfully transitioned to NYC Health + Hospitals/Coler. She moves

freely and independently throughout the unit and participates in a number of unit

activities. She no longer needs 1-to-1 observation, listens to her own music on

her personalized I Pod. Her reliance on antipsychotic medications has been

eliminated.

Healing with Harmony

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Acknowledgement

Memory Care Team NYC Health+ Hospitals | Coler

Robert Hughes, CEO , NYC Health+ Hospitals | Coler

Leah Matias, Deputy Exec Director , NYC Health+ Hospitals | Coler

Floyd Long, CEO, NYC Health+ Hospitals | HJC

Susan Tadique, DON, NYC Health+ Hospitals | Coler

Ravindra Amin, Chief of Psychiatry, NYC Health+ Hospitals | Coler

Jovemay Santos, Therapeutic Recreation Department NYC Health+ Hospitals | Coler