Call for Less Antipsychotics in Residential Care

CLeAR Kick-off EventOctober 9th, 2013

Elisabeth Antifeau, RN, MScN, GNC(C)

Behavioural and Psychological Symptoms of Dementia (BPSD)

Consensus Algorithm

BPSD: What is it?Behavioural and Psychological Symptoms of Dementia

Behavioural Symptoms

Psychological Symptoms

observable behaviours that are:

inappropriate or excessive within the situational context or setting;

disturbing, disruptive, distressing or potentially damaging to the person or others;

are: discrete or overt

mental disorders that commonly include, but are not limited to: depression, apathy, withdrawal, psychosis, etc.

BPSD: Why is it important?

BPSD is reported to affect 80-90% of people with dementia at some time in their disease course (Canadian Coalition for Seniors Mental Health (2006);

BPSD is a Quality of Life issue.

Background and History

December 2011 – BC MoH Review of antipsychotic drug use in residential care facilities;

Plan B (April to June 2010) indicated 50.3% residents (n=30,032) prescribed an antipsychotic.

Missing information: how long? for what condition?

2002, 2004, 2006, 2007 – Health Canada Advisories, about mortality risk and adverse reactions antipsychotic use - risperidone only approved med’n for BPSD use

June 2009 – CIHI Analysis in Brief released, 2006-07 data - 37.7% of seniors in nursing homes were using antipsychotic drugs (Manitoba, NB and P.E.I.)

History of the BPSD Algorithm

Original work written in 2010 for the Phased Dementia Pathway;

Best Practice Guidelines for Accommodating and Managing BPSD in Residential Care (Oct 2012);

Jan 2013 – August 2013: Consensus BPSD Algorithm Working Group

“The evidence indicates that successful management of BPSD requires care providers to understand and accommodate BPSD, not control it”.

IH Phased Dementia Pathway

What is the purpose of theBPSD Algorithm?

Simple, comprehensive one stop resource

An interactive and decisional resource tool to guide clinicians & physicians when faced with managing the behavioural and psychological symptoms of dementia;

Provides frontline clinicians & physicians with access to: Best Practice Recommendations for assessment, care-

planning and medications recommendations in a logical flow;

Evidence Based Assessment ToolsClinical References and information (e.g., which

behaviours respond to medications, and which don’t)

Part I: Interdisciplinary Decisional and Practice Support for BPSD:

•Assessment (green)

• Problem Solving (yellow)

• Care Planning (blue)

The Algorithm is meant to be used from the top down:

Part II: Reassessment with Family GP/NP for BPSD:

• Assessment (green)

•Medication Options (yellow)

•Monitoring (blue)

The Algorithm is meant to be used from the top down:

Decision Points…

At certain points along the Algorithm, users will encounter decision points identified as Diamonds…

These decision points pause the clinician to make a decision before correctly proceeding further down a pathway within the algorithm.

Walk through Algorithm

Page 1

Part I: Interdisciplinary Decisional and Practice Support for BPSD:AssessmentProblem SolvingCare Planning

Page 2

Reassessment with Family Physicians or Nurse Practitioner for BPSD:AssessmentMedication OptionsMonitoring

Part I: Interdisciplinary Decisional and Practice Support for BPSD

Identify and use the algorithm for the right population

Identify and priorize the urgency of the situation

Emergency pathwayNon-emergency pathway – tool selection

guide for assessment

Example1: Safetyescalation

continuum:anxietyagitationverbal/physical

aggression

staff approaches:attentiveresponsivedirective

Example2: Least RestraintsLink

Defining restraints

Differentiating chemical restraint versus treatment

Meets legislative requirements:Residential Care

Regulation S.74(1)a and S.77

Selecting the right assessment tool

Depression Screening Tools:GDS(15)CornellPHQ-9RAI-2.0 DRS

Cohen Mansfield Agitation Inventory (CMAI)

Dementia Observation Scale (DOS)

RAI-2.0Progress Notes

Differentiating 3DsRecognizing changes in usual thought,

mood, function, and behaviour as significant and important to probe and assess further

Selecting the right tool

Part I: Interdisciplinary Decisional and Practice Support for BPSD

Problem Solving focus using the PIECES Framework and A-B-C approach

Each link provides 1-2 page synopsis of evidence-based information to better understand multiple factors that contribute to behaviours

Example3: Common physical changes

Short and pithy, one page sources of informationLinks behaviour to wide variety of known causes using

PIECES – assists clinicians to appreciate multiple reasons for behavioural development

Part I: Interdisciplinary Decisional and Practice Support for BPSD

Create an individualized care planFirst Line intervention: non-pharmacological

interventionsOngoing monitoringWhen to seek (further) medical assistance

Part 2: Reassessment with GP or NP for BPSD

Re-assessment with medical lensPharmacological considerations: behaviour that

is dangerous, distressing, disturbing, and damaging/ & not responding

Distinguish behaviours that are/are not likely to respond to medications

Example4:Behaviours that are not like to respond to medications

Resistiveness to care“…the repertoire of behaviours with which

persons with dementia withstand or oppose the efforts of a caregiver”

(Mahoney et al)

Example5Resistiveness to Care Scale

Part 2: Reassessment with GP or NP for BPSD

Behaviours that may respond to medicationsSecond-line intervention support Evidence-informed behavioural categories:

sleep disturbance, anxiety, psychosis, aggression, depression and sexually inappropriate behaviour.

Page 1 – Medication Templates

Page 2 – Medication Templates

Key Messages and considerations:Start low and go slow;Strive for a good clinical trialdrug-specific cautionsorder of decreasing side-effects within a

class linkage with CCDTD4(2012)

recommendationscautions for renal/hepatic clientstitration and weaning information

References and other medication information

Part 2: Reassessment with GP or NP for BPSD

Monitoring effectiveness of treatment, side effectsContinued integration with non-pharm strategies in care

planReassessing the need for continued therapy, exploring

discontinuing therapyMonitoring for recurrence/emergence of BPSD

Next steps…

This Fall 2013:

Alpha testing (testing, QA, usability testing)

Beta launch (pilot site to trial)

Deployment – announcement and ready for use

Making the algorithm available

BCPSQC website

Personal Computer

Tablets

App for Smart & Android Phones

Smart Phone/Android version

BCBPSD.ca domainwill look differentstill guided by

colourQuick Links MenuChart ViewSave the PageNavigation BarFavourites Point-Click-Print

capacity

Implementation Planning – IntentBPSD Guideline 2012BPSD Algorithm 2013-14

Education – promoting integration of both BPSD tools with various other initiatives across BC: Revised GPAC guidelines (Cognitive Impairment in the

Elderly) will reinforce BPSD tools, approach, e.g.,

use of CAM-PRISME in deliriumuse of GDS-15; Cornell, for depression, etc

Caring JourneyGentle Persuasion training

PIECES implementation and training events provincially (2013-14)

Anticipated Fall to

Winter 2013 Delivery

Acknowledgements