Nanette Lavoie-Vaughan, MSNDNP St d tDNP Student

Vanderbilt University School of NursingNursing

To critically analyze the clinical practice To critically analyze the clinical practice guidelines for management of long-term care resident’s behavior problems and to draft an adaptation for implementation into practice.

Select individualized interventions. Base on evidence-based research. Strategize to assure staff buy-in. Long-range goal to decrease psychotropic

medication use.

43% of those over age 85 have dementia 43% of those over age 85 have dementia 89,223 residents in North Carolina and 70,494

in Tennessee 43% have dementia 80-90% of those have behavior problems 80 90% of those have behavior problems

http://www.alz.org (2012)

Few clinical practice guidelines address non- Few clinical practice guidelines address nonpharmacologic interventions

Barriers to implementation are staff buy-in, p y ,cost, and staffing patterns

Evidence-based interventions exist Issues: Federal regulations, CMS initiative and

black box warnings.

Behavioral problems are a complex issue. Behavioral problems are a complex issue. Influenced by biology of the disease, the

environment in which the resident resides, ,psychosocial factors and the staff’s expertise.

Behavior often reflects an effort to meet a need. Working in long-term care is associated with a

higher risk of physical or verbal assault by residents.

Reaction to stressful situations. Reaction to stressful situations. Wandering and interfering with normal

activities. Failure to inhibit actions, thoughts, and

emotions. Mismatch between the person and the

environment.

Cohen-Mansfield, J. (2008). Agitated behavior in persons with dementia.

Journal of Psychiatric Research, 43 (1), 64-69.

Vericare- national company Vericare national company Provides psychotropic drug management and

behavioral interventions, and psychological , p y gcounseling

9 states 400 professionals 1,100 nursing homes, g 22 in North Carolina and 40 in Tennessee

Nursing skills are carried out to achieve a Nursing skills are carried out to achieve a specific patient-centered purpose rather than the skill itself.

Whatever an individual does at any given moment represents the best available judgment for that person.

Wiedenbach, E. 91963). The Art of Clinical Nursing. Accessed at

http://www.curentnursing.com

With disease progression individuals With disease progression individuals experience increasing vulnerability and a lower threshold to stress and external stimuli.

Physical environment: auditory and visual stimulation.

Social environment: communication style of caregivers, impact of other residents.

Internal modifiable factors: pain, fatigue, medical conditions.

Hall, G.R. & Buckwalter, R.C. (1987). A conceptual model of care for adults

with Alzheimer's disease. Archives of Psychiatric Nursing, 1 (6), 399-406.

Appraise available clinical practice guidelines Appraise available clinical practice guidelines using AGREE checklist

Present to clinical team Comprehensive literature review Screen data- use CONSORT and PRISMA tools Screen data use CONSORT and PRISMA tools Consult with medical director and team Draft adaptation Draft adaptation Review with team

American Medical Directors Association American Medical Directors Association AGREE checklist score = 6/7 Scope and purpose = 21 Scope and purpose 21 Stakeholder involvement = 19 Rigor of development = 54 Rigor of development = 54 Clarity of presentation = 21 Applicability = 23 Applicability = 23 Editorial independence = 14

S ifi t l t id t Specific to long-term care residents

CINHL, PubMed, and EBM reviews. CINHL, PubMed, and EBM reviews. Key Words: Dementia, behavior, interventions 200 articles found 200 articles found Search narrowed to specific interventions Key words: bright light Montessori Key words: bright light, Montessori,

aromatherapy, massage, therapeutic touch, pet therapy, music therapy, and activities.py, py,

159 articles found

CONSORT and PRISMA tools CONSORT and PRISMA tools Studies with Level 1-4 on the hierarchy of

evidence. Level A or B on the SORT criteria. 82 articles selected. 82 articles selected.

Issues: Studies had small sample sizes, 50% Issues: Studies had small sample sizes, 50% were alternative therapies and half of those from outside the United States, need for replication.

Strengths: Data that is available is robust, interventions are simple and easy to implement, staff education is included.B l l (2012) id ifi d i l f Boltz et. al. (2012) identified essentials of care for behavioral problems related to the PLST modelmodel.

Maximize safe function. Maximize safe function. Provide unconditional regard. Use behaviors to gauge activities and Use behaviors to gauge activities and

stimulation. Teach caregivers to listen to behaviors. Teach caregivers to listen to behaviors. Modify the environment. Provide ongoing assistance to the caregiver Provide ongoing assistance to the caregiver.

Hand massage Hand massage Foot massage Therapeutic touch Therapeutic touch Individualized music Music therapy Music therapy Aromatherapy

Montessori activities Montessori activities Individualized activities Horticultural therapy Horticultural therapy Creative therapy The SMILE project The SMILE project

Facility dog Facility dog Pet therapy Robotic pets Robotic pets Simulated family presence

Bright light Bright light Night time monitoring system Decrease crowding Decrease crowding Monitor likely event times Consistency of routine and care Consistency of routine and care Paint and signage

77% decrease in behaviors after staff training. 77% decrease in behaviors after staff training. Internet-based multi-media education

program.p g Come Talk With Me

Wiedenbach’s theory meshes with the complex Wiedenbach s theory meshes with the complex issues of behavioral problems.

Purpose of the guideline mirrors the p gcomponents of theory: observation of the presenting behavior, exploration of the meaning and cause, and determining how to resolve the problem with the assist of a health care professionalcare professional.

PLST model can be applied to the specific types of intervention using Boltz’s essentialsof intervention using Boltz s essentials.

Dr. Khuri, medical director at Vericare has Dr. Khuri, medical director at Vericare has accepted the guideline for use by providers.

Currently there is no plan or method for introduction and orientation of the guideline.g

Pivotal role in disseminating evidence-based Pivotal role in disseminating evidence based research.

Continuing researchg Training staff Assist in formulating individual plans Assist in formulating individual plans Consultation to assist facilities Adding algorithm Adding algorithm

Publish results in peer-reviewed journals in Publish results in peer reviewed journals in geriatrics and long-term care management.

Present at national conferences focusing on ggeriatrics and long-term care.

Submit guideline to data base. g