presented by deepa vinoo, rn milana leviyev, rn 2018 ... then, there has been a decrease of 27...
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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Apathy/Withdrawn/Depression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
22
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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1
2
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
.
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