Educational program aiming to optimize the management of behavioral and psychological symptoms of de

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Educational program aiming to optimize the
management of behavioral and psychological
symptoms of dementia in nursing homes

• Lynn Fournier
• Nurse clinician in geriatrics
• Research assistant

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Research team

• Johanne Monette, MD, MSc (PI)
• Nathalie Champoux, MD, MSc (PI)
• Christina Wolfson, PhD,
• Guillaume Galbaud Dufort, MD, PhD
• Brian Gore, MD
• Lucie Tremblay, RN, M.Sc.
• Harold Frank, MD
• Sponsored by Maimonides geriatric Centre,
• Institut universitaire de gériatrie de
  Montréal (CAREC)

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Plan

• Behavioral symptoms of dementia
• Review of non-pharmacological approaches of
  behavioral and psychological symptoms of dementia
  (BPSD)
• The importance of your role
• Antipsychotics classic and atypical
• Brief summary of the research project

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Behavioral and Psychological Symptoms of Dementia
(BPSD)
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Residents presenting these different symptoms...

• are at high risk of injuring themselves or be
  harmed by others
• are at high risk of being judged or more
  isolated
• involuntarily can cause fatigue, frustration or
  feelings of helplessness among the caregivers

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To care for the resident

• We must try to understand the origin of the
  behavior, identify the underlying need, to
  prevent it from happening again or to prevent
  negative consequences for the resident or his
  surrounding, and to respond quickly.

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Who knows the resident?

• The more we know the resident, the better our
  care will be
• (Life history, occupation, likes and
  dislikes, non-pharmacological interventions,
  family involvement,)
• Families and/or significant others share the
  caring of their loved ones with the staff and
  represent a primary source of information

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We must not forget to rule out

• Delirium
• Pain
• Infection
• ? Comfort
• Multiple triggers or causes

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Towards a better relationship

• Establish a trustful climate
• Maintain a tolerant, calm manner
• Approach person by the front
• Communicate face-to-face with simple statements
• Be an active listener allow for expression of
  feelings without censure

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Towards a better relationship...

• Share your understanding of his/her situation
• Maintain attention on the person when giving
  care, be respectful
• Use a gentle, friendly tone of voice
• Use simple words but not demeaning
• Use slow deliberate gestures avoid sudden
  movements

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Non-pharmacological interventions

• Do not argue about realities that differ
• If the resident becomes agitated, do not insist,
  remain calm, stop the care and attempt to calm
  the person before trying any other intervention
• ? The more agitated the resident becomes, the
  calmer the caregiver must be

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Non-pharmacological interventions

• Eliminate the sounds or stimuli that interfere
  with communication
• Distract the resident (use diversion, talk about
  other subjects, that interest him)
• Allow the resident to feel good during an
  activity in order for him to associate pleasure
  with the activity when it will be repeated

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Non-pharmacological interventions

• Ignore or tolerate certain behaviors
• Always think of the persons safety
• Use humor to de-dramatize
• Modify the environment
• Adopt a comforting routine
• Involve the resident in structured recreational
  activities

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Non-pharmacological interventions

• Music therapy or zoo therapy
• Gentle sensory stimulation i.e. physical touch,
  bathing, back-rubs, brush hair, relaxing music
• Orientation devices i.e. radio, t.v., clocks,
  calendars, family photos, familiar objects from
  home

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Evidence-based information suggest that

• Walking, light exercise
• Music therapy/music
• decreases anxiety and agitation
• facilitates falling asleep
• decreases hostility

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Non-pharmacological interventions

• Increase daytime stimulation for residents
  experiencing sundown syndrome
• Invite to accompany on rounds
• Make available night time activities (snacks in
  kitchen, activity cart, etc.)
• Control noise levels
• Make quiet room available
• Use soothing background music

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Important role

• Your observation of any changes in the
  residents behavior will be critical to perform a
  proper assessment of the behavior and then plan a
  therapeutic non-pharmacological intervention

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Antipsychotic medication

• Classic antipsychotics
• Atypical antipsychotics

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Classic antipsychotic

• Haldoperidol (Haldol)

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Common side-effects

• Extrapyramidal symptoms (EPS)
• (parkinsonism, akathesia, dystonia, tardive
  dyskinesia)
• Anticholinergic effects
• (dry mouth, constipation, blurred vision,
  urinary retention)
• Drowsiness
• Gastro-intestinal effects
• ( anorexia, dyspepsia, constipation)
• Orthostatic hypotension
• Accelerated cognitive decline
• Cardiac effects (hypotension, tachycardia,
  arrythmia)
• Hyperglycemia
• High risk of fall/hip fractures

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Pharmacotherapy

• Respond more
• Delirium and hallucinations
• Anxiety
• Affective problems
• Regressed behaviors
• Verbal or physical agitation
• Verbal or physical aggression
• Apathy,depression,
• sadness
• Certain inappropriate sexual behaviors

• Respond less
• Wandering
• Non-goal oriented and repetitious activities
• Altered social judgement
• Personality problems
• Tendency to steal and to hoard objects
• Vocalizations (screamers)
• Pica
• Pulling repetitiously on

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Pharmacological strategies

• Administer medication for clearly defined goals
  aimed at a specific target behavior for which the
  drug is effective,i.e., striking out at others
• Use drug for short period of time in the lowest
  possible dosage

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Schneider meta-analysis

• Analysis of 33 studies with placebo
• Rx used chlorpromazine, trifluoperazine,
  acetophenazine, thiothixene, loxapine,
  thioridazine, haloperidol
• Only 18 of the patients had a better response
  with neuroleptics than with placebo
• Haldol improved aggressivity but not agitation

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Schneider meta-analysis

• non-pharmacological approaches helped 40 of
  patients. Different non-pharmacological
  approaches were experimented as for example, zoo
  therapy and drummers groups to allow patients to
  express themselves musically.

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Classic antipsychotics

• The decision to prescribe antipsychotic
  medication for agitation in dementia should
  involve a careful analysis of the risks as well
  as the potential benefits. Elderly people with
  dementia are particularly sensitive to the common
  adverse effects of these drugs, such as sedation,
  parkinsonism, tardive dyskinesia, postural
  hypotension, and falls. In addition, some
  evidence suggests that these agents may be
  associated with accelerated cognitive decline
• McShane et al. 1997
• Geoffroy Melançon, MD

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Atypical antipsychotics

• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Clozapine (Clozaril)
• Ziprasidone (Geodon) future med.

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Common side-effects

• Extrapyramidal signs
• Sedation
• Hypotension
• Insomnia
• Confusion
• ? Triglycerides
• ? Glycemia
• ? Weight
• Anticholinergic effects

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Atypical antipsychotics

• Few studies compare classic and atypical
  antipsychotics in the elderly population
• Clinical experience suggests
• decreased frequency of EPS
  
• comparable efficiency
• risperidone few anticholinergic
  effects

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Important to keep in mind

• Non-pharmacological intervention ?/- Rx
• Impact of Rx modest
• Some will benefit, others wont
• Regular re-evaluation of the Rx necessary to
  ensure residents well-being
• Long treatment ? need medication anymore?

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BRIEF SUMMARY OF RESEARCH PROJECT
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General objective

• Assess the impact of an interdisciplinary
  educational program implemented in nursing homes
  to optimize the management of behavioral and
  psychological symptoms of dementia (BPSD)

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Specific objectives

• To provide educational sessions to nursing and
  support staff regarding non- and pharmacological
  approaches of BPSD.
• To provide an educational session to physicians
  regarding non- and pharmacological approaches of
  BPSD and a guidebook specifying the indications,
  the efficacy, the potential side effects and a
  flow chart for antipsychotic withdrawal.
• To sensitize physicians to the importance of
  regularly re-evaluating antipsychotics use and to
  consider a possible gradual drug withdrawal.

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Specific objectives

• To evaluate the potential impacts of the
  education program in terms of
• use of antipsychotic prescribing and other
  medications
• use of physical restraints
• manifested BPSD (NHBPS)
• perception of stress re BPSD in nursing staff

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Nursing Home Behavior Problem Scale NHBPS

• Emphasis on behavior disturbances severe enough
  to result in the use of Rx or physical restraints
  
• 29 items to be completed according to
  observations over the last 3 days
• Likert scale 0-4
• Validated tool
• Completion time ? 5 minutes
• Flow-sheet section/residents chartRay WA,
  Talyor JA, Lichtenstein MJ, Meador K. The
  Nursing Home Behavior Problem Scale. J Gerontol
  199247M9-M16.

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Stressful Events Questionnaires SEQ

• Identify stressful events for staff working with
  demented nursing home residents.
• 45 questions divided into 3 categories related
  to patients (1-16), to staff (17-26) to
  environment (27-45).Benjamin LC, Spector J.The
  relationship of staff, resident and environmental
  characteristics to stress experienced by staff
  caring for the dementing. Int J Geriatr
  Psychiatry 1990 525-31.

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Data collection

• Residents with dementia
• Medication profile
• Antipsychotics users (new and long term)
• Memo to treating physicians
• SEQ
• NHBPS
• Physical restraints

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Your Role

• Observation of any pertinent changes in
  residents behavior
• Communication of information to
• 
  treating physician
• 
  interdisciplinary team
• 
  research assistant

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My Role

• Participate in interdisciplinary team discussions
  around BPSD and possible interventions
• Collect comments, answer questions
• Collect data re changes in the prescription of
  antipsychotic meds and the use of physical
  restraints

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Availability

• Lynn Fournier
• Research assistant
• Beeper 330-4939 M-F 0800-1600
• 3 days/week at Maimonides
  

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• Thank you for your participation!