Managing Behavioral Symptoms of Dementia in a Person Center - PowerPoint Presentation

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Managing Behavioral Symptoms of Dementia in a Person Centered Care Environment

Type Contact Information for Presenter Here

Elizabeth Weingast , RN, MSN, GNP

VP Clinical Excellence

Orah Burack, MA Senior Research Associate

Jewish Home LifecareSlide2

What is Dementia?

Dementia is a general term for a decline in mental ability severe enough to interfere with daily life.

Alzheimer’s 60-80% of dementias

Vascular Dementia

Dementia related to other diseases – Parkinson’s, Huntington’s Reversible causes – thyroid disease, vitamin B12 deficiency

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While

symptoms of dementia can vary greatly, at least two of the following core mental functions must be significantly impaired to be considered dementia:

Memory Communication and language

Ability to focus and pay attention

Reasoning and judgment

Visual perceptionSlide4

Stages of Alzheimer’s Dementia

Staged from 1 – 7 , no impairment to very severe cognitive decline

Stage 3 “mild cognitive decline”

Stage 6 – common access point to nursing home careSlide5

Stage 6: Severe cognitive decline

(Moderately severe or mid-stage Alzheimer's disease)Memory continues to worsen, personality changes may take place and individuals need extensive help with daily activities. At this stage, individuals may: Lose awareness of recent experiences as well as of their surroundings

Remember their own name but have difficulty with their personal history Distinguish familiar and unfamiliar faces but have trouble remembering the name of a spouse or caregiver

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Need help dressing properly and may, without supervision, make mistakes such as putting pajamas over daytime clothes or shoes on the wrong feet Experience major changes in sleep patterns — sleeping during the day and becoming restless at night

Need help handling details of toileting Have increasingly frequent trouble controlling their bladder or bowels Experience major personality and behavioral changes, including suspiciousness and delusions (such as believing that their caregiver is an impostor)or compulsive, repetitive behavior like hand-wringing or tissue shredding

Tend to wander or become lost

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CMS – approach to behavior management in nursing homes

Rise in use of antipsychotics for control of behaviors

23-25% of nursing home residents prescribed antipsychoticsOften without diagnosis of psychosis

Atypical antipsychotics (

Seroquel

, Risperidal, Zyprexa) carry a black box warning for people with dementia due to increased risk of cardiovascular events, including stroke or heart attack.

No research supporting us of these medications for behavioral symptoms of dementia

Goal to reduce use by 15% over six months in 2012

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CMS approach – Education and Survey Focus

Person Centered Care

Quality and Quantity of StaffThorough Evaluation of New or Worsening BehaviorsIndividualized Approaches to Care

Critical Thinking Related to Antipsychotic Drug Use

Engagement of Resident and/or Representatives in Decision Making

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Person Centered CareGreenhouse Model

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Comfort FirstUnderstanding Behavior as Communication

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Programming and TrainingModeling Communication

Personal Care approaches Meaningful activitiesSpecial Care Units – inconclusive outcomes

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Music and Memory

Everyone benefits from a calmer, more supportive social environment. Staff regain valuable time previously lost to behavior management issues. There is growing evidence that a personalized music program gives professionals one more tool in their effort to reduce reliance on antipsychotic medications

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http://www.youtube.com/watch?v=5FWn4JB2YLU&list=UUWSW0VyPUvG8dfJc9VtFQRg

Alive Inside13Slide14

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INTRODUCTION

Distressing behavioral symptoms often associated with dementia are not uncommon in the LTC setting.

The MDS 3.0 categorizes these symptoms as:

physical behavioral symptoms directed toward others (e.g., pushing, hitting)

verbal behavioral symptoms directed towards others (e.g., screaming, cursing at others)

behavioral symptoms not directed toward others (e.g., hurting self, pacing, making disruptive sounds)Slide15

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INTRODUCTION CON’T

Potential antecedents of these symptoms

illness

distress

pain unrecognized need

caregiving actions not understood by the elder

Culture change with its “person-centered approach to care” provides a potential non-pharmacological approach to reducing these symptoms Slide16

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INTRODUCTION CON’T

Different behavioral symptoms may have different causes; thus, interventions could address those causes

forceful behaviors such as kicking may be related to caregiving assistance (e.g., bathing or feeding); elder may not understand or find frightening

physical agitation (e.g., pacing) may be due to an inadequate amount of stimulation in the environment

verbal agitation may be related to discomfort, pain, or depression Slide17

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CULTURE CHANGE INTERVENTION

Community Coordinators

Education

Organizational and Community Structure Changes

Meaningful Activities and Resident Choice

Family Involvement

Reduced Floating

Consistent Staffing

Environmental Changes Slide18

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RESEARCH QUESTION

What is the impact of a culture change intervention on the following categories of behavioral symptoms:

forceful behaviors

physical agitation

verbal agitationHypothesis

: elders receiving culture change intervention compared to controls will have reduced behavioral symptoms (can be addressed by a person-centered approach to care )Slide19

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STUDY DESIGN

13 long term care comm across 3 campuses

7 Culture change pilot communities

6 Comparison communities

Longitudinal study - 2 time points

Time 1 – 2003

Time 2 – 2005 Slide20

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COHEN MANSFIELD AGITATION INVENTORY (CMAI)

29 behavioral symptoms

CNA rated frequency with which the elder manifested each behavior during past two weeks

each behavior rated on a 7 point scale (1)“Never”(2) “Less than once a week but still occurring”

(3) “Once or twice a week”

(4) “Several times a week”

(5) “Once or twice a day”

(6) “Several times a day”

(7) “A few times an hour”. Slide21

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CMAI – FORCEFUL BEHAVIORS

(12 ITEMS)

Hitting, Kicking, Scratching

Biting, Pushing, Grabbing

Throwing things, Cursing & Verbal Aggression

Spitting, Tearing things or Destroying Property

Hurting self or others

Screaming Slide22

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CMAI – PHYSICAL AGITATION (6 ITEMS)

pacing and aimless wandering

attempting to exit area inappropriately

general restlessness

inappropriate dressing and disrobing

handling things inappropriately

repetitious behaviorsSlide23

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CMAI – VERBAL AGITATION (4 ITEMS)

Complaining

Constant requests for attention or help

Repetitive sentences or questions

Expressing a negative attitude Slide24

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MEASURES

Behavioral Symptoms – Cohen Mansfield Agitation Inventory (CMAI) – captures forceful behaviors, physical agitation, and verbal agitation (CNA interviews)

Cognitive Impairment – MDS2.0 Cognitive Performance Scale (high score indicates greater severity)

ADL Impairment – 4 ADL items from MDS2.0 (high score indicates greater dependence)

Number of Diagnoses - use MDS2.0 med record dataSlide25

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STUDY PARTICIPANTS

N = 101

65 (64%) female

36 (36%) male

58% White; 28% Black, and 14% Hispanic Age range = 63 to 105 years (M

=83.65,

SD

=9.29).

Length of stay on communities; Range= 4 months to 14 years (M=34 months, SD=29 months)Slide26

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2 (Group) X 2 (Time) ANOVA*

Time 1

Time 2

Culture Change

Comparison

ANALYSIS PLANSlide27

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RESULTSSlide28

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PREVALENCE OF BEHAVIORAL SYMPTOMS

All

Time 1 Time 2

Forceful Behaviors 49% 57%

Physical Agitation 39% 44%

Verbal Agitation 52% 57%

Comparison

Forceful Behaviors 44% 61%

Physical Agitation 32% 37%

Verbally Agitation 36% 56%

Culture Change

Forceful Behaviors 54% 52%

Physical Agitation 45% 51%

Verbal Agitation 68% 58%

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Forceful Behaviors:

Adjusted mean scores.

Significant Interaction. F(1,92)=5.40, p=.022. Slide30

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Physical Agitation:

Adjusted mean scores.

Significant Interaction. F(1,89)=6.34, p=.014 Slide31

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Verbal Agitation:

Adjusted mean scores.

Interaction Approaching Significance. F(1,86)=3.62, p=.061 Slide32

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Summary

forceful behaviors and physical agitation increased over time on comparison communities, but not on culture change communities

implementing a culture change model can be an effective non-pharmacological approach to ameliorating behavioral symptoms

future studies should examine changes in pharmacological approaches when implementing culture change.

unique study feature - the inclusion of elders with wide ranging cognitive abilities, ranging from no cognitive impairment to more severe impairmentSlide33

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Possible Links between Culture Change & Behavioral Symptoms

physical agitation (related to inadequate stimulation in environment) may have been affected by increasing selected meaningful activities for elders

forceful behavior (resistance to care) may have been affected by increasing choice over when to participate in activities, environmental changes (e.g. calmer atmosphere), more consistent staffing

verbal agitation (related to depressed affect) showed a trend; may be related to quality of relationships; may need to further enhance these culture change elementsSlide34

Handouts –

Questions to post to facility leadership

Are programs in place to ensure best practice in care for residents with behavioral symptoms

of dementia?

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