Deepa Vinoo,
Introduction 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). These impact heavily on resident’s quality of life, caregiver stress, and management options for the team. In the United States, the National Partnership to Improve Dementia Care, established a new national goal of reducing the use of antipsychotic medications in long-stay nursing home residents by providing person centered Comprehensive interdisciplinary care. 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 memory care programs • Reduce falls and physical altercations by meaningful engagement including Music and Memory • Reduce the usage of antipsychotics by implementing comfort care program in Dementia related behavior. 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 and psychological symptoms of dementia (BPSD) • 75% of people with dementia will spend time in a nursing home, most typically in the moderate and advanced stages • The average time between diagnosis and death is 8 to 10 years; extreme variability with some dementias lasting up to 20 years or more • Someone who reaches the age of 80 and has dementia has an approximately 80% chance of spending time in a nursing home. • Manifestations of BPSD (behavioral and psychological symptoms of dementia (BPSD) ï??· Wandering ï??· Impulsive; Pulling, pushing, grabbing ï??· Verbal; Disinhibited language ï??· Hallucinations and Delusions ï??· Sleep and appetite disturbance ï??· Apathy/Withdrawn/Depression ï??· Sun downing ï??· Anxiety/Pacing Antipsychotic medications for BPSD • Not FDA approved for BPSD • Antipsychotic use peaked in 1990’s to a high of 1 in 3 dementia residents receiving an antipsychotic • Despite a federal “black box warning” starting 2006 regarding risks ,antipsychotic usage in Dementia remained high • In 2011 Q4;percent of long stay nursing home residents were receiving an antipsychotic medication -24% • In 2016 Q4; percent of long stay nursing home residents were receiving an antipsychotic medication16% CMS Standards F-329: Drug regimen is free from unnecessary drugs; Residents on Antipsychotic receive gradual dose reduction and behavior intervention unless clinically contra indicated, in an effort to discontinue these drugs • F-248: Activities AND F-309 Quality of care; The facility must provide ongoing activities and services to maintain highest physical, mental and psychosocial wellbeing of the residents Comfort Care • In the absence of an effective therapy to prevent, treat or cure Alzheimer’s disease and related dementias, the best therapy is good care/Comfort care Nonpharmacological management of BPDS Comfort Care at NYC Health +Hospitals/ Coler Background “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. Methods/Intervention This study was conducted in four Memory care units with 108 residents at an 815-bed long-term nursing care facility. All residents in Memory Care Units from last quarter of 2014 to last quarter of 2016 were individually assessed for, Usage of Antipsychotics, Physical Altercations, fall. Liberalized Diet. Memory Care Programs: • Created a “neighborhood’ culture, where all services are integrated • Neighborhood co-ordinator to integrate the services • Modified Job Functions of interdisciplinary staff to improve meaningful engagement • Consistent staff • Liberalized Diet • Snack on Demand Resident centered structured programs • Live Musical performance by the staff and residents • Therapeutic walk in the garden if weather permits • Monthly barbeque if the weather permits. • Weekly Cooking program • Meaningful activities for short duration and multiple activities in different stations • Music and Memory Program, 24X7 • Personalized ipods with music. • “Adopt a resident” program • I GLANCE/I CARE PLAN • Enhancement of student volunteers participation in Memory Care • Structured in vivo training • 90% of Interdisciplinary staff are Certified Dementia Care Practitioners by NCCDP • Memory Care Garden • Sensory Room /Quiet Room for the residents to relax, • Bathing without Battle Results Cost effectiveness • Reduction of Antipsychotic • Significant Reduction in transfer to Psych ER by providing comfort Care • Reduction of falls and fights resulted in reduced transfer to acute hospital for further fall related management • Reduction of 1;1 • Flow of Patients; we accept Dementia patients with challenging behavior from our acute hospitals, we save an average of $2500 /day References 1.Remington, Ruth(2002), Calming Music and Hand Massage with agitated Elderly Nursing Research, Volume 51, 317-323 2. Beverly Hoeffer, Joanne Rader etal(2004) , Effect of person centered showering and the towel bath on bathing associated aggression, agitation and discomfort of Nursing Home Residents with Dementia; A Randomized controlled Trial, American Geriatric Society,1795-1804 3. Alzheimer's Disease Education & Referral Center, A. (2011). Alzheimer's Disease Fact sheet. Silver Spring: National Institute on Aging. 4. Abi V. Rayner, J. G. (2006). Behavior Disorders of Dementia: Recognition and Treatment. American Academy of Family Physicians, 647-652. 5. American Society of Consultant Pharmacists. (n.d.). Antipsychotic Medication Use in Nursing Facility Residents. Retrieved 3 21, 2013, from www.ascp.com: https://www.ascp.com/articles/antipsychotic-medication-usenursing-facility-residents 6. Bharucha, A. J., Rosen, J., Mulsant, B. H., & Pollock, B. G. (2002). Assessment of Behavioral and Psychological Symptoms of Dementia. Primary Psychiatry, 797-802. 7. Cohen-Mansfield, J. (Fall, 2001). Nonpharmacologic Interventions for Inappropriate behaviors in Dementia. American Journal of Geriatric Psychiatry 9:4,, 361-381
