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Principles that promote and support mental health for all LTC residents (CCSMH, 2006) . individualized, person-centred care; respect for family ties; a biopsychosocial care planning framework; a culture of caring that prioritizes quality of life; a social and physical environment that is responsive to changing needs; a focus on early intervention and prevention as well as treatment; and staff training and development.
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1. Behaviour Support Units: Staffing, Models of Service Provision & Education David K. Conn Baycrest Centre and University of Toronto
2. Principles that promote and support mental health for all LTC residents(CCSMH, 2006) individualized, person-centred care;
respect for family ties;
a biopsychosocial care planning framework;
a culture of caring that prioritizes quality of life;
a social and physical environment that is responsive to changing needs;
a focus on early intervention and prevention as well as treatment; and
staff training and development
3. Mental Health Issues in Nursing Home Care - Expert MeetingTuesday, 1 September 2009 ? Montréal, CanadaHeld in Conjunction with the 2009 IPA International Congress
5. Download from www.ccsmh.caSummaries Can J. Geriatrics (2006)
6. Guideline Development Group Members: LTC Homes
7. A total of 74 studies examining the prevalence of psychiatric disorders and psychological symptoms in LTC populations were identified including:
30 studies on prevalence of dementia
9 studies on behavioural symptoms in dementia
26 studies on depression
Int Psychogeriatrics, Nov. 2010
8. Prevalence of Dementia 30 studies13 from N. America12 from Europe2 from Middle East1 from Africa1 from Asia1 from Australia/ NZ
16 different diagnostic instruments
9. Range The estimated prevalence of dementia in nursing homes varied between 12.0% (Van den Berg, Spijker et al. 1995) and 95% (Serby, Chou et al. 1987) with a median prevalence of dementia of 58% from all the studies.
10. Prevalence of BPSD A total of 9 studies reporting the prevalence of behavioural symptoms in LTC resident with dementia or cognitive impairment were identified
6 from Europe, 2 from N. America, 1 from Australia
11. Range The prevalence of any behavioural symptom in LTC residents with dementia varied between 38% (Wancata, Benda et al. 2003) and 92% (Brodaty, Draper et al. 2001).
The median prevalence of any behaviour symptom in dementia in LTC residents from the 9 studies was 78%.
12. Brodaty et al, MJA, 2003: 178:231-234
13. Prevalence of Depression A total of 26 studies reported on the prevalence of major depression or depressive symptoms in LTC residents
9 from N. America, 7 from Europe, 4 from Asia, 4 from Australia /NZ, 1 from Africa, 1 from Middle East
14. Range . The prevalence of major depression in LTC ranged from 4% (Teresi, Abrams et al. 2001) to 25% (McSweeney and O'Connor 2008)
the prevalence of depressive symptoms varied between 29% (McSweeney and O'Connor 2008) to 82% (Lin, Wang et al. 2007).
15. Possible Etiologies of Aggression / Agitation Caregiver related
Environment related
Manifestation of a medical disorder r/o pain / discomfort
Psychiatric comorbidity
Delirium
Medication side effects
Neurotransmitter changes
17. Behavioural Support Unit (BSU)Recommendations (2007) BSUs be created as a regional resource
Staffing ratio of regulated to unregulated ranging from 40:60 to 50:50 rather than 20:80
Staffing levels of allied HPs be increased to include a range of providers. Regular access to pharmacist
Maximum of 15 to 20 residents
18. Behavioural Support Unit (BSU)Recommendations - cont. (2007) Support “patient choice”
BSUs should be affiliated with a LTC home or another facility
Admissions managed by CCAC in cooperation with PG team
Regular priority review of admissions & discharges
Highly specific admission & discharge criteria
19. Behavioural Support Unit (BSU)Recommendations - cont. (2007) Residents being transferred to a LTC setting should have assistance from a PG Outreach team and funds
BSUs must be funded from outside the current resident classification system
Funded based on 100% capacity not per diem rate
Referrals to PG Outreach team mandatory if resident has potential for aggression
20. Are Special Care Units better for individuals with behavioural problems ?Cochrane Review 2009, Lai CK et al. No RCTs
4 studies available with extractable data
Studies suggested a small improvement in NPI scores favouring SCUs & less use of physical restraints
Authors concluded that there is no strong evidence of benefit from a SCU.
They suggest the implementation of Best Practices is most important !
21. Cross-sectional study of 28 SCUs compared with traditional care in GermanyWeyerer et al. Int J Ger Psych (2010) 594 res in SCUs vs. 573 res in usual care
After controlling for confounding variables: In SCUs….- More “social contact to staff”
- More involvement in activities- More volunteer involvement- Fewer physical restraints- More use of psychiatrists- Less antipsychotics, more antidepressants
22. Longitudinal study comparing residents of SCUs versus those in traditional NHsNobili et al Alz Dis Assoc Disord (2008) 349 res in 35 SCUs vs. 81 res in 9 NHs
Res admitted to SCUs were younger, less cognitively and functionally impaired but had more behavioural problems
Over 18 months – SCU residents had less hospitalization, less use of physical restraints and had a higher rate of withdrawal from antipsychotics
24. Non-Pharmacological Interventions
(Beck & Shue, 1994)
26. Ballard et al. 2009
28. Behavioural Management Approach Cognitive Assessment
Behavioural Assessment (ABC Analysis)
Staff Perceptions
Utilize Extinction, Reinforcement, Prompting
Staff Stress Innoculation Rewilak, 2001
29. www.bendigohealth.org.au
30. Remembering the forgotten: psychotherapy groups for the nursing home resident. Ken Schwartz Int J Group Psychother. 2007 Oct;57(4):497-514. Weekly groups
Co-facilitated by social worker from the unit
An integrated model utilizing developmental, cognitive-behavioral, and psychodynamic approaches
31. Questions to be asked in evaluating any drug use in a NH Avorn & Gurwitz, 1995 What is the target problem being treated ?
Is the drug necessary ?
Are nonpharmacologic therapies available ?
Is this the lowest practical dose ?
Could discontinuing therapy with a medicine help to reduce symptoms ?
Does this drug have adverse effects that are more likely to occur in an older pt. ?
Is this the most cost-effective choice ?
By what criteria, and at what time, will the effects of therapy be assessed ?
32. Medication Use in 2004 National Nursing Home Survey Participants and Estimates in U.S. Nursing Home Population
33. Mental Health Care Systemin LTC Facilities IntrinsicProvided by the frontline staff of the facility Extrinsic Mental Health and other professionals(usually visiting consultants or outreach teams)
34. Models of mental health services in nursing homes: a review of the literature.Bartels SJ, Moak GS, Dums AR. Psychiatr Serv. 2002 Nov;53(11):1390-6. psychiatrist-centered nurse-centered & multidisciplinary team models
Uncontrolled observational studies suggested that mental health services may result in improved clinical outcomes and less use of acute services. However, few well-designed controlled intervention studies have been conducted.
The least effective model involved traditional consultation-liaison service in which a lone clinician provided a one-time, written consultation on an as-needed basis.
35. Snowdon 2010, Int Psychogeriatrics
37. Moyle et al, Int Psychogeriatrics 2010
38. Moyle et al, Int Psychogeriatrics 2010
39. Moyle et al, Int Psychogeriatrics 2010
40. Quality of the educational input
Individual motivation
Nature, complexity and acceptability of the proposed change initiative
Receptivity of the care environment and its organizational context
41. Conclusions Literature on the effectiveness of SCUs is sparce. No RCTs.
Some studies suggest less use of physical restraints and more optimal use of medications in SCUs vs usual care.
Little data on staffing levels. Clear need for significantly higher levels with a full complement of health disciplines.
Several models for mental health service provision exist. Clear need for involvement of staff with high levels of expertise.
Education & training of staff is essential.