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Presented by Zoe Dearing BME,MT Alzheimer’s Association Education Institute St Louis Chapter

When To Pop or Drop The Pill Reducing the Need for Anti-psychotics for People with Dementia MHPCA 2013 Spring Symposium May 13, 2013. Presented by Zoe Dearing BME,MT Alzheimer’s Association Education Institute St Louis Chapter. Does Dementia Cause Behavior Problems?. Old thinking

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Presented by Zoe Dearing BME,MT Alzheimer’s Association Education Institute St Louis Chapter

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  1. When To Pop or Drop The PillReducing the Need for Anti-psychotics for People with DementiaMHPCA2013 Spring SymposiumMay 13, 2013 Presented by Zoe Dearing BME,MT Alzheimer’s Association Education Institute St Louis Chapter

  2. Does Dementia Cause Behavior Problems? Old thinking • people with dementia have behavior problem • We can’t change it, only manage it • It is managed with antipsychotic medications

  3. New thinking • Behavior is a form of communication ( neutral) • 90% of all behavior can be eliminated without the use of medication • Most behavior is not random- caused by pain, the environment or caregiver approach

  4. CMS- Anti-Psychotic Reduction Initiative The Centers for Medicare and Medicaid Services (CMS) launched the Partnership to Improve Dementia Care initiative, which calls for a reduction in the use of off-label antipsychotics by 15% by the end of 2012. 

  5. Up to 80% of antipsychotics prescribed in nursing homes are for off-label uses (prescribed to treat a condition that is not among the reasons the drug was originally approved by the FDA).

  6. Management of the behaviors associated with advanced dementia is not an approved indication.  A January 2007 Agency for Healthcare Research and Quality (AHRQ) report found that all of these drugs increase the risk of death and, in some cases, stroke for elderly persons with dementia.

  7. CMS emphasizes non-pharmacologic, individualized, person-centered, evidence-based interventions.  These include understanding behaviors and symptoms as a form of communication, often related to an unmet need or lack of comfort; consistent staff assignments; need for increased exercise or time outdoors; monitoring and managing acute and chronic pain; and planning purposeful activities.  

  8. So, When IS Medication Needed? • When there is IMMINENT danger to the individual or others • When the problem is excessive and constant • When it is causing complete disruption of the environment AND all non pharmaceuticals have been tried without success

  9. In Other Words… Medication should be used ONLY • as a last resort • weighing the benefits and risks • with a clear understanding of the consequences

  10. BEHAVIOR IS COMMUNICATION Behavior : • Occurs when other ways of communication (usually verbal) are no longer effective • Is often a result of the ineffective interpretation of communication by the caregiver • Can be alleviated or significantly reduced without medication about 90% of the time

  11. Objectives • Gain an overall understanding of behavior as a means of communication • Become aware of various triggers that result in certain behaviors • Discover various communication tips and techniques that aid in developing a meaningful relationship with the person in your care • Determine what approaches need to be care-planned, including ongoing monitoring needs

  12. How Would You feel… What Would You Do? (Group Exercise) … if you were snoozing while watching TV and a complete stranger woke you up, took you by the arm and walked you to a dark room, telling you “it is time for me to take you to bed”

  13. Case study discussion What you “do” is in response to how you feel… and Your feeling is legitimate… … So, the response is justified because of the feeling behind it

  14. It is the same for people who have dementia!

  15. There is NOTHING in this disease that takes away a person’s feelings. Their feelings are no different than anyone else’s. They have the complete range of emotion

  16. Short attention span Poor judgment Memory loss Poor concentration Disorientation Confusion Hallucinations Inability to handle stress Inability to communicate Symptoms due to Alzheimer’s Disease Process

  17. Resulting in fear… and the inability to cope

  18. Progressively Lowered Stress Threshold (PLST) • Model developed by Kathleen Buckwalter, PhD, RN (1987) • Foundation for understanding behaviors in persons with dementia

  19. PLST Model As the disease progresses the ability to tolerate stress declines Progressive reduction in normal behavior and an increase in anxious & dysfunctional behavior

  20. ALL BEHAVIOR HAS MEANING! Six factors that contribute to stress: • physical stressors • misleading/inappropriate stimuli • Changes in environment / routine • Demand beyond functional capability • Fatigue • Affective response to perception of loss

  21. Indicators of PLST In a 24-hour period of time: • fewer stressors in early a.m. • Stressors accumulate-anxiety w/ loss of eye contact & restlessness • If unattended: mid-afternoon stress threshold exceeded-severe agitation, cognitive & social dysfunction • Cycle will continue between anxiety and agitation if stress threshold is repeatedly exceeded

  22. Principles for Best Practices of Dementia Care When Behavior Occurs: • Reactive versus Proactive • Use ABC Approach to Problem Solving

  23. Stop, Look & Listen What happened just before the behavior occurred? When? Where? With whom? Environment?

  24. Physical Needs Physical comfort Nutrition/hydration Sleep/rest Elimination Exercise Physical hygiene Relief of pain/discomfort Psychosocial Needs Identity Attachment Inclusion Comfort Occupation Love (Six Needs of People with Dementia- Tom Kitwood) Are their needs being met?

  25. Environment Can the environment “cause” a behavior? What in an environment could make you feel agitated?

  26. Assess their environment • Over stimulated or under stimulated? • Noise • Light • Things/people • Activities • Time of the day “Sundowning”

  27. Caregiver Approach • Approach • slowly • from the front • with a warm demeanor and a quiet, calm voice • Call the person by name • Introduce yourself every time to build a new rapport • Face them at eye level (or slightly below) • Reassure them that you are there to help

  28. Caregiver Approach • Offer a hand • If they refuse care or show signs of agitation – walk away and re-approach later • Try the same approach or try a different approach YOU SET THE TONE; THEY SET THE TIME

  29. Aggressive Behaviors Most common due to: • Fear or uncertainty • Pain/discomfort • Touch or invasion of personal space • Loss of control or choice • Lack of attention to needs or wishes • Frustration due to loss of function or ability • Exhaustion • Elderspeak

  30. How to PREVENTAggressive Behaviors Look for cues/signs of agitation • Facial expressions • Body language • Vocalizations STOP! NEVER FORCE…

  31. Aggression/Agitation During ADLs: • Usually indicative of pain or discomfort • Use the PAINAD assessment

  32. How to handleAggressive Behaviors • STAY CALM- Assure safety • Look at what their emotions are telling you: consider emotional discomfort • Build rapport • Do not try to reason- hand over the control!!! • Watch non-verbals- Verbal communication is probably not effective in later stage • Give space & try again later • Assess the surroundings for environmental clues

  33. Tips for handling behaviors… • Watch your own communication • Know their life story- Honor routines and choices • Validate their feelings • Redirect & distract • Simplify the environment • Simplify tasks & give them some control Use these best practices for care-planning

  34. Summary • Goal in the management of behaviors is to do no harm (that means physical or emotional) to the individual • We need to think about … • Safety • Comfort • Respect • Dignity • Compassion • Individuality

  35. Summary • Focus on the unmet need that the behavior is communicating to us. • Never make assumptions as to why there is a behavior – Investigate. • Step into their shoes – think about how would you feel as well as how you would like to be treated.

  36. What do people with Alzheimer’s Disease need most? Love Comfort & To Feel Safe

  37. The Good News If you find the trigger for the behavior and eliminate it… …The behavior goes away!

  38. Understanding Behavior without the use of medication • Allows elders with dementia to function at a higher level, improving quality of care • Allows care partners to spend quality time with elders, improving their quality of life • Allows family and friends some peace of mind Everyone wins!

  39. St. Louis Chapter800 / 272-3900www.alz.org/stl The compassion to care,the leadership to conquer

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