Journal of Gerontological Nursing

CNE Article 

Improving Antipsychotic Agent Use in Nursing Homes: Development of an Algorithm for Treating Problem Behaviors in Dementia

Marianne Smith, PhD, RN; Susan K. Schultz, MD; Linda L. Seydel, MS, LNHA; Jeffrey Reist, PharmD; Michael Kelly, PharmD, MS; Michelle Weckman, MD; Brian Gryzlak, MSW, MA; Ryan Carnahan, PharmD, MS

Abstract

How to Obtain Contact Hours by Reading this Article
Instructions

1.3 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at https://villanova.gosignmeup.com/dev_students.asp?action=browse&main=Nursing+Journals&misc=564. To obtain contact hours you must:

Read the article, “Improving Antipsychotic Agent Use in Nursing Homes: Development of an Algorithm for Treating Problem Behaviors in Dementia” found on pages 24–35, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until April 30, 2015.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Activity Objective

Describe the development of an algorithm for treating problem behaviors in nursing home patients with dementia that can improve the use of antipsychotic agents.

Disclosure Statement

Neither the planners nor the authors have any conflicts of interest to disclose.

This article has been amended to include factual corrections. To read the erratum, click here. The online article and its erratum are considered the version of record.

 

Many issues related to safety and quality care emerge from reports that nearly one in three nursing home residents is treated with antipsychotic medication, a rate that exceeds levels that led to nursing home reform more than 2 decades ago. Atypical antipsychotic medications have become the mainstay of treatment for behavioral problems among residents with dementia, despite federal “black box” warnings about health risks and research demonstrating their limited effectiveness. The purpose of this article is to briefly describe a dissemination research project designed to increase appropriate antipsychotic prescribing for older adults with dementia. A step-wise problem-solving algorithm designed to reduce unnecessary psychotropic medication use is described. Formative evaluation results provided by nursing home personnel are reviewed. Discussion focuses on nursing home culture as an important influence on the adoption of evidence-based practices and changes needed to promote use of behavioral interventions in dementia care and reduction of reliance on antipsychotic medications.

Dr. Smith is Assistant Professor, University of Iowa College of Nursing, Dr. Schultz is Professor, Department of Psychiatry, Ms. Seydel is Program Administrator, Iowa Geriatric Education Center, Department of General Internal Medicine, Dr. Weckman is Assistant Professor (Clinical), University of Iowa Carver College of Medicine, Dr. Reist is Assistant Professor (Clinical), Dr. Kelly is Associate Dean, University of Iowa College of Pharmacy, Mr. Gryzlak is Research Specialist, and Dr. Carnahan is Assistant Professor (Clinical), Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This project was supported by grant R18HS019355 (principal investigator: R. Carnahan) from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not necessarily represent the official views of the AHRQ. The authors thank all of the study participants, stakeholder panel members, and others who provided feedback to improve the resources. They also thank other members of the Improving Antipsychotic Appropriateness in Dementia Patients team who contributed to development and refinement of the algorithm and pocket guides and/or provided direction on the project: Kristin Johnson, BA; Susan Lenoch, MA; Paul Mulhausen, MD; Jeanette Daly, RN, PhD; Barcey Levy, MD, PhD; Kathleen Buckwalter, RN, PhD, FAAN; Kristi Ferguson, PhD; Elizabeth Chrischilles, PhD; and Mary Ann Abrams, MD.

Address correspondence to Marianne Smith, PhD, RN, Assistant Professor, University of Iowa College of Nursing, 50 Newton Road, Iowa City, IA 52242; e-mail: marianne-smith@uiowa.edu.

Received: August 19, 2012
Accepted: October 23, 2012
Posted Online: March 22, 2013

Do you want to Participate in the CNE activity?

Abstract

How to Obtain Contact Hours by Reading this Article
Instructions

1.3 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at https://villanova.gosignmeup.com/dev_students.asp?action=browse&main=Nursing+Journals&misc=564. To obtain contact hours you must:

Read the article, “Improving Antipsychotic Agent Use in Nursing Homes: Development of an Algorithm for Treating Problem Behaviors in Dementia” found on pages 24–35, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until April 30, 2015.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Activity Objective

Describe the development of an algorithm for treating problem behaviors in nursing home patients with dementia that can improve the use of antipsychotic agents.

Disclosure Statement

Neither the planners nor the authors have any conflicts of interest to disclose.

This article has been amended to include factual corrections. To read the erratum, click here. The online article and its erratum are considered the version of record.

 

Many issues related to safety and quality care emerge from reports that nearly one in three nursing home residents is treated with antipsychotic medication, a rate that exceeds levels that led to nursing home reform more than 2 decades ago. Atypical antipsychotic medications have become the mainstay of treatment for behavioral problems among residents with dementia, despite federal “black box” warnings about health risks and research demonstrating their limited effectiveness. The purpose of this article is to briefly describe a dissemination research project designed to increase appropriate antipsychotic prescribing for older adults with dementia. A step-wise problem-solving algorithm designed to reduce unnecessary psychotropic medication use is described. Formative evaluation results provided by nursing home personnel are reviewed. Discussion focuses on nursing home culture as an important influence on the adoption of evidence-based practices and changes needed to promote use of behavioral interventions in dementia care and reduction of reliance on antipsychotic medications.

Dr. Smith is Assistant Professor, University of Iowa College of Nursing, Dr. Schultz is Professor, Department of Psychiatry, Ms. Seydel is Program Administrator, Iowa Geriatric Education Center, Department of General Internal Medicine, Dr. Weckman is Assistant Professor (Clinical), University of Iowa Carver College of Medicine, Dr. Reist is Assistant Professor (Clinical), Dr. Kelly is Associate Dean, University of Iowa College of Pharmacy, Mr. Gryzlak is Research Specialist, and Dr. Carnahan is Assistant Professor (Clinical), Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This project was supported by grant R18HS019355 (principal investigator: R. Carnahan) from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not necessarily represent the official views of the AHRQ. The authors thank all of the study participants, stakeholder panel members, and others who provided feedback to improve the resources. They also thank other members of the Improving Antipsychotic Appropriateness in Dementia Patients team who contributed to development and refinement of the algorithm and pocket guides and/or provided direction on the project: Kristin Johnson, BA; Susan Lenoch, MA; Paul Mulhausen, MD; Jeanette Daly, RN, PhD; Barcey Levy, MD, PhD; Kathleen Buckwalter, RN, PhD, FAAN; Kristi Ferguson, PhD; Elizabeth Chrischilles, PhD; and Mary Ann Abrams, MD.

Address correspondence to Marianne Smith, PhD, RN, Assistant Professor, University of Iowa College of Nursing, 50 Newton Road, Iowa City, IA 52242; e-mail: marianne-smith@uiowa.edu.

Received: August 19, 2012
Accepted: October 23, 2012
Posted Online: March 22, 2013

Do you want to Participate in the CNE activity?

 

A wide variety of labels are used interchangeably to describe the behavior problems that affect 90% or more of individuals with dementia, including neuropsychiatric symptoms; behavioral and psychological symptoms of dementia; and agitated, resistive, challenging, and catastrophic behaviors, among others. Regardless of the label used, problem behaviors are an important ongoing focus of daily care in nursing homes (NHs), where an estimated 50% of residents have dementia (Barton, Miller, & Yaffe, 2006; Magaziner et al., 2000). Difficulties managing dementia-related behaviors in NHs were illuminated more than 20 years ago when the Omnibus Budget Reconciliation Act (OBRA) of 1987 included NH reform legislation that regulated use of antipsychotic medications and physical restraints.

Restricted use of antipsychotic medications had the desired effects in the short run as antipsychotic agent use fell from an estimated 24% to 17% in the pre- to post-OBRA years (Garrard, Chen, & Dowd, 1995; Shorr, Fought, & Ray, 1994). However, antipsychotic agent use in NHs has risen again, as analysis of nationwide data indicates that nearly one third (29%) of NH residents were prescribed antipsychotic medications in 2006 (Chen et al., 2010). Nationally representative data from 2004 indicated that 23.5% of elderly NH residents received one or more atypical antipsychotic medications, and of those, 86.3% were prescribed for off-label uses. One third (32.8%) of residents with dementia received an antipsychotic agent (Kamble, Sherer, Chen, & Aparasu, 2010). These trends are particularly alarming in light of evidence that atypical antipsychotic agents have limited effectiveness and many adverse effects among older adults with dementia, including increased risks of mortality and cerebrovascular events (e.g., stroke, transient ischemic events) (U.S. Food and Drug Administration, 2005; Jeste et al., 2008; Schneider et al., 2006).

The frequency of antipsychotic medication use, high dosing levels, and inappropriate indications among NH residents stimulated the Centers for Medicare & Medicaid Services (CMS, 2013) to announce the “CMS Partnership to Improve Dementia Care: Rethink, Reconnect, Restore” in May 2012. The goal of this state-public partnership was to reduce administration of antipsychotic drugs in NH residents by 15% by the end of 2012 by using three main activities: enhanced training, increased transparency about rates of antipsychotic agent use in each NH, and use of nonpharmacological alternatives to antipsychotic medications for NH residents (Bonner, 2012).

The purpose of this article is to briefly describe an adaptation and dissemination research project that was designed to improve appropriate use of atypical and other antipsychotic medications to treat behavioral symptoms of dementia in NHs and related long-term care (LTC) settings. The development of a step-wise problem-solving guide, the Algorithm for Treating Behavioral and Psychological Symptoms of Dementia (called “Algorithm” in this article) is described. Formative evaluation methods and feedback from NH providers about using the Algorithm in practice are reviewed. Implications for practice and research are discussed in the context of literature, suggesting that NH culture is an important component in changing antipsychotic agent prescribing practices.

IA-ADAPT Overview

A suite of problem-solving products, including the Algorithm, were developed as part of a 3-year research study initiated in 2010 called “Improving Antipsychotic Appropriateness in Dementia Patients,” or IA-ADAPT for short (Agency for Healthcare Research and Quality [AHRQ] grant 1 R18 HS019355-01). The IA-ADAPT project was stimulated by the AHRQ comparative effectiveness research review and summary guide (CERSG) on off-label use of atypical antipsychotic medications (Maglione et al., 2011; Saha, Robinson, Bianco, Schechtel, & Hickman, 2007; Shekelle et al., 2007). The AHRQ report provides an excellent foundation of information on the efficacy, effectiveness, and adverse events associated with using atypical antipsychotic agents for treatment of behavioral problems in dementia. However, incorporating new information into daily dementia care practices often requires translation of “facts” into formats that are easily understood and used by providers. Thus, this project sought to place information about antipsychotic agent use in the context of an overall approach to managing problem behaviors in dementia.

The goal of the IA-ADAPT project was to adapt and disseminate information in the AHRQ report about off-label use of atypical antipsychotics in dementia by creating clinical tools and supportive materials that target optimal use in daily practice. More specifically, decision aids and case-based learning (called “project materials” throughout this article) are designed to (a) guide assessment of behavioral disturbances; (b) promote a step-wise approach to treatment, including use of nonpharmacological interventions; (c) examine risk-benefit issues when considering antipsychotic agent use; (d) select antipsychotic agents based on evidence of efficacy, effectiveness, adverse effects, and individual patient characteristics; and (e) monitor treatment outcomes.

The collaborative project includes a steering committee of experts who advise the principal investigator on scientific issues; a Stakeholder Advisory Panel composed of LTC providers, quality improvement experts, and health professionals who provide input and feedback about needs; and Adaptation, Dissemination, and Evaluation Teams composed of experts who focus on specific project aims. The target audience includes three groups of related learners: (a) prescribers and clinicians with some pharmacology training, such as physicians, physician assistants (PAs), pharmacists, nurse practitioners (NPs), and RNs; (b) direct care providers with limited training in pharmacology, such as licensed practical nurses (LPNs), certified nursing assistants (CNAs), and home health aides; and (c) family members of patients with dementia.

An iterative process was used to best assure that project materials fit the needs of the target audience. The content is based on information provided in the CERSG reviews and dementia care evidence from literature reviews. Materials were designed to facilitate the transfer of factual knowledge into procedural knowledge (also called knowledge in action) that involves “if-then” rules that direct specific actions (Green & Seifert, 2005). Thus, information and examples in digitized Case-Based Mini-Lectures are reinforced by the Algorithm and Pocket Guides to promote application and mastery and, in turn, overcome shortcomings of purely lecture-based educational approaches that produce little or no change in daily practices (Oxman, Thomson, Davis, & Haynes, 1995).

Project materials are available through the Iowa Geriatric Education Center, a well-established resource for geriatric learning. Table 1 lists review materials that are now available on the website for national dissemination ( http://www.healthcare.uiowa.edu/igec/IAADAPT). Information in the Pocket Guides is illustrated in the online Case-Based Mini-Lectures that apply the problem-solving methods to “Mrs. Klein” following her admission to the NH (Carnahan et al., 2012). The Pocket Guides are color coded to promote easy reference to assessment information (blue), non-pharmacological approaches (yellow), and antipsychotic agent use (pink).

Improving Antipsychotic Appropriateness in Dementia Patients (IA-ADAPT) Products

Table 1: Improving Antipsychotic Appropriateness in Dementia Patients (IA-ADAPT) Products

Algorithm for Problem Behaviors

The IA-ADAPT project operated from the premise that improving appropriate use of antipsychotic medications relies on two main factors: reducing the overall use of antipsychotic agents to treat behavioral problems in dementia (e.g., through enhanced assessment and use of nonpharmacological approaches) and optimizing medication use when selected as a necessary intervention. The Algorithm includes three steps that are presented in a flow-chart style poster (8.5 × 14 inches). A simplified version is provided as a Pocket Guide for quick reference.

The Algorithm builds on problem-solving methods and nonpharmacological care approaches that are recommended in both dementia treatment guidelines and care models (Alexopoulos et al., 2005; Buettner & Fitzsimmons, 2009; Hall & Buckwalter, 1987; Kolanowski, 1999; Teri, 1990). Ideas and concepts from successful dementia training programs (Smith, Buckwalter, & Mitchell, 1993; Smith, Johnson, Seydel, Buettner, & Buckwalter, 2009; Smith, Kolanowski, Buettner, & Buckwalter, 2009; Smith & Vanden Bosch, 1998) are combined with information from literature reviews. A supportive narrative review, available on the website, describes the rationale for activities that are only briefly outlined in the Algorithm to help users better understand and apply ideas. Case-Based Mini-Lectures on assessment and nonpharmacological interventions illustrate problem-solving principles and step-wise care. The Algorithm and narrative are not designed for use as a “stand-alone” educational training program for nonpharmacological interventions. Rather, the intent is to guide learners to ideas and practices that are often successful, and encourage learners to pursue additional training if needed. To facilitate that option, the IA-ADAPT site is linked to an 8-hour online Dementia Care Course that is focused on behavioral and psychosocial (non-drug) interventions and person-centered care.

Step 1: Identify, Assess, and Treat Contributing Factors

The first step in the Algorithm is to identify and treat causal and contributing factors that lead to behavioral disturbances. This step is guided by two main dementia care models. The Need-Driven Dementia-Compromised Behavior model (Algase et al., 1996; Kolanowski, 1999) emphasizes the interaction between stable background factors and fluctuating environmental factors in causing problem behaviors. The Antecedent-Behavior-Consequence, or A-B-C approach, described by Smith et al. (1993) and Teri (1990) directs caregivers to consider one behavior at a time and carefully examine antecedents or triggers.

Step 1 instructs users to determine and document the frequency, duration, intensity, and characteristics of each problem behavior. The next action is to identify, assess, treat, or eliminate antecedents or triggers to the behavior. Four main categories of contributing factors (antecedents) are included: unmet physical needs, unmet psychological needs, environmental causes, and psychiatric causes. Examples are provided in each category (Figure 1). The list of contributing factors is further supported by three Pocket Guides: the Introduction and Overview, which highlights common causes and assessment parameters; Delirium Screening; and Drugs that May Cause Delirium or Problem Behaviors. The supportive narrative provides assessment questions for triggers in each category (e.g, pain, embarrassment, boredom, noise level, comorbid psychiatric symptoms) to stimulate problem solving. The narrative also discusses the value of adjusting daily routines, using teamwork to personalize care, and monitoring outcomes to ensure a full treatment response. The approaches in Step 2 are recommended to support and extend problem-solving related to identifying and treating contributing factors.

Algorithm for Treating Behavioral and Psychological Symptoms of Dementia, Step 1.Source. Iowa Geriatric Education Center (http://www.healthcare.uiowa.edu/igec/IAADAPT). Used with permission.

Figure 1. Algorithm for Treating Behavioral and Psychological Symptoms of Dementia, Step 1.Source. Iowa Geriatric Education Center (http://www.healthcare.uiowa.edu/igec/IAADAPT). Used with permission.

Step 2: Select and Apply Nonpharmacological Interventions

In Step 2, caregivers are directed to select interventions based on the type of problem behavior and to use the person’s retained abilities, preferences, and resources to guide individualized approaches to the person. Tailoring daily care and interventions follows the N.E.S.T. (Needs, Environment, Stimulation, Techniques) Approach to dementia care (Buettner & Fitzsimmons, 2009). To best assure that interventions “fit” the person and situation, caregivers are asked to consider the person’s cognitive level; physical functional level; long-standing personality, life history, interests, and abilities; preferred personal routines and daily schedule; and personal, family, and facility resources that may facilitate more adaptive behaviors. Consistent with the IA-ADAPT philosophy that procedural learning better ensures that knowledge is used in daily practice, Step 2 stresses staff training, support, and assistance to apply care approaches.

Step 2 interventions fall into three main categories: (a) adjusting caregiver approaches, (b) changing the physical and social environments, and (c) using evidence-based interventions that are personalized to the individual and the behavior (Figure 2). Recommended approaches to care and environmental adaptations are based on two main theoretical models. The Progressively Lowered Stress Threshold model (Hall & Buckwalter, 1987) provides specific guidance for adjusting daily approaches and routines and adapting the environment to keep “stress” at a manageable level for individuals with dementia. The N.E.S.T. Approach (Buettner & Fitzsimmons, 2009) emphasizes the relationship between behavioral symptoms and the person’s activity level, particularly the lack of appropriate activities.

Algorithm for Treating Behavioral and Psychological Symptoms of Dementia, Step 2.Source. Iowa Geriatric Education Center (http://www.healthcare.uiowa.edu/igec/IAADAPT). Used with permission.

Figure 2. Algorithm for Treating Behavioral and Psychological Symptoms of Dementia, Step 2.Source. Iowa Geriatric Education Center (http://www.healthcare.uiowa.edu/igec/IAADAPT). Used with permission.

Adjust Caregiver Approaches. The goal is to help care providers understand how they can change their approach to get different results. Simplifying tasks, striving for clear communication, using the person’s history as a guide to daily care tasks, and not “confronting” the person with information he or she is unable to remember are main strategies. Caregivers are encouraged to break tasks into simple, “doable” steps using verbal and physical cues and to accept “misbeliefs” as real to the person using validation-style approaches (Feil, 1982) instead of reality orientation. Replacing negative and restrictive feedback (Hall & Buckwalter, 1987) such as “That’s not your room,” “Don’t touch that,” and “You can’t go home” with distracting activities and/or gentle redirection is advised. Involvement in person-appropriate activities that are tailored to current abilities and preferences is emphasized as both a care approach and a component of changing the environment to accommodate dementia-related needs and behaviors.

Change the Environment. Simplifying the world around the person with dementia is the second main approach in Step 2. Adjusting the physical and social environment to be “dementia friendly” relies on thoughtful examination of the level and type of stimulation (e.g., noise, people, television, pictures) that may be stressful to, or misunderstood by, the person with dementia. Additional strategies include providing signage to promote way-finding, improving sensory input to minimize misinterpretations and/or illusions, and offering activities that promote function and comfort and—in turn—reduce problem behaviors. The overall goal is to promote successful engagement in a comfortable, understandable, homelike setting that promotes autonomy and choice.

Use Evidence-Based Interventions. The third strategy is to select and implement nonpharmacological approaches to distract, soothe, and engage individuals with dementia. Users are advised that some interventions work very well with some individuals, but none work well with all individuals with dementia. The narrative directs users to (a) think about the person and his/her unique characteristics, interests, and abilities; (b) think about the problem behavior; (c) select a type of intervention; and (d) personalize the intervention to the person and his/her needs. The timing and duration of interventions should be adjusted to achieve the best possible outcome. Providers are also reminded that the same intervention, such as music, may be “activating” or “soothing” based on application. As before, users are advised that additional reading and/or training is needed to effectively use and personalize the interventions.

Interventions are grouped by the general type of behavior problem, including agitated/irritable, resistive, wandering/restless/bored, disruptive vocalization, apathetic/withdrawn, repetitive, and depression/anxiety. Simple Pleasures, a group of sensorimotor interventions that may alternately be used to reduce agitation, boredom, or passivity, provide an important foundation (Buettner, 1999; New York State Department of Health, n.d.). Simple Pleasures’ interventions have been extensively evaluated and are the basis of several dementia training programs (Buettner & Fitzsimmons, 2009; Kolanowski & Buettner, 2008; Smith, Johnson, et al., 2009). Directions for both making the activity items and applying them as an intervention are available at no cost (New York State Department of Health, n.d.), making them highly accessible and practical to recommend to daily care providers. Additional interventions are selected from systematic literature reviews and evidence-based practices (Ayalon, Gum, Feliciano, & Areán, 2006; Livingston et al., 2005).

Step 3: Monitor Outcomes and Adjust Course as Needed

The last step in the Algorithm emphasizes the importance of systematically quantifying behavior symptoms using a standardized rating scale or individualized behavior logs that are tailored to the person and target problem. Providers are directed to ensure that the intervention is delivered at the right “dose,” including frequency, duration, and intensity, to achieve optimal outcomes. Providers are cautioned that inconsistent or inappropriate use of interventions may result in erroneous conclusions about the effect of the nonpharmacological approaches, and in turn, premature or inappropriate use of antipsychotic agents. Involving direct care providers (who know the person with dementia well) and family members (who know their history and preferences) as key informants is essential to assessing outcomes and adjusting care approaches. Finally, the provision of staff education and skill development activities to ensure that interventions are both understood (e.g., how, when, why to use them) and routinely used in daily care is reiterated. Step 3 concludes with the recommendation that antipsychotic medication interventions should be used only when problem behaviors are persistent and severe and meet criteria for use. Users are referred to the Antipsychotic Prescribing Guide that is part of the IA-ADAPT program.

Formative Evaluation

The participating university’s institutional review board approved the IA-ADAPT study and its evaluation. Documentation of consent was waived. Protection of participants included using numeric identification for data, maintaining separate locked files for pages containing names (consent forms) and coded data forms, and storing electronic data on a secure, password-protected research drive that only select research team members may access. Participants were all volunteers who were advised that participating in the evaluation as a whole or responding to individual questions was optional.

The formative evaluation was an iterative process that examined the content, readability, ease of use, level of detail, color coding, and other issues pertaining to accuracy and usability of the suite of products. Structured evaluation methods included surveys, focus groups, and a product review questionnaire. Informal feedback was collected through discussions with a broad cross-section of individuals and groups at professional meetings, conference presentations and poster sessions, NH presentations, and other venues conducted statewide and nationally. Informants included end users (i.e., physicians, pharmacists, nurses, and nursing personnel) and content and literacy experts to enhance user- and reader-friendly formats. Revisions targeted repetitive themes that emerged in both structured and informal feedback.

Provider Product Review Questionnaire

The product review questionnaire, the focus of this article, was accompanied by a copy of the Pocket Guides and Poster (Table 1) to promote examination of the products as questions were answered. Regardless of their mode of participation in the evaluation (e.g., focus groups, presentations, need assessment surveys), all individuals were invited to complete the product questionnaire. Those who were interested were provided packets that contained the questionnaire, project materials, and a posted return envelope. A small honorarium was provided to offset time spent reviewing materials and completing the questionnaire.

The first page requested basic demographic information about participants (gender, age, professional role/title, years in practice, and years working with patients with dementia). The remaining pages assessed the IA-ADAPT Pocket Guides and Algorithm poster (called “tools” in the questionnaire). The same five questions were posed for each product, including usefulness in making decisions on managing challenging behaviors; potential usefulness to other providers; things that may be inaccurate, confusing, or missing; aspects that may be unnecessary or difficult to implement; and suggestions for improving the product. A request to “please discuss” answers followed each question.

Nursing Home Respondents

Of the 62 individuals who returned product review questionnaires, 18 were NH employees, 19 were prescribers (e.g., physicians, NPs, PAs), 18 were pharmacists, and 7 were hospice providers. Because of inherent differences among these groups related to their roles in improving appropriate antipsychotic agent use, results were sorted and reviewed separately. Results for NH respondents are described here.

The NH participants included 14 RNs, 2 LPNs, and 2 CNAs who were employed as either directors of nursing (n = 11) or daily care providers (n = 7) in 15 nursing facilities statewide. All were women whose ages ranged from 21 to 64 (median age = 44.5). Participants reported working in clinical practice from 1 to 37 years (median = 20.5 years) and working directly with patients with dementia from 1 to 36 years (median = 17.5 years).

Nonpharmacological Management Feedback

Responses to the five questions for the Algorithm poster and abbreviated Pocket Guide are summarized in Table 2. Overall, ratings and comments were very positive for all questions. The Algorithm poster and related Pocket Guide were considered useful, both for the participant and other providers that they know (Questions 1 and 2). Many positive comments were related to the format (e.g., “great flow,” “nice arrangement,” “these steps are so important”) and content (e.g., “valuable content,” “great questions to ask oneself,” “it explains what unmet needs may cause”). One participant noted, “I personally do not favor complex wordy algorithms.” Additional comments focused on the importance of training to use the tools, such as “Without training some of the interventions won’t make sense.”

Nursing Home Participants’ Perceptions of Nonpharmacological Tools (N = 18)

Table 2: Nursing Home Participants’ Perceptions of Nonpharmacological Tools (N = 18)

Participants also found the content accurate and understandable (Question 3). One participant appeared to disagree with the concept of assessing multiple domains simultaneously: “Based on Maslow’s hierarchy, the nurse should always start by assessing for unmet physical needs. The algorithm seems to suggest that any piece can be an origin.” The majority of participants replied “none” to the open-ended question about aspects that are unnecessary or difficult to implement (Question 4). Additional responses about potential difficulties related to the need for training, time constraints (e.g., “Difficult because you don’t always have lots of time to try some of these things”), and assessment challenges (e.g., “You can’t always communicate with the resident that cannot speak, [or] take in what is different from one day to another”).

Suggestions for making the tools more useful (Question 5) included a mixture of positive comments about the Algorithm (“Easy to follow”), as well as comments that the layout was slightly confusing, poster size was cumbersome, and that Step 2 repeated some items. Suggestions for improvements included putting the information on a two-sided 8.5- x 11-inch sheet and using interventions from the poster to create reference cards that could be used as care plan card (Kardex®) inserts. Suggestions for improving the Pocket Guide included developing checklists to document behavior frequency, intensity, duration, and characteristics; creating a training video to go with the guide; and making sure all language is appropriate for paraprofessionals (i.e., “antecedents” may not be a familiar term to all end users).

Discussion

The problem-solving Algorithm developed as part of the IA-ADAPT dissemination project holds considerable promise as a guide to help daily care providers better understand and manage problem behaviors among older adults with dementia. Feedback provided by NH personnel in the formative evaluation suggests that the Algorithm Poster and associated Pocket Guide provide important directions for assessing contributing factors, adjusting approaches, adapting the care environment to reduce the risks of problem behaviors, and tailoring interventions to address specific and persisting behaviors. Although some participants found the format somewhat confusing, the majority favored the step-wise approach to identifying and treating problem behaviors.

Feedback provided through the formative evaluation guided editing and additional product development to support and extend use of the Algorithm and other project materials. Comments about training to use the Algorithm directed the development of an educational program to facilitate understanding and use of ideas in the Algorithm and Pocket Guide and to personalize approaches to individual NH needs (e.g., Kardex, checklists). This program will be posted on the website with other projects to promote easy use. Project materials have been reviewed again for readability by health literacy experts, and a list of definitions is being developed for words that may be unfamiliar to paraprofessionals or family providers. Suggestions for reformatting the Algorithm for other uses (e.g., front/back on standard sheet, Kardex) are being reviewed for feasibility.

Comments related to time constraints as a barrier to using strategies in the Algorithm are consistent with other reports in the literature. Lack of available time and resources are primary barriers to the adoption of evidence-based practices in NHs, along with limited decision-making authority of staff to implement changes, problems related to understaffing, lack of well-trained staff, and non-receptive organizational cultures (Maas, Specht, Buckwalter, Gittler, & Bechen, 2008). Although all of these factors are salient to successfully implementing practices in the Algorithm and other IA-ADAPT materials, organizational culture may be particularly influential.

Organizational culture, which encompasses the goals, roles, processes, values, communication practices, attitudes, and assumptions shared by the work group (Denning, 2011), is an important focus of research about antipsychotic agent use in NHs. Both external factors (e.g., regulations, reimbursement policies, market characteristics) and internal factors (e.g., resident, physician, and NH characteristics) are increasingly recognized as influencing prescribing practices in NHs (Castle, Hanlon, & Handler, 2009; Chen et al., 2010; Gruneir & Lapane, 2008; Hughes, Lapane, Watson, & Davies, 2007; Huybrechts et al., 2012). Although overall rates suggest that nearly one third (29%) of NH residents receive one or more antipsychotic agents, differences among individual nursing facilities are considerable (Chen et al., 2010). When facility-level rates are divided into quintiles, the lowest rates of antipsychotic agent use range from 3% to 25% (Quintile 1) and the highest rates (Quintile 5) range from 40% to 66% (Chen et al., 2010; Rochon et al., 2007). Of equal importance, the variations in antipsychotic prescribing practices are independent of residents’ clinical characteristics. That is, differences among facilities are not explained by diagnoses, behavioral severity, or case-mix, suggesting that decisions rely on the “prescribing culture” of the NH (Chen et al., 2010; Huybrechts, et al., 2012; Rochon et al., 2007).

This evidence is particularly important to implementing educational approaches such as IA-ADAPT that target appropriate use of antipsychotic medications. The organizational culture of the NH is an important component of any quality initiative, particularly those aimed at improving psychosocial and nonpharmacological treatment of behavioral disturbances in dementia, including the CMS (2013) Partnership to Improve Dementia Care. Although diverse clinical trials indicate that educational programs can be effective in reducing use of antipsychotic agents to treat behavioral symptoms in dementia (Fossey et al., 2006; Monette et al., 2008; Rovner, Steele, Shmuely, & Folstein, 1996), long-term adoption of care practices hinges on the NH culture. In addition to providing choice, dignity, respect, self-determination and purposeful living that are widely associated with culture change in NHs (Pioneer Network, n.d.), safety issues associated with antipsychotic medication use in dementia are another critical dimension of culture that must be addressed now and in the future. The return of antipsychotic agent use rates to pre-OBRA levels indicates that regulations alone are insufficient to address this problem. Instead, thoughtful attention to the underlying culture of care that determines daily dementia care and prescribing practices must be a focus in clinical care and research.

Implications and Conclusion

By design, IA-ADAPT materials focus on educating those who direct or influence prescribing practices (physicians, PAs, NPs, RNs), provide daily care (LPNs, CNAs, health aides), and know residents best (e.g., family members) to promote mutual perspectives about antipsychotic agent use. The provision of a shared framework and language for decision making that precedes and accompanies use of antipsychotic medications may enhance choices that improve quality of living for those with dementia. Formative evaluation, although limited in scope, suggests that the step-wise problem-solving approach in the Algorithm and associated Pocket Guide may provide important direction to shift attitudes, beliefs, assumptions, and roles of NH providers that, in turn, may influence the “prescribing” culture of the individual NHs. Evaluation of clinical outcomes of the IA-ADAPT project will better inform its impact on day-to-day care and antipsychotic agent prescribing of older adults with dementia in NHs. In the meantime, nurses and their interdisciplinary health care team members have important opportunities to apply IA-ADAPT principles and practices in the context of NH organizational culture. As emphasized in the CMS (2013) initiative, nonpharmacological approaches and interventions are essential to reducing inappropriate antipsychotic use and improving quality of life for older adults with dementia.

References

  • Alexopoulos, G.S., Jeste, D.V., Chung, H., Carpenter, D., Ross, R. & Docherty, J.P. (2005). The expert consensus guideline series. Treatment of dementia and its behavioral disturbances. Introduction: Methods, commentary, and summary. Postgraduate Medicine, Special Issue November, 6–22.
  • Algase, D.L., Beck, C., Kolanowski, A., Whall, A., Berent, S., Richards, K. & Beattie, E. (1996). Need-driven dementia-compromised behavior: An alternative view of disruptive behavior. American Journal of Alzheimer’s Disease & Other Dementias, 11, 10–19. doi:10.1177/153331759601100603 [CrossRef]
  • Ayalon, L., Gum, A.M., Feliciano, L. & Areán, P.A. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: A systematic review. Archives of Internal Medicine, 166, 2182–2188. doi:10.1001/archinte.166.20.2182 [CrossRef]
  • Barton, C., Miller, B. & Yaffe, K. (2006). Improved evaluation and management of cognitive impairment: Results of a comprehensive intervention in long-term care. Journal of the American Medical Directors Association, 7, 84–89. doi:10.1016/j.jamda.2005.06.008 [CrossRef]
  • Bonner, A. (2012, July2). Next steps for patient safety: Assuring high value health care across all points of care. Testimony provided to Committee on Aging, U.S. Senate. Retrieved from http://www.hhs.gov/asl/testify/2012/07/t20120702a.html
  • Buettner, L.L. (1999). Simple Pleasures: A multilevel sensorimotor intervention for nursing home residents with dementia. American Journal of Alzheimer’s Disease & Other Dementias, 14, 41–52. doi:10.1177/153331759901400103 [CrossRef]
  • Buettner, L.L. & Fitzsimmons, S. (2009). N.E.S.T. approach: Dementia practice guidelines for disturbing behavior. State College, PA: Venture.
  • Carnahan, R., Smith, M., Schultz, S.K., Kelly, M., Reist, J., Weckman, M. & Seydel, L. (2012). IA-ADAPT: Improving Antipsychotic Appropriateness in Dementia Patients. Retrieved from http://www.healthcare.uiowa.edu/igec/IAADAPT
  • Castle, N.G., Hanlon, J.T. & Handler, S.M. (2009). Results of a longitudinal analysis of national data to examine relationships between organizational and market characteristics and changes in antipsychotic prescribing in U.S. nursing homes from 1996 through 2006. American Journal of Geriatric Pharmacotherapy, 7, 143–150. doi:10.1016/j.amjopharm.2009.05.001 [CrossRef]
  • Centers for Medicare & Medicaid Services. (2013). Advancing Excellence in America’s Nursing Homes. Retrieved from http://www.nhqualitycampaign.org/star_index.aspx?controls=dementiaCare
  • Chen, Y., Briesacher, B.A., Field, T.S., Tjia, J., Lau, D.T. & Gurwitz, J.H. (2010). Unexplained variation across US nursing homes in antipsychotic prescribing rates. Archives of Internal Medicine, 170, 89–95. doi:10.1001/archinternmed.2009.469 [CrossRef]
  • Denning, S. (2011, July23). How do you change an organizational culture?Forbes. Retrieved from http://www.forbes.com/sites/steve-denning/2011/07/23/how-do-you-change-an-organizational-culture/
  • Feil, N. (1982). V/F validation—The Feil Method: How to help disoriented old-old. Cleveland, OH: Edward Feil Productions.
  • Fossey, J., Ballard, C., Juszczak, E., James, I., Alder, N., Jacoby, R. & Howard, R. (2006). Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: Cluster randomised trial. BMJ, 332, 756–761 doi:10.1136/bmj.38782.575868.7C [CrossRef] .
  • Garrard, J., Chen, V. & Dowd, B. (1995). The impact of the 1987 federal regulations on the use of psychotropic drugs in Minnesota nursing homes. American Journal of Public Health, 85, 771–776 doi:10.2105/AJPH.85.6.771 [CrossRef] .
  • Green, L.A. & Seifert, C.M. (2005). Translation of research into practice: Why we can’t “just do it.”Journal of the American Board of Family Practice, 18, 541–545 doi:10.3122/jabfm.18.6.541 [CrossRef] .
  • Gruneir, A. & Lapane, K.L. (2008). It is time to assess the role of organizational culture in nursing home prescribing patterns. Archives of Internal Medicine, 168, 238–239. doi:10.1001/archinternmed.2007.43 [CrossRef]
  • Hall, G.R. & Buckwalter, K.C. (1987). Progressively lowered stress threshold: A conceptual model for care of adults with Alzheimer’s disease. Archives of Psychiatric Nursing, 1, 399–406.
  • Hughes, C.M., Lapane, K., Watson, M.C. & Davies, H.T. (2007). Does organisational culture influence prescribing in care homes for older people? A new direction for research. Drugs & Aging, 24, 81–93 doi:10.2165/00002512-200724020-00001 [CrossRef] .
  • Huybrechts, K.F., Rothman, K.J., Brookhart, M.A., Silliman, R.A., Crystal, S., Gerhard, T. & Schneeweiss, S. (2012). Variation in antipsychotic treatment choice across US nursing homes. Journal of Clinical Psychopharmacology, 32, 11–17. doi:10.1097/JCP.0b013e31823f6f46 [CrossRef]
  • Jeste, D.V., Blazer, D., Casey, D., Meeks, T., Salzman, C., Schneider, L. & Yaffe, K. (2008). ACNP white paper: Update on use of antipsychotic drugs in elderly persons with dementia. Neuropsychopharmacology, 33, 957–970. doi:10.1038/sj.npp.1301492 [CrossRef]
  • Kamble, P., Sherer, J., Chen, H. & Aparasu, R. (2010). Off-label use of second-generation antipsychotic agents among elderly nursing home residents. Psychiatric Services, 61, 130–136 doi:10.1176/appi.ps.61.2.130 [CrossRef] .
  • Kolanowski, A. & Buettner, L. (2008). Prescribing activities that engage passive residents. An innovative method. Journal of Gerontological Nursing, 34(1), 13–18 doi:10.3928/00989134-20080101-08 [CrossRef] .
  • Kolanowski, A.M. (1999). An overview of the need-driven dementia-compromised behavior model. Journal of Gerontological Nursing, 25(9), 7–9.
  • Livingston, G., Johnston, K., Katona, C., Paton, J. & Lyketsos, C.G. (2005). Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. American Journal of Psychiatry, 162, 1996–2021 doi:10.1176/appi.ajp.162.11.1996 [CrossRef] .
  • Maas, M.L., Specht, J.P., Buckwalter, K.C., Gittler, J. & Bechen, K. (2008). Nursing home staffing and training recommendations for promoting older adults’ quality of care and life: Part 2. Increasing nurse staffing and training. Research in Gerontological Nursing, 1, 134–152. doi:10.3928/19404921-20080401-04 [CrossRef]
  • Magaziner, J., German, P., Zimmerman, S.I., Hebel, J.R., Burton, L., Gruber-Baldini, A.L. & Kittner, S. (2000). The prevalence of dementia in a statewide sample of new nursing home admissions aged 65 and older: Diagnosis by expert panel. Epidemiology of Dementia in Nursing Homes Research Group. The Gerontologist, 40, 663–672 doi:10.1093/geront/40.6.663 [CrossRef] .
  • Maglione, M., Ruelaz Maher, A., Hu, J., Wang, Z., Shanman, R., Shekelle, P.G. & Perry, T. (2011). Off label use of atypical antipsychotics: An update (Comparative Effectiveness Review No. 43). Retrieved from http://effectivehealthcare.ahrq.gov/ehc/products/150/786/CER43_Off-LabelAntipsychotics_execsumm_20110928.pdf
  • Monette, J., Champoux, N., Monette, M., Fournier, L., Wolfson, C., du Fort, G.G. & Gore, B. (2008). Effect of an interdisciplinary educational program on antipsychotic prescribing among nursing home residents with dementia. International Journal of Geriatric Psychiatry, 23, 574–579 doi:10.1002/gps.1934 [CrossRef] .
  • New York State Department of Health. (n.d.). Simple Pleasures intervention. Retrieved from http://www.health.state.ny.us/diseases/conditions/dementia/edge/interventions/simple/index.htm
  • Omnibus Budget Reconciliation Act of 1987, Pub. L. No. 100-203, §2, 101 Stat. 1330 (1987).
  • Oxman, A.D., Thomson, M.A., Davis, D.A. & Haynes, R.B. (1995). No magic bullets: A systematic review of 102 trials of interventions to improve professional practice. Canadian Medical Association Journal, 153, 1423–1431.
  • Pioneer Network. (n.d.). What is culture change? Retrieved from http://www.pioneernetwork.net/CultureChange
  • Rochon, P.A., Stukel, T.A., Bronskill, S.E., Gomes, T., Sykora, K., Wodchis, W.P. & Anderson, G.M. (2007). Variation in nursing home antipsychotic prescribing rates. Archives of Internal Medicine, 167, 676–683. doi:10.1001/archinte.167.7.676 [CrossRef]
  • Rovner, B.W., Steele, C.D., Shmuely, Y. & Folstein, M.F. (1996). A randomized trial of dementia care in nursing homes. Journal of the American Geriatrics Society, 44, 7–13.
  • Saha, S., Robinson, S., Bianco, T., Schechtel, M. & Hickman, D. (2007). Off-label use of atypical antipsychotic drugs: A summary for clinicians and policymakers (AHRQ Publication No. 07-EHC003-2). Retrieved from http://www.effectivehealthcare.ahrq.gov/repFiles/Atypical_Antipsychotics_Off_Label_Use.pdf
  • Schneider, L.S., Tariot, P.N., Dagerman, K.S., Davis, S.M., Hsiao, J.K., Ismail, M.S. & Lieberman, J.A. (2006). Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. New England Journal of Medicine, 355, 1525–1538. doi:10.1056/NEJMoa061240 [CrossRef]
  • Shekelle, P., Maglione, M., Bagley, S., Suttorp, M., Mojica, W.A., Carter, J. & Newberry, S. (2007). Efficacy and comparative effectiveness of off-label use of atypical antipsychotics (AHRQ Publication No. 290-02-003). Retrieved from http://effectivehealthcare.ahrq.gov/ehc/assets/File/Atypical_Antipsychotics_Final_Report.pdf
  • Shorr, R.I., Fought, R.L. & Ray, W.A. (1994). Changes in antipsychotic drug use in nursing homes during implementation of the OBRA-87 regulations. Journal of the American Medical Association, 271, 358–362 doi:10.1001/jama.1994.03510290040034 [CrossRef] .
  • Smith, M., Buckwalter, K.C. & Mitchell, S. (1993). The geriatric mental health training series. New York: Springer.
  • Smith, M., Johnson, K., Seydel, L., Buettner, L.L. & Buckwalter, K.C. (2009). Dementia training to promote involvement in meaningful activity. Iowa City: Iowa Geriatric Education Center.
  • Smith, M., Kolanowski, A., Buettner, L.L. & Buckwalter, K.C. (2009). Beyond bingo: Meaningful activities for persons with dementia in nursing homes. Annals of Long-Term Care, 17, 22–30.
  • Smith, M. & Vanden Bosch, J. (1998). Choice and challenge: Caring for aggressive older adults across levels of care. Washington, DC: American Psychiatric Nurses Association.
  • Teri, L. (1990). Managing and understanding behavior problems in Alzheimer’s disease and related disorders: A videotape training series for caregivers. Retrieved from http://depts.washington.edu/adrcweb/ManagingBehaviorProblems.shtml
  • U.S. Food and Drug Administration. (2005, April11). Public health advisory: Deaths with antipsychotics in elderly patients with behavioral disturbances. Retrieved from http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/PublicHealthAdvisories/ucm053171.htm

Improving Antipsychotic Appropriateness in Dementia Patients (IA-ADAPT) Products

Training Component Brief Description
Pocket Guides: Six main topicsa 1. Introduction and overview of the recommended step-wise approach

Overview of the step-wise approach that introduces main sections and color coding: evaluation/assessment issues (blue), non-drug approaches (yellow), and antipsychotic agent management (pink)

Checklist of common causes; brief list of assessment parameters

2. Delirium screening and management

Definition, assessment, and management

Delirium screening tool

3. Drugs that may cause delirium or problem behaviors

Drugs organized by categories

Anticholinergic drugs all on one side

4. Nonpharmacological management of problem behaviors and psychosis in dementia

Short version of the poster-sized three-step Algorithm (described below)

5. Dementia antipsychotic prescribing guides: Clinician versionb

General guidelines and treatment targets

Antipsychotic agent choice; comparison of adverse effects by drug type (table format)

Dosing guidelines; guidance for special populations

Monitoring for response and adverse effects

6. Dementia antipsychotic guides: Caregiver version

General guidelines and treatment targets

Monitoring for response and side effects

Poster: Algorithm for treating behavioral and psychological symptoms of dementia (“problem behaviors”)

Three-step process presented in flow-chart format: (a) Identify, assess, and treat contributing factors; (b) Select and apply nonpharmacological interventions; (c) Monitor outcomes and adjust course as needed; go to medication intervention if indicated

Case-Based Mini-Lectures: Digital presentations that present a case study to illustrate principles described in pocket guides and poster

Short program on six topics

Continuing education credits available with posttest completion

Sequential learning recommended but not mandatory

Supportive Written Materials: Narrative descriptions provide rationale and supporting details

Antipsychotic medication guide

Delirium identification and management

Algorithm for nonpharmacological interventions

Dementia Care Training Course: Adjunctive training programc

Focused on formal caregivers but suitable for anyone

Teaches principles of nonpharmacological management of challenging behaviors

Nursing Home Participants’ Perceptions of Nonpharmacological Tools (N = 18)

Questions/Comments Rating Scale Poster Pocket Guide
1. How useful would this tool be in helping you actually make and/or guide decisions on managing challenging behaviors in people with dementia? Very useful 15 13
Somewhat useful 2 5
Not at all useful 1 0
Poster: “I never know how much the environment and surroundings can affect one with dementia. Having this source on hand would be great to remind me in times of frustration.”
Pocket Guide: “It shows there are so many things that contribute to problem behaviors.”
2. Overall, do you think this tool would be useful to other providers you know, either in your practice or elsewhere? Yes, very or mostly useful 17 10
Yes, but only somewhat useful 1 7
Poster: “All people, such as family and caregivers, should know what factors to look at.”
Pocket Guide: “Particularly useful for CNAs and recreation staff… volunteers, too.”
3. Is there anything in this tool that strikes you as clinically inaccurate or confusing, or is there anything that you think is missing from this tool? Yes 2 1
No 15 17
Poster: “Really like this one. Easy; it helps staff step by step to determine options.”
Pocket Guide: “[Surveyors] are monitoring non-medical approaches so this is very helpful.”
4. Please discuss any aspect of this tool that you think is unnecessary or would be difficult to implement.
Poster: “It is not as convenient as the other guides. It would not be handy to carry.”
Pocket Guide: “Most of the interventions will take training to be utilized properly; however, the tool has good information.”
5. Do you have any suggestions for making this product more useful or effective in guiding decisions, such as design or format of this tool? Yes 4 3
No 14 15
Poster: “I like that there is a detailed poster.”
Pocket Guide: “Easy to follow. Great small size.”

Keypoints

Smith, M., Schultz, S.K., Seydel, L.L., Reist, J., Kelly, M., Weckman, M. & Carnahan, R. (2013). Improving Antipsychotic Agent Use in Nursing Homes: Development of an Algorithm for Treating Problem Behaviors in Dementia. Journal of Gerontological Nursing, 39(5), 24–35.

  1. Nearly one third (29%) of nursing home residents are prescribed one or more antipsychotic medications, a rate that is higher than before nursing home reform legislation was passed.

  2. The important role of using nonpharmacological interventions to treat behavioral symptoms in dementia is underscored in the recent Centers for Medicare & Medicaid Services’ Partnership to Improve Dementia Care.

  3. Step-wise behavioral problem-solving methods include assessing one problem at a time, treating contributing factors, adjusting daily care routines and environmental factors, and tailoring interventions to the person with dementia.

  4. Widely different rates of antipsychotic agent use are not explained by diagnoses, behavior severity, or case-mix, suggesting the “prescribing culture” of the nursing facility influences decisions.

10.3928/00989134-20130314-04

Sign up to receive

Journal E-contents