Medication management in older adults with cognitive impairment (CI) is particularly challenging for geriatric practitioners (GPs) and nursing home (NH) staff. Moreover, polypharmacy is an additional common problem in this complex patient population. NH residents with CI are at high risk for polypharmacy and its prevalence increases with advanced age, disability, and recent hospitalization (Vetrano et al., 2013). Important tasks for GPs include managing complex chronic comorbidities, preventing return to acute care, and effectively reducing polypharmacy and psychotropic drug use.
Inappropriate medication use in NH residents continues to be problematic and is associated with adverse drug events, hospitalizations, increased mortality, and increased health care costs (Anrys et al., 2016). In addition, research shows that prescribing psychotropic medication along with certain staffing characteristics (e.g., low staffing ratios) led to a 216% increase in antidepressant medication use from 1996 to 2006 (Hanlon, Handler, & Castle, 2010). Psychotropic medication use in older adults can have deleterious health effects, such as worsening orthostatic hypotension; problems with over-sedation, memory, and psychomotor impairment; and can contribute to poor functional autonomy, cognitive decline, blurred vision, and addiction (Lindsey, 2009). These side effects of psychotropic drugs in NH residents can have profound effects, including falls, increased confusion, and decreased quality of life. Approximately two thirds of long-term care residents are prescribed one or more psychotropic medications (Simoni-Wastila et al., 2014). In addition, the risks of deleterious effects may further increase when psychotropic medications are used in combination with other drugs in patients with multiple comorbidities (Cox et al., 2016).
The Centers for Medicare & Medicaid Services (CMS; 2018b) has partnered with federal and state agencies, NHs, providers, advocacy groups, and caregivers to discover new ways to decrease the use of antipsychotic medication, increase goal-directed care, and improve quality of life by implementing person-centered care (PCC) for NH residents with dementia. Due to this partnership, a 15% reduction of antipsychotic medication use was achieved between 2011 and 2013. CMS has now expanded focus on reduction of other psychotropic medications, such as antidepressant, anxiolytic, and hypnotic agents apart from antipsychotic medications. Moreover, it has encouraged the implementation of nonpharmacological interventions to enhance behavioral health and manage communication of distress symptoms of residents with dementia. Nonpharmacological interventions are recommended by CMS as the first-line approach in the management of non-cognitive neuropsychiatric symptoms (NPS) associated with dementia. However, due to limited understanding of effective nonpharmacological behavioral management approaches among NH staff, paired with the long-standing culture of psychotropic drug use, nonpharmacological behavior management techniques are underutilized (Peri et al., 2015).
Psychotropic Medication Use in Older Adults
In the United States, 41.4% of adults age >70 years with dementia take psychotropic medications (Maust, Langa, Blow, & Kales, 2017). Often, the transition of residents with dementia from a familiar home environment to a NH affects older adults' mental health. This transition often leads to an adjustment disorder and separation anxiety (Acton, Yauk, Hopkins, & Mayhew, 2007). It takes time for residents to adjust to the new, unfamiliar environment. During this transition, NH residents' probability of being prescribed psychotropic medications increases significantly (Maguire, Hughes, Cardwell, & O'Reilly, 2013). Without proper assessment for the need for psychotropic drugs after the initial transition period has passed, residents with dementia may take these medications for several years and perhaps the rest of their lives.
The loss of a spouse often precedes a transition from home to a NH for the remaining spouse. GPs commonly prescribe psychotropic medications to older adults who have recently lost their spouses, and these medications may be continued after a transition to a NH (Möller, Björkenstam, Ljung, & Yngwe, 2011). Loss and separation from loved ones, adjustment to the new environment, and the inactive lifestyle of NH residents increase the risk for anxiety and depression, which may in turn increase the use of psychotropic drugs with these residents.
NH residents with advanced dementia are the most vulnerable when exposed to an unfamiliar environment and staff; therefore, managing their behavior can be challenging. Although research has shown that NH residents with advanced dementia can communicate their needs and distress (Acton et al., 2007), they may be unable to express what they need and how they are feeling to busy, new, or temporary NH staff. Frustration, apprehension, loneliness, detachment, and isolation are in part the result of the failure to comprehend their needs and desires (Acton, Mayhew, Hopkins, & Yauk, 1999; Acton et al., 2007; Mayhew, Acton, Yauk, & Hopkins, 2001). Moreover, it is easy for NH staff to misinterpret NPS of dementia for other psychiatric illness. Poor diagnostic capability may increase requests from NH staff for orders of psychotropic medications, as well as increase early referral to psychiatry consultations. Seeking support from a psychiatry consultant for management of challenging behaviors does not always solve the problem, as consultants may not have knowledge about key history details and may lack coordination with NH staff and primary GPs (Levenson & Desai, 2017). In addition, consultant psychiatrists are not trained to emphasize the use of nonpharmacological behavioral management techniques. Thus, the consultant psychiatrist may feel pressure from NH staff to enable a quick fix, in the form of psychotropic medications, to address communications of distress. On the other hand, primary GPs involved in residents' daily care (i.e., who visit them more often) may be familiar with their baseline behaviors.
Organizational Culture and Psychotropic Medication Use
Organizational culture guides the life of the organization through basic assumptions regarding the world and its organizational values (Schneider, Ehrhart, & Macey, 2013). These assumptions/values guide all aspects of the organization, including care provision, in the case of NHs. It is important for staff to understand the values of their organization to provide care consistent with NH culture. However, there may be a clash between what is best for the organization and what is best for individual NH resident's care. Clarifying and aligning organizational values and care staff values is imperative, and if consensus is reached, can result in improved resident care (Killett et al., 2016). An organizational culture that strives for proper nurse/patient staffing ratios and allows expert NH staff to handle complex care situations can result in optimal resident outcomes.
Organizational culture also plays an important role in determining increased or decreased use of psychotropic medications as it relates to NH personnel's normative beliefs, values, and pattern of behaviors (Hughes, Lapane, Watson, & Davies, 2007). For example, when staff members are regularly assigned the same residents, they gain familiarity with residents' needs and behavior patterns and that familiarity may decrease reliance on psychotropic medications to manage challenging behaviors. However, if the NH organizational culture maintains minimal permanent staff, this practice may promote the use of temporary or as-needed agency care staff to overcome permanent short staffing issues. Staffing shortage is a nationwide problem. Temporary staff are not familiar with residents' communication of needs/distress, which may lead to inappropriate care due to lack of knowledge related to resident needs and baseline behaviors. In addition, it is common for NHs to staff a minimum number of care staff in the evening and night shift; therefore, it is not unusual to see exacerbation of communications of distress during the evening and night hours (Dewing, 2003; Nazarko, 2011). Managing these residents can be challenging, time-consuming, and disruptive to care staff's work routine (van Duinenvan den Ijssel et al., 2018). These staffing practices can lead to implementation of inappropriate care strategies, such as psychotropic drug use to manage communication of distress.
CMS emphasizes PCC approaches to provide safe, effective, efficient, and appropriate care (Kales, Gitlin, & Lyketsos, 2014). Organizations that use PCC approaches are likely to endorse an individualized plan of care for each resident (CMS, 2018a). However, in organizational cultures where profit is paramount, there may be lower staffing ratios, which negatively affect direct care models (Sawan, Jeon, Fois, & Chen, 2017). Administrators' prioritization on lower staffing ratios to control costs can increase staff's reliance on quick fixes, such as psychopharmacological interventions to manage communication of distress. Protocol development to assist frontline NH staff in the use of nonpharmacological approaches to manage NPS of dementia can be a valuable time saver for NH staff, although changing staff practice and organizational culture is not an easy task. Figure 1 is a representation of a model of PCC that could lead to organizational culture change, better management of communication of distress, and better NH resident outcomes.
Model of person-centered care.
PCC depends on the development of an organizational culture that emphasizes meeting residents' individualized needs and goals and uses appropriate staffing ratios to provide care. Gathering information about residents with dementia on admission will assist staff to get to know them better, which is a key first step in developing a blueprint for PCC. Information that is important for PCC may be available in each resident's chart, but these data may be dispersed throughout the chart and hard to find. Availability of resident's information, such as baseline dementia behaviors, communication strategies, family background/support system, preferences of foods/drinks/desserts, and choices of physical and recreational activities (e.g., walking, Bingo, coloring, cards, music, movies), should be accessible in the chart in one designated area for easy review by all NH staff. If the NH community values knowing and honoring preferences, staff can observe likes and dislikes even if the individual is unable to communicate verbally. Managing behavioral symptoms of dementia can be time consuming; often it is impossible to identify residents' preferences as they may not be good historians and staff may lack time to compile information scattered throughout the chart. Written, accessible, and centrally located information concerning NH residents is particularly important to new, temporary, part-time, or agency staff.
Identification of residents' support systems is also crucial and requires understanding of the relationship with family and/or friends. These individuals may be able to provide information about residents' pattern of communication of distress and strategies that will alleviate or escalate behavioral episodes related to communication of distress (Frey, 2011). For example, sundowning, an escalation of communication of distress after dark, may be prevalent in some residents with dementia, so knowing certain times their behaviors may escalate can be meaningful in their plan of care (Dewing, 2003; Nazarko, 2011). Most importantly, recognizing what is important to the resident and his/her family (if involved in care) should be a primary focus in residents with advanced dementia. This information may be valuable in effectively managing communication of distress of dementia while reducing direct care time, especially for staff who are unfamiliar with residents. Social workers can also serve as an important resource for gathering information at admission and during resident stay. Table 1 outlines an easy method of compiling “Get to Know the Resident” data to be placed in a centralized area of the resident's chart.
Get To Know Your Resident Form: Dementia Behavior Management
Non-cognitive NPS of dementia are largely related to psychosocial and physical unmet needs of residents that can be best managed by PCC plans. Changes in NH culture and aligned values can decrease psychotropic medication use in this population (Pieper et al., 2016). Needs of residents with dementia can be divided into three categories: (a) basic needs, (b) physical needs, and (c) environmental needs. Before making any assumption for the causes of dementia behaviors, it is important to ensure that the basic needs (e.g., hunger, thirst, diaper change) of the patient with dementia are met. Physical reasons for communication of distress can include uncontrolled pain, insomnia, dehydration, constipation, and acute infections (e.g., pneumonia, urinary tract infections). Delirium is a common result of these diagnoses in NH residents. Instead of relying on psychotropic medication to manage delirium, identification and treatment of the root cause is the most important step to enhance PCC. The symptoms of delirium can be difficult to differentiate from NPS of dementia, as these symptoms present similarly and can coincide with other psychotic disorders (CMS, 2018a). Antipsychotic medications are not recommended for treating delirium, but their use has nonetheless been prevalent in clinical practice. It is critical for GPs to distinguish between worsening dementia symptoms and delirium symptoms. Differentiating new behaviors from baseline dementia can assist GPs and staff members to differentiate between delirium and NPS of dementia. The use of psychotropic medication for NPS of dementia and during delirium decreases the quality of life of NH residents and exposes them to unnecessary risks/side effects (Harrison et al., 2018).
Environmental stimulation can also have a significant impact in managing communications of distress of dementia. Because the physical environment influences NH residents' activities and interactions, designing facilities that are easy and safe to navigate for older adults can help promote quality care (Nordin et al., 2017). Participation in regular physical activity as well as gardening is also associated with decreased risk of communication of distress in persons with dementia (Lee, 2018). Any pleasant and engaging activity facilitated by nursing staff may help improve quality of life in people with severe dementia (Seitz et al., 2012). Nursing staff training for the application of nonpharmacological interventions—such as recreational activities, exercise, music therapy, aromatherapy, and sensory stimulation to manage NPS of dementia—is universally recommended as a first-line approach (Lok, Lok, & Canbaz, 2017). The implementation of structured physical activity programs improves quality of life and significantly decreases depression among older adults (Cohen-Mansfield, Thein, Marx, & Dakheel-Ali, 2012). Nonpharmacological techniques are underutilized in the standard of care, even though extensive evidence supports them (Ervin, Finlayson, & Cross, 2012; Jones, Hungerford, & Cleary, 2014; Shinagawa et al. 2015).
NH staff should devote more time to nonpharmacological interventions, and these should be first-line treatment of NPS of dementia (Ballard & Cream, 2005). Encouraging older adults to participate in routine structured physical and recreational activities helps maintain functional status and decrease depression, and older adults should be encouraged to engage in physical activity depending on their strength and capacity (Harrison et al., 2018). Physical activity programs in an institutional setting maximize the physical and mental functioning of older adults (de Guzman, Lacampuenga, & Lagunsad, 2015). Table 2 demonstrates a step-by-step guide for NH staff on how to develop PCC for NH residents.
Person-Centered Care for Dementia Behavior Management in Nursing Home Residents: Step-by-Step Guide for Nurses
Role of Primary Geriatric Practitioners
One way to reduce psychotropic drug use is for GPs to carefully evaluate the cause of behavioral problems at the time they receive requests from NH staff for psychotropic medication. In addition, GPs must evaluate the knowledge base of NH staff in relation to the use of nonpharmacological interventions. If NH staff knowledge is lacking, it is incumbent on GPs to develop a teaching plan to introduce nonpharmacological strategies for use by NH staff. GPs' prescribing decisions should not be affected by pressure from NH staff. In addition, pharmacy consultants conduct monthly drug regimen reviews for NH residents. Their recommendations to GPs can have a meaningful impact on reducing inappropriate use of psychotropic medications and can guide gradual dose reduction (GDR) considerations. However, pharmacists' recommendations are based on review of patients' charts or medical records; these providers are not familiar with NH residents as they lack face-to-face interactions. Therefore, it is inappropriate for GPs to depend solely on the consultant pharmacist for advice (Levenson & Desai, 2017). GPs who are familiar with NH residents, their families/caretakers, and frontline NH care staff are able to gather appropriate data to better identify the reason behind each resident's behavioral issues. GDR should be attempted at least biannually, with proper documentation of attempt, success/failure, and benefits clearly documented in the medical record. Significant improvement in the reduction of psychotropic medication can be seen when all team members participate in a structured medication review (van der Spek et al., 2018). Psychotropic medications that are prescribed for adjustment disorder should not be continued for long periods of time without reevaluation of their need. Periodic behavioral management meetings with the interdisciplinary team (IDT) should be mandatory. Primary GPs should take charge of these behavioral meetings to facilitate the team's focus and outcomes. Unfortunately, the use of a consultant provider's services in NHs is common; therefore, fee-for-service systems can be a barrier to interdisciplinary teamwork because GPs and consultants do not receive CMS reimbursement for their participation in behavioral team meetings. Klaasen, Lamont, and Krishnan (2009) found integration of a full-time nurse practitioner (NP) in NHs increased NPs' participation in interdisciplinary care planning and family conferences. This integration enhanced patient/family satisfaction and a significant reduction of antipsychotic medication and polypharmacy, as well as transfer to acute care because full-time NPs are more involved in care coordination with residents, staff, and families (Klaasen et al., 2009).
IDTs should include NH care staff, social workers, activity directors, dietitians, and consultant providers (e.g., psychologists, psychiatrists, GPs, pharmacists). Each member of the IDT in the NH has a unique role. Together they can create individualized behavior management plans to identify effective interventions for each resident. Lack of IDT initiatives to identify barriers for patients, staff, and families, as well as financial and physical limitations, can negatively affect successful implementation of nonpharmacological behavior management approaches. Analysis of existing barriers is an important step toward establishing much needed nonpharmacological intervention programs in NHs (van der Spek et al., 2018). Table 3 is a guide for GPs implementing psychotropic medication GDR, and Table 4 reviews practice strategies for GPs.
Psychotropic Medication Gradual Dose Reduction (GDR) Guide
Practice Guidelines for Primary Geriatric Practitioners (GPs)
Conclusion and Implications
The use of psychotropic medications has been shown to be mostly ineffective to control non-cognitive NPS of dementia in NH residents (Ervin et al., 2012; Jones et al., 2014; Shinagawa et al., 2015). However, the use of psychotropic medication in NH residents continues. Compounding the problems is that once NH residents are prescribed psychotropic medications, they are likely to continue receiving them throughout their lifespan. Periodic PCC meetings among IDT members are necessary to achieve GDR and develop nonpharmacological interventions to replace pharmacological treatments. GPs should periodically re-evaluate residents' needs for psychotropic medication and document results of GDR. Training NH community staff/leaders on nonpharmacological approaches as first-line treatments for behavioral management is crucial, along with emphasizing documentation of attempted nonpharmacological approaches for behavior management. Individualized support plans should be established for residents with dementia by the IDT on admission to the NH or as needed for any changes in their baseline mentation. The IDT should emphasize restricting the use of chemical restraints through navigation of innovative strategies to manage communication of distress by addressing unmet basic, environmental, and physical needs. These strategies can facilitate the culture of PCC in NH organizations.
- Acton, G. J., Mayhew, P. A., Hopkins, B. A. & Yauk, S. (1999). Communicating with individuals with dementia: The impaired person's perspective. Journal of Gerontological Nursing, 25(2), 6–13 doi:10.3928/0098-9134-19990201-04 [CrossRef] PMID:10347432
- Acton, G. J., Yauk, S., Hopkins, B. A. & Mayhew, P. A. (2007). Increasing social communication in persons with dementia. Research and Theory for Nursing Practice, 21(1), 32–44 doi:10.1891/rtnpij-v21i1a005 [CrossRef] PMID:17378463
- Anrys, P., Strauven, G., Boland, B., Dalleur, O., Declercq, A., Degryse, J. M. & Foulon, V. (2016). Collaborative approach to optimise medication use for older people in nursing homes (COME-ON): Study protocol of a cluster controlled trial. Implementation Science; IS, 11(35), 35 doi:10.1186/s13012-016-0394-6 [CrossRef] PMID:26968520
- Ballard, C. & Cream, J. (2005). Drugs used to relieve behavioral symptoms in people with dementia or an unacceptable chemical cosh? Argument. International Psychogeriatrics, 17(1), 4–12 doi:10.1017/S1041610205221026 [CrossRef] PMID:15945588
- Centers for Medicare & Medicaid Services. (2018a). CMS quality strategies. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiatives-GenInfo/Legacy-Quality-Strategy.html
- Centers for Medicare & Medicaid Services. (2018b). National partnership to improve dementia care in nursing homes. Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/National-Partnership-to-Improve-Dementia-Care-in-Nursing-Homes.html
- Cohen-Mansfield, J., Thein, K., Marx, M. S. & Dakheel-Ali, M. (2012). What are the barriers to performing nonpharmacological interventions for behavioral symptoms in the nursing home?Journal of the American Medical Directors Association, 13(4), 400–405 doi:10.1016/j.jamda.2011.07.006 [CrossRef] PMID:21872537
- Cox, C. A., van Jaarsveld, H. J., Houterman, S., van der Stegen, J. C., Wasylewicz, A. T., Grouls, R. J. & van der Linden, C. M. (2016). Psychotropic drug prescription and the risk of falls in nursing home residents. Journal of the American Medical Directors Association, 17(12), 1089–1093 doi:10.1016/j.jamda.2016.07.004 [CrossRef] PMID:27650670
- de Guzman, A. B., Lacampuenga, P. E. U. & Lagunsad, A. P. V. (2015). Examining the structural relationship of physical activity, cognition, fear of falling, and mobility limitation of Filipino in nursing homes. Educational Gerontology, 41(7), 527–542 doi:10.1080/03601277.2014.986398 [CrossRef]
- Dewing, J. (2003). Sundowning in older people with dementia: Evidence base, nursing assessment and interventions. Nursing Older People, 15(8), 24–31 doi:10.7748/nop2003.11.15.8.24.c2281 [CrossRef] PMID:14649151
- Ervin, K., Finlayson, S. & Cross, M. (2012). The management of behavioural problems associated with dementia in rural aged care. Collegian (Royal College of Nursing, Australia), 19(2), 85–95 doi:10.1016/j.colegn.2012.02.003 [CrossRef] PMID:22774350
- Frey, C. (2011). About the informal support for family caregivers in case of dementia— Which role play family, friends and volunteers?Pflegewissenschaft, 13(7–8), 398–403.
- Hanlon, J. T., Handler, S. M. & Castle, N. G. (2010). Antidepressant prescribing in US nursing homes between 1996 and 2006 and its relationship to staffing patterns and use of other psychotropic medications. Journal of the American Medical Directors Association, 11(5), 320–324 doi:10.1016/j.jamda.2010.01.007 [CrossRef] PMID:20511098
- Harrison, S. L., Bradley, C., Milte, R., Liu, E., Kouladjian O'Donnell, L., Hilmer, S. N. & Crotty, M. (2018). Psychotropic medications in older people in residential care facilities and associations with quality of life: A cross-sectional study. BMC Geriatrics, 18(1), 60 doi:10.1186/s12877-018-0752-0 [CrossRef] PMID:29478410
- Hughes, C. M., Lapane, K., Watson, M. C. & Davies, H. T. O. (2007). Does organ-isational culture influence prescribing in care homes for older people? A new direction for research. Drugs & Aging, 24(2), 81–93 doi:10.2165/00002512-200724020-00001 [CrossRef] PMID:17313197
- Jones, T., Hungerford, C. & Cleary, M. (2014). Pharmacological versus nonpharmacological approaches to managing challenging behaviours for people with dementia. British Journal of Community Nursing, 19(2), 72–77 doi:10.12968/bjcn.2014.19.2.72 [CrossRef] PMID:24514107
- Lee, J. (2018). The relationship between physical activity and dementia: A systematic review and meta-analysis of prospective cohort studies. Journal of Gerontological Nursing, 44(10), 22–29 doi:10.3928/00989134-20180814-01 [CrossRef] PMID:30257021
- Kales, H. C., Gitlin, L. N. & Lyketsos, C. G. (2014). Management of neuropsychiatric symptoms of dementia in clinical settings: Recommendations from a multidisciplinary expert panel. Journal of the American Geriatrics Society, 62(4), 762–769 doi:10.1111/jgs.12730 [CrossRef] PMID:24635665
- Killett, A., Burns, D., Kelly, F., Brooker, D., Bowes, A., La Fontaine, J. & O'Neill, M. (2016). Digging deep: How organizational culture affects care home residents' experiences. Ageing and Society, 36(1), 160–188 doi:10.1017/S0144686X14001111 [CrossRef]
- Klaasen, K., Lamont, L. & Krishnan, P. (2009). Setting a new standard of care in nursing homes. The Canadian Nurse, 105(9), 24–30 PMID:19998690
- Levenson, S. A. & Desai, A. K. (2017). Reforming management of behavior symptoms and psychiatric conditions in long-term care facilities: A different perspective. Journal of the American Medical Directors Association, 18(4), 284–289 doi:10.1016/j.jamda.2017.01.005 [CrossRef] PMID:28242193
- Lindsey, P. L. (2009). Psychotropic medication use among older adults: What all nurses need to know. Journal of Gerontological Nursing, 35(9), 28–38 doi:10.3928/00989134-20090731-01 [CrossRef] PMID:19715261
- Lok, N., Lok, S. & Canbaz, M. (2017). The effect of physical activity on depressive symptoms and quality of life among elderly nursing home residents: Randomized controlled trial. Archives of Gerontology and Geriatrics, 70, 92–98 doi:10.1016/j.archger.2017.01.008 [CrossRef] PMID:28110207
- Maguire, A., Hughes, C., Cardwell, C. & O'Reilly, D. (2013). Psychotropic medications and the transition into care: A national data linkage study. Journal of the American Geriatrics Society, 61(2), 215–221 doi:10.1111/jgs.12101 [CrossRef] PMID:23320828
- Maust, D. T., Langa, K. M., Blow, F. C. & Kales, H. C. (2017). Psychotropic use and associated neuropsychiatric symptoms among patients with dementia in the USA. International Journal of Geriatric Psychiatry, 32(2), 164–174 doi:10.1002/gps.4452 [CrossRef] PMID:26889640
- Mayhew, P. A., Acton, G. J., Yauk, S. & Hopkins, B. A. (2001). Communication from individuals with advanced DAT: Can it provide clues to their sense of self-awareness and well-being?Geriatric Nursing, 22(2), 106–110 doi:10.1067/mgn.2001.115198 [CrossRef] PMID:11326220
- Möller, J., Björkenstam, E., Ljung, R. & Yngwe, M. A. (2011). Widowhood and the risk of psychiatric care, psychotropic medication and all-cause mortality: A cohort study of 658,022 elderly people in Sweden. Aging & Mental Health, 15(2), 259–266. doi:10.1080/13607863.2010.513041 [CrossRef] PMID:21140303
- Nazarko, L. (2011). Tackling “sundowning” in dementia care. British Journal of Healthcare Assistants, 5(11), 544–547 doi:10.12968/bjha.2011.5.11.544 [CrossRef]
- Nordin, S., McKee, K., Wallinder, M., von Koch, L., Wijk, H. & Elf, M. (2017). The physical environment, activity and interaction in residential care facilities for older people: A comparative case study. Scandinavian Journal of Caring Sciences, 31(4), 727–738 doi:10.1111/scs.12391 [CrossRef] PMID:27862156
- Peri, K., Kerse, N., Moyes, S., Scahill, S., Chen, C., Hong, J. B. & Hughes, C. M. (2015). Is psychotropic medication use related to organisational and treatment culture in residential care?Journal of Health Organization and Management, 29(7), 1065–1079 doi:10.1108/JHOM-10-2013-0236 [CrossRef] PMID:26556168
- Pieper, M. J., Francke, A. L., van der Steen, J. T., Scherder, E. J., Twisk, J. W., Kovach, C. R. & Achterberg, W. P. (2016). Effects of a stepwise multidisciplinary intervention for challenging behavior in advanced dementia: A cluster randomized controlled trial. Journal of the American Geriatrics Society, 64(2), 261–269 doi:10.1111/jgs.13868 [CrossRef] PMID:26804064
- Sawan, M., Jeon, Y. H., Fois, R. A. & Chen, T. F. (2017). Exploring the link between organizational climate and the use of psychotropic medicines in nursing homes: A qualitative study. Research in Social & Administrative Pharmacy, 13(3), 513–523 doi:10.1016/j.sapharm.2016.06.012 [CrossRef] PMID:27503242
- Schneider, B., Ehrhart, M. G. & Macey, W. H. (2013). Organizational climate and culture. Annual Review of Psychology, 64(1), 361–388 doi:10.1146/annurev-psych-113011-143809 [CrossRef] PMID:22856467
- Seitz, D. P., Brisbin, S., Herrmann, N., Rapoport, M. J., Wilson, K., Gill, S. S. & Conn, D. (2012). Efficacy and feasibility of nonpharmacological interventions for neuropsychiatric symptoms of dementia in long term care: A systematic review. Journal of the American Medical Directors Association, 13(6), 503–506.e2. doi:10.1016/j.jamda.2011.12.059 [CrossRef] PMID:22342481
- Shinagawa, S., Nakajima, S., Plitman, E., Graff-Guerrero, A., Mimura, M., Nakayama, K. & Miller, B. L. (2015). Nonpharmacological management for patients with frontotemporal dementia: A systematic review. Journal of Alzheimer's Disease, 45(1), 283–293 doi:10.3233/JAD-142109 [CrossRef] PMID:25737152
- Simoni-Wastila, L., Wei, Y. J., Luong, M., Franey, C., Huang, T. Y., Rattinger, G. B. & Lucas, J. A. (2014). Quality of psycho-pharmacological medication use in nursing home residents. Research in Social & Administrative Pharmacy, 10(3), 494–507 doi:10.1016/j.sapharm.2013.10.003 [CrossRef] PMID:24355380
- van der Spek, K., Koopmans, R. T. C. M., Smalbrugge, M., Nelissen-Vrancken, M. H. J. M. G., Wetzels, R. B., Smeets, C. H. W. & Gerritsen, D. L. (2018). The effect of biannual medication reviews on the appropriateness of psychotropic drug use for neuropsychiatric symptoms in patients with dementia: A randomised controlled trial. Age and Ageing, 47(3), 430–437 doi:10.1093/ageing/afy001 [CrossRef] PMID:29432518
- van Duinen-van den Ijssel, J. C. L., Mulders, A. J. M. J., Smalbrugge, M., Zwijsen, S. A., Appelhof, B., Zuidema, S. U. & Koopmans, R. T. C. M. (2018). Nursing staff distress associated with neuropsychiatric symptoms in young-onset dementia and late-onset dementia. Journal of the American Medical Directors Association, 19(7), 627–632 doi:10.1016/j.jamda.2017.10.004 [CrossRef] PMID:29146222
- Vetrano, D. L., Tosato, M., Colloca, G., Topinkova, E., Fialova, D., Gindin, J. & Onder, G.the SHELTER Study. (2013). Polypharmacy in nursing home residents with severe cognitive impairment: Results from the SHELTER Study. Alzheimer's & Dementia, 9(5), 587–593 doi:10.1016/j.jalz.2012.09.009 [CrossRef] PMID:23232271
Get To Know Your Resident Form: Dementia Behavior Management
|Family background/support system (whom patient trusts and listens):|
|Favorite physical/recreational activities (e.g., walking, Bingo, coloring, cards, dominoes):|
|Favorite genre-appropriate song (year):|
|Favorite movie types:|
|Patterns of problematic behaviors:|
|Time of behaviors:|
|What worked to control problematic behavior in the past?|
|What makes the behavior worse?|
|What matters to the resident?|
Person-Centered Care for Dementia Behavior Management in Nursing Home Residents: Step-by-Step Guide for Nurses
|Identify challenging behaviors (e.g., agitation, aggression, wandering, paranoia, delusion, hallucination, sleep disturbances, euphoria, irritability, crying, apathy, disinhibition).|
|Refer to GET TO KNOW YOUR RESIDENT FORM in the chart|
|Describe the situation when this behavior is challenging. Who is/are affected by this behavior?
a. Patient b. Nursing staff|
|a. Patient's Need Assessment|
|1. Perform basic need assessment and make sure basic needs (e.g., hunger, thirst, clean diaper) are met. If this intervention is ineffective, move to Step 2.|
|2. Perform physical need assessment (e.g., pain, lack of sleep). Consult with primary geriatric practitioner. If this intervention is ineffective, move to Step 3.|
|3. Perform environmental need assessment (e.g., loud noise, crowded/noisy area, alone in the room for long time). Try genre-appropriate music, group movies, group sitting area or remove from crowded and noisy area (if trigger for behavior), short walk if able, physical/recreational activities, offer juice/dessert (e.g., ice cream, cookies, snacks).|
|b. Nursing Staff|
|1. Activities of daily living (ADL) care such as feeding, dressing, toileting, bathing. Develop trustworthy environment, engage patients in their care, be respectful, empathetic, use calm and soothing voice (avoid being commanding), introduce yourself each time, explain your role and reason for performing care, be a good listener. If resident refuses care, move to Step i.|
|Feeding—Provide option to eat in own room or dining hall. Give choices of food and time. Verbalize understanding by using repeat back method. If resident refuses, leave the room and after a few minutes send another nurse or come back and try different approach or nurse. If ineffective, move to Step ii.|
|Bathing—Ask for preferred time or give two to three options (e.g., morning, afternoon, evening). If resident refuses, leave and come back after some time and ask again; be calm with your approach.
Explain how the shower will be performed, and how the water in the shower will feel warm. If resident refuses, leave the room and after a few minutes send another nurse or come back and try a different approach or nurse. If ineffective, move to Step ii.|
|Dressing/changing diaper—Greet and introduce self, explain why performing care, give choices, and use simple directions. Try to engage residents in their care that makes them feel they have power and control over the situation. Rushing residents to get things done hinders cooperation and escalates problematic behavior.|
|ii. Distraction—Play genre-appropriate music, movies, talk about families, offer favorite foods (e.g., “Do you want some ice cream/cookies/juice/snack bar?”) then reapproach.|
|2. Medication administration—Use redirection and distraction techniques that are mentioned above as applicable.|
Psychotropic Medication Gradual Dose Reduction (GDR) Guide
|How many years has this resident taken psychotropic medications?|
|What was the reason for initiating this treatment?|
|What kind of problematic behavior was the reason for psychotropic medication prescribing?|
|Was it sta rted for delirium in the hospital, or was it prescribed for adjustment disorder or during a transition period?|
|Does the resident still have behavioral symptoms while on psychotropic medication?|
|Is there any documentation of previous GDR attempt effort?|
|Is there any documentation of attempted effective and non-effective nonpharmacological interventions?|
Practice Guidelines for Primary Geriatric Practitioners (GPs)
|1.||Psychotropic medication should not be used as behavioral control. If required, it should be used as a last resort in nursing home (NH) residents after unsuccessful attempts of nonpharmacological interventions have been tried and documented.|
|2.||Multidisciplinary teams should be invo lved in making individualized, nonpharmacological patient-centered care (PCC) intervention plans.|
|3.||GPs should inquire and educate nursing staff about nonpharmacological interventions that are proven successful to manage problematic behaviors of dementia as a first-line approach prior to making decision to prescribe psychotropic medications.|
|4.||There should be a PCC nonpharmacological intervention plan documented in each chart of NH residents with dementia.|
|5.||Create a category of NH residents based on their physical abilities, mental status, and activity preferences to design routine structured physical and recreational activities. Activities coordinators should be involved.|
|6.||NH should have a variety of routine recreational and physical activities to which residents have easy access.|
|7.||Primary GPs should work closely with consultant pharmacists, psychologists, psychiatrists, social workers, and frontline nursing staff to discuss effective nonpharmacological approaches and a gradual dose reduction (GDR) plan.|
|8.||GPs should periodically reevaluate patients' need for psychotropic medications and consider GDR as appropriate.|
|9.||Nursing staff should receive training on dementia behavior management using nonpharmacological interventions.|
|10.||Periodic behavioral management meeting with interdisciplinary team should be mandatory.|