1 Louisiana Dementia Partnership Workgroup Eliminating Off-Label Use of Antipsychotics A 10 Step Guide for Nursing Homes Appendix B Three Part Training for Staff Cathie Brady & Barbara Frank B&F Consulting

Three part staff training Overview: – Why AP’s are dangerous for people with dementia; black box warning – This is not going to “go away” Experiential Exercise – Putting yourself in the resident’s place Understanding Behavioral Communication – Agitation = HELP – Aggression = STOP – Share approaches and interventions ©B&F Consulting

We know the danger when it looks like this... ©B&F Consulting

We don’t react to black box warnings… ©B&F Consulting

©B&F Consulting

Studies Show Low Effectiveness and High Danger Antipsychotic effect takes 3-7 days to start working – Only immediate effect is sedation David Gifford, MD, AHCA,

Associated with adverse outcomes Off-label use of antipsychotics in nursing facility residents are associated with an increase in: – Death (heart failure or pneumonia) – Hospitalization – Falls & fractures – Venothrombolic events (stroke) David Gifford, MD, AHCA,

©B&F Consulting

Imagine… ©B&F Consulting

©B&F Consulting

Imagine… ©B&F Consulting

©B&F Consulting

Challenge is changing attitude Many health care professionals and families believe that these behaviors are “abnormal,” are caused by the dementia, and need medications to stop Most health care professionals and families believe these medications are effective at stopping these “abnormal behaviors” David Gifford, MD, AHCA,

Dementia re-examined What are actions by individuals with dementia? Abnormal behaviors OR Predictable human responses to the situation perceived David Gifford, MD, AHCA,

Are they “Delusions?” Are they Abnormal behavior needing a Psychiatric Intervention? Are they a Predictable response to the world as perceived by the resident? ©B&F Consulting

Video Explaining Dementia g-alzheimers-in-three-minutes ©B&F Consulting

Dementia can affect how an individual perceives the world. A person with dementia may think that she can see or hear something that isn't there or believe something that is not true. In earlier stages of the disease, she will usually be able to recognize that this is simply a figment of her imagination. However, as the disease progresses, these individuals may begin to have more and more trouble distinguishing between fantasy and reality. If we react to her delusions and treat them as if they are a symptom of a major mental illness we will use antipsychotic drugs. If we understand that this is part of the disease process we will see this behavior as an expression of need and react accordingly. Delusions ©B&F Consulting

Hunger, thirst Too hot, too cold Tired Bored Overstimulated Pain Toileting Look for unmet needs ©B&F Consulting

Employ the 3 R's (Reassure, Respond, and Refocus) With anger and emotional reactions, do not simply try to correct or to explain away what the resident is experiencing. Whether s/he realizes what s/he is experiencing is real or not, you can respond to his or her needs and react appropriately. This is not to say that you have to lie to or to “humor” them when they hallucinate. You can be honest while also showing respect. ”I don't hear or see anyone outside the window, but you seem worried.“ ©B&F Consulting

Understanding Behavioral Communication Differentiating Between Agitation and Aggression Susan Wehry, MD ©B&F Consulting

Agitation From Susan Wehry, MD 21 ©B&F Consulting

Agitation Slapping thighs Clapping Yelling Screaming Self-referred – Something is wrong with me – Do something! From Susan Wehry, MD 22 ©B&F Consulting

Aggression From Susan Wehry, MD 23 ©B&F Consulting

Aggression Hitting out Kicking Pinching Biting Threatening Swearing From Susan Wehry, MD 24 ©B&F Consulting

Aggression OTHER - REFERRED FEAR - BASED From Susan Wehry, MD 25 ©B&F Consulting

Joanne Rader 26 ©B&F Consulting

If a resident with dementia is escalating and demanding that you remove their tray RIGHT NOW but you are taking care of someone else…what will work best? a.Explain that you will get to them as soon as you can b.Tell them they have to wait their turn, you are caring for someone else c.Go find someone else to help them d.Tell the resident you are helping that you will be right back, then go to the other resident and remove the tray. ©B&F Consulting

28

Contact Information Cathie Brady Barbara Frank and ©B&F Consulting