1. 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 www.BandFConsultingInc.com

2. 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 2015 www.BandFConsultingInc.com 2

3. We know the danger when it looks like this... ©B&F Consulting 2015 www.BandFConsultingInc.com 3

4. We don’t react to black box warnings… ©B&F Consulting 2015 www.BandFConsultingInc.com 4

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6. 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, 2013 6

7. 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, 2013 7

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9. Imagine… ©B&F Consulting 2015 www.BandFConsultingInc.com 9

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11. Imagine… ©B&F Consulting 2015 www.BandFConsultingInc.com 11

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13. 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, 2013 13

14. Dementia re-examined What are actions by individuals with dementia? Abnormal behaviors OR Predictable human responses to the situation perceived David Gifford, MD, AHCA, 2013 14

15. 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 2015 www.BandFConsultingInc.com 15

16. Video Explaining Dementia http://blog.thealzheimerssite.com/understandin g-alzheimers-in-three-minutes ©B&F Consulting 2015 www.BandFConsultingInc.com

17. 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 2015 www.BandFConsultingInc.com 17

18. Hunger, thirst Too hot, too cold Tired Bored Overstimulated Pain Toileting Look for unmet needs ©B&F Consulting 2015 www.BandFConsultingInc.com 18

19. 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 2015 www.BandFConsultingInc.com 19

20. Understanding Behavioral Communication Differentiating Between Agitation and Aggression Susan Wehry, MD http://www.susanwehrymd.com http://www.susanwehrymd.com ©B&F Consulting 2015 www.BandFConsultingInc.com 20

21. Agitation From Susan Wehry, MD 21 ©B&F Consulting 2015 www.BandFConsultingInc.com

22. Agitation Slapping thighs Clapping Yelling Screaming Self-referred – Something is wrong with me – Do something! From Susan Wehry, MD 22 ©B&F Consulting 2015 www.BandFConsultingInc.com

23. Aggression From Susan Wehry, MD 23 ©B&F Consulting 2015 www.BandFConsultingInc.com

24. Aggression Hitting out Kicking Pinching Biting Threatening Swearing From Susan Wehry, MD 24 ©B&F Consulting 2015 www.BandFConsultingInc.com

25. Aggression OTHER - REFERRED FEAR - BASED From Susan Wehry, MD 25 ©B&F Consulting 2015 www.BandFConsultingInc.com

26. Joanne Rader 26 ©B&F Consulting 2015 www.BandFConsultingInc.com

27. 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 2015 www.BandFConsultingInc.com 27

28. www.cms-handinhandtoolkit.info 28

29. Contact Information Cathie Brady cbrady01@snet.net Barbara Frank bfrank1020@aol.com www.BandFConsultingInc.com and www.BandFConsultingInc.com/WhatYouDoMatters www.BandFConsultingInc.com/WhatYouDoMatters ©B&F Consulting 2015 www.BandFConsultingInc.com 29