1. IMPROVING MENTAL HEALTHCARE IN NURSING HOMES Brenda K. Keller, MD,CMD, Cameo Rogers, CTRS, CDP, Jennifer Medlin Hannah Fillman, Thomas M. Magnuson, MD

2. Goal of Project  To teach non-pharmacological interventions for management of behavioral problems in dementia to nursing home staff.  To test the effectiveness of these educational efforts.  To reduce the overall prn and scheduled psychotropic use by introducing non- pharmacological methods into daily resident care.

3. Part I: Education

4. Methods  All staff at 120 bed facility received two- hour long sessions focused on non-pharmacological behavioral management and use of activities to prevent behaviors.  Tip sheets group- learned about aggression, wandering, and disruptive vocalizations  Activities group- learned how to use activities as a proactive measure for behavior management and lead and adapt small group activities for multiple ability levels

5. Lectures with case examples Tip sheets placed on MAR / activity guides on units Weekly Small groups/DVD sessions testing

6. Mental Health Topics General Principles Aggression Wandering Disruptive vocalizations Depression treatments Anxiety Relaxation techniques Insomnia treatments

7. Activity Guides / DVD

8. Assessment Tools KnowledgeAttitudes

9. Participants N=40*

10. Results Pre-TestPost-TestX2X2 P-value Basic Sub-Category 2.873.002.040.179 Epidemiology Sub-Category 0.911.090.870.357 Cause Sub-Category* 3.744.617.450.012 Symptom Sub-Category 7.177.000.140.670 Test Total14.7015.702.470.108 Dementia Knowledge Questionnaire Results for Tip Sheets Group *significant data

11. Difference Between Pre and Post Test Scores for Tip Sheets Group Basic Sub- Category Epidemiology Sub-Category Cause Sub- Category Symptom Category Test Total CNA (N=11) 0.090.271.64*-0.541.46 MA (N=4) 0.500.00 0.751.25 LPN (N=4) 0.00 0.25 0.50 RN (N=3) 0.000.33 -0.660.00 Activities (N=1) 0.00 *X 2 = 8.77 p < 0.05 CNA participants improved their knowledge of the causes of dementia

16. Part II: Resident Outcomes

17. Methods  Measured the percent of residents on routine antidepressants, antipsychotics, anxiolytics, and hypnotics each month.  Measured the number of residents using prn doses of psychotropic drugs more than twice monthly.  Measured the number of incidents of behavior problems affecting other residents monthly. (MDS)  Measured the percent of residents feeling more depressed and the percent with depression without treatment monthly. (MDS)  Used data from November 2009 to April 2010 to calculate the 6 month historical average for comparison.

18. Months New ave =49.3 Stdev= 3.2 Historical Ave: 48.5

19. Resident Antipsychotic Drug Use New Average 8.125 STD 1.73 PercentPercent

20. Percent Resident Antianxiety Drug Use New Average= 8.25 Stdev=2.12

21. Percent Resident Hypnotics Drug Use New average= 4.85 Stdev=0.83

23. +Intervention Began: June 18, 2010 * P < 0.05

25. Limitations  Low participation 40/152 in survey may minimize the true effect of educational intervention on patient outcomes.  Change in MDS mid intervention allows for only 3 months of f/u of behaviors

26. Conclusions  The tip sheets lecture overall helped increase the CNAs’ knowledge of dementia etiology.  The lectures did not significantly affect the knowledge and confidence of the participants, however an overall increase in both areas was observed.  The percent of residents using routine antipsychotics, anxiolytics, and hypnotics showed a trend toward decrease following the intervention but did not reach statistical significance.  The percent of residents using prn psychotropic medications used decreased significantly during the intervention  The percentage of resident behaviors affecting others significantly decreased during the of intervention.

27. Unanticipated outcomes  Lectures now part of new staff orientation at test site  Tip sheets and Activities DVD to be incorporated into education policies and procedure for Vetter Health Services, owner/operators of 32 long-term care facilities in Nebraska, Kansas, Iowa, Missouri and Wyoming  Tip sheets available at:  http://www.unmc.edu/intmed/geriatrics/nursing_ho me_personnel.htm

28. Thanks  AMDA Foundation/Pfizer for support of this project  Staff and Administration at Brookestone Village  Cameo Rogers, CTRS, CDP  Jennifer Medlin, M1 supported by AFAR MSTAR program  Hannah Fillman, supported by the UNMC Student Undergraduate Research Program  Thomas M. Magnuson, MD