1. www.HQOntario.ca Health Quality Ontario The provincial advisor on the quality of health care in Ontario Expert panel on Agitation and Aggression in Dementia Quality Standards and Clinical Handbook AGHPS Summit November 13, 2015

2. 1 Population and topic in scope Individuals with agitation and aggression in the context of Dementia being cared for in the following settings: Emergency Department, Inpatient Hospital, LTCF Transitions between these 3 environments Population and topics out of scope Individuals with agitation and aggression in Dementia in the Community (non-LTCF) Individuals with Dementia where agitation and aggression is not an area of clinical concern Clinical issues related to the care of individuals with Dementia that are not specific to agitation and aggression www.HQOntario.ca Project Scope

3. 2 For each prioritized key area: www.HQOntario.ca Summary of relevant recommendations and guidance statements CE will identify recommendations or statements from relevant guidelines (such as NICE or NICE-accredited guidelines, guidelines used in current practice, or those otherwise identified through scoping exercise) that support potential quality statement development. Evidence review If limited or no evidence exists for a key area, the CE will ideally conduct an evidence review using the most appropriate review method. Establishment of consensus If there is no evidence, the panel may wish to: Use expert consensus Note prioritized key area for future consideration Methods: Review of Evidence

4. 3 Identification and Inclusion of Clinical Guidelines Identify relevant guidelines covering the population(s) and setting(s) of interest, with guidance from the medical librarians and input from the advisory panel Use the AGREE II instrument to select 4–5 highest quality clinical guidelines, including at least 1 contextually relevant (Canadian) guideline www.HQOntario.ca Methods: Review of Evidence Appraisal of Guidelines for Research & Evaluation II 1)Scope and Purpose 2)Stakeholder Involvement 3)Rigour of Development 4)Clarity of Presentation 5)Applicability 6)Editorial Independence

5. 4 5–10 quality statements will be drafted, based on either recommendations from relevant guidelines or an evidence review Quality statements are not verbatim restatements of the relevant recommendations from source guideline(s) One quality statement may map to recommendations from one or more guidelines, and/or may be derived by rewording one or more recommendations into a single statement www.HQOntario.ca Methods: Drafting of Quality Statements

6. 5 # Titl e First Name Last NameAffiliationSpecialization 1Dr.IlanFischlerOSCMHSGeriatric Psychiatrist 2Dr.TarekRajjiCAMHGeriatric Psychiatrist 3Dr.KristaLanctotSunnybrook Health Sciences CentrePhD Pharmacologist 4Ms.VincciTangOntario Shores Centre for Mental Health Sciences Deputy CFO & Director of IT & Decision Support 5Ms.SaimaAwanCAMH – clinical pathway support Manager, Integrated Care Pathways Program 6Dr.AmerBurhanWestern University (London)Geriatric Psychiatrist 7Dr.DallasSeitzQueen's University Providence CareGeriatric Psychiatrist 8Dr.EvelynWilliamsSunnybrook Health Sciences Centre Head, Division of Long Term Care 9Ms.CarrieActonMuskoka Landing LTC - HuntsvilleAdministrator 10Ms.AshleyMillerRegina Gardens Long Term Care CenterAdministrator 11Ms.DeniseMalhotraErie St. Clair Community Care Access Centre (CCAC)Decision Support Analyst 12Ms.NatashaWardThunder Bay Regional Health Science CenterNursing 13Dr.Richard ShulmanTrillium Health Partners Geriatric Psychiatrist 14Ms.LoriWhelanSt. Michael's HospitalOccupational Therapist 15Dr.JennyIngramKawartha Regional Memory ClinicGeriatrician 16Dr.BarryGoldlistMount Sinai Hospital (MSH)Geriatrician 17Ms.SandiRobinsonAccalaim Health Alzheimer ServicesSocial Worker 18Mr.KenWongFull-Time CaregiverPatient Advocate 19Ms.MargaretWeiserPrivate PracticePsychologist HQO's Expert Advisory Panel on Dementia with Agitation or Aggression

7. 6 Primary Key Areas 1.Assessment and monitoring 2.Nonpharmacological interventions 3.Pharmacological interventions 4.Physical restraint minimization 5.Provider education and training 6.Caregiver education and training 7.Access to specialty care 8.Physical care environment 9.Consent and decision-making capacity 10.Transition of care www.HQOntario.ca

8. 7 Examples of possible Quality Standards People with dementia receive a comprehensive evaluation with the use of appropriate validated tools or instruments, which includes early identification of individual risk for behavioural challenges. People with dementia and agitation or aggression receive behavioural interventions that are tailored to their specific needs and symptoms, as specified in their care plan. Evidence-based behavioural interventions include: –Aromatherapy, –Multisensory therapy, –Therapeutic music and dance therapy, –Pet-assisted therapy –Massage therapy www.HQOntario.ca

9. 8 Examples of possible Quality Standards Medication review for dosing reduction and discontinuation is performed on a regular basis (at least every 3 months) for people with dementia who receive pharmacological agents for agitation or aggression Physical restraints are only used in people with dementia and agitation or aggression when behavioural and/or pharmacological measures have been unsuccessful, and individuals continue to pose an imminent risk of harm to themselves or others People with dementia and agitation or aggression receive care from providers with structured specialized training in dementia and its behavioural symptoms, which are consistent with the provider’s roles and responsibilities. www.HQOntario.ca

10. 9 Examples of Possible Quality Standards Carers of people with dementia and agitation or aggression are informed of advocacy and support groups and services and how to access them. People with dementia and agitation or aggression receive access to mental health and behavioural support services from a multidisciplinary team, which provides specialized care in dementia with behavioural and psychological symptoms People with dementia and agitation should be assessed and treated in a physical care environment that is supportive and therapeutic. People with dementia and agitation and/or carers are actively engaged in the transition preparation process, and receive an up-to-date proactive care plan that is agreed upon by all providers and considers the changing needs of the person with dementia. www.HQOntario.ca

11. 10 The Ontario Shores Approach to Implementing CPGs – Step 1: Guideline selection – Step 2: Development of Algorithm – Step 3: Gap Analysis – Step 4: Create supporting governance structure – Step 5: Selection of adherence and outcome measures – Step 6: Create Project Charter – Step 7: Utilize informatics – eg. electronic templates, automated decision support – Step 8: Realignment of Therapeutic Services – Step 9: Monitor Adherence and Promote Quality Improvement

12. 11 Key Changes for Dementia Program – Electronic ABC tracking tool – Implement Evidence-based non-pharmacologic interventions: »Pet therapy, Aromatherapy, Massage Therapy, Formalized exercise program (already had multisensory stimulation, music therapy, reminiscence, etc.) – New training program for all clinical staff – with a focus on person-centred care

13. 12 Key Changes for Dementia Program – New assessment tools to be completed by interprofessional staff at prescribed times PAIN-AD, Cornell, CAM, Prompted voiding trial assessment, environmental assessment, NPI-NH and others – New interprofessional care plan – New social work psychosocial assessment with a focus on caregiver assessment and support and relationship with Long-term care – New physician assessment tools to standardize family meetings and follow-up of treatment response – Incorporate CAMH medication algorithm

14. 13 NPI-NH

15. 14 Integrated Care Pathways CAMH Experience with Agitation and Aggression due to Alzheimer’s or Mixed Dementia

16. 15 Treatment Algorithms: Evidence  Algorithm use in clinical practice associated with:  Improved quality of care  Enhanced patient outcomes  Reduced health care costs Adli. M et al. 2006. Biological Psychiatry. 59. 1029.

17. 16 Pathway Assessment & Medications Discontinuation Cognitive Enhancers (AChEI, Memantine) Pharmacological Non- Pharmacological

18. Zaraa, 2003

19. 18

20. 19 Non-Pharmacological Interventions Consent Caregiver education and support Enhance communication with the patient Ensure safe environment Increase or decrease stimulation in the environment

21. 20 Non-Pharmacological Interventions Allied Health Professional NON-PHARMACOLOGICAL INTERVENTIONS IDENTIFIED INITIALLY AS MOST APPROPRIATE* Please check discipline: Occupational Therapist Recreation Therapist Social Worker Primary Nurse Name: Sign: Date: Social Contact Pet therapy One-to-one visit Other:___________ ____ Sensory Enhancement/ Relaxation Hand massage Individualized Music Individualized art Sensory modulation Other:___________ ____ Purposeful Activity Helping tasks / Volunteer role Inclusion in group programs of identified interest Access to outdoors Other:___________ ____ Physical Activity Exercise group Indoor/outdoor walks Individual exercise program Other:____________ ___

22. 21 Multisensory Snoezelen System

23. 22 Paro Therapeutic Robot

24. 23 Pharmacological Interventions Risperidone Aripiprazole Carbamazepine Citalopram Gabapentin Prazosin ECT Quetiepine For partial responders: 1.Extend the trial 2.Increase the dose 3.Augment with another agent that showed also partial response PRNs: 1.Trazodone 2.Lorazepam

25. 24

26. 25 Combined Total Patients Enrolled (Alzheimer’s and Frontotemporal Dementia) Combined Total Patients Completed ICP’s (Alzheimer’s and Frontotemporal Dementia) Alzheimer’s/Mixed Vascular Frontotemporal Dementia Completed Step One of Medication Algorithm Step Two of Medication Algorithm Exited (no meds) Currently being treated Completed 211918134111 Combined Total Patients (Alzheimer’s and Frontotemporal Dementia) Patients Enrolled and Tolerating Three or More Non- Pharmacological Interventions (any selected combination from algorithm) Patients Enrolled and Tolerating Two or Less Non-Pharmacological Interventions (any selected combination from algorithm) Did Not Respond, Tolerate or Accept any Non- Pharmacological Interventions 211515 Pharmacological Interventions Non-Pharmacological Interventions

27. 26 Dr. Amer Burhan Dr. Simon Davies Dr. Donna Kim Dr. Benoit Mulsant Dr. Bruce Pollock Dr. Vincent Woo Ms. Rong Ting Dr. Sawsan Kalache Ms. Saima Aiwan Mr. Christopher Uranis Dr. Angela Golas Dr. Kaila Rudolph Dr. Evan Weizenberg Integrated Care Pathway