BPSD Consensus Algorithm: CLeAR Kick-Off Event

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This presentation was delivered by Elisabeth Antifeau at the kick-off event for CLeAR on October 9, 2013. Elisabeth is the home health integration lead, community integration for Interior Health.

The aim of CLeAR – our Call for Less Antipsychotics in Residential Care – is to achieve a reduction in the number of seniors in residential care on antipsychotic medications by 50% across BC by December 31, 2014 through a province-wide, voluntary initiative that supports participating sites.

Learn more at www.CLeARBC.ca.

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BPSD Consensus Algorithm: CLeAR Kick-Off Event

  1. 1. Behavioural and Psychological Symptoms of Dementia (BPSD) Consensus Algorithm Call for Less Antipsychotics in Residential Care CLeAR Kick-off Event October 9th, 2013 Elisabeth Antifeau, RN, MScN, GNC(C)
  2. 2. BPSD: What is it? Behavioural and Psychological Symptoms of Dementia Behavioural Symptoms observable behaviours that are:  inappropriate or excessive within the situational context or setting;  disturbing, disruptive, di stressing or potentially damaging to the person or others; Psychological Symptoms are:  discrete or overt mental disorders that commonly include, but are not limited to: depression, apathy, with drawal, psychosis, etc.
  3. 3. BPSD: Why is it important?  BPSD is reported to affect 80-90% of people with dementia at some time in their disease course (Canadian Coalition for Seniors Mental Health (2006);  BPSD is a Quality of Life issue.
  4. 4. Background and History  2002, 2004, 2006, 2007 – Health Canada Advisories, about mortality risk and adverse reactions antipsychotic use risperidone only approved med’n for BPSD use  June 2009 – CIHI Analysis in Brief released, 2006-07 data - 37.7% of seniors in nursing homes were using antipsychotic drugs (Manitoba, NB and P.E.I.)  December 2011 – BC MoH Review of antipsychotic drug use in residential care facilities;  Plan B (April to June 2010) indicated 50.3% residents (n=30,032) prescribed an antipsychotic.  Missing information: how long? for what condition?
  5. 5. History of the BPSD Algorithm  Original work written in 2010 for the Phased Dementia Pathway;  Best Practice Guidelines for Accommodating and Managing BPSD in Residential Care (Oct 2012);  Jan 2013 – August 2013: Consensus BPSD “The evidence indicates that successful management of BPSD requires care providers to understand and
  6. 6. What is the purpose of the BPSD Algorithm?  Simple, comprehensive one stop resource  An interactive and decisional resource tool to guide clinicians & physicians when faced with managing the behavioural and psychological symptoms of dementia;  Provides frontline clinicians & physicians with access to:  Best Practice Recommendations for assessment, care- planning and medications recommendations in a logical flow;  Evidence Based Assessment Tools  Clinical References and information (e.g., which behaviours respond to medications, and which don’t)
  7. 7. The Algorithm is meant to be used from the top down: Part I: Interdisciplinary Decisional and Practice Support for BPSD: •Assessment (green) • Problem Solving (yellow) • Care Planning (blue)
  8. 8. The Algorithm is meant to be used from the top down: Part II: Reassessment with Family GP/NP for BPSD: • Assessment (green) •Medication Options (yellow) •Monitoring (blue)
  9. 9. Decision Points…  At certain points along the Algorithm, users will encounter decision points identified as Diamonds…  These decision points pause the clinician to make a decision before correctly proceeding further down a
  10. 10. Walk through Algorithm  Page 1  Page 2  Part I: Interdisciplinary  Reassessment with Decisional and Practice Support for BPSD: Family Physicians or Nurse Practitioner for BPSD:  Assessment  Assessment  Problem Solving  Medication Options  Care Planning  Monitoring
  11. 11. Part I: Interdisciplinary Decisional and Practice Support for BPSD  Identify and use the algorithm for the right population  Identify and priorize the urgency of the situation  Emergency pathway  Non-emergency pathway – tool selection guide for assessment
  12. 12. Example1: Safety  escalation continuum:  anxiety  agitation  verbal/physical aggression  staff approaches:  attentive  responsive  directive
  13. 13. Example2: Least Restraints Link  Defining restraints  Differentiating chemical restraint versus treatment  Meets legislative requirements:  Residential Care Regulation S.74(1)a and S.77
  14. 14. Selecting the right assessment tool  Depression Screening Tools:     GDS(15) Cornell PHQ-9 RAI-2.0 DRS  Cohen Mansfield Agitation Inventory (CMAI)  Dementia Observation Scale (DOS)  Differentiating 3Ds  RAI-2.0  Recognizing changes in usual  Progress Notes thought, mood, function, and behaviour as significant and important to probe and assess further  Selecting the right tool
  15. 15. Part I: Interdisciplinary Decisional and Practice Support for BPSD  Problem Solving focus using the PIECES Framework and A-B-C approach  Each link provides 1-2 page synopsis of evidence- based information to better understand multiple factors that contribute to behaviours
  16. 16. Example3: Common physical changes  Short and pithy, one page sources of information  Links behaviour to wide variety of known causes using PIECES – assists clinicians to appreciate multiple reasons for behavioural development
  17. 17. Part I: Interdisciplinary Decisional and Practice Support for BPSD  Create an individualized care plan  First Line intervention: non-pharmacological interventions  Ongoing monitoring  When to seek (further) medical assistance
  18. 18. Part 2: Reassessment with GP or NP for BPSD  Re-assessment with medical lens  Pharmacological considerations: behaviour that is dangerous, distressing, disturbing, and damaging/ & not responding  Distinguish behaviours that are/are not likely to respond to medications
  19. 19. Example4:Behaviours that are not like to respond to medications Resistiveness to care  “…the repertoire of behaviours with which persons with dementia withstand or oppose the efforts of a caregiver” (Mahoney et al)
  20. 20. Example5 Resistiveness to Care Scale
  21. 21. Part 2: Reassessment with GP or NP for BPSD  Behaviours that may respond to medications  Second-line intervention support  Evidence-informed behavioural categories: sleep disturbance, anxiety, psychosis, aggression, depres sion and sexually inappropriate behaviour.
  22. 22. Page 1 – Medication Templates
  23. 23. Page 2 – Medication Templates  Key Messages and considerations:  Start low and go slow;  Strive for a good clinical trial  drug-specific cautions  order of decreasing side-effects within a class  linkage with CCDTD4(2012) recommendations  cautions for renal/hepatic clients  titration and weaning information  References and other medication information
  24. 24. Part 2: Reassessment with GP or NP for BPSD  Monitoring effectiveness of treatment, side effects  Continued integration with non-pharm strategies in care plan  Reassessing the need for continued therapy, exploring discontinuing therapy  Monitoring for recurrence/emergence of BPSD
  25. 25. Next steps… This Fall 2013:  Alpha testing (testing, QA, usability testing)  Beta launch (pilot site to trial)  Deployment – announcement and ready
  26. 26. Making the algorithm available  BCPSQC website  Personal Computer  Tablets  App for Smart & Android Phones
  27. 27. Smart Phone/Android version  BCBPSD.ca domain  will look different  still guided by colour  Quick Links Menu  Chart View  Save the Page  Navigation Bar  Favourites  Point-Click-Print capacity
  28. 28. Implementation Planning – Intent  BPSD Guideline 2012  BPSD Algorithm 2013-14  Education – promoting integration of both BPSD tools with various other initiatives across BC:  Revised GPAC guidelines (Cognitive Impairment in the Elderly)  will reinforce BPSD tools, approach, e.g.,  use of CAM-PRISME in delirium  use of GDS-15; Cornell, for depression, etc  Caring Journey  Gentle Persuasion training  PIECES implementation and training events provincially
  29. 29. Acknowledgements

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