Managing Behaviours in Residential Care Without the Use of Antipsychotics

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On January 18, 2013, the BC Patient Safety & Quality Council invited key stakeholders from across the province to join together in a day of meaningful discussion around:
1. The meaning of dignity in care, with a special focus on more appropriate use of antipsychotics;
2. The current state of antipsychotic use by people living in residential care in BC;
3. An overview of work currently underway throughout BC, nationally and internationally to identify opportunities for alignment as well as learning from others;
4. Envisioning an ideal state whereby more appropriate use of antipsychotic medications can be achieved; and
5. Framing a call to action that will ask teams from residential care facilities in BC to join our initiative.

This is a presentation from the event delivered by Dena Kanigan BScN RN.

Learn more about this initiative at http://www.bcpsqc.ca

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Managing Behaviours in Residential Care Without the Use of Antipsychotics

  1. 1. By: Dena Kanigan BScN RNDirector of Nursing Care Castleview Care Center
  2. 2. Why We Decided to DecreaseAntipsychotics at Castleview Winter 2012: as part of a quality improvement initiative, I choose to conduct a perspective analysis on the use of antipsychotics at Castleview After careful and lengthy research I came to a decision: “antipsychotics are chemical restraints” PharmaNet data indicates that 50.3 percent of PharmaCare Plan B (residential care) patients were prescribed an antipsychotic between April 2010 to June 2011 These data, however, do not provide information about how long each medication was used, or the condition for which these drugs were prescribed.
  3. 3. Prospective AnalysisAIM: Objective: To reduce the amount of residents onantipsychoticsMEASURE:Outcome Measure/ Indicator: There will fewer residents on antipsychotics by the fall of 2012.Current Performance: 39% of residents—February 5, 2012Performance Goal 2012/2013: To reduce the amount of antipsychotic (under 20%)Priority: To target residents on antipsychotics who are experiencing negative side effects
  4. 4. Prospective AnalysisCHANGE: Improvement Initiative: Stage 1: Audit all the MARs Stage 2: Research antipsychotic uses Stage 3: Prior to discontinuing the medications outline daily behaviors Stage 4: Discuss with Pharmacist and doctors about new proposed action for decreasing the use of antipsychotics at Castleview. Stage 5: Implement policy for all new residents coming to facility; targeting those who arrive on antipsychotics, finding a documented reason for the prescription
  5. 5. Spring 2012 Looking at the Data February 2012: 39% of the residents are on antipsychotics (considered on the lower side of average) By reviewing the MAR, and critically looking at antipsychotic use at Castleview: We were able to decrease the use by 12% with-in 6 weeks, the first residents to be tapered off medications were those prescribed the medication for an “inappropriate behavior”
  6. 6. Examples of Behaviors Typically NotAmenable To Pharmacologic Managementlook at those residents who were being treated with antipsychotics for any of the following reasons: Wandering Hiding &Hoarding Vocally disruptive Repetitive Activity Inappropriate (un)dressing Inappropriate voiding Tugging at restraints Eating inedible objects Pushing wheelchair bound Resident Carol Ward MD Sept. 20, 2008
  7. 7. Analyzing the Data We looked at:  Duration of time on the medication  who/where the medication was prescribed  if there was any documented reason There were many residents on antipsychotics with no documentation as to why, thus by May 2012 we had only 20% of residents on antipsychotics.  At that time 6 of the residents had underlying mental illness being treated by the medication.  The rest of the residents were on the medication for behaviors associated with dementia.
  8. 8. Summer 2012 Behavioral CarePlanning July 2012 16% on this date- Behavioral Care Planning in- services started at CastleviewBehavioral Care PlanningUsing the model from, Sandra Psiurski, Castleview created a system of educating staff about behavioral care planning and the use of antipsychotics as a restraint.
  9. 9. How to Behavioral Care Plan How do we figure out the behaviours?We take a trip down memory lane. We remember our residents grew up and lived in a different time then the staff who care for them We understand how a residents past shapes who they are today. We take into account how past experiences influence how residents respond to their current demands of life. By investigating fully who a resident was and is, a tailored successful care plan for behaviors can be created.
  10. 10. The Process1) What are the residents strengths and successes2) Define the behaviour (What, when, where)3) Describe what we have done in response to these behavioursIntended goal: What you want from the resident and family
  11. 11. Communicate, Communicate,CommunicateThe most important part of this is to communicate to all members of the health care team and families. * Families are a wealth of information *At Castleview if a resident is being physically abusive and resistive to care the first course of action is to stop providing care immediately. *Families need to know the procedures of this, if they come for a visit and their family member is not up for the day. *Letting families know we are working on it, we have some techniques that do work but ultimately their loved one still has a choice
  12. 12. Explain ClearlyWhen nursing explains the situation in a manner families understand, they are able to participate in the decision making process: - your father wants to sleep in, your mother has chosen at this time to not get dressed, your sister does not want to get out of her chair right now -your family member has lost almost all of their ability to make choices, he/she is still a strong willed adult with the right to choose
  13. 13. Quality of Life Over Quantity of TimeAt Castleview we constantly talk to staff and families about quality of life. Quality of Life includes: autonomy, comfort, control over life, dignity, respect and engagement in meaningful activities and relationshipsWe investigate residents tirelessly before involving the doctor in interventions. If a doctor is involved, we attempt to source out medical reasons for the behavior; medications of other classes are tried first (pain, depression)Staff and families realize now an antipsychotic is a chemical restraint, and will ultimately sedate them. Once sedate their ability to enjoy any part of life is seriously compromised.
  14. 14. Finding What WorksThis part of the care planning process is time consuming but very rewarding for all staff members: monitor staff interaction while a resident is experiencing a time of a behavioral challenge; watching multiple times, chart what works and does not work, finding the pattern make a 5-7 step care plan to manage a specific behavior, staff know once created this is the plan to follow ***this process can take hours, and days***
  15. 15. Fall 2012All but 2 residents are tapered and taken off antipsychotics. Other residents with behavioral challenges have been investigated, triggers found, care plans created Staff still leave some residents at times, residents still have the right to choose the direction of the day Staff are recognizing the negative side effects suffered by residents from antipsychotic use: sedation, increased falls and unfortunately we have three residents with TD (tardive dyskinesia)
  16. 16. Case in PointA new male resident hits the care-aides during brief changes every time, I have many incident reports on my desk. Care aides are refusing to do care, the wife has tried to be present he still lashes out. His wife comes everyday to visit and assist with lunches. By monitoring care, speaking with wife and speaking to direct care staff I discover: He was in Europe during WWII, he yells during care to stop hurting him, he has said out loud to the staff he was abused by male German soldiers when he was nine, distraction only works sporadically, having a male in the room makes him very tense I was able to tailor a care plan with only a soft calming female voice speaking, this works 99% of the time. He is not sedated and he gets to enjoy his wife’s visits
  17. 17. Winter 2012Currently there are two residents (4%) on antipsychotics: both have been tapered and failed, both have a diagnosed mental illness that was present prior to the onset of dementia.***I had to start an antipsychotic on a resident in December, the side effects were detrimental and very easily seen by all staff
  18. 18. Thought for the DayIT IS BETTER TO SPEND TIME NOW TO GET THE RESIDENT TO BE SUCCESSFUL THAN TO FIGHT THEM FOR THE REST OF THEIR LIFESometimes getting a resident to do something different and be successful, opens up a new world to them , and for you....
  19. 19. ReferencesH. C. Kales, K. Zivin, H. M. Kim, M. Valenstein, C. Chiang, R. Ignacio, D. Ganoczy, F. Cunningham, L. S. Schneider, F. C. Blow. Trends in Antipsychotic Use in Dementia 1999-2007. Archives of General Psychiatry, 2011; 68 (2): 190 DOI: 10.1001/archgenpsychiatry.2010.200A REVIEW OF THE USE OF ANTIPSYCHOTIC DRUGS IN BRITISH COLUMBIA RESIDENTIAL CARE FACILITIES http://www.health.gov.bc.ca/library/publications/year/2011/use- of-antipsychotic-drugs.pdfAccommodating and Managing Behaviours in Dementia Decisional and Practice Support for BPSD 28 February 2012Behaviour Management and Care Planning: Power point by Psiurski, Sandra

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