Post on 17-Jan-2016
NON PHARMACOLOGICAL NON PHARMACOLOGICAL APPROACHES TO APPROACHES TO
REDUCING THE USE OF REDUCING THE USE OF ANTIPSYCHOTICSANTIPSYCHOTICS
Presented byPresented byWanda Raby Spurlock, DNS, RN-BC, Wanda Raby Spurlock, DNS, RN-BC, CNE, FNGNACNE, FNGNA
Associate Professor, Southern University and Associate Professor, Southern University and A&M CollegeA&M College
School of NursingSchool of Nursing
PSYCHOSIS: KEY PSYCHOSIS: KEY POINTSPOINTS
HallucinationsHallucinations Perceptions without stimuliPerceptions without stimuli Can occur in any sensory modalityCan occur in any sensory modality
DelusionsDelusions Fixed or false perceptions or Fixed or false perceptions or
beliefs not in keeping with realitybeliefs not in keeping with reality Unfounded ideas that can be Unfounded ideas that can be
suspicious (paranoid), grandiose, suspicious (paranoid), grandiose, somatic, self-blaming, etc.somatic, self-blaming, etc.
Not the result of religious or Not the result of religious or cultural normscultural norms
Psychosis in the Psychosis in the ElderlyElderly
Commonly used to describe a severe mental illness in which delusions and hallucinations are prominent
Can be seen in a wide range of conditions
Psychotic symptoms of acute onset are usually the result of a delirium secondary to a medical condition, drug misuse, and drug-induced psychosis
Increased Risk of Psychosis in Increased Risk of Psychosis in Elderly Persons: Contributing Elderly Persons: Contributing
FactorsFactors
Age related deterioration of Age related deterioration of frontal and temporal corticesfrontal and temporal cortices
Social isolationSocial isolation Sensory deficitsSensory deficits Age related pharmacokinetic Age related pharmacokinetic
and pharmacodynamic and pharmacodynamic changeschanges
PolypharmacyPolypharmacy
Parkinson’s Disease and Parkinson’s Disease and HallucinationsHallucinations
Anti-Parkinson Anti-Parkinson medications improve medications improve motor disorder but motor disorder but may also induce may also induce psychotic symptoms, psychotic symptoms, namely visual namely visual hallucinationshallucinations
Examples of Medical Examples of Medical Conditions that May Cause Conditions that May Cause
Psychotic SymptomsPsychotic Symptoms Cerebrovascular Cerebrovascular
diseasedisease CNS traumaCNS trauma Fluid or electrolyte Fluid or electrolyte
imbalanceimbalance Hepatic diseaseHepatic disease Hypo-Hypo-
hyperthyroidismhyperthyroidism NeoplasmsNeoplasms
Metabolic conditionsMetabolic conditions Hypoxia, Hypoxia,
hypoglycemiahypoglycemia Normal pressure Normal pressure
hydrocephalushydrocephalus Vitamin deficiency Vitamin deficiency
(B(B1212)) Huntington’s diseaseHuntington’s disease
Four Common Types of Four Common Types of Misidentifying Delusion in Misidentifying Delusion in
Persons with Alzheimer’s #1 Persons with Alzheimer’s #1
The Capgras TypeThe Capgras Type
False belief that previously known people (e.g. wife or caregiver) have been replaced by impostersSpouse or caregiver is an
imposter
Four Common Types of Four Common Types of Misidentifying Delusion in Misidentifying Delusion in
Persons with Alzheimer’s #2 Persons with Alzheimer’s #2
Phantom Boarder Phantom Boarder SymptomSymptom
False belief that guests are living in the person’s house
Four Common Types of Four Common Types of Misidentifying Delusion in Misidentifying Delusion in
Persons with Alzheimer’s #3Persons with Alzheimer’s #3
The Mirror The Mirror SignSign
Person misidentifies his or her own mirror image as someone else
Four Common Types of Four Common Types of Misidentifying Delusion in Misidentifying Delusion in
Persons with Alzheimer’s #4Persons with Alzheimer’s #4
The TV SignThe TV Sign
Misidentification of TV images as real
Points to RememberPoints to Remember
Hallucinations and delusions that Hallucinations and delusions that do not cause distress do not require do not cause distress do not require pharmacological interventionpharmacological intervention
Correcting auditory and visual Correcting auditory and visual deficits may improve symptomsdeficits may improve symptoms
Late-onset schizophrenia is a Late-onset schizophrenia is a rarerare disorderdisorder
Paradigm Shift in Dementia Care
Biomedical ModelBiomedical Model
Defined in terms of pathological changes
Inevitable decline; incurable Progressive cognitive and
functional decline Centered around deficits -
expectation of loss of competency
As communication and cognitive functioning are affected by the disease progression, care is aimed at meeting basic biologic needs
Person-Centered CarePerson-Centered Care
Knowledge of individual’s personal history, life-long patterns, standing personality traits, and coping patterns
Aimed to maximize existing strengths Abilities oriented care – retained
abilities; prevention of excess disability
Modification of environment to support and enhance safety
Adaptation of environment to meet changing needs
Social engagement Personal preferences, likes,
dislikes
The Progressively Lowered Stress Threshold (PLST) Model
Major premises: internal and environmental stressors
beyond a person’s threshold for coping lead to increased disability Examples: fatigue; adverse effects of medications; noise; pain; multiple competing stimuli
environmental modifications will reduce environmental stressors and prevent or lessen behavioral symptoms
(Smith, Gerdner, Hall, & Buckwalter, 2004)
Needs Driven Dementia Compromised Behavior
Provides a different way of viewing behaviors
Examines source of behaviors Expression of unmet needs Unmet needs manifest in behavioral symptoms
Key is to identify root cause of behavior All behavior is meaningful Triggers Focus on treating, reducing, eliminating or modifying
factors that cause or contribute to behaviors
(Algase et al., 1996)
Behavioral TriggersBehavioral Triggers
Environmental Environmental
Poor lighting Poor lighting with with shadowing shadowing effect, glareeffect, glare
Excessive Excessive noisenoise
ClutterClutter Uncomfortable Uncomfortable
temperaturestemperatures
PsychologicalPsychological
AngerAnger FearFear LonelinesLonelines
ss Boredom Boredom FrustratioFrustratio
nn
• Hunger• Pain • Thirst• Constipati
on• Fatigue• Infection
Physical
Communication Communication Validation vs Reality Validation vs Reality
OrientationOrientation Don’t argue with, attempt to convince or Don’t argue with, attempt to convince or
force person to accept reality force person to accept reality Use a matter of fact approachUse a matter of fact approach More effective to address the person’s More effective to address the person’s
feelings in relation to what they perceive feelings in relation to what they perceive as realityas reality
Responding to the emotional content of what the person is saying, rather than presenting “factual reality” is more beneficial and less likely to result in increased agitation or a catastrophic reaction.
Prior to Using Prior to Using Antipsychotic Drugs: Antipsychotic Drugs:
ChecklistChecklist Rule out medication side Rule out medication side
effect effect Underlying medical Underlying medical
condition condition Social and physical Social and physical
environmentenvironment sensory overloadsensory overload sensory deprivationsensory deprivation
Result of unmet needResult of unmet need Life-long personality traitsLife-long personality traits Use of non-pharmacological Use of non-pharmacological
interventions as interventions as front-line front-line approachapproach
DopamineDopamine
Antipsychotics and Dopamine
Parkinson’s Disease and Dopamine
Target SymptomsTarget Symptoms Target symptoms should be Target symptoms should be
clearly identified prior to clearly identified prior to antipsychotic treatment and antipsychotic treatment and carefully monitored over the carefully monitored over the course of treatmentcourse of treatment
Medication intervention for Medication intervention for poorly defined eccentricities poorly defined eccentricities provide limited clinical benefit provide limited clinical benefit and unnecessary exposure to and unnecessary exposure to medication risks and poor medication risks and poor health outcomeshealth outcomes
Antipsychotic Drugs and Antipsychotic Drugs and Inappropriate Treatment Inappropriate Treatment
Targets Targets UnsociabilityUnsociability Poor self-carePoor self-care RestlessnessRestlessness Impaired memoryImpaired memory Inattention or Inattention or
indifference to indifference to surroundingssurroundings
WanderingWandering UncooperativenessUncooperativeness
https://www.healthcare.uiowa.edu/IGEC/IAAdapt/document/Antipsychotic_Prescribing_Guide_Both.pdf
Antipsychotic Drugs and Antipsychotic Drugs and Inappropriate Treatment Inappropriate Treatment
Targets Targets Mild anxietyMild anxiety Verbal expression Verbal expression
or behaviors not or behaviors not representing a representing a danger or threat danger or threat to othersto others
Nervousness Nervousness FidgetingFidgeting
https://www.healthcare.uiowa.edu/IGEC/IAAdapt/document/Antipsychotic_Prescribing_Guide_Both.pdf
Atypical Antipsychotics and Atypical Antipsychotics and
FDA Black Box WarningsFDA Black Box Warnings In 2005 the FDA issued a black-box warning of In 2005 the FDA issued a black-box warning of
increased risk of death associated with use of atypical increased risk of death associated with use of atypical antipsychotics in the elderly population with dementiaantipsychotics in the elderly population with dementia
“Increased Mortality in Elderly Patients with Dementia-Related Psychosis – Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Analysis of seventeen placebo-controlled trials (modal duration of 10 weeks) in these patients revealed a risk of death in the drug-treated patients of between 1.6 to 1.7 times that seen in placebo –treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5% compared to a rate of 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infections (e.g., pneumonia) in nature. [this drug] is not approved for the treatment of patients with dementia related psychosis. “ (p. 4)
Example of a Boxed Warning
Levinson, D. (2011). Medicare atypical antipsychotic drug claims for elderly nursing home residents. Department of Health and Human Services. Office of the Inspector General. OEI-07—8-00150
Black Box Warning Extended Black Box Warning Extended to Conventional Antipsychoticsto Conventional Antipsychotics
The FDA extended the black box The FDA extended the black box warning to conventional warning to conventional antipsychotic drugs in 2008antipsychotic drugs in 2008 Elderly persons with dementia-related Elderly persons with dementia-related
psychosis treated with antipsychotic psychosis treated with antipsychotic drugs (conventional or atypical) are at drugs (conventional or atypical) are at ↑risk of death↑risk of death
Neither class of drugsNeither class of drugs is FDA approved is FDA approved for use in treatment of dementia related for use in treatment of dementia related psychosispsychosis
Office of Inspector General Office of Inspector General (OIG)(OIG)
May 2011 Report May 2011 Report Evaluation requested regarding use of atypical Evaluation requested regarding use of atypical
antipsychotics in elderly NH residentsantipsychotics in elderly NH residents Atypicals approved by FDA for use in treatment of Atypicals approved by FDA for use in treatment of
schizophrenia and/or bipolar disorderschizophrenia and/or bipolar disorder Concern regarding use for off-label conditions Concern regarding use for off-label conditions
(i.e., conditions other than schizophrenia and/or (i.e., conditions other than schizophrenia and/or bipolar disorders) and/or for residents with the bipolar disorders) and/or for residents with the condition specified in the FDA boxed warning condition specified in the FDA boxed warning (i.e., dementia).(i.e., dementia).
Side effect of atypical drugs include increased risk of death in elderly
persons with dementiaLevinson, D. (2011). Medicare atypical antipsychotic drug claims for elderly nursing home residents. Department of Health and Human Services. Office of the Inspector General. OEI-07—8-00150
Other Adverse Side Other Adverse Side EffectsEffects
CardiovascularCardiovascular Hypotension
Orthostatic hypotension Cardiac arrhythmias
prolongation of QT intervall
Central Nervous SystemCentral Nervous System Sedation Reduction in
seizure threshold
EndocrineEndocrine• Nausea• Diarrhea• Constipation
GastrointestinalGastrointestinal• Weight gain• Diabetes
mellitus
• Cholestatic jaundice• ↑transaminase enzyme
activities
LiverLiver
Potential Antipsychotic Potential Antipsychotic DrugsDrugs
Side EffectsSide EffectsExtrapyramidalExtrapyramidal
Akathisia Drug induced
Parkinsonism Dystonia
Acute dystonic reaction
Tardive dyskinesia
AnticholinergicAnticholinergic Dry mouth, blurred
vision Glaucoma Constipation Urinary
hesitancy/retention Impairment in
cognitive functioning and hallucinations
Extrapyramidal Side Effects Extrapyramidal Side Effects (EPSEs)(EPSEs)
Side Effect
Nursing Considerations
Akathisia • Most often with high potency antipsychotics• Hallmark symptoms: inability to sit still, pacing, squirming • Critical to distinguish between ↑ anxiety or psychotic agitation
Drug induced Parkinsonism
• 3 major hallmark symptoms: tremors, rigidity, and bradykinesia• Mental effects: bradyphrenia and cognitive impairment• ↑ susceptibility to aspiration or to injury due to falls
Acute Dystonias
• Early recognition of hallmark symptoms: tightening of jaw, stiff neck, swollen tongue• Later signs: Severe and bizarre muscle contractions i.e. oculogyric crisis , torticollis, opisthotonos, glossopharyngeal constrictions• Painful and very frightening • Accurate observation promotes prompt recognition and treatment
Example of objective EPSE assessment tool: The Abnormal Involuntary Movement Scale (AIMS)
Sensory Enhancement Sensory Enhancement MeasuresMeasures
ExamplesExamples Landscaped outdoor
gardens Soothing environmental
sounds such as singing birds, waterfall, soft music
Pleasing odors that stimulate the senses (baking smells, fresh brewed coffee, tea, fresh flowers)
Provide for periods of exposure to natural lighting when possible
Incorporate items in environment that stimulate the 5 senses: visual (memory books and scrap books containing family pictures, different textures such as cotton balls, perfumes, citrus odors from fruits such as lemons and oranges, smells from plants such as lavender, and roses)
Measures to Prevent Sensory Measures to Prevent Sensory OverloadOverloadExamplesExamples
Decrease environmental stimuli ( noise generated from equipment, TVs, stereos and background noise from loud conversations
Keep use of overhead paging at a minimum
Avoid use of large mirrors
Use appropriate level of lighting to prevent casting of shadows in environment
Comfortable room temperature
Assess for unmet physical needs such as toileting, hunger, thirst, pain, constipation
Utilize therapeutic communication strategies to prevent catastrophic reactions
Maintain a calm, non-hurried approach to care
Allow for periods of rest between challenging activities
Resistance to Care During BathingResistance to Care During BathingNursing ApproachesNursing Approaches
Person-Centered Care Approaches
Communication Strategies
Environmental Modifications
• Requires knowledge of lifelong bathing preferences, individual rituals surrounding bathing, and awareness of cultural considerations
• “See” through the eyes of the person with dementia
• Focus is on “individual” not the task being performed
• Avoid hurried movements
• Allow participation in care to the degree possible
• Calming voice• Simple, step by
step, directions and instructions
• Avoid use of “elderspeak”
• Engage in “pleasant” conversations on topics of interest
• Verbal cueing, sequencing, gesturing, priming, or mirroring
• Never scold; Offer praise and unconditional regard
• ↓ extraneous noise
• Soft, relaxing, preferred music
• Avoid bright lights, glare or shadows
• Maintain comfortable room and water temperature
• Remove clutter and items that could be distracting or frightening
Examples of Stage Related Symptoms
and Non-Pharmacological Interventions
Stage
Symptoms Interventions
Mild Forgetfulness Generalized anxiety Restlessness, pacing Isolation or withdrawal from usual activities Apathy Depression
Memory books Reminiscence therapy Meaningful structured activity/ exercise Indoor/outdoor gardening Music therapy (individual preferred)
*Note: Interventions from either stage can be used based on individualized needs/response
Examples of Stage Related Symptoms
and Non-Pharmacological Interventions
Stage Symptoms Interventions*Moderate
Shadowing ↑ restlessness and
pacing Wandering Physical aggression; agitation Sundowning More severe diurnal
or circadian rhythm
disruptions Suspiciousness,
accusatory paranoia Delusions,
hallucinations
Simulated presence therapy Individualized, preferred music; soothing music Validation therapy White noise Pet therapy Aromatherapy, message therapy Video-respite
*Note: Interventions from either stage can be used as appropriate based on individualized needs/response
Examples of Stage Related Symptoms
and Non-Pharmacological Interventions
Stage Symptoms Interventions*
Severe
Repetitive vocalizations Screaming, yelling, crying out, moaning
Soft, calming music Snoezelen® (multisensory) Simulated presence therapy
*Note: Interventions from either stage can be used based on individualized needs/response
Benefits of SleepBenefits of Sleep
Brain tissue restorationBrain tissue restoration Body restoration Body restoration Energy conservationEnergy conservation Memory reinforcement Memory reinforcement Regulation of immune functionRegulation of immune function Metabolism and regulation of certain Metabolism and regulation of certain
hormoneshormones ThermoregulationThermoregulation
A Single Normal Sleep A Single Normal Sleep PatternPattern
Non Drug Measures to Non Drug Measures to Promote SleepPromote Sleep
Warm milk, soothing, preferred music, aromatherapy, light message
Eliminate intake of caffeine in late afternoon and evening, offer opportunity for toileting prior to retiring for sleep
Encourage periods of interaction between family and staff during daytime
Engage in meaningful individual and/or group activities
Reduce levels of environmental stimuli (i.e. sounds and images from TVs kept playing in room during evening and night-time hours)
Proper lighting in room to avoid shadowing effect
Honors importance of keeping the “Person” at the center of care planning and decision making
Promotes choice, purpose and meaning in daily life of the “Person”
“Person” supported in achieving a maximal level of physical, mental and psychosocial well-being
Premium placed on active listening to and observingthe “Person”
REMEMBER: A “Person”-Centered Approach Builds on Individual Strengths and Abilities
to Maximize and Promote Independence
The End