Dementia Care Without Restraints: Think Critically and Change Practices Anthony Chicotel Staff...
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Transcript of Dementia Care Without Restraints: Think Critically and Change Practices Anthony Chicotel Staff...
Dementia Care Without Restraints: Think Critically
and Change Practices
Anthony ChicotelStaff AttorneyCalifornia Advocates for Nursing Home Reform
The IntroBehavioral challenges associated with
dementia are expression of need, not “symptoms.”
Medicalizing the the problem means medicalizing the response: 60% of nursing home residents receive a psychoactive drug.
A least medicating approach, based on relationships, is superior for health, safety, and quality of life.
Drug ClassesDrugs Used to Change “Behaviors”:
1) Anti-Depressants (e.g. Zoloft, Celexa)
2) Hypnotics (e.g. Remeron, Ambien)
3) Anti-Anxieties (e.g. Ativan, Xanax)
4) Anti-Psychotics (e.g. Zyprexa, Risperdal, Seroquel, Haldol)
5) Misc.: Depakote, Neudexta
Antipsychotics: Risks Galore, Including DEATH
Side Effects: too many to name - strokes, falls, dizziness,weakness, headache, tardive diskinesia
Some side effects are the symptoms the drugs are supposed to treat: agitation, restlessness, confusion, delirium, cognitive decline, seizures
Double risk of death for elderly with dementia (FDA Black BoxBlack Box warning)
DART-AD StudyNo. of Months on Antipsychotic
Survival Rate (%) of those Who Continued to Receive Antipsychotic
Survival Rate (%) of those Receiving Placebo
12 70 77
24 46 71
36 30 59
New Dementia Drug XBenefits
Relieves Pain
Reduces Anxiety
Easier Sleeping
Light Euphoria
Side Effects
Sedation
Reduced Activity
Some Withdrawal when Discontinued
Define the ProblemCare providers perceive explainable
actions/reactions of residents with dementia as a “behavioral and psychological symptom of dementia.”
When behavior is a symptom, it becomes medicalized. Instead of a human problem, it becomes a medical problem necessitating medical intervention.
This often meansLoss with attendant sadness
Decreased activity
Discomfort
Fear
Less ability to meet immediate needs
Less ability to engage help
Immeasurably exacerbated in an institutionalized or congregate living setting
Think about it
“Behaviors” are not symptoms of dementia - they are the natural response to distress and unmet needs.
What we are observing are behavioral and psychological symptoms of being a person with lots of confusion and no way to verbally communicate.
Why Psych Drugs Fail
Psych drugs sedate – less activity, more falls, more incontinence, more confusion
Psych drugs do not resolve the underlying problem that led to the behaviors, so problems worsen
Sedation + Masking the Problem = Negative Outcomes, including doubling the risk of death
A Different Approach: Least Medicating
Behavior is communication.
Know the care recipient (relationships as the new medicine).
Meet them where they are.
Least Medicating Approach (cont’d)
Almost all behavior has a discernible cause – you have to think it through.
Team Approach: use staff, family, and experts to find the right intervention.
Agitation is easier to prevent than to treat.
Drugs only as last resort
Comfort-focused Care
Prophylactic Pain Management
Culture Change components: liberalized diet, personalized sleeping and showering schedules
Active observation, notation, and collaboration
Comfort as the goal of every experience
Relationships
Our needs survive our ability to consider and convey themBiological needs – food, shelter, activityPsychological needs – choice, control, connection
Validation therapy, Music & Memory, activity programs – what do they have in common?
Knowing who they were and who they are and loving them both
A New Standard of CareAHCA: These drugs don’t get to the heart of the reason for
the person’s actions.
Leading Age: Antipsychotics rarely help and present significant dangers.
AMDA: I do not prescribe antipsychotic drugs for treatment of agitation or other behaviors in patients with dementia.
APA: Antipsychotics ought to be the last resort for dementia.
Dr. Jonathan Evans: The use of these drugs represents a failure.
Nursing Home Law Demands
Good Dementia Care
Informed Consent
No Unnecessary Drugs
Chemical Restraints Prohibited
Gradual Dose Reduction
This is Chemical Restraintimposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms (42 C.F.R. Sec. 483.13(a))
Convenience: any action by the facility to control or manage a resident’s behavior with a lesser amount of effort.
Neurologic Suppression is ALWAYS the goal.
No Unnecessary DrugsInadequate Indications for
Use:
http://www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf (F-Tag 329, 42 CFR 483.25(l))
wandering; poor self-care; restlessness; impaired memory; mild anxiety; insomnia; unsociability; inattention; fidgeting; uncooperativeness; behavior that is not dangerous to others
Gradual Dose Reduction
Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated. (42 CFR 483.25(l))
National Initiative to Improve Dementia Care
and Reduce Antipsychotic Use
Led by CMS, a collaborative education campaign to reduce AP use in nursing homes has led to a 14% reduction since 2012.
In California, the reduction has been 16%.
One County’s Story
“There’s a Problem” Symposium, March 2011
“Comfort Care as the Alternative” Symposium, August 2011
“Local Adopters Lead Other Providers” Symposium, March 2013
Local group of stakeholders meet bi-monthly, watch statistics closely
Next: training for doctors, focus on laggards
One County’s Results
4th Quarter 2010 Nursing Home AP use: 19.07%
2nd Q 2014: 13.57% (29% reduction)
Antianxieties down 16%, Antidepressants down 13%, and Hypnotics down 48%
Resources
1) https://www.nhqualitycampaign.org/files/Dementia_Care_Training_Crosswalk.pdf
2) Dementia Beyond Drugs