www.HQOntario.caHealth Quality OntarioThe provincial advisor on the quality of health care in Ontario

Expert panel on Agitation and Aggression in DementiaQuality Standards and Clinical Handbook

AGHPS Summit November 13, 2015

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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

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Project Scope

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For each prioritized key area:

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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

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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

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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

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• 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

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Methods: Drafting of Quality Statements

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# Title First

NameLast Name Affiliation Specialization

1 Dr. Ilan Fischler OSCMHS Geriatric Psychiatrist

2 Dr. Tarek Rajji CAMH Geriatric Psychiatrist

3 Dr. Krista Lanctot Sunnybrook Health Sciences Centre PhD Pharmacologist

4 Ms. Vincci Tang Ontario Shores Centre for Mental Health SciencesDeputy CFO & Director of

IT & Decision Support

5 Ms. Saima Awan CAMH – clinical pathway supportManager, Integrated Care

Pathways Program

6 Dr. Amer Burhan Western University (London) Geriatric Psychiatrist

7 Dr. Dallas Seitz Queen's University Providence Care Geriatric Psychiatrist

8 Dr. Evelyn Williams Sunnybrook Health Sciences CentreHead, Division of Long

Term Care

9 Ms. Carrie Acton Muskoka Landing LTC - Huntsville Administrator

10 Ms. Ashley Miller Regina Gardens Long Term Care Center Administrator

11 Ms. Denise Malhotra Erie St. Clair Community Care Access Centre (CCAC) Decision Support Analyst

12 Ms. Natasha Ward Thunder Bay Regional Health Science Center Nursing

13 Dr. Richard Shulman Trillium Health Partners Geriatric Psychiatrist

14 Ms. Lori Whelan St. Michael's Hospital Occupational Therapist

15 Dr. Jenny Ingram Kawartha Regional Memory Clinic Geriatrician

16 Dr. Barry Goldlist Mount Sinai Hospital (MSH) Geriatrician

17 Ms. Sandi Robinson Accalaim Health Alzheimer Services Social Worker

18 Mr. Ken Wong Full-Time Caregiver Patient Advocate

19 Ms. Margaret Weiser Private Practice Psychologist

HQO's Expert Advisory Panel on Dementia with Agitation or Aggression

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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

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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

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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.

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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.

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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

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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

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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

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NPI-NH

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Integrated Care Pathways

• CAMH Experience with Agitation and Aggression due to Alzheimer’s or Mixed Dementia

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Treatment Algorithms: Evidence

Algorithm use in clinical practice associated with: Improved quality of careEnhanced patient outcomesReduced health care costs

Adli. M et al. 2006. Biological Psychiatry. 59. 1029.

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Pathway

Assessment & Medications

Discontinuation

Cognitive Enhancers

(AChEI, Memantine)

Pharmacological

Non-Pharmacological

Zaraa, 2003

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Non-Pharmacological Interventions

• Consent• Caregiver education and support• Enhance communication with the patient• Ensure safe environment• Increase or decrease stimulation in the environment

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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:_______________

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Multisensory Snoezelen System

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Paro Therapeutic

Robot

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Pharmacological Interventions

Risperidone

Aripiprazole

Carbamazepine

Citalopram

Gabapentin

Prazosin

ECT

Quetiepine

For partial responders:1. Extend the trial2. Increase the dose 3. Augment with another agent that showed also partial response

PRNs:1. Trazodone2. Lorazepam

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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

21 19 18 13 4 1 1 1

Combined Total Patients (Alzheimer’s and Frontotemporal

Dementia)

Patients Enrolled and ToleratingThree or More

Non-Pharmacological

Interventions (any selected

combination from algorithm)

 

Patients Enrolled and Tolerating

Two or LessNon-Pharmacological

Interventions (any selected combination

from algorithm)

Did Not Respond, Tolerate or Accept

any Non-Pharmacological

Interventions

21 15 1 5

Pharmacological Interventions

Non-Pharmacological Interventions

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• 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