Educational program aiming to optimize the management of behavioral and psychological symptoms of de

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Educational program aiming to optimize the
management of behavioral and psychological
symptoms of dementia in nursing homes

• Lynn Fournier
• Nurse clinician in geriatrics
• Research assistant

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Research team

• Johanne Monette, MD, MSc (PI)
• Nathalie Champoux, MD, MSc (PI)
• Christina Wolfson, PhD,
• Guillaume Galbaud Dufort, MD, PhD
• Brian Gore, MD
• Lucie Tremblay, M.Sc.
• Harold Frank, MD
• Sponsored by Maimonides geriatric centre,
  Institut universitaire de gériatrie de Montréal
  (CAREC)

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Plan

• Goal of the research project
• The importance of your role
• Review of dementias and cognitive impairment
• Behavioral symptoms of dementia
• Non-pharmacological interventions
• Use of medication

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Goal of the research project

• Assess the impact of an interdisciplinary
  educational program implemented in nursing homes
  to optimize the management of behavioral and
  psychological symptoms of dementia (BPSD)

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Your Role

• Communication of any observed changes in
  residents behavior to the nurse
• Communication of any observed changes in
  residents behavior by the family to the nurse
• Active participation in the assessment of the
  behavior, elaboration and evaluation of
  non-pharmacological interventions

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My Role

• Participate in interdisciplinary team discussions
  around BPSD and possible interventions
• Collect comments, answer questions
• Collect data re changes in the prescription of
  antipsychotic meds and the use of physical
  restraints

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Availability

• Lynn Fournier
• Research assistant
• Beeper 330-4939 M-F 0800-1600
• Up to 3 days/week at Maimonides

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Dementias...

• Alzheimers dementia
• Vascular dementia
• (great fatigue, attention problems,altered
  mobility)
• and others

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Review of dementias and cognitive impairment

• difficulty to communicate verbally what he
  wishes to say (aphasia) or may have difficulty to
  understand what we are trying to tell him
• difficulty to recognize familiar objects or
  persons
• difficulty to remember how to do a certain
  activity i.e. getting dressed

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Cognitive impairment

• Deterioration of intellectual faculties
• ? memory
• ? orientation (time, person, space)
• ? concentration
• ? learning ability
• ? abstract thinking

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Behavioral symptoms of dementia

• sometimes surprise, disturb and/or are less
  socially accepted
• occur mostly during hygiene care, mealtimes or
  when the staff is positioning the resident in bed
  

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Some of these symptoms are

• Agitation
• Aggression (verbal or physical)
• Resisting care
• Wandering
• Sleep disturbances (day/night reversal)
• Emotional lability (cursing, shouting, crying)
• Delusions and hallucinations
• Apathy
• Restlessness
• Climbing

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Residents presenting these different symptoms

• are at a high risk of injuring themselves
  or be harmed by others
• are at high risk of being judged or more
  isolated
• involuntarily can cause fatigue,
  frustration or feelings of helplessness among the
  caregivers
• Do not hesitate to ask for help or support
• ? Essential to work in a multi-disciplinary team

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Language impairment

• In dementia, reasoning and language skills are
  gradually lost and communication becomes more
  behavioral. Even when speech is intact, it is
  often limited by difficulties in forming and
  expressing thoughts correctly.

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To care for the resident...

• we must try to understand the origin of the
  behavior, identify the underlying need, to
  prevent it from happening again or to prevent
  negative consequences for the resident or his
  surrounding, and to respond quickly

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To care for the resident

• The we know the resident, the
• the care will be
• (life history,occupation, likes and dislikes,
  therapeutic interventions that work,family
  involvement,)
• Families and/or significant others share the
  caring of their loved ones with the staff and
  represent

better
more
a primary source of information
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Probable triggers/causes

• Physiological
• Thirst
• Hunger
• Discomfort
• Psychosocial
• Fear
• Change
• Loss of autonomy /control
• Low self-esteem

• Environmental
• Sensory overload/excessive stimulation
• Sensory deprivation and isolation
• Restricted movement (physical restraint)
• Pathological
• Agitated behavior distress

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Towards a better relationship

• Identify self with each contact
• Share your understanding of his situation
• Maintain attention on the resident when giving
  care
• Communicate face-to-face with simple statements
  (eye contact)
• Speak in a gentle, friendly tone of voice
• Provide new information slowly in small amounts
• Use slow deliberate gestures avoid sudden
  movements

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Non-pharmacological interventions

• Try to maintain the residents interest in the
  outside world
• Do not argue about realities that differ
• If the resident becomes agitated, do not insist,
  remain calm, stop the care and attempt to calm
  the person before trying any other intervention
• ? The more agitated the resident becomes, the
  calmer the caregiver must be

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Non-pharmacological interventions

• Eliminate sounds or stimuli that interfere with
  communication
• Distract the resident (use diversion, talk about
  other subjects, that interest him)
• Allow the resident to feel good during an
  activity in order for him to associate pleasure
  with the activity when it will be repeated

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Non-pharmacological interventions

• Ignore or tolerate certain behaviors
• Always think of the persons safety
• Use humor to de-dramatize
• Modify the environment
• Adopt a comforting routine
• Involve the resident in recreational activities

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Non-pharmacological interventions

• Use music therapy or zoo therapy
• Use gentle sensory stimulation
• i.e. physical touch, bathing, back-rubs,brush
  hair, relaxing music
• Use orientation devices
• i.e. radio, t.v., clocks, calendars, family
  photos, familiar objects from home

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Non-pharmacological interventions

• Increase daytime stimulation for residents
  experiencing sundown syndrome
• Invite to accompany on rounds
• Make available night time activities (snacks in
  kitchen, activity cart, etc.)
• Control noise levels
• Make quiet room available
• Use soothing background music

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Pharmacotherapy

• Respond less
• Wandering
• Non-goal oriented and repetitious activities
• Altered social judgment
• Personality problems
• Tendency to steal and to hoard objects
• Vocalizations (screamers)
• Pica
• Pulling repetitiously on

• Respond
• Delirium and hallucinations
• Anxiety
• Affective problems
• Regressed behaviors
• Verbal or physical agitation
• Verbal or physical aggression
• Apathy, depression,sadness
• Certain inappropriate sexual behaviors
• Hostility

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Important to keep in mind

• Non-pharmacological intervention ?/- Rx
• Impact of Rx modest
• Some will benefit from Rx, others wont
• Regular reevaluation of the Rx necessary to
  ensure residents well-being
• Long treatment need anymore?

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Important role

• Your observation of any changes in the residents
  behavior will be critical to perform a proper
  assessment of the behavior and then plan a
  therapeutic non-pharmacological intervention(s).

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Thank you for your participation!