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ou’re the physician on call for the weekend. At 9 p.m. on Saturday, you get a call from a nurse at a local nursing home saying they’ve tried everything to calm an agitated resident. They’re asking you to order something. This is still a very familiar scenario, even though the long-term care profession in Minnesota has made progress in decreasing the use of unnecessary drugs. To change the way antipsychotic drugs are used in nursing homes, Ecumen (a provider of senior housing and services in Minnesota) is going further, implementing a comprehensive program called Awakenings. The goal is to awaken Alzheimer’s and dementia patients to a fuller, richer life by decreasing their dependence on unnecessary medications. Physicians are key partners in this work. How Awakenings began
Awakenings was piloted at an Ecumen nursing home in Two Harbors, Minnesota in 2009. Based on those remarkable results and thanks to a $3.8 mil-
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Awakenings Transforming Alzheimer’s care in Minnesota By Laurel Baxter, MA, RN lion, three-year state grant, the initiative is expanding to 15 other Ecumen nursing homes in Minnesota. We hope that what we learn from this expansion will provide Alzheimer’s “best practice” guidance to physicians and care centers in Minnesota and across the country. Earlier this year, a New York Times blog discussed the promise of this initiative (Paula Span, “Clearing the Fog in Nursing Homes,” New York Times, Feb. 15, 2011). The Two Harbors pilot demonstrated that residents with Alzheimer’s could enjoy a better quality of life if behavioral and environmental interventions, rather than antipsychotic drugs, were tried first. These drugs not only can rob residents of their personalities and energy; in some cases they actually worsen cognitive functioning
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among elderly dementia patients, and can speed their decline—making strokes, pneumonia, or serious adverse drug effects more likely. Despite the fact that antipsychotic drugs carry a Food and Drug Administration black-box warning that elderly patients who use them have an increased risk of death, their use has skyrocketed in recent years. Medicaid spends more on antipsychotics than any other class of drugs—including antibiotics, AIDS drugs, or medications to treat high blood pressure. As nursing home residents in Two Harbors were weaned off antipsychotics, staff members engaged more with them, taking them on walks, and playing games and exercising with them. Certified nursing assistants assumed a more important role. A variety of therapies using validation, reminiscence, music, aroma, and pets were employed to improve residents’ physical and cognitive functions. Within six months, the use of antipsychotics was eliminated among all residents, and antidepressant use decreased by 30 to 50 percent. Before the pilot project, the home was quiet; several residents preferred to stay in bed, and others had a far-off, vacant look. Today, residents are engaged in meaningful activities and relationships, and relationship-based care has become the normal routine for the entire home. Indeed, the Awakenings approach has far-reaching effects in reducing unnecessary psychotropic medications or other potentially unnecessary medication for any nursing home resident. Key strategies for change
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This shift toward nonpharmaceutical interventions involves every staff member. Awakenings takes a holistic, individualized approach to Alzheimer’s care to get to the root cause of behavioral issues. Collaborative teams
CARE
—“circles of care”—are built around each resident, involving family, case workers, and the right doctors and nurses. A team evaluates the situation of each resident to find the right mix of care to help ensure best quality of life. Again, the focus of care becomes human relationships rather than solely drugs. One of the first steps in introducing Awakenings is recruiting project leads and rehabilitation nursing staff. Rehabilitation nursing is a key element of success, along with enhanced, personalized activities. Residents are less likely to get agitated when their individual preferences are met. These staff members, who are trained in several areas, including assessment for delirium and alternative care plan interventions, share this learning with all team members. The team considers the underlying causes of agitation before calling the physician. Training is also provided for administrators and directors of nursing in each care center, teaching them to ask “why” when they hear about a resident’s behavioral symptoms. Physicians are an important part of Awakenings care teams. Attending physicians and medical directors are invited to meet with a physician certified in psychiatry and neurology to share the latest knowledge about the use of psychotropic medications. Physicians are encouraged to consider underlying causes of agitation prior to ordering treatment with medication. Family members are also key members of the team. They are directly involved with resident activities and help share their relative’s life story, which is part of assessment and alternative care planning, including spiritual care. It’s crucial that staff understand as much about each resident’s needs and preferences as possible in order for relationship-based care to succeed. Teams also work with pharmacy consultants in creating individual care plans. This allows the pharmacist to understand more about a resident than can be gained by reading clinical records. If deemed beneficial by the attending physician,