Issuu on Google+

An Evaluation of a Training Program in Restraint-Free Care for Individuals with Dementia Christina Garrison-Diehn, Clair Rummel, & Jane E. Fisher


Background ƒ LQSHRSOHDJHGDUHDIIHFWHGE\$O]KHLPHUÂśV Disease. (Xu, Kochanek & Tejada-Vera, 2009) ƒ Dementia is the leading cause of nursing home admission (Eaker, Vierkant, & Mickel, 2002). Âą 70% of individuals with dementia are living in a nursing home at the end of their life (Mitchell, Kiely & Hamel, 2005) ƒ Top reasons for nursing home placement: (Buhr, Kuchibhatla & Clipp, 2006)

Âą Need for more skilled care Âą &DUHJLYHUVÂśKHDOWK Âą Dementia related behaviors


Background ƒ Behavioral challenges: Agitation Aggression Delusional speech Hallucinations

Repetitive vocalizations Wandering Depressed affect Social withdrawal

ƒ Prevalence rates = over 60% (Lyketsos, et al. 2002).


Traditional Model of Dementia ƒ Behavioral challenges = symptoms of neuropathology ƒ Attribution of behavioral disturbances as a symptoms of dementia Æ increases the risk of excess disability ± Impairment in function beyond that which can be accounted for by the disease. (Dawson, Wells & Kline, 1993) ± Frequency of adaptive behavior is diminished prematurely. (Fisher et al.,2007) ƒ First line of treatment: antipsychotic medications


Antipsychotics ƒ Most common treatment = antipsychotic medications ± Prescribed off-label ƒ 32-58% of nursing home residents are prescribed antipsychotics (Ronchon et al., 2007; Margallo-Lana et al., 2001; Kamble et al., 2009) ± Typical: haloperidol, thorazine ± Atypical: risperidone, olanzapine ‡ Moderate evidence of efficacy (Agency of Healthcare Research and Quality, 2007)


Antipsychotics ƒ Adverse effects offset the advantages (Ballard et al., 2009; Schneider et al., 2006; Ballard & Waite, 2006).

ƒ Increased risk of: ‡ Mortality ‡ Cerebrovascular adverse events ‡ Extrapyramidal symptoms ‡ Upper respiratory infections ‡ Sedation & confusion ƒ Premature reduction of adaptive functioning ƒ Decreased quality of life (Ballard & Margallo-Lana, 2004)


Contextual Model of Dementia ƒ Behavioral challenges = inability to report private events & have needs met (Fisher et al., 2007) ƒ Behavior communicates what words cannot

ƒ Intervention = medical assessment + environmental assessment ƒ Evidence for contextual model: modification of the social and physical environment results in a reduction of these problems and a reduction in excess disability (Yury & Fisher, 2007; Burgio & Stevens, 1999; Buchanan & Fisher, 2002; Cohen-Mansfield & Werner, 1998).


Restraint Free Care Training Program Development ƒ )XQGHGE\WKH6WDWHRI1HYDGD¶V%XUHDXRI+HDOWK&DUH Quality and Compliance ƒ Goals: 1. Increase staff knowledge of evidence-based practices for dementia care. 2. Reduce the use of psychotropic medications to manage behavioral challenges in residents with dementia. 3. Increase facilities ability to keep challenging residents. 4. Improve quality of life for residents with dementia by reducing excess disability and preserving adaptive functioning.


Restraint Free Care Training Program Development ƒ Program characteristics ± Available to long-term care facilities on a voluntary basis ± No cost to the facility ± Needs assessment conducted pre-training ± Train-the-trainer model ± 10 hours of training ± Consultation services post-training ‡ Aid in providing trainings to full staff ‡ Behavioral consultation for challenging cases

± Satisfied state requirement for dementia training


Restraint Free Care Training Program Overview ƒ Topics Covered: ± Stress of Dementia Care ± Communication Techniques ± Excess Disability ± Assessing Pain ± Delirium

± Depression ± Promoting Choice ± Delusions and Hallucinations ± Sexuality ± Behavioral Interventions

ƒStructured trainings designed to include idiographic examples from each specific facility throughout the trainings


Program Timeline Development & Recruitment

January 2010 ± April 2010

Trainings Conducted

May 2010 ± November 2010

Data Collection

Through April 2011


Facility Characteristics

Facility Type

N

Residents on Antipsychotic Medication Âą Pre Training

Residents on Antianxiety medication Âą Pre Training

Skilled Nursing Group Home

8

<10% - 60%

10% - 50%

12 <10% - 100%

<10% - 80%


Participant Demographics Asian

‡ N = 64 ‡ Gender: 85% Female ƒ Education: ± ± ± ± ±

High School: 5% Some College: 17% AA: 17% BA: 38% Masters/Professional: 15%

9%

30%

African American Hispanic

5% 47%

3% 6%

Native Islander Caucasian Unreported


Outcome Measures: Trainers Â&#x192; Pre & Post- Training Measures Âą $O]KHLPHUÂśV'LVHDVH.QRZOHGJH6FDOH- Modified (ADKS; Carpenter et al., 2009)

Âą Approaches to Dementia Questionnaire (ADQ; Lintern et al., 2000 )

Âą Vignette Â&#x2021; Â&#x2021; Â&#x2021; Â&#x2021;

79-year-old woman 'LDJQRVHV$O]KHLPHUÂśVGLVHDVHDUWKULWLVDQGFRQJHVWLYHKHDUWIDLOXUH Facility resident: 2 years. Recently Mrs. Hansen has been less talkative to her fellow residents and less FRPSOLPHQWDU\WRVWDIIPHPEHUV0UV+DQVHQÂśVFU\LQJHSLVRGHVDUHKDSSHQLQJ more frequently and she is refusing to let staff give her a shower. Â&#x2021; :KDWZRXOG\RXGRDERXW0UV+DQVHQÂśVFXUUHQWEHKDYLRU"


Outcome Measures ƒ Observational Data Collection ± Two skilled-nursing facilities in Reno, NV ± Resident criteria ‡ Dementia diagnosis ‡ Staff report of challenging behaviors

± Systematic observation of residents ‡ 5HVLGHQWDGDSWLYHDQG³SUREOHP´EHKDYLRUV ‡ Staff behavior and affect when interacting with observed residents

± Pre- and post-training & post-facility wide training ƒ Chart review ± PRN administration, behavioral incidents, assessments, consults, illness, hospitalizations ± Medication Administration Records, nursing notes, behavioral reports, incident reports


Outcome Measures ƒ 3- Month Follow Up ± Facility characteristics ‡ Antipsychotic medication use ‡ Staff turnover ± Evaluation and feedback form ‡ Rate specific training objectives ‡ Room for comments ± Status of facility wide trainings


Pre & Post Results Measure

N

Pre

Post

P-value

ADKS

40

24.95

25.95

.002*

ADKS - Contextual

40

4.8

5.13

.02*

ADQ

30

72.2

73.4

.058

Vignette

34

3.21

3.62

.12

Vignette - Communication Strategies

34

.56

.26

.02*

Vignette Âą Assessment

34

1.01

1.53

.005*

Vignette - Consultation

34

.71

.56

.08

Vignette Âą Environmental Strategies

34

.91

1.26

.06


Data Analysis underway ƒ Resident behavior + Chart review (staff behavior) ± Systematic review of impact of training on staff behavior ‡ Examining observed changes in adaptive behavior and ³SUREOHP´EHKDYLRURILQGLYLGXDOUHVLGHQWV ‡ Versus staff charted behavior ± Pain assessment ± Medical assessment ± Medication administration ± $WWULEXWLRQRIEHKDYLRU³SUREOHPV´


Aggregate Observational Data of Staff Trials

Positive Staff Behavior

Negative Staff Behavior

Positive Affect

Negative Affect

Neutral Affect

Pre

38

84%

12%

87%

5%

16%

Post

63

86%

6%

68%

1%

7%

3 month follow-up

48

72%

13%

48%

10%

69%

Facility II

Trials

Positive Staff Behavior

Negative Staff Behavior

Positive Affect

Negative Affect

Neutral Affect

Pre

84

81%

4%

50%

4%

74%

Post

123

84%

16%

49%

3%

49%

3 month follow-up

83

87%

11%

43%

4%

69%

Facility I IRR trials = 15%

IRR trials = 45%


Agreement Facility  I

Mean

Range

&RKHQ¶V.DSSD

.885

.722 ± 1.0

% agreement

.96

.90 ± 1.0

Facility  II

Mean

Range

&RKHQ¶V.DSSD

.815

.688 - .958

% agreement

.93

.89 - .98


Status of Trainings at 3 month follow-up (9 forms received) Modules given to full staff Managing the stress of dementia care

5

Knowing the facts about dementia

5

Communicating the facts about dementia

5

Knowing about excess disability

5

Assessing pain

4

Promoting choice

4

Making sense of delusions and hallucinations

3

Sexuality in long-term care

3

Ruling out excess disability

3

Ruling out delirium and depression

3

The contextual ABCs of dementia care

2

Searching for clues Part 1: Antecedent interventions

3

Searching for clues Part 2: Consequent Interventions

2


3-Month Follow-up Feedback (9 respondents) Criteria Articulation of training program objectives Meeting of training program objectives Effectiveness of teaching methods Flow and style of presentation Relevance of information to your situation Usefulness of handouts &/or training material Usefulness of examples

Excellent Ratings 3

Very Good Ratings 4

Good Ratings 1

Average Ratings 0

Poor Ratings

3

4

1

0

0

4

3

1

0

0

3

4

1

0

0

3

4

1

0

0

4

3

1

0

0

3

4

1

0

0

0


3-Month Follow-up Feedback ƒ Reported psychotropic medication use ± No significant changes ‡ Anti-psychotic ‡ Anti-anxiety

ƒ Responders comments ± Helpfulness of the training program ± Suggested improvements ± Trainings impact on staff ability to manage challenging behaviors ‡ $OOFRPPHQWVLQGLFDWHGWKDWWUDLQLQJVLQFUHDVHGVWDII¶VDELOLW\WR manage challenging behaviors


Discussion ƒ Observational data does not indicate that the training program had an impact on staff interactions with residents ± Chart review data will indicate if there was an impact on other staff behavior ƒ Staff reported enjoying content and delivery of the training ± Especially the use of in-facility examples


Discussion ƒ Model based on identifying idiosyncratic barriers to effective caregiving and guided practice ± More intense intervention may be needed ƒ ³%XUHDXRI+HDOWK&DUH4XDOLW\ &RPSOLDQFH´ODEHO ± )DFLOLWLHVRIWHQZDQWHGWR³SXWWKHLUEHVWIDFHIRUZDUG´ ± Limited use of follow-up consultation ± Buy-in from administration ƒ /RJLVWLFDOOLPLWDWLRQVRI³UHDOZRUOG´


Contact: christinagarrisondiehn@gmail.com


References Agency of Healthcare Research and Quality (2007). Efficacy and comparative effectiveness of off-label use of atypical anti-psychotics [publication no. 07-EHC003-EF]. Rockville (MD): Agency of Healthcare Research and Quality. Ballard C. & Waite J. (2006). The effectiveness of atypical antipsychotics for the treatment of aggression DQGSV\FKRVLVLQ$O]KHLPHUÂśVGLVHDVH&RFKUDQH'DWDEDVH6\VW5HY&' Ballard, C., Hanney, M.L., Douglas, S., McShane, R., Kossakowski, K., et al. (2009). The dementia antipsychotic withdrawal trial (DART-AD): Long-term follow-up of a randomized placebo-controlled trial. The Lancet Neurology, 8, 151-157. Ballard, C.G. & Margallo-Lana, M.L. (2004). The relationship between antipsychotic treatment and quality of life for patients with dementia living in residential and nursing home care facilities. Journal of Clinical Psychiatry, 65(11), 23-28. Buchanan, J.A., & Fisher, J.E. (2002). Functional assessment and noncontingent reinforcement in the treatment of disruptive vocalization in elderly dementia patients. Journal of Applied Behavior Analysis, 35, 68-72 %XKU*7.XFKLEKDWOD0 &OLSS(&  &DUHJLYHUVÂśUHDVRQVIRUQXUVLQJKRPHSODFHPHQW&OXHV for improving discussions with families prior to the transition. The Gerontologist, 46, 52-61. Burgio, L.D., & Stevens, A.B. (1999). Behavioral interventions and motivational systems in the nursing home. In R. Schulz, G. Maddox, & M.P. Lawton (Eds.), Annual review of gerontology and geriatrics: Vol. 18. Focus on interventions research with older adults (pp.284-320). New York: Springer Cohen-Mansfield J, & Werner, P. (1998). The effects of an enhanced environment on nursing home residents who pace. Gerontologist 38(2), 199-208 Dawson, P., Wells, D.L., & Kline, K. (1993). (QKDQFLQJWKHDELOLWLHVRISHUVRQVZLWK$O]KHLPHUÂśVDQG related dementias. New York: Springer.


References Eaker, E.D., Vierkant, R.A., & Mickel S.F. (2002). Predictors of nursing home admission and/or death in LQFLGHQW$O]KHLPHUÂśVGLVHDVHDQGRWKHUGHPHQWLDFDVHVFRPSDUHGWRFRQWUROVDSRSXODWLRQ-based study. Journal of Clinical Epidemiology, 55: 462-8. Lyketsos, C. G.,Lopez, O., Jones, B., Fitzpatrick, A.L., Breitner, J., Dekosy, S. (2002). Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: Results from the cardiovascular health study. Journal of the American Medical Association, 288, 1475-1483. Margallo-/DQD06ZDQQ$2Âś%ULHQ-)DLUEDLUQ.5HLFKHOWHWDO  3UHYDOHQFHDQG pharmacological management of behavioural and psychological symptoms amongst dementia sufferers living in care environments. International Journal of Geriatric Psychiatry, 16, 39-44. Mitchell, S.L., Kiely, D.K., Hamel, M.B. (2004). Dying with advanced dementia in the nursing home. Archives of Internal Medicine, 164, 321-3 Ronchon, P.A., Stukel, T.A., Bronskill, S.E., Gomes, T., Sykora, K. et al. (2008). Variation in nursing home antipsychotic prescribing rates. Archives of Internal Medicine, 167(7), 676-683. Schneider, L.S., Tariot, P.N., Dagerman, K.S., Davis, S.M., Hsiao, J.K., et al. (2006). Effectiveness of DW\SLFDODQWLSV\FKRWLFGUXJVLQSDWLHQWVZLWK$O]KHLPHUÂśV'LVHDVHThe New England Journal of Medicine, 355, 1525-1538. Xu, J., Kochanek, K.D. & Tejada-Vera, B. (2009). Deaths: Preliminary Data for 2007. National Vital Statistics Reports 58(1). Hyattsville, Md.: National Center for Health Statistics. Yury, C., & Fisher, J.E. (2007). Meta-analysis of the effectiveness of atypical antipsychotics for the treatment of behavioral problems in persons with dementia. Psychotherapy and Psychosomatics, 76, 213-218

.


Garrison-Diehn (2011) An evaluation of a training program