More than 50% of all Long Term Care (LTC) residents have some form of dementia This affliction in mental ability is severe enough to interfere with daily life. Memory loss is one result of dementia. Residents may also have difficulty in completing familiar tasks and may have problems with forming words while speaking or writing and may become easily confused. They may often misplace items and have lost the cognitive ability to retrace their steps. Residents with dementia can also display some untoward behaviors or psychological symptoms. These behaviors may be wandering, hallucinations, aggressiveness and difficulty with sleeping or eating, with various degrees of severity based on the underlying cause of the dementia and the progress of the disease.
Caring for these residents can pose a significant challenge to the direct care staff. Staff should always remember that the resident is not being deliberately difficult. His or her sense of reality may be different from the staff’s, but it is still very real to the patient. Caregivers should learn not to take problem behaviors personally and do their best to keep their sense of humour and understanding.
Caring for residents with dementia by the use of unnecessary antipsychotic medication pose a big concern. Studies show that over 25% of LTC residents receive psychotropic medication. In 2012 Centers for Medicare and Medicaid (CMS) introduced explicit regulatory requirements to curtail the use of unnecessary psychotropic medications and improve behavior management in LTC facilities. The initiative expected a 15% reduction nationwide by the end of that year. Reports vary on the response but there is definitely a concerted effort by LTC facilities to use a non-pharmacological approach to treating behaviors. The initiative is ongoing and by the end of this year (2015), CMS expects an overall total reduction of 25%.
Without a doubt, the state public health surveyors will be paying close attentions to LTC dose reductions and documentation when they visit a facility. The surveyors will also scrutinize F-tags 309 and 329 to see if the facility is in compliance with them. Nurses should really understand these F-tags and their interpretive guidelines. As nurses, the administering of the proper and necessary drugs to insure the highest practicable level of physical and mental well being of our patients should be the greatest priority.
Prior to a resident being prescribed an antipsychotic medication, four aspects must be clearly identified:
- An appropriate indication for use.
- A specific and documented therapeutic goal.
- Ongoing monitoring of the resident for effectiveness and presence of any adverse reactions from the medication.
- The prescribed medication should be at the lowest effective dose and for the shortest duration needed.
Soon after the drug has been prescribed, the patient’s record must reflect a continuing and concerted effort to decrease the dose and discontinue the drug. Psychotropic drugs are targeted for gradual dose reduction (GDR) because consensus has been reached that they have been overused and that their risk is higher than any potential benefits with continuous use.
Documentation should be very thorough in describing the adverse behaviors and the nonpharmacological approaches used to curtail the behaviors. If the behavioral symptoms represent a change or worsening, a medical workup should be performed to rule out underlying physical or medical causes of the behaviors. Causes to be considered can be either physical (gastrointestinal distress, constipation, pain or respiratory difficulties) or medical (infection, dehydration, delirium, hypoglycemia or hypothyroidism). If other causes are identified (environmental), was treatment initiated timely?
Psychotropic medications should not be administered without a signed consent by the patient or the person designated as the patient's power of attorney (POA). A verbal consent will cover an emergency situation but should be signed as soon as possible. (Follow your facility’s protocol).
The Black Box warning issued by the Food and Drug Administration in 2004 states ”that there is an increased mortality in elderly patients with dementia related psychosis”. It is important that the nurse informs the POA or the patient's family of this warning and should document in the medical record that this information was provided and the response from the family or POA that was received. The FDA also has a list of approved diagnosis for prescribing antipsychotic medications. When prescribed without the FDA approved diagnosis, it is considered “off label use”. Appropriate monitoring of blood levels or systemic response needs to be evaluated at frequent intervals.
It is important that the direct care staff are educated on dementia and the behavioral techniques available to manage the behavior problems. A smile and reassuring touch can go a long way to convey your message and show your understanding. Try and figure out what caused the behavior, if the resident is wandering, where does he/she want to go? Are they hungry, thirsty or need to go to the toilet? These needs should be met as quickly as possible.
A calm and soothing environment should be created to reduce noise levels and confusion. Exercise is a very important factor in mental health. Short walks should be utilized if the patient is physically able or if not, looking out the window to admire the scenery can be helpful. Even looking at the different colors and makes of cars in the parking lot may spark an interest for some residents, Chair or seated exercises with a background of soothing music may be beneficial. Simple activities such as folding towels, watering plants or winding yarn can provide an alternative to the behavior. Reading simple poetry or stories or discussing appropriate current events to small groups and asking questions during the discussions may be of interest to some. Reminiscing can be very helpful as residents with dementia seem to have a better grasp of the distant past rather than the immediate present. Discuss previous occupations and hobbies. Pets can provide some positive non verbal communication and the resident may remember owning a pet previously.
Above all, the need for human interaction is the greatest one the resident has. Even the shortest visit can increase their physical and social activity, and provide sensory stimulation.
Always follow the facility policy and document behaviors, interventions and responses. Documentation should include date, time, location, specific behavior, triggering factors and how it interferes with care. Also document the intervention and response, and always include in the care plan. If a drug is administered document the resident’s response to it.
I have found some very current and informative presentations from LeadingAge Illinois (formerly Life Services Network) https://www.lsni.org/. I cannot stress enough how necessary it is for caregivers to keep up with current information.
