Prevention of Infections in LTC Facilities

Precautions for Prevention of Infection Transmission in Long Term Care Facilities

Last month I discussed the more common infections that occur in long term care (LTC) facilities. I will discuss how these transmissions can be prevented or reduced.

Preventing the spread of infectious organisms include using standard precautions with every resident and practicing hand hygiene before and after every resident contact. Identification of infectious organisms quickly and initiating appropriate treatment in addition to prompt isolation when indicated is imperative.

These are the precautions that must be in place to prevent the spread of infections:

• Standard Precautions
• Contact Precautions
• Droplet Precautions
• Airborne Precautions

Standard precautions apply to all residents, and all healthcare workers in any setting without a specific infectious process or diagnosis identified. The other precautions are transmission-based precautions that should be applied when a specific organism is known or suspected to be present in a resident. These precautions are applied in conjunction with standard precautions.

Standard precautions should be applied in all healthcare delivery systems.They are based on the concept that all body fluids may contain transmissible infectious agents. Standard precautions are designed to eliminate exposure to blood and other potentially infectious material (OPIM).

 

Standard precautions include proper hand hygiene and the use of gloves, gown, mask, face shield, eye protection and safe injection practices including the proper disposal of needles as indicated.

Contact precautions are designed to cut down on the transmission of organisms that are easily spread by contact with hands and other objects, and areas of the residents’ environment that may be contaminated.

Droplet precautions attempt to prevent the transmission of diseases that are easily spread by particle droplets produced when a person sneezes, coughs or talks. Wearing a simple surgical mask will protect the caregiver when entering the the room or cubicle. When the resident shares a room, spacial separation of three feet or more and drawn cubicle curtains are required.

Airborne precautions are designed to prevent the spread of disease by the true airborne route. The organisms leave the resident in respiratory droplets that evaporate into the atmosphere. Most organisms die when they dry out but tuberculosis, chickenpox, measles and smallpox can survive drying out and can be widely dispersed by air currents. These precautions require a negative-pressure airborne infection isolation room (AIR) with the door closed and use of an N95 respirator. Please follow the facility policy.

As we all know hand hygiene is the single most important procedure for preventing the spread of infection. All employees should be randomly requested to perform hand hygiene on a routine basis. This will encourage using the correct technique. The use of an alcohol based hand rub should not replace hand washing.

Inservice education on infection control issues is mandatory and a record of the occurrences must be maintained. The infection control procedure manual should be available for review by all employees as needed.

Follow the facility policies for the routine care, cleaning and disinfection of environmental surfaces, beds and bedside equipment. Proper decontamination and sterilization of equipment and supplies is important.

Linens must be handled, transported and processed in a manner that prevents contamination. Ensure that single use items are discarded properly Do not use single dose vials for several residents.

Food and drink should be be removed from places where blood or OPIM is present. Environmental controls help prevent the spread of infection by reducing the concentration of organisms in the environment. Housekeeping, waste management and linen (laundry) management must be performed with this concept in mind.

Before I conclude this blog, I would like to discuss the Occupational Health and Safety Administration (OSHA) requirements.

OSHA was established by an Act of Congress in 1970 “to assure the safety and health of American workers, by setting and enforcing standards, providing training and education, by outreach and establishing partnerships and encouraging continual improvements in workplace safety and health”.

OSHA came to the forefront in the healthcare environment with the emergence of the HIV virus and concern for the risk of healthcare workers acquiring the virus through patient contact.

The Bloodborne Pathogens Act became law in 1991 and Standards were put in place to provide  workplace safety.

Employers should have an exposure control plan in place that makes universal precautions mandatory where all blood and body fluids (except sweat) are considered infectious.

• Personal Protective Equipment (PPE) must be available to employees at no personal cost.
• Employees who are in contact with contaminated laundry must wear gloves and other PPE as appropriate.
• All employees whose job involves tasks with potential exposure to blood and OPIM must be offered Hepatitis B vaccination. This vaccination is free, safe and highly effective.
• Provide bloodborne pathogen training to employees annually.
• Employers must provide safe needles and sharps containers their disposal.

As healthcare workers, we should remember if we do not explicitly follow these directives we are breaking the law and are subject to legal ramifications.

Refer to the OSHA website for a complete list of guidelines.

Infections in Long Term Care Facilities

Infections are a common occurrence in Long Term Care (LTC) facilities. Residents who reside there are usually elderly, are in declining health and have comorbid chronic illnesses. More than one and a half million people reside in LTC facilities and as the acuity of illness has increased drastically, therefore, the risk of acquiring Healthcare Associated Infections (HAI) has also increased.

Residents are frequently transferred between LTC facilities and hospitals, providing additional dynamics to the transmission and acquisition of HAIs.   

The causative agents of infections are microorganisms (germs). Bacteria, fungi, protozoa, viruses and parasites are the most common types. These are usually harmless in the environment. It takes thousands to cause disease and vary in infectivity (how easy are they to catch) and in virulence (the severity of illness from the infection they cause). Residents in LTC facilities are, as mentioned above, more susceptible to infection and their immune systems are weaker.

Bacteria are single cell organisms. All people live with many bacteria (normal flora) in their bodies. Usually they  do not cause disease unless (1) their balance is disturbed or (2) they are moved to a part of the body where they do not belong or (3) to a new susceptible host.

Important bacteria causing human disease include:

• E. coli (urinary tract infections and diarrhea).
• Streptococcal (wound infections, cellulitis  sepsis, and death)
• Clostridium difficile (severe diarrhea, colitis)
• Staphylococcus (skin boils, pneumonia, endocarditis  sepsis, death).
• Mycobacterium (tuberculosis)

Fungi have a worldwide prevalence and healthy people are not usually affected. Fungi illnesses usually affect the skin, nails and subcutaneous tissue. Candida is a fungus that causes yeast infections. These are often seen in obese residents with pendulous breasts and abdominal folds.

Protozoa are also singled celled organisms but are larger than bacteria. The disease causing variety include amoebas, giardia and Pneumocystis carinii. The latter often causes pneumonia and may be fatal in immunocompromised individuals.

Viruses are intracellular parasites because they can reproduce inside a living cell. Some viruses, such as human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) have the ability to enter and survive in the body for years before symptoms of the disease occur. These viruses can be transmitted to others before the source is aware they are infected.

The influenza virus makes its presence known quickly

through characteristic symptoms. All of these viruses are of concern in the healthcare setting.

Parasites are larger organisms that can infect or infest residents. Infestation with lice or scabies occur by direct contact and is highly contagious. Ingestion of the eggs of roundworm, tapeworms and pinworms can occur. Penetration of the skin or mucous membranes with their larvae can also cause infections.

We need to be aware of how infections occur and are  transmitted. This process is called the Chain of Infection:

The causative organism (pathogen) has many paths for entering the human body and these are referred to the Port of Entry. This can be through the mouth, nose, eye, cuts, skin abrasions, surgical incisions, wounds, needle sticks and intravenous sites. Anatomical openings with tubes, such as gastrostomy tubes, tracheostomy tubes or surpapubic catheters can also be ports of entry as well as urinary tract catheters.

The reservoir is the person in whom the organism lives and multiplies. The gastrointestinal (GI) tract is the place in the body for many different types of organisms, including viruses, bacteria and parasites.

The mode of transmission is how the organism is transferred from the infected person to another person, who is named the susceptible host. The mechanisms by which the transmission may occur are as follows:

• The most common mode of transmission is unwashed hands.

• Direct contact is person-to-person transmission of the pathogens.
• Indirect contact is the spread of pathogens by a person or an inanimate go-between, such as unwashed hands and unclean instruments.
• Droplet transmission occurs by coughing, sneezing, and speaking and the pathogens can travel approximately three to six feet before dying off or falling on another surface.
• Airborne transmission can occur when respiratory droplets evaporate and are suspended in the air.

     Diseases transmitted by this route are smallpox,       tuberculosis chickenpox and measles.

The portal of Exit is the path by which the organism gets out of the reservoir. In a person, this is often by a bodily fluid. Blood, feces, nasal exudates, respiratory secretions and wound drainages are all examples of body fluids and how pathogens can exit the body. However, some bacteria, such a Methicillin Resistant Staphylococcus Aureus (MRSA) can live and grow on the skin.

Not all people who become infected with a pathogen have symptoms or signs of a disease at the time they transmit the infection to others, that person is asymptomatic and the transmission is referred to as asymptomatic transmission.

Some individuals are prone to becoming transiently or permanently colonized with organisms they have been exposed to. They may never develop symptoms of the infection but are an important source of transmission to others.

An endogenous infection occurs when a person becomes infected with microbes from their own natural flora, when their own germs get in the wrong place. For example, the urinary tract may become infected with microbes from the

GI tract, such as with Enterococcus (e-coli).

Due to the high occurrence of infections in LTC facilities, not just treatment but prevention is of the utmost importance. There are many standards and guidelines designed to proactively prevent the spread of infections.

Many states and most medical professional organizations

have designed standards of professional behavior and responsibility as the pertain to infection control.

Prevention and Control standards are a collaborative effort between the Centers for Disease Control (CDC),

the Joint Commision (JC), World Health Organisation (WHO), the Occupational Health and Safety Administration (OSHA). ( Further information on their standards may be obtained online at their individual websites.)

The immune system is the body’s defense mechanism against disease. In frail elderly or ill residents this may be compromised and these individuals are said to be immunocompromised. The immune system becomes less responsive with age.  Nutritional status is a key factor in the immune system and a person who is poorly nourished may not be able to fight an infection. Also, gastric acid which is a natural barrier against invading organisms decrease with age. Certain medications can impair immunity.Anti- inflammatory drugs like corticosteroids, and cancer drugs can interfere with the immune system.

Infections and Infection Control is so diverse and of such vital importance that I will continue the subject in my blog over the next two months. I will discuss infection control precautions and what constitutes a good Infection Control Program and who should be responsible for it in the coming months.

When I was researching for this blog I came across “Wild Iris Medical Education” online. They had a fantastic course on Infection Control. I took the course, passed the examination and for a very reasonable fee, I got a certificate and 6 hours of Continuous Education credit. The course was well laid out with current information and was easy to comprehend.  I would recommend it to any nurse. I will certainly revisit them for further continuing education programs.

Dehydration

Dehydration is the abnormal loss of body fluids and if not corrected can lead to electrolyte imbalance. It is caused by increased fluid loss or decreased fluid intake and is a common occurrence for residents in Long Term Care (LTC) facilities. The advancement of disease is a major cause of dehydration in residents.

The Mayo Clinic’s definition: Dehydration occurs when you use or lose more fluid than you take in and your body does not have enough water or other fluids to carry out its normal functions. If you don’t replace lost fluids, you will become dehydrated

Nurses need to be aware that aging causes change in the body’s water composition. Thirst perception and renal function decline among older adults. Age related changes make older adults more vulnerable to shifts in water balance that can result in overhydration but more commonly in dehydration. Also, the thirst center does not function as well in geriatric residents. Dehydration can also cause the delayed healing of wounds as the wound bed requires adequate moisture to granulate.

Approximately 50% of elderly people have chronic kidney disease (CKD).

Usually, elderly people can maintain normal electrolyte balance. However, under stressful conditions hyponatremia, hypernatremia, volume depletion, hyperkalemia and metabolic acidosis can occur and if not quickly corrected can lead to high rates of morbidity and mortality.

It is also important that direct care staff know the residents who are at high risk for dehydration and recognize the risk factors, assess those risk factors and develop a care plan with measurable goals.

In order to maintain a good hydration program in a LTC facility, the following factors must be in place:

1. Staff education: the direct care staff must know the risks of dehydration and the signs and symptoms associated with the condition. Make the staff realize that restricting fluids, does not decrease episodes of incontinence. Fever, infections, intense diarrhea, vomiting, excessive sweating in hot weather, inadequate intake and profuse wound drainage can all lead to dehydration.
2. Staff assistance: you must have adequate staff and must give them enough time to feed residents as necessary and provide adequate fluids. Staff should also be aware of residents’ preference ( use of a straw, water temperature, ice etc.)
3. A beverage cart during rounds should be used at least twice daily and between meals to provide water, fruit juice, watermelon and/or jello to provide additional hydration. The Activity department may be employed for that task.
4. During the medication pass, 4-6 ounces of fluid should be provided to the patient. The staff should always be assisting, encouraging, providing verbal prompts and praise for the patient’s fluid intake.
5. Nurses need to be aware of any medication or other situations that can cause increased output (diuretics or profuse diaphoresis in hypoglycemia).
6. Water pitchers must be replenished as needed, placed within reach of the patient and be light enough for easy lifting. Clean cups or glasses should be provided.
7. Fluids may also be provided during group activities and therapies and ambulatory residents should be provided with a water bottle.   

Many of the residents in LTC facilities may be on thickened liquids. I have never found a resident who liked them. Neither taste nor consistency are very palatable. There are some that are fruit flavored but they are more costly. However with the help of the dietician and an order from the physician, naturally thick beverages may be substituted. Nectars, tomato juice, buttermilk, drinkable yogurt, ice cream, soups, jello and milk shakes offered frequently and in small volume may be an appropriate alternative.

The power of attorney holder or family need to be made aware of the risks of dehydration and may be very helpful in encouraging the resident to consume more fluids. As always, keep the care plan up to date.  Monitoring intake and output (I&O) especially during an acute phase of an illness will keep you aware of progress or decline.

Monitoring Weight Variance

Monitoring weight variance, either loss or gain, is an important factor in keeping Long Term Care (LTC) residents as healthy as possible. Accurate weight measurement is critical to a nutritional assessment. The information is necessary to calculate fluid needs as well as macronutrient amounts and is often used to calculate medication dosages. A patient’s weight  measures health and nutritional status over time.

The resident should be weighed as soon as possible after admission to obtain a base weight and provide the dietician with the information prior to the nutritional assessment. The resident should be weighed weekly for the next three weeks and monthly thereafter (follow the facility protocol).

The physician may request a daily weight for some diagnosis (like congestive heart failure) or if the resident is receiving diuretics or is on hyperalimentation. The resident should be weighed at the same time and if possible, by the same person. Having the same caregiver assigned to the weighing process will assure procedural consistency. The resident should be weighed without shoes and with as little clothing as possible.

Scales need to be calibrated monthly and a log maintained of the measurements. Ambulatory residents may use a platform scale. The resident should stand on the center of the platform without hanging on to anything. If the resident wears an adaptive device or a prosthesis, it should be documented if the weight was obtained with or without the device and should be consistent every month.

Chair scales should be used for non ambulatory residents. The wheelchair is weighed separately and then the resident is weighed in the wheelchair. The resident should be seated in the center of the chair and the wheelchair centered on scale for accurate measurement. Subtract the chair weight from the overall  weight to obtain the resident’s weight and be sure the math is accurate.  Sling scales and bed scales may be used but follow the manufacturer's’ directions for safety and make sure staff receive appropriate training on their use.

There are set parameters for reporting weight gain or loss. These are reported to the physician and documented in the resident’s record.

5% gain or loss in one month

7.5% gain or loss in three months

10% gain or loss in six months

The dietician should also be informed and physician’s orders must be in place to correct any problems. Federal regulation 325 refers to a patient's nutrition, “Receives a therapeutic diet when their is a nutritional problem”.

I love acronyms as they help me remember important facts. The Texas Department of Aging and Disability (DADS) use the following to list the risk factors associated with weight loss.

M- medication

E-emotional problems

A-anorexia

L-late life paranoia

S-swallowing disorders

O-oral problems

N-nosocomial infections

W-wandering

H-hyperthyroidism

E-enteric problems

E-eating problems

L-low salt and low cholesterol diets

S-social problems.

Nurses need to recognise these factors and identify the residents who are at risk. Should a significant weight loss occur, the resident must be reweighed within 72 hours. If the weight loss continues, the physician, family and dietician must be notified and an intervention must be put in place immediately.

Interventions may include:

Reassess the effects of medication.

3 day calorie count, document food intake at each meal for 3 days.

Manage underlying conditions.

Facilitate increased food consumption by providing snacks, nutritional supplements, finger foods and provide socialization by inviting family members to sit with resident at meal times.

Staff may assist with feeding and should offer praise for improved endeavours.

It is very important to document dates and notifications concerning nutrition in the medical record. Results of interventions and a weekly weight needs to be documented until the patient's weight stabilizes.

Many times there is an apparent reason for loss or gain. If the resident is on a diuretic or has had a recent paracentesis, weight loss is the expected outcome. Awareness of the resident’s appetite and food dislikes is important. Certain religious beliefs may interfere with dietary choices (A social service assessment should have picked up on this and should be in the care plan). Cultural choices and dislike of certain foods may also play a role in weight loss. Depression is the most identified cause of weight loss and must be treated. As terminal illness advances and end of life approaches, loss of appetite and weight loss occurs naturally.

Weight gain is expected when a resident recovers from surgery or an infection. Nutritional supplements and mineral and vitamin therapy also help in increasing appetite and gaining weight. In cultural and religious areas, getting family involved in bringing an occasional appropriate meal from home can be helpful.

As always be sure to careplan problems, changes and interventions.

Diabetic Mangagement

Diabetes can be a lifelong condition that affects the body’s ability to use the energy contained in food. There are 3 types of diabetes, Type One, Type Two and Gestational.

The common factor involved in all three types is that the Insulin required to utilize glucose is either inadequate or unavailable. The hormone Insulin is required to enable the body’s cells to take in and utilize glucose. Without this hormone, high levels of glucose can accumulate in the blood stream, resulting in damage to the tiny vessels in the eyes, heart, kidneys and nervous system.

I will give a brief description of the other two types of diabetes. Type Two is, by far the most common, especially in patients in Long Term Care (LTC) facilities

In Type One diabetes, the hormone Insulin, secreted by the pancreas is not available. Studies show there may be two reasons for this: (1) the body may produce antibodies that damage the pancreas and therefore it is unable to  produce insulin or (2) there may be a genetic disposition that result in faulty beta cells that are unable to make Insulin.

Gestational diabetes is triggered by pregnancy and usually abates with childbirth. It can, however, put the mother at risk for developing Type Two diabetes later in life.

Type Two diabetes was previously called adult onset diabetes. However, it is now occurring in much younger people. If left untreated, it can eventually cause heart disease, stroke,kidney disease, blindness and nerve damage (neuropathy).

There is no cure for diabetes but it can be controlled with good nutrition, weight management and exercise.

Type Two diabetes occurs when the pancreas does not produce enough insulin or the insulin cannot be used appropriately by the body’s cells (insulin resistance) or a combination of both.

Statistics from the American Diabetic Association (ADA) indicate that 25% of residents living in LTC facilities have Type Two diabetes. Of this number, 80% of patients have cardiovascular disease, 56% have hypertension and 70% have 2 or more other chronic conditions, such as, chronic kidney disease (CKD), coronary artery disease (CAD) and stroke.

Studies in Great Britain have shown that by keeping the Hemoglobin AIc levels of blood below 7, preferably at 6.5, the risk of these diseases occurring, are drastically reduced. When hemoglobin joins with glucose in the blood it becomes “glycated”. By measuring the “glycated” blood (HbA1c) clinicians can get an overall picture of the average blood glucose concentration over a 3 month period. In people without diabetes the level is 6 or less. For good control in diabetics it should be maintained at 7 or below. This test is taken a few times a year and can be used to monitor the effects of diet, exercise or medication.

In LTC facilities, the residents with Type Two diabetes, will decline in health if not treated. Dehydration, depression, confusion, eye problems, foot ulcers, neuropathy, and recurrent infections, slow healing wounds and decline in performing the activities of daily living (ADL) will be present if the diabetes is not controlled. This control is individualized according to the patient’s condition.

Many factors associated with aging can affect glucose metabolism in older adults. Selecting the correct medication based on these factors can be difficult. Some of these factors include, increased adipose tissue and decreased muscle mass. Alteration in food intake and ability to exercise. Insulin resistance in the cells, co-morbid health conditions and drug interactions. Some psychosocial factors include stress and depression.  As most of LTC residents are admitted with a history of type two diabetes of many years duration, the medical staff  need to be aware of the disease processes already present.

As always, the resident and family need to be  involved in discussing how aggressive treatment (diet, exercise, blood testing and medication) will be. The ADA has very good information on all issues pertaining to appropriate treatment. The hands-on care staff must follow the physician’s orders and be aware of the resident’s plan of care.

Blood sugar control is the key to good diabetes management. Preventing episodes of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) is of the utmost importance. Be aware of the parameters provided by the laboratory and follow the facility guidelines for treatment.

Hypoglycemia occurs when the blood glucose levels are at 70 mg/dL or less. Signs or symptoms  include:

Weakness or tiredness

Hunger

Dizziness or feeling shaky

Sweaty

Rapid pulse

Blurred vision

Unresponsiveness

The main reasons for hypoglycemic episodes are:

skipping a meal or consuming too few carbohydrates,

increased physical activity and some medications. A long time interval between taking insulin diabetes medications and eating can also cause hypoglycemia.

The best way to treat this illness is to be prepared. Follow the facility guidelines and know where the necessary equipment is stored. Nurses need to be aware of residents with dementia who also have diabetes. These residents are unable to recognize or discuss symptoms and must be monitored carefully. Parameters must always be available for administering insulin and other diabetes related medications. Physician and family must be notified of any episodes that may occur and these must be included in the nurses’ documentation in the clinical record.

Once again, I will say how important is good communication. “How do you feel this morning” can provide a wealth of information. The resident may not know why she is shaky, sweaty or thirsty, but we do and if she is a diabetic, we should test her blood sugar levels.

Hyperglycemia occurs when there is a high level of glucose in the blood. Some laboratories indicate a fasting blood sugar greater than 130 mg/dL as hyperglycemic.

S/Ss usually include increased thirst, headache,frequent urination, blurred vision, fatigue and weight loss.

May occur when an insulin dose or prescribed diabetes medication is omitted, consumption of high carbohydrate meals, an infection or illness and some medications (steroids) may produce hyperglycemia.

Blood sugar monitoring is ordered by the physician and should be performed exactly as prescribed and the results documented in the diabetic flow sheet immediately after testing.

Accu-chek Meters. There are many different types of meters in use for testing the levels of glucose in blood. The nurse must become familiar with the type used in the facility and must follow the policy for care, infection control and privacy during testing. An abnormal reading, high or low, should be followed by a nursing intervention.

Always refer to the physician’s orders and document.

It is very important that there is a limited time lapse between testing and administering the prescribed insulin or medication and between the medication and food intake. By being consistent and observant, our residents are kept more safe and our workload is made lighter by preventing complications.

Psychotropic Drug Reduction

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:

1. An appropriate indication for use.
2. A specific and documented therapeutic goal.
3. Ongoing monitoring of the resident for effectiveness and presence   of any adverse reactions from the medication.
4. 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.