1. Managing Behavioral Symptoms of Dementia in a Person Centered Care Environment
Elizabeth Weingast , RN, MSN, GNP
VP Clinical Excellence
Orah Burack, MA Senior Research Associate
Jewish Home Lifecare
Type Contact Information for Presenter Here

2. What is Dementia? Alzheimer’s 60-80% of dementias Vascular Dementia
Dementia is a general term for a decline in mental ability severe enough to interfere with daily life.
Alzheimer’s % of dementias
Vascular Dementia
Dementia related to other diseases – Parkinson’s, Huntington’s
Reversible causes – thyroid disease, vitamin B12 deficiency

3. While symptoms of dementia can vary greatly, at least two of the following core mental functions must be significantly impaired to be considered dementia:
Memory
Communication and language
Ability to focus and pay attention
Reasoning and judgment
Visual perception

4. Stages of Alzheimer’s Dementia
Staged from 1 – 7 , no impairment to very severe cognitive decline
Stage 3 “mild cognitive decline”
Stage 6 – common access point to nursing home care

5. Stage 6: Severe cognitive decline (Moderately severe or mid-stage Alzheimer's disease)
Memory continues to worsen, personality changes may take place and individuals need extensive help with daily activities. At this stage, individuals may:
Lose awareness of recent experiences as well as of their surroundings
Remember their own name but have difficulty with their personal history
Distinguish familiar and unfamiliar faces but have trouble remembering the name of a spouse or caregiver

6. Need help dressing properly and may, without supervision, make mistakes such as putting pajamas over daytime clothes or shoes on the wrong feet
Experience major changes in sleep patterns — sleeping during the day and becoming restless at night
Need help handling details of toileting Have increasingly frequent trouble controlling their bladder or bowels
Experience major personality and behavioral changes, including suspiciousness and delusions (such as believing that their caregiver is an impostor)or compulsive, repetitive behavior like hand-wringing or tissue shredding
Tend to wander or become lost

7. CMS – approach to behavior management in nursing homes
Rise in use of antipsychotics for control of behaviors
23-25% of nursing home residents prescribed antipsychotics
Often without diagnosis of psychosis
Atypical antipsychotics (Seroquel, Risperidal, Zyprexa) carry a black box warning for people with dementia due to increased risk of cardiovascular events, including stroke or heart attack.
No research supporting us of these medications for behavioral symptoms of dementia
Goal to reduce use by 15% over six months in 2012

8. CMS approach – Education and Survey Focus
Person Centered Care
Quality and Quantity of Staff
Thorough Evaluation of New or Worsening Behaviors
Individualized Approaches to Care
Critical Thinking Related to Antipsychotic Drug Use
Engagement of Resident and/or Representatives in Decision Making

9. Person Centered Care Greenhouse Model

10. Comfort First Understanding Behavior as Communication

11. Programming and Training Modeling Communication Personal Care approaches Meaningful activities Special Care Units – inconclusive outcomes

12. Music and Memory
Everyone benefits from a calmer, more supportive social environment.
Staff regain valuable time previously lost to behavior management issues.
There is growing evidence that a personalized music program gives professionals one more tool in their effort to reduce reliance on antipsychotic medications

13. http://www. youtube. com/watch
yPUvG8dfJc9VtFQRg
Alive Inside

14. INTRODUCTION
Distressing behavioral symptoms often associated with dementia are not uncommon in the LTC setting.
The MDS 3.0 categorizes these symptoms as:
physical behavioral symptoms directed toward others (e.g., pushing, hitting)
verbal behavioral symptoms directed towards others (e.g., screaming, cursing at others)
behavioral symptoms not directed toward others (e.g., hurting self, pacing, making disruptive sounds)

15. INTRODUCTION CON’T Potential antecedents of these symptoms illness
distress
pain
unrecognized need
caregiving actions not understood by the elder
Culture change with its “person-centered approach to care” provides a potential non-pharmacological approach to reducing these symptoms

16. INTRODUCTION CON’T
Different behavioral symptoms may have different causes; thus, interventions could address those causes
forceful behaviors such as kicking may be related to caregiving assistance (e.g., bathing or feeding); elder may not understand or find frightening
physical agitation (e.g., pacing) may be due to an inadequate amount of stimulation in the environment
verbal agitation may be related to discomfort, pain, or depression

17. CULTURE CHANGE INTERVENTION
Community Coordinators
Education
Organizational and Community Structure Changes
Meaningful Activities and Resident Choice
Family Involvement
Reduced Floating
Consistent Staffing
Environmental Changes

18. RESEARCH QUESTION
What is the impact of a culture change intervention on the following categories of behavioral symptoms:
forceful behaviors
physical agitation
verbal agitation
Hypothesis: elders receiving culture change intervention compared to controls will have reduced behavioral symptoms (can be addressed by a person-centered approach to care )

19. STUDY DESIGN 13 long term care comm across 3 campuses
7 Culture change pilot communities
6 Comparison communities
Longitudinal study - 2 time points
Time 1 – 2003
Time 2 – 2005

20. COHEN MANSFIELD AGITATION INVENTORY (CMAI)
29 behavioral symptoms
CNA rated frequency with which the elder manifested each behavior during past two weeks
each behavior rated on a 7 point scale
(1)“Never”
(2) “Less than once a week but still occurring”
(3) “Once or twice a week”
(4) “Several times a week”
(5) “Once or twice a day”
(6) “Several times a day”
(7) “A few times an hour”.

21. CMAI – FORCEFUL BEHAVIORS (12 ITEMS)
Hitting, Kicking, Scratching
Biting, Pushing, Grabbing
Throwing things, Cursing & Verbal Aggression
Spitting, Tearing things or Destroying Property
Hurting self or others
Screaming

22. CMAI – PHYSICAL AGITATION (6 ITEMS)
pacing and aimless wandering
attempting to exit area inappropriately
general restlessness
inappropriate dressing and disrobing
handling things inappropriately
repetitious behaviors

23. CMAI – VERBAL AGITATION (4 ITEMS)
Complaining
Constant requests for attention or help
Repetitive sentences or questions
Expressing a negative attitude

24. MEASURES
Behavioral Symptoms – Cohen Mansfield Agitation Inventory (CMAI) – captures forceful behaviors, physical agitation, and verbal agitation (CNA interviews)
Cognitive Impairment – MDS2.0 Cognitive Performance Scale (high score indicates greater severity)
ADL Impairment – 4 ADL items from MDS2.0 (high score indicates greater dependence)
Number of Diagnoses - use MDS2.0 med record data

25. STUDY PARTICIPANTS N = 101 65 (64%) female 36 (36%) male
58% White; 28% Black, and 14% Hispanic
Age range = 63 to 105 years (M=83.65, SD=9.29).
Length of stay on communities; Range= 4 months to 14 years (M=34 months, SD=29 months)

26. ANALYSIS PLAN 2 (Group) X 2 (Time) ANOVA* Time 1 Time 2 Culture Change
Comparison

27. RESULTS

28. PREVALENCE OF BEHAVIORAL SYMPTOMS
All Time 1 Time 2
Forceful Behaviors 49% 57%
Physical Agitation 39% 44%
Verbal Agitation 52% 57%
Comparison
Forceful Behaviors 44% 61%
Physical Agitation 32% 37%
Verbally Agitation 36% 56%
Culture Change
Forceful Behaviors 54% 52%
Physical Agitation 45% 51%
Verbal Agitation 68% 58%

29. Forceful Behaviors: Adjusted mean scores.
Significant Interaction. F(1,92)=5.40, p=.022.

30. Physical Agitation: Adjusted mean scores.
Significant Interaction. F(1,89)=6.34, p=.014

31. Verbal Agitation: Adjusted mean scores.
Interaction Approaching Significance. F(1,86)=3.62, p=.061

32. Summary
forceful behaviors and physical agitation increased over time on comparison communities, but not on culture change communities
implementing a culture change model can be an effective non-pharmacological approach to ameliorating behavioral symptoms
future studies should examine changes in pharmacological approaches when implementing culture change.
unique study feature - the inclusion of elders with wide ranging cognitive abilities, ranging from no cognitive impairment to more severe impairment

33. Possible Links between Culture Change & Behavioral Symptoms
physical agitation (related to inadequate stimulation in environment) may have been affected by increasing selected meaningful activities for elders
forceful behavior (resistance to care) may have been affected by increasing choice over when to participate in activities, environmental changes (e.g. calmer atmosphere), more consistent staffing
verbal agitation (related to depressed affect) showed a trend; may be related to quality of relationships; may need to further enhance these culture change elements

34. Handouts – Questions to post to facility leadership Are programs in place to ensure best practice in care for residents with behavioral symptoms of dementia?