1. Interventions

2. Objectives Implement changes to address unmet needs and prevent disruptive behavior Utilize de-escalation techniques Utilize non-pharmacologic interventions

3. Review All behavior has… All behavior is an attempt to … Our first question is NOT HOW DO I GET THEM TO STOP? but

4. Review Primary Objective is Prevention Anticipating needs(Maslow) Addressing unmet needs(Cohen-Mansfield) Changing our own behavior(STAR) Secondary Objective is avoiding use of antipsychotics Morbidity/Death Limited effectiveness

5. Maslow’s Hierarchy of Needs MEANING ESTEEM & SELF RESPECT BELONGING & AFFECTION SAFETY AND SECURITY PHYSIOLOGIC INTEGRITY Trying to meet these needs drives human behavior, including many of the behaviors of individuals with Alzheimer’s Disease

6. Conflict Between Residents What happens?

7. Prevention Person-centered care plans Identify needs, strengths Anticipation Vigilance Debriefing

8. Intervention: De-escalation De-escalation techniques Signal breath Body language and tone of voice Monitor proximity Ask, don’t tell Listen actively Make sense of communication Address underlying problem Offer immediate and/or interim solution Insert pleasurable activity (divert or distract)

9. Intervention Address underlying problem Learning Circle Loneliness Boredom

10. Addressing the underlying problem Loneliness Boredom

11. What are the risks? What are the benefits?

12. Psychotropics Anti-anxiety Anti-depressants Anti-psychotics Mood stabilizers Sedative-hypnotics

13. Problem of medications No “anti-agitation/anti-aggression” medication Miss the point Off-label use ‘OK’ risk/benefit equation more critical Antipsychotics   mortality  stroke

14. Anti-Psychotics Side effects – Sedation – Restlessness – Stiffness – Dry mouth – Blurred vision – Weight gain Risks Falls Failure to thrive Pressure ulcers Diminished quality of life Akithesia Neuroleptic malignant syndrome (NMS) Tardive dyskinesia (TD) In dementia STROKES DEATH

15. Anti-Psychotics Target Hallucinations Delusions Disorganized thinking Negative symptoms Behavioral symptoms of dementia IF AND ONLY IF Meeting unmet needs a la Maslow doesn’t work AND Non-pharmacological interventions haven’t worked AND Benefits strongly outweigh risks

16. Approach to medication use Does benefit justify risk? What is my target? Are there alternatives? Have I given alternatives a fair trial? How will I know if it works? When will I stop if it is not working? How long will I keep going if it is working?

17. What helps us NOT Use Medication Changing our practices: New paradigm Not just symptoms Communication Not the task Prevention not intervention Address loneliness, helplessness, boredom

18. What helps us NOT Use Medication Tools Individualized, strength-based care planning Anticipating needs Addressing unmet needs Engaging strengths, wishes Engaging family, community Huddle and analyze disruptive behaviors

19. What helps us NOT Use Medication Changing our behavior De-escalate, not escalate Shift to relationship building as “the job” The tasks are not the job Monitoring own fear response Monitor environment

20. Successful Interventions  Environment  Eden Alternative (loneliness, helplessness, boredom)  Music  (Massage)  Recreation  (Aromatherapy)