1. Reducing Agitation Through Non-Pharmacological Therapies Govind Bharwani, Ph.D. Director of Nursing Ergonomics and Alzheimer’s Care Nursing Institute of West Central Ohio Wright State University, Dayton, OH

2. Speaker Disclosure Dr. Bharwani occasionally provides strategic consulting services for long-term care facilities in Ohio through his position in the Nursing Institute of West Central Ohio

3. Acknowledgement The authors gratefully acknowledge the support of the AMDA Foundation and Pfizer for an unrestricted Quality Improvement Award.

4. Application of Behavior-Based Ergonomics Therapies (BBET) to Improve Quality of Life of Alzheimer’s/Dementia Residents

5. BBET Program Description BBET = Behavior-Based Ergonomics Therapies to manage behaviors and promote engagement Individualized therapeutic activities (as a complement to group activities) to get ahead of resident stress caused by boredom or disengagement  Music therapy (M1 to M30)  Video therapy (D1 to D30)  Stimulating therapy (S1 to S30)  Memory Prop therapy (provided by the family) 90+ tools available in the BBET Resource Center Staff can provide an intervention within a few minutes The customized action plan allows staff to initiate a therapy and move to other tasks (1:1 care not required) A memory care training strategy (including an internal certification and continuing education) is implemented with the program

6. Benefits of BBET Program Families can enjoy interacting with their loved ones using these items during their visits. Families can also review a BBET engagement report in care conferences. Risk of residents falls is greatly reduced. Challenging behaviors are managed proactively (or redirected as needed), reducing the need for medication. Residents sleep better due to being engaged longer with activities they enjoy at the times they are most ready. In addition to the engagement during the therapy, the residents are also more calm and alert after the therapy. This can help with personal care (inc. bathing), meals, group activities, family visits, shift changes, and any other triggers of stress/behaviors. The staff takes pride in their certification & expertise. They are more cohesive and confident as a care team. Direct care staff have less stress and are able to spend more quality time with residents. This helps to attract and retain the right staff for this type of specialized care.

7. Retrospective Research Study (IRB Approval obtained July 2011) Research Time Period Pre-implementation period = Aug 2009 –Jan 2010 Implementation period = Feb 2010 Post-Implementation period = Mar 2010 – Aug 2010 Research Site 18-bed Alzheimer’s secured unit Target cohort = 9 residents Total hall population = 48 residents

8. Sources for Data Analysis Optimus EMR  ADT dates  Progress notes  Incident reports  eMAR  PRN usage  Routine medication orders  STAT orders  Mood & Behavior charting  ADL flowcharts Pharmacy data Paper charts BBET tracking sheets MDS 2.0 reports

9. Study Results for Target Cohort Metric Pre- implementation Post- implementation Change Resident Falls 1912-37% MDS Mood counts 7623-69% MDS Behavior counts 16358-63% Number of behavioral episodes 4015-61% PRN (Ativan) usage* 73-57% *Excludes: 1)PRN used during the 1 st week on the unit 2)PRN used for special medical conditions, i.e. stroke, hospice, etc...

10. Study Results for Hall Population Metric Pre- implementation Post- implementation Change Resident Falls 4027-33% MDS Mood counts 13142-68% MDS Behavior counts 27994-66% Number of behavioral episodes 9660-38% PRN (Ativan) usage* 1910-47% *Excludes: 1)PRN used during the 1 st week on the unit 2)PRN used for special medical conditions, i.e. stroke, hospice, etc...

11. Comments by Care Team “Before I used to have many problems with giving bath to residents. Now I use BBET program to calm them before giving them a bath” – STNA “One resident loves the music therapy & begins to start dancing” – STNA “We use BBET a lot before dinner time while they wait for food” – STNA “There has been a reduction in medication because there is much more focus to use BBET program to calm the residents” – Unit Manager “The BBET program has a calming effect on the residents, and they react to their environment in a more positive way” – Unit Nurse “I think that BBET program is excellent. This program has created some consistency in approach to handle behavior problems” – Medical Director “As staff got to use the BBET program, we stopped getting emergency phone calls” – Geriatric Nurse Practitioner “I feel that the anti-psychotic meds have been reduced because the staff is using BBET program” – Geriatric Nurse Practitioner

12. Conclusions from the Research Study The results of our research study shows that there is strong evidence that the non-pharmacological BBET program can reduce agitation and improve the quality of life of Alzheimer’s residents. The BBET program can improve quality of life by reducing falls, behavior and mood counts, number of behavioral episodes & PRN medications. There is also evidence to support that BBET program can reduce routine behavioral medications. However, a further controlled study must be conducted to conclusively validate this claim. The effectiveness of BBET program during the late stage of Alzheimer’s disease and/or hospice is inconclusive.