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Optimization of the management of behavioural and psychological

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Optimization of the management of behavioural and psychological Powered By Docstoc
					    Optimization of the
management of behavioural
and psychological symptoms
  of dementia (BPSD) in
      nursing homes

                       November 30, 2007


                              Investigators:
              Johanne Monette, MD, MSc, Hôpital Général juif
              Maryse L. Savoie, RN, MSc, St. Anne’s Hospital
 Nathalie Champoux, MD, MSc, Institut universitaire de gériatrie de Montréal
      Christina Wolfson, PhD, Institut Lady Davis, Hôpital Général juif
               Michèle Monette, OT, MSc, McGill University
   Lise Fortin, RN, MAP, CSSS de Laval, site CLSC-CHSLD du Marigot
Table of Contents

Acknowledgement ......................................................................................................................... 3

Main Messages .............................................................................................................................. 4

Executive Summary ...................................................................................................................... 6

Context ......................................................................................................................................... 10

Implications ................................................................................................................................. 11

Approach, Methodology, Rationale, Assumptions .................................................................. 12

Results, Conclusions ................................................................................................................... 19

Recommendations ....................................................................................................................... 33

References .................................................................................................................................... 36




                                                       Optimization of the management of
This project is
                                                         behavioural and psychological                               Investigators:
partially
                                                       symptoms of dementia (BPSD) in                              Monette et al. 2007
funded by:
                                                                 nursing homes
Acknowledgement

We acknowledge the Canadian Patient Safety Institute (CPSI) for the financial contributions

towards this project.




                                 Optimization of the management of
This project is
                                   behavioural and psychological        Investigators:
partially
                                 symptoms of dementia (BPSD) in       Monette et al. 2007
funded by:
                                           nursing homes

                                                                                        3 of 36
Main Messages

The majority of elderly residents with dementia, who live in nursing homes, present disruptive

behaviours. In the study we completed, antipsychotics were prescribed to more than 40% of

residents despite their modest efficacy to treat such behaviour as well as the increased risk of

generating multiple adverse events. Such adverse events can seriously compromise the safety of

users because they increase, among other things, the risk of falls, fractures, use of restraints, and

potentially cerebral thrombosis or death. Insufficient training of healthcare staff contributes to

the overuse of antipsychotics.

In such a context where there is neither legislation nor guidelines recognised by Health Canada,

the implementation of our disciplinary educational program allowed us to re-assess indications

for antipsychotic prescribing, to either discontinue or reduce the use of the drug, to ensure the

quality of care and safety for residents. These results are very encouraging, when considering the

numerous methodological challenges and obstacles encountered. We therefore recommend that

our program be implemented in a clinical context for the purposes of adopting best practices

which should be integrated into all such residential centres in Canada.

For this to be achieved, the establishment of national standards norms for the use of

antipsychotics and the creation of external committees to ensure compliance by means of regular

annual follow-up is essential. A key factor will be to obtain the administrative support of

managers and decision makers of each center as well as access to a uniform data collection

program. The creation of a committee in each center is necessary to ensure 1) the organisation of

regular and targeted training sessions, 2) systematic re-assessment of residents who have been




                                     Optimization of the management of
This project is
                                       behavioural and psychological            Investigators:
partially
                                     symptoms of dementia (BPSD) in           Monette et al. 2007
funded by:
                                               nursing homes

                                                                                                4 of 36
receiving the same dosage of antipsychotics for more than three months, 3) an assessment of the

impact of the interventions by objective measurements and interdisciplinary meetings.




                                   Optimization of the management of
This project is
                                     behavioural and psychological          Investigators:
partially
                                   symptoms of dementia (BPSD) in         Monette et al. 2007
funded by:
                                             nursing homes

                                                                                            5 of 36
Executive Summary

Introduction

Insufficient training of caregivers working in nursing homes may result in a less than optimal

management of disruptive behaviours which are manifested in the majority of elderly residents

suffering from dementia. Atypical antipsychotics are the drugs that are most frequently used to

treat such behaviour, despite their modest efficacy and the considerable risk of developing

multiple adverse events. Such events may seriously compromise the safety of users because they

increase the risk of falls, fractures, use of restraints and potentially cerebral thrombosis or death.

Most of the educational programs that helped improve the management of disruptive behaviours

and reduce the use of antipsychotics in nursing homes, were implemented in the United-States

where a regulation (Omnibus budget Reconciliation Act – OBRA-87) has been in force since

1990. Programs conducted in other countries were based on recognised guidelines but they were

not established in law. In Canada, there are no recognised guidelines or legislation governing the

management of disruptive behaviours and the usage of antipsychotics in nursing homes.

This was the context that led to the development of our interdisciplinary educational program

which was implemented in two selected centres (A and B) to assess the effects of the program on

antipsychotic prescribing. Administrators, physicians, pharmacists, nursing staff, and personal

care attendants (PCA) were involved in this program. The level of participation varied between

81% and 96%, depending on the activity and the center. The program was implemented mainly

by a nurse working in the respective centres.




                                      Optimization of the management of
This project is
                                        behavioural and psychological             Investigators:
partially
                                      symptoms of dementia (BPSD) in            Monette et al. 2007
funded by:
                                                nursing homes

                                                                                                  6 of 36
Methodology

The effects of our 6-month program were assessed among residents suffering from dementia in

terms of the proportion of attempts, whether or not successful, of discontinuations of

antipsychotics and dose reductions and the proportion of sustained discontinuations and dose

reductions. The two proportions were compared to those observed during the 6-month pre-

program. Other drugs of interest that could be used as substitutes to antipsychotics

(benzodiazepines, cholinesterase inhibitors, antidepressants) were assessed for both periods. The

use of restraints, the frequencies of disruptive behaviours among residents, and stressful events

experienced by nursing staff and PCA were also measured. A 4-month follow-up was also

conducted.

Results

The proportion of attempts, whether or not successful, of discontinuations of antipsychotics and

dose reductions that was observed in centres A+B rose from 38.5% during pre-program to 51.7%

during the program. The proportion of sustained discontinuations of antipsychotics or dose

reductions increased respectively from 33.0% to 43.1%. The results were more significant in one

of the centres. The frequencies of disruptive behaviours and stressful events experienced

decreased slightly. The 4-month follow-up demonstrated a tendency to revert to the initial

antipsychotic prescribing habits at center A whereas at center B a greater number of

discontinuations of antipsychotics or dose reductions was observed. During the 4-month follow-

up, the proportion of users of restraints slightly increased in both centres. The frequencies of

disruptive behaviours and stressful events remained lower than the first measurement taken.




                                    Optimization of the management of
This project is
                                      behavioural and psychological          Investigators:
partially
                                    symptoms of dementia (BPSD) in         Monette et al. 2007
funded by:
                                              nursing homes

                                                                                             7 of 36
Conclusions

The implementation of the interdisciplinary educational program, in the absence of any

legislation or guidelines recognised by Health Canada, made it possible to re-assess the

indication for antipsychotic prescribing, and to discontinue or reduce the dose in order to ensure

the quality of care and safety for residents.

Among other things, our results demonstrate the need to implement this interdisciplinary

educational program on a permanent basis to maintain if not increase its efficacy and to obtain

sustainable modifications to the care that is practiced in nursing homes.

Recommendations

Considering the experience acquired and results obtained, we recommend that our

interdisciplinary educational program be implemented in a clinical context for the purposes of

adopting best practices. The measures to be emphasised for the successful implementation of

such a program in other nursing homes in Canada are:



         1) Establishment of national standards norms for the use of antipsychotics and for the

             creation of external committees to ensure compliance and regular follow-up.

         2) Administrative support from           managers and decision makers in facilities with a

                  commitment from all healthcare staff to make good use of the educational program

                  and to apply the guidelines so that they will become and integral part of the culture.

         3) Accessibility to uniform and reliable data collection programs regarding data on the

                  clientele, the medications, and the use of restraints.




                                          Optimization of the management of
This project is
                                            behavioural and psychological           Investigators:
partially
                                          symptoms of dementia (BPSD) in          Monette et al. 2007
funded by:
                                                    nursing homes

                                                                                                    8 of 36
         4) Systematic re-assessment a) of residents taking an antipsychotic at the same dosage

                  for more than three months and b) the impact of the interventions using objective

                  measurements of disruptive behaviours and regular interdisciplinary meetings.




                                        Optimization of the management of
This project is
                                          behavioural and psychological          Investigators:
partially
                                        symptoms of dementia (BPSD) in         Monette et al. 2007
funded by:
                                                  nursing homes

                                                                                                  9 of 36
Context

Disruptive behaviours such as agitation, aggression, delusions and hallucinations may be

manifested among the majority of elderly persons suffering from dementia. They are an

important source of stress both for residents displaying such behaviours and for caregiver staff.

Insufficient training of caregivers can lead to a less than optimal management of such behaviours

and compromise the safety of residents. Atypical antipsychotic drugs are the medications that are

most often used to treat such behaviour despite modest efficacy and a considerable risk of

developing multiple adverse events. Among such events, we may mention iatrogenic

parkinsonism, which is mainly characterized by balance disorders, unstable posture, rigidity, and

tremor. There is increased risk of developing confusion, urinary incontinence, impaired vision,

diabetes, as well as a drop in blood pressure with the use of antipsychotics. All these events can

seriously compromise the safety of users because they increase the risk of falls, fractures, and

potential risk of cerebral thrombosis and death.

The majority of educational programs used to improve the management of disruptive behaviours

and to reduce the use of antipsychotics in nursing homes were implemented in the United-States

where regulations (Omnibus Budget Reconciliation Act – OBRA-87) have been in force since

1990. Programs conducted in the United Kingdom and Sweden were based on recognized

guidelines but they do not have force of law. In Canada, there are neither recognized guidelines

nor legislation governing the management of disruptive behaviours and the use of antipsychotics.

Taking into account the Canadian context, our group of experts in geriatrics and psychiatry

developed an interdisciplinary educational program, mainly based on OBRA-871 and on

guidelines recognised in other countries2,3. Relevant outcome measurements in the previously



                                    Optimization of the management of
This project is
                                      behavioural and psychological           Investigators:
partially
                                    symptoms of dementia (BPSD) in          Monette et al. 2007
funded by:
                                              nursing homes

                                                                                             10 of 36
cited educational programs were incorporated into our own program as well as were the key

factors4 necessary for successful program implementation.

The program was first implemented in 2004 as a pilot study in one nursing home. Among 81

antipsychotic users, we had observed 61 (75.3%) attempts, whether or not successful, of

discontinuations of antipsychotics or dose reductions. The results at the end of the program were

40 (49.4%) discontinuations, 11 (13.6%) dose reductions and 10 (12.3%) unsuccessful attempts.

There was no change reported for 20 (24.7%) residents. Every attempt, whether or not

successful, to discontinue or reduce the dose requires that the physician re-assess the indication

of the antipsychotic for his patient, as is recommended in standard practice. Such promising

results and the experience acquired resulted in the development of this longitudinal study, which

includes comparison groups to assess more precisely the effects of our program. Our research

question was the following: To what extent will the implementation of an interdisciplinary

educational program aimed at managing disruptive behaviours result in optimal and safer

antipsychotic prescribing among Canadian residents suffering from dementia?

Implications

The implementation of our interdisciplinary educational program allowed us to re-assess

indications for antipsychotic prescribing and to discontinue and reduce the dose and thus ensure

better quality of care and safety for residents. These encouraging results were obtained in spite of

the many methodological challenges and obstacles encountered and have resulted in our

recommendation for the implementation of our program in a clinical context for the purposes of

adopting best practices rather than establishing a research project.




                                     Optimization of the management of
This project is
                                       behavioural and psychological           Investigators:
partially
                                     symptoms of dementia (BPSD) in          Monette et al. 2007
funded by:
                                               nursing homes

                                                                                              11 of 36
The observed increase of the use of restraints during the 6-month program in one of the centres

and during the 4-month follow-up in both centres contributed to the development of an action

plan aimed at reducing the use of restraints to ensure residents’ safety.

The study results revealed that the frequencies of disruptive behaviours among residents and of

stressful events experienced by the staff were reduced during the program. At the end of the 4-

month follow-up, these frequencies remain lower than during the period of initial measurements.

The implementation of our program on a permanent basis should make it possible to maintain

and even increase its efficacy to obtain sustainable modifications to practices in nursing homes

and ensure the safety of residents.

Approach, Methodology, Rationale, Assumptions

Experimental design and population

This longitudinal study was conducted in two centres (A and B) that volunteered to be in the

study. In each center, two groups of residents were identified for comparison. The pre-program

group included residents suffering from dementia, who were present at November 1, 2005 in the

units targeted in each of the centres. Data for these residents was gathered over a 6-month period

(November 1, 2005 to April 30, 2006). The program group included all residents suffering from

dementia present at June 1, 2006 within the same targeted units. Our interdisciplinary

educational program was implemented in May 2006. The effects of the program were evaluated

over a 6-month period (June 1 to November 30, 2006). A 4-month follow-up was conducted

(December 1 to March 31, 2007).

Characteristics of residents of both groups (birth date, gender and date of admission) were

gathered. Pharmaceutical records were used to classify the residents of both groups according to



                                      Optimization of the management of
This project is
                                        behavioural and psychological         Investigators:
partially
                                      symptoms of dementia (BPSD) in        Monette et al. 2007
funded by:
                                                nursing homes

                                                                                             12 of 36
the status of their antipsychotic use: 1) users at the beginning of a 6-month period (prevalent), 2)

became users during one of the 6-month periods or the 4-month follow-up (incidents), and 3) non

users during either of the periods in question. Data related to other drugs that could be used as

substitutes for antipsychotics (benzodiazepines, cholinesterase inhibitors, antidepressants) and

data on deaths and transfers were obtained from both the pharmaceutical and medical charts from

November 1, 2005 to March 31, 2007.

Written consent was obtained from physicians, nursing staff (nurses, auxiliary nurses and

educators for center B) and personal care attendants (PCA). There was no direct intervention

with residents. Protocol was accepted by the Research Ethics Committee of the Jewish General

Hospital, McGill University for center A and for center B, by the hospital center Cité de la Santé

de Laval.

Interdisciplinary educational program

Our program included three parts: 1) consciousness-raising, 2) training and 3) clinical follow-up.

The primary emphasis focused on the need to give first consideration to a non pharmacological

approach to manage disruptive behaviours and to only use the pharmacological approach when

the former proved to be insufficient. The first two parts took place in May 2006 and the clinical

follow-up was conducted from June 2006 until March 2007.

Members of the interdisciplinary team of centres A and B, administrators and decision makers

were informed about the study. Parts 2 and 3 were aimed more specifically at physicians and

pharmacists as well as the nursing staff and PCA working over three shifts (day, evening and

night).




                                     Optimization of the management of
This project is
                                       behavioural and psychological           Investigators:
partially
                                     symptoms of dementia (BPSD) in          Monette et al. 2007
funded by:
                                               nursing homes

                                                                                              13 of 36
To ensure program acceptability and compliance with the guidelines as an integral part of the

practices, the involvement of administrators throughout the program and follow-up was essential

to both support and facilitate implementation of the program. In each center, an in-house nurse

who was well known within the milieu was in charge of implementing the program. The nurse

clinician, who had been in charge of the implementation of our pilot study, also assisted program

preparation and follow-up in both centres.

Consciousness-raising

We launched our program by sending formal letters to all physicians and heads of care units. The

centres also published a short announcement in their respective newsletters to inform the staff,

residents and families about the general objectives of the program implementation. A document

outlining the major goals of the project was also made available to members of the

interdisciplinary team and administrators. Consciousness-raising meetings were organised with

the nursing staff and PCA, as well as the head nurses and administrators. The consciousness-

raising session for the rehabilitation team and social workers, as planned in our research

protocol, did not take place due to time constraints.

Training sessions

Three separate training sessions were developed: one for the nursing staff (1.5 hours), one for the

PCA (45 minutes) and one for the physicians and pharmacists (1.5 hours). Sessions for the

nursing staff and PCA were organised over the three different work shifts by the nurse in charge

of the project. A brochure summarising the key elements of the training was made available to

the staff on the units. A geropsychiatrist consultant gave one session in each center to the




                                     Optimization of the management of
This project is
                                       behavioural and psychological          Investigators:
partially
                                     symptoms of dementia (BPSD) in         Monette et al. 2007
funded by:
                                               nursing homes

                                                                                             14 of 36
physicians and pharmacists. They were also provided with a pocket guide summarising the key

recommendations on the use of antipsychotics, and their discontinuation.

The core content of the educational sessions was adapted for each target group. Sessions focused

on: 1) disruptive behaviours in dementia and the need to understand their origin and the

residents’ potential underlying needs, 2) non pharmacological approaches including successful

communication with residents, adaption of the environment to prevent negative consequences,

resident involvement in therapeutic activities and cooperation with families, 3) behaviours more

or less likely to respond to antipsychotics, 4) the need to administer the lowest effective

antipsychotic dose and to practice vigilant surveillance of desired and adverse effects and 5) the

importance of re-assessing residents taking an antipsychotic at the same dosage over three

months and considering discontinuation or dose reduction when possible.

Clinical follow-up

Follow-up of antipsychotic prescriptions was conducted with the cooperation of the nurses in

charge of the study and pharmacists. A memo was sent monthly to physicians, whose patients

were taking an antipsychotic at the same dosage for more than three months. Physicians had to

re-assess whether the dose could be reduced or the antipsychotic discontinued. They also had to

identify the symptoms and behaviours targeted by the antipsychotic where possible as well as the

reason or reasons why they would not consider a dose reduction or discontinuation of the

antipsychotic, by checking off relevant items in a pre-established list.

The clinical follow-up also included the use of safety measures to prevent the occurrence of

undesirable changes such as 1) use of other drug as substitutes to antipsychotics




                                     Optimization of the management of
This project is
                                       behavioural and psychological          Investigators:
partially
                                     symptoms of dementia (BPSD) in         Monette et al. 2007
funded by:
                                               nursing homes

                                                                                             15 of 36
(benzodiazepines, cholinesterase inhibitors, and antidepressants), 2) increased use of restraints,

3) increased disruptive behaviours among residents and 4) increased stress for staff.

Data on antipsychotics and other drugs were gathered simultaneously. Data on restraints was

gathered from June 2006 to March 2007. For center A, nurses in each care unit used their own

data collection system with regards to the use of restraints, which complicated the task of

computerizing data. The collection of data at center B went much more smoothly because of the

ability to use the historical data about the use of restraints generated by the SICHELD program

(client information system in long-term care facilities).

The frequency of disruptive behaviour among residents, whether or not they were using

antipsychotics, was measured monthly from June to November 2006 and in March 2007. The

Nursing Home Behaviour Problem Scale (NHBPS) was included in residents’ charts. The scale

was filled out each month by nurses on the three shifts who were familiar with the resident.

These objective measurements made it possible to track the evolution of residents and to ensure

that there were no adverse effects on resident safety during program implementation and follow-

up. It also helped nurses to gain practice in the use of the scale during their work activities.

Frequency of stressful events experienced by the nursing staff and PCA was measured using the

Stressful Event Questionnaire (SEQ). The SEQ was completed before the beginning of the

program (May 2006), at the end of the 6-month program (November 2006) and at the end of the

4-month follow-up (March 2007). The SEQ made it possible to measure the potential effect of

the program on staff to ensure that there were no undesirable effects related to implementation.

The questionnaire was also used to help staff gain a better understanding on how to manage

disruptive behaviours.




                                      Optimization of the management of
This project is
                                        behavioural and psychological             Investigators:
partially
                                      symptoms of dementia (BPSD) in            Monette et al. 2007
funded by:
                                                nursing homes

                                                                                                 16 of 36
Throughout the course of program, the nurse in charge encouraged the care staff to attend

interdisciplinary meetings. Specific meetings were also organised to discuss the approach needed

for some of the more difficult residents.

Level of participation in program

Consent forms were signed by the staff involved in the program in a proportion of 96.3% at

center A and 90.0% at center B. The mean level of participation varied between 81.1% and

96.3%, depending on program activities (consciousness-raising, training sessions, SEQ

completion) and centres. All physicians at both centres attended the training session. The

pharmacist of center B attended the session whereas two of the four pharmacists at center A

attended the session. The lowest level of participation in the training sessions was recorded for

the PCA (71.4%) of center B.

Hypotheses: Clarifications had to be made to the hypotheses presented in the initial design:

Hypothesis 1 (H1): The proportion of attempts, whether or not successful, of discontinuation of

antipsychotics and dose reduction during the 6-month program will be higher than the proportion

observed during the 6-month pre-program.

Hypothesis 2 (H2): The proportion of sustained discontinuations of antipsychotics and dose

reductions during the 6-month program will be higher than the proportion observed during the 6-

month pre-program.

Hypothesis 3 (H3): The proportion of antipsychotic users during the 6-month program will be

lower than the one observed during the 6-month pre-program.




                                     Optimization of the management of
This project is
                                       behavioural and psychological         Investigators:
partially
                                     symptoms of dementia (BPSD) in        Monette et al. 2007
funded by:
                                               nursing homes

                                                                                            17 of 36
Analysis techniques

Descriptive analyses were produced to verify hypotheses 1 and 2. The proportion of attempts,

whether or not successful, of discontinuations of antipsychotics and dose reduction, the

proportions of sustained discontinuation and dose reductions and the proportions of unsuccessful

attempts were calculated for each of the centres and compared. To verify what would happen

after the end of the program, data on antipsychotics obtained during the 4-month follow-up were

grouped together with the data from the 6-month program. Proportions were calculated for this

period of 10 months and compared to those obtained over the 6-month program.

Descriptive analyses were first conducted to verify hypothesis 3. Proportions of antipsychotic

users were calculated for each of the centres and for each period of six months. These

proportions were illustrated in graphs. The proportion of antipsychotic users during the 4-month

follow-up was also calculated.

A statistical model was then used to determine whether or not there was a statistical difference

between the proportion of antipsychotic users in the pre-program group and the program group,

while taking into account the variability between centers. The model was repeated including the

4-month follow-up period.

Resident demographic data, data on drugs used as substitutes for antipsychotics, the use of

restraints, the frequency of disruptive behaviours among residents, measured with the NHBPS

scale and the frequency of stressful events experienced by the nursing staff and PCA, measured

by the SEQ, were analysed in a descriptive way.

A statistical model was used to compare results of the disruptive behaviour frequency. A

logarithmic transformation was done to standardize data distribution. The model was adjusted for




                                   Optimization of the management of
This project is
                                     behavioural and psychological          Investigators:
partially
                                   symptoms of dementia (BPSD) in         Monette et al. 2007
funded by:
                                             nursing homes

                                                                                           18 of 36
age, sex, length of stay in the center, and the resident status as either a user or non user of

antipsychotics. The model took into account repeated measurements for the same resident,

differences between work shifts and centres.

A statistical model was also used to compare results of the frequency of stressful events

experienced by the nursing staff and PCA. This model also took into account repeated measures

for the same person, differences between work shifts and centres.

Results, Conclusions

Table 1 illustrates characteristics of the caregivers and residents of the pre-program group from

November 1, 2005, for each center. The proportion of residents with dementia and the proportion

of antipsychotic users, as well as their age and length of stay, were similar in both centres. By

vocation, center A houses mainly men. The number of caregivers was much higher in center A.

The proportion of benzodiazepines, cholinesterase inhibitors (ChE-I) and antidepressant users

varied widely between the two centres.




                                    Optimization of the management of
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partially
                                    symptoms of dementia (BPSD) in         Monette et al. 2007
funded by:
                                              nursing homes

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Table 1. Characteristics of caregivers and residents of the pre-program group at November 1, 2005, by center
Characteristics                                                             Center A               Center B
Physicians N                                                                   8                           5
Pharmacists N                                                                 4*                 1 consultant**
Nurses and auxiliary nurses N                                                 89                       32
Educators N                                                                    -                           4
Personal care attendants N                                                    141                      90
Residents N***                                                                238                      191
Residents with dementia n (%)                                             161 (67.7)               132 (69.1)
Antipsychotic users n (%)                                                  66 (41.0                 58 (43.9)
Antidepressant users n (%)                                                 27 (16.8)                35 (26.5)
Benzodiazepine users n (%)                                                 26 (16.2)                65 (49.2)
ChE-I users† n (%)                                                         81 (50.3)                 9 (6.8)
Age, mean (standard deviation)                                             85.2 (3.9)               82.8 (9.6)
Women n (%)                                                                 5 (3.1)                 96 (72.7)
Length of stay, mean years (standard deviation)                            3.5 (3.8)                2.9 (2.4)
* full time, ** one day/week, ***N = total number of residents in units targeted by the study, † ChE-I =
cholinesterase inhibitors
Antipsychotic prescriptions

Results: Table 2 provided descriptive data of residents with dementia depending on whether

they are non users or prevalent users of antipsychotics for the periods under study, both per

center and for the combined centres (A+B). New users from the pre-program and program

groups were not taken into consideration for the calculation of proportions, due to the variability

of the subsequent follow-up. This period, which was less than six months, sometimes consisted

of only a few days, depending on the case. Because these follow-ups were incomplete, it was

impossible to evaluate the effect of our program on new users. For both centres, we counted 22

new users among the pre-program group and 11 among the program group. During the 4-month

follow-up period, there were only three new users at center A.




                                           Optimization of the management of
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                                             behavioural and psychological                   Investigators:
partially
                                           symptoms of dementia (BPSD) in                  Monette et al. 2007
funded by:
                                                     nursing homes

                                                                                                               20 of 36
Combined data from the two centres (A+B) revealed high proportions of antipsychotic users

among the pre-program group (42.3%) and program group (45.0%). The proportions of death

and transfers among non users were similar for both groups as well as the proportions of

prevalent users. Among users who were still present at the end of the follow-up of both groups,

respectively 109 and 116 residents, the proportion of attempts, whether or not successful, of

discontinuation of antipsychotics and dose reduction went from 38.5% in pre-program to 51.7%

during the program. The proportion of sustained antipsychotic discontinuations during the

program for the combined centres (A+B) (25%) was higher than the pre-program (13.8%)

whereas the proportion of sustained dose reductions remained similar (respectively 18.1% and

19.3%).




                                   Optimization of the management of
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                                     behavioural and psychological         Investigators:
partially
                                   symptoms of dementia (BPSD) in        Monette et al. 2007
funded by:
                                             nursing homes

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Table 2: Descriptive data for residents with dementia depending on whether they are non users or prevalent users of antipsychotics during study
periods.

                                              Pre-program group                          Program group                    Program group + follow-up
                                     Period: November 1, 05 to April 30, 06   Period: June 1, 06 to November 30, 06    Period: June 1, 06 to March 31, 07
          Antipsychotics
                                     Center A     Center B        A+B         Center A     Center B        A+B        Center A    Center B         A+B
                                      N=161        N=132         N=293         N=163        N=135         N=298        N=163       N=135          N=298

Non users, n (%)                     95 (59.0)    74 (56.1)     169 (56.1)    97 (59.5)    67 (49.6)    164 (55.0)    97 (59.5)   67 (49.6)     164 (55.0)

Deaths/transfers, n (%)              16 (16.8)    12 (16.2)     28 (16.6)     21 (21.7)    12 (17.9)     33 (20.1)    38 (39.2)   18 (26.9)     56 (34.2)

Prevalent users at the beginning
                                     66 (41.0)    58 (43.9)     124 (42.3)    66 (40.5)    68 (50.4)    134 45.0)     66 (40.5)   68 (50.4)     134 (35.0)
of each period, n (%)

Deaths/transfers, n (%)              10 (15.2)     5 (8.6)      15 (12.1)     7 (10.6)     11 (16.2)     18 (13.4)    14 (21.2)   19 (27.9)     33 (24.6)

Prevalent users present at the end
                                     56 (84.9)    53 (91.4)     109 (87.9)    59 (89.4)    57 (83.8)    116 (88.6)    52 (78.8)   49 (72.1)     101 (75.4)
of each period, n (%)
Attempts, whether or not
                                     24 (42.9)    18 (34.0)     42 (38.5)     38 (64.4)    22 (38.6)     60 (51.7)    31 (59.6)   26 (5301)     57 (56.4)
successful, n (%)

Sustained discontinuation, n (%)     13 (23.2)     2 (3.8)      15 (13.8)     21 (35.6)    8 (14.0)      29 (25.0)    15 (28.9)    9 (18.4)     24 (23.8)

Sustained dose reductions, n (%)      9 (16.1)    12 (22.6)     21 (19.3)     11 (18.6)    10 (17.5)     21 (18.1)    12 (23.1)   13 (26.5)     25 (24.8)

Unsuccessful attempts, n (%)          2 (3.6)      4 (7.6)       6 (5.5)      6 (10.2)      4 (7.0)      10 (8.6)      4 (7.7)     4 (8.2)        8 (7.9)




                                                       Optimization of the management of behavioural and
This project is partially                                                                                                   Investigators:
                                                     psychological symptoms of dementia (BPSD) in nursing
funded by:                                                                                                                Monette et al. 2007
                                                                             homes

                                                                                                                                                  22 of 36
The proportion of attempts that was calculated for the combined centres (A+B) over a 10-month

period (program group + follow-up) increased to 56.4% compared to the proportion obtained

during the 6-month program period (51.7%). The proportion of sustained discontinuation of

antipsychotics remained similar, but the proportion of sustained dose reductions went from

18.1% during the program to 24.8% during program + follow-up. The review of the results for

each center did reveal however a slight decrease from 64.4% to 59.6% of the proportion of

attempts at center A, whereas an increase from 38.6% to 53.1% was observed for center B.

The proportion of residents receiving antipsychotics during the pre-program, the program, and

the 4-month follow-up are illustrated for the combined centres (A+B) (figure 1), center A (figure

2) and center B (figure 3). These proportions include prevalent and incident users.

The combined data for centres A and B show that the proportion of antipsychotic users were

similar at the beginning of the pre-program and the program (figure 1). The proportion of users

remained much the same during the pre-program, whereas it decreased at the end of the program.

The 4-month follow-up demonstrated a slightly higher proportion.

Data for each center shows however that at the end of the program, the proportion of

antipsychotic users had a bigger decrease in center A (from 41.6% to 31.1%) than in center B

(51.3% to 47.3%). However, during the 4-month follow-up, the proportion of users increased in

center A (37.6%) whereas it continued to decrease in center B (42.4%).




                                    Optimization of the management of
This project is
                                      behavioural and psychological           Investigators:
partially
                                    symptoms of dementia (BPSD) in          Monette et al. 2007
funded by:
                                              nursing homes

                                                                                             23 of 36
Figure 1.Proportion of residents with dementia who were receiving antipsychotics and other
drugs during the pre-program, the program and the 4-month follow-up period for centres A and
B

                                                        Antipsychotics – Pre-program
                                                        Antipsychotics – Program and 4 month follow-up
                                                        Benzodiazepines – Pre-program
                                                        Benzodiazepines – Program and 4 month follow-up
                                                        Cholinesterase inhibitors - Pre-program
                                                        Cholinesterase inhibitors – Program and 4 month follow-up
                                                        Antidepressants - Pre-program
                                                        Antidepressants – Program and 4 month follow-up
    Proportion of residents (%)




                                                   Weeks




                                  Optimization of the management of
This project is
                                    behavioural and psychological                             Investigators:
partially
                                  symptoms of dementia (BPSD) in                            Monette et al. 2007
funded by:
                                            nursing homes

                                                                                                                    24 of 36
Figure 2. Proportion of residents with dementia who were receiving antipsychotics and other
drugs during the pre-program, the program and the 4-month follow-up period for center A

                                                     Antipsychotics – Pre-program
                                                     Antipsychotics – Program and 4 month follow-up
                                                     Benzodiazepines – Pre-program
                                                     Benzodiazepines – Program and 4 month follow-up
                                                     Cholinesterase inhibitors - Pre-program
                                                     Cholinesterase inhibitors – Program and 4 month follow-up
                                                     Antidepressants - Pre-program
                                                     Antidepressants – Program and 4 month follow-up
    Proportion of residents (%)




                                                  Weeks




                                  Optimization of the management of
This project is
                                    behavioural and psychological                                Investigators:
partially
                                  symptoms of dementia (BPSD) in                               Monette et al. 2007
funded by:
                                            nursing homes

                                                                                                                 25 of 36
Figure 3. Proportion of residents with dementia who were receiving antipsychotics and other
drugs during the pre-program, the program and the 4-month follow-up period for center B



                                                     Antipsychotics – Pre-program
                                                     Antipsychotics – Program and 4 month follow-up
                                                     Benzodiazepines – Pre-program
                                                     Benzodiazepines – Program and 4 month follow-up
                                                     Cholinesterase inhibitors - Pre-program
                                                     Cholinesterase inhibitors – Program and 4 month follow-up
                                                     Antidepressants - Pre-program
                                                     Antidepressants – Program and 4 month follow-up
  Proportion of residents (%)




                                                   Weeks

To establish a homogenous population, the statistical model used included residents who were

present both at the pre-program and during the program for both centres, namely 244/293

(83.3%). The model showed an important decrease of the proportion of antipsychotic users

during the course of the program (p=0.0063). In fact, this decrease was more important for center

A than B (p<0.0001). When the follow-up period was added to the model, the proportions of

users in each of the three periods (pre-program, program and follow-up) were not statistically

different.

The model comparing the pre-program and program groups was repeated for each center

separately. A significant decrease of the proportion of antipsychotic users during the program




                                    Optimization of the management of
This project is
                                      behavioural and psychological                                Investigators:
partially
                                    symptoms of dementia (BPSD) in                               Monette et al. 2007
funded by:
                                              nursing homes

                                                                                                                  26 of 36
was demonstrated by the center A model (p=0.0005) and the center B (p=0.0489). For center A,

the model comparing the three periods showed a significant increase of the proportion of

antipsychotic users during the follow-up compared to pre-program (p<0.0001) and program

(p<0.0001) periods. For center B, the model demonstrated a significant decrease in the

proportion of antipsychotic users during the follow-up compared to the pre-program period

(p=0.0011). This decrease however was not different from the one observed during the program

(p=0.3190). The large variability observed between the centres did in fact take away the

precision of the model which combined the data for centres A and B to assess the effect of our

program.

Conclusions: Results demonstrate the need to implement an interdisciplinary educational

program on a permanent basis to maintain and possibly increase its efficacy and to obtain

sustainable changes to antipsychotic prescribing patterns. In fact, the marked tendency in center

A to revert to initial antipsychotic prescribing habits at the end of the program might possibly

have been offset if it had been continued. It should be noted that the residents targeted by our

study in this center were transferred to a new building between November 14 and 21, 2006. The

team of caregivers who had been preparing for several months for the reorganization of their

roles as a function of the establishment of new living environments, was at this point exhausted

which translated into reduced involvement for the rest of the study. For center B, it appears that a

longer follow-up would have been necessary to observe the effects of the program. The nurse

from the center as well as other caregivers expressed their interest and the need to continue the

program. It must also be noted that the implementation of our program coincided with major

restructuring at the center, including the creation of the Laval Health and Social Services Center,




                                     Optimization of the management of
This project is
                                       behavioural and psychological           Investigators:
partially
                                     symptoms of dementia (BPSD) in          Monette et al. 2007
funded by:
                                               nursing homes

                                                                                              27 of 36
which include, among others, five nursing homes. The changes that happened at the beginning of

our study, affecting the decision makers, administrative staff, and caregivers, probably had an

impact on our program, but one that is difficult to measure. Although centres expressed the

desire to adopt some of the program components, none of the components were systematically

introduced after the 6-month program. The year 2008 has been targeted to modify some of the

practices.

The use of a research protocol with a comparison group brings a nuance to the proportion of

attempts, whether or not successful, of discontinuation of antipsychotics and dose reduction,

which was observed during our pilot study (75.3%), although this proportion is considerably

higher than our present study (51.7%). The proportion of attempts, whether or not successful, of

discontinuation and dose reduction, that was observed during the pre-program (38.5%) is an

indication that a re-assessment of antipsychotic prescribing, as recommended in the standards of

practice, was done by physicians for more than a third of their patients without program

implementation. Our program however had the effect of increasing by 13.2% the proportion of

attempts of discontinuation of antipsychotics and dose reduction. It should be noted that there

were fewer new antipsychotic prescriptions (incident users) during program and the 4-month

follow-up.

Use of other drugs

Results/conclusion: As illustrated in figures 1, 2 and 3, it appears that the reduction of

antipsychotic prescriptions did not result in the increase of the use of other drugs that might have

caused adverse drug events.




                                     Optimization of the management of
This project is
                                       behavioural and psychological           Investigators:
partially
                                     symptoms of dementia (BPSD) in          Monette et al. 2007
funded by:
                                               nursing homes

                                                                                              28 of 36
Memos to physicians:

Results: A memo was sent to physicians for each of their patients receiving the same dosage of

antipsychotics for more than three months. Memos were sent during the months of June, August,

September, October and November, 2006. For center A, 98.9% of the memos sent were

completed and returned to the nurse in charge. For center B, the nurse had to send out several

reminders to obtain a response rate of 65.1%. It should be noted that one of the physicians of the

center was on an extended leave of absence. Physicians responded that they expected to attempt

discontinuation or dose reduction in 27.6% of the memos at center A and 37.0% of the memos at

center B.

Among the list of pre-established symptoms or behaviours potentially to be targeted by an

antipsychotic, agitation, an attitude of resistance, and paranoia were the ones that were most

often identified by physicians. Behaviours, less likely to respond to antipsychotics, were also

identified (by decreasing order): repeated statements or words, anxiety, wandering, restlessness

and pacing.

Physicians deemed that an attempt of discontinuation or dose reduction was not advisable for

72.4% of the cases in center A and for 63.0% of the cases in center B. The main reason given

was that targeted symptoms were still present. The failure of an attempt in the past, the insistence

of a family member to continue treatment, and the reticence of members of the caregiver team

were also mentioned as reasons.

Conclusion: The use of memos allowed us to gather information on symptoms and behaviours

leading up to antipsychotic prescribing. The fact that physicians often prescribed antipsychotics




                                     Optimization of the management of
This project is
                                       behavioural and psychological           Investigators:
partially
                                     symptoms of dementia (BPSD) in          Monette et al. 2007
funded by:
                                               nursing homes

                                                                                              29 of 36
for behaviours that have poor response to this medication demonstrates a clear need to provide

more targeted training sessions on a regular basis.

Use of restraints:

Results: Figure 4 illustrates the proportion of users of restraints during the 6-month program and

the 4-month follow-up for centres A and B. No difference was observed in the use of restraints

between residents who were either users or non users of antipsychotics.

In June 2006, the proportion of residents using restraints was much higher in center B (50.4%)

than in center A (16.4%). During the program, the proportion of users increased at center B

while it decreased in center A. At the end of the 4-month follow-up, proportion of users at center

A was slightly higher than the one observed at the beginning of the program (17.4%) and at

center B, this proportion increased to 60.4%.

Conclusions: Results obtained in center B contributed to the establishment of a program aimed

at reducing the use of restraints to ensure residents’ safety. Results obtained in center A and data,

which was collected with great difficulty throughout the study, were used to convince the center

of the importance of adopting a uniform data collection program between care provider units to

facilitate follow-up.




                                     Optimization of the management of
This project is
                                       behavioural and psychological            Investigators:
partially
                                     symptoms of dementia (BPSD) in           Monette et al. 2007
funded by:
                                               nursing homes

                                                                                               30 of 36
                                                  Figure 4.   Proportion of residents using restraints during the 6-month program and
                                                              the 4-month follow-up at centers A and B, depending on the antipsychotic
                                                              user status
                                                                  6-month program                                                4-month follow-up



                                                                                                                    Center A – All
   Proportion of residents using restraints (%)




                                                                                                                    Center A – Non users
                                                                                                                    Center A – Prevalent users
                                                                                                                    Center B – All
                                                                                                                    Center B – Non users
                                                                                                                    Center B – Prevalent users




                                                                     Aug06                                    Dec06                          Feb07
                                                                                                Months



Frequency of disruptive behaviours among residents

Results: The mean scores obtained on the Nursing Home Behaviour Problem Scale (NHBPS)

for all residents with dementia (Table 3) decreased from 11.5 at month 1 of the program (June

2006), to 9.9 at the last month (November 2006) in both centres. The scores increased slightly to

10.6 at the end of the 4-month follow-up (March 2007) but were lower than the one obtained in

June 2006.




                                                                                Optimization of the management of
This project is
                                                                                  behavioural and psychological                        Investigators:
partially
                                                                                symptoms of dementia (BPSD) in                       Monette et al. 2007
funded by:
                                                                                          nursing homes

                                                                                                                                                      31 of 36
Table 3 Summary of Nursing Home Behaviour Problem Scale (NHBPS) global scores
                                                                     Study period
Global NHBPS scores                          1        2        3          4          5        6           10
N                                           292      209      278        269        264      251          207
Mean                                        11.5     11.2     10.3       9.8        9.5      9.9          10.6
Standard deviation                          9.5      9.1      8.6        8.0        8.0      8.8          9.3



The statistical model used showed a significant decrease of the NHBPS mean scores during the

6-month program (p<0.001). These scores were higher on the evening shift compared to those on

the day shift (p=0.0222), higher among men (p=0.0016) and higher among prevalent

antipsychotic users compare to non users (p=0.0001). The mean scores at center B were also

higher than those at center A (p=0.0012).

The addition of the NHBPS scores, obtained in March 2007, to the statistical model attenuated

the observed decreases, which nonetheless remain significant (p<0.0001).

Conclusions: Program implementation did not have an adverse effect on resident safety. The

frequency of disruptive behaviours observed during the program and at the end of the 4-month

follow-up remains lower than the frequency observed during the first month of the program. It is

to be noted that several members of the nursing staff gave positive feedback about the NHBPS.

This tool allowed them to provide a better description of disruptive behaviours rather than to

refer to a non specific term of agitation, and made easier to take notes in resident charts.

Frequency of stressful events experienced by the nursing staff and personal care attendants

Results: Among the 292 caregivers who completed the Stressful Event Questionnaire (SEQ) in

May 2006, 100 (33.9%) did not respond in November 2006 and/or March 2007. In the majority




                                     Optimization of the management of
This project is
                                       behavioural and psychological                  Investigators:
partially
                                     symptoms of dementia (BPSD) in                 Monette et al. 2007
funded by:
                                               nursing homes

                                                                                                     32 of 36
of cases, the lack of data was not attributable to refusal but rather to absence for vacation,

departures or cessation of work.

The mean SEQ score decreased from May 2006 (15.5) to November 2006 (13.9) and remained

very much the same in March 2007 (14.0).

Results of the statistical model used demonstrated a significant decrease of the mean SEQ score

between May 2006 and November 2006 (p=0.0005) and between May 2006 and March 2007

(p=0.0041). In every measurement, the mean score was higher at center B than at center A

(p<0.0001).

Conclusions: Program implementation did not have any adverse effects on the nursing staff and

PCA in terms of the frequency of stressful events they experienced. This frequency, which was

observed at the end of the 6-month program and at the end of the 4-month follow-up, remain

even lower than the one observed prior to the program. The mean scores that were higher at

center B might be explained by the fact that this center has a smaller number of caregivers than

center A that has almost the same number of residents with dementia (Table 1).

Recommendations

In a research context, the implementation of our study with a similar design in other facilities

requires a great deal of human and financial resources. In consideration of the experience

acquired and results obtained at our pilot study prior to the longitudinal study, we believe that

our program should be implemented in a clinical context for the purposes of adopting best

practices rather than as a research project.

Program implementation in a clinical situation will be greatly simplified because it will not

require consent from staff. Furthermore, assessment of stressful events experienced by the nurses



                                      Optimization of the management of
This project is
                                        behavioural and psychological        Investigators:
partially
                                      symptoms of dementia (BPSD) in       Monette et al. 2007
funded by:
                                                nursing homes

                                                                                            33 of 36
and PCA will no longer be necessary in our opinion. In fact, results from the pilot study and the

present study have shown that the implementation of an interdisciplinary educational program

does not increase the mean score of stressful events experienced by staff. The integration of an

instrument to measure disruptive behaviours into resident charts will ensure that the tool is

available for use at the opportune time, but not systemically every month for the purposes of a

research project. Often too short, the duration of research project implementation and the follow-

up of their potential impact will no longer be a problem when the community adopts the program

as regular and ongoing practices to ensure quality of care and as a result, the safety of residents.

The following key factors set out the measures that should be emphasised for the implementation

of our interdisciplinary educational program and its success in other nursing homes in Canada:

1)     Establishment of national standards norms for the use of antipsychotics and creation of

       external committees to ensure compliance and regular follow-up.

2)     Administrative support from managers and decision makers in facilities with a

       commitment from all healthcare staff to make good use of the educational program and to

       apply the guidelines so that they will become an integral part of the culture.

3)     Identification of persons already well established in the local milieu and who are seen as

       leaders. Such persons must be open to suggestions for change to optimize quality of care.

4)     Educational sessions provided at regular intervals to ensure training for new staff members

       and to provide regular members with the opportunity to engage in follow-up and an update

       of their knowledge.

5)     Systematic collection of pharmaceutical data to ensure that discontinuation of

       antipsychotics does not lead to the increase of another category of drugs which might be




                                      Optimization of the management of
This project is
                                        behavioural and psychological            Investigators:
partially
                                      symptoms of dementia (BPSD) in           Monette et al. 2007
funded by:
                                                nursing homes

                                                                                                34 of 36
       associated with adverse events and/or increased use of restraints. Accessibility to a uniform

       and reliable data collection program to collect pharmaceutical data and data on the use of

       restraints is essential to ensure resident safety.

6)     Documentation of observed disruptive behaviours into resident charts using a tool that is

       accepted by the center. This will make it all the more easier to objectively access whether

       or not interventions have lead to a decrease in disruptive behaviours.

7)     Establishment of objectives and an intervention plan including both non pharmacological

       and pharmacological approaches.

8)     Systematic re-assessment a) of residents taking an antipsychotic at the same dosage for

       more than three months and b) the impact of interventions using objective measurements of

       disruptive behaviours and regular interdisciplinary meetings.

9)     Re-assessment of treating team by external committee to ensure proper application of

       criteria for antipsychotic indications.

10)     Establishment of cooperation is essential between medical staff, pharmacists, nurses,

       personal care attendants and any other members of the interdisciplinary team, including

       among others, occupational therapists, physiotherapists and social workers.




                                       Optimization of the management of
This project is
                                         behavioural and psychological            Investigators:
partially
                                       symptoms of dementia (BPSD) in           Monette et al. 2007
funded by:
                                                 nursing homes

                                                                                                 35 of 36
References

1. Health Care Financing Administration. 1990. Survey procedures and interpretive guidelines
   for skilled nursing facilities and intermediate care facilities. Baltimore: US Dept. of Health
   Human Services.

2. Sink KM, Holden KF, Yaffe K. 2005. Pharmacological treatment of neuropsychiatry
   symptoms of dementia – A review of the evidence. JAMA 293: 596-608.

3. Howard R. Ballard C, O’Brien J, et al. 2001. Guidelines for the management of agitation in
   dementia. In Geriatric Psychiatry 16: 714-707.

4. Stole p, Esbaugh J, Aylward S et al. 2005. Factors associated with the effectiveness of
   continuing education in long-term care. Gerontologist 45: 399-409.




                                   Optimization of the management of
This project is
                                     behavioural and psychological           Investigators:
partially
                                   symptoms of dementia (BPSD) in          Monette et al. 2007
funded by:
                                             nursing homes

                                                                                            36 of 36

				
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