Elizabeth McManamy, RPh Pharmacist Quality Monitor Jennifer Wills, BSN, RN Nurse Manager DADS Quality Monitoring Program

Transcription

1 Elizabeth McManamy, RPh Pharmacist Quality Monitor Jennifer Wills, BSN, RN Nurse Manager DADS Quality Monitoring Program

2 Objectives 1.Summarize the pharmacology of the antipsychotic drug class 2.Describe how the use of antipsychotic medications burden the quality of life in the elderly 3.Explain the CMS appropriate use of antipsychotic medications in the long-term care setting 4.Describe the dementia disease process 5.Describe strategies to monitor and target behaviors in the long-term care population 2

3 What s the Big Deal? Antipsychotics are: extensively used in nursing homes prescribed for the off-label for dementia-related illnesses where effectiveness is little and use is unsupported 3

4 Antipsychotic Mechanism of Action Block neurotransmitters in the brain at dopaminergic, histaminic, cholinergic, and serotonergic receptors in the brain A specific antipsychotic drug may be prescribed over another due to varying activity at these brain receptor sites The main action is to block dopaminergic pathways to reduce the core symptoms of psychosis: hallucinations, delusions, and paranoid ideation 4

5 Treatment for Schizophrenia-Related Disorders Antipsychotics have been the first-line treatment since the 1950 s with first-generation antipsychotics (i.e. the typical antipsychotics) The down-side risk of blocking dopaminergic receptors is the occurrence of extrapyramidal side effects (EPS) 5

6 Common Typical Antipsychotics Haloperidol (Haldol ) Chlorpromazine (Thorazine ) Fluphenazine (Prolixin ) Perphenazine (Trilafon ) Thioridazine (Mellaril ) Thiothixene (Navane ) 6

7 Atypical Antipsychotics Second-generation antipsychotics were developed in the 1980 s with the first being Clozapine (Clozaril ) Atypicals commonly seen in the long-term care setting: Aripiprazole (Abilify ) Lurasidone (Latuda ) Olanzapine (Zyprexa ) Paliperidone (Invega ) Quetiapine (Seroquel ) Ziprasidone (Geodon ) Risperidone (Risperdal ) 7

8 Atypical Antipsychotic Design Along with treating hallucinations and delusions these newer drugs have a better side effect profile and greater effects on other symptoms seen in schizophrenia: emotional withdrawal/blunted affect suspiciousness or persecution grandiosity hostility poor impulse control active social avoidance anxiety somatic concerns 8

9 Antipsychotic Side Effects sedation; drowsiness/dizziness; disorientation confusion; memory or functional impairment risk of delirium fall risk; orthostatic hypotension (sudden drop in blood pressure when standing) constipation, urinary retention, dry mouth; blurred vision restlessness; inability to sit still; anxiety; sleep disturbances 9

10 Antipsychotic Side Effects tremor; slowed movements; muscle rigidity; strong muscle spasms (neck, tongue, face, or back); drooling tardive dyskinesia low white blood cell count; irregular heart rate; seizures; metabolic issues; neuroleptic malignant syndrome; increased risk of sudden cardiac death 10

11 Atypical Prescribing Considerations Quetiapine and aripiprazole cause the least amount of extrapyramidyl side effects (EPS). Quetiapine or aripiprazole are often a choice in Parkinson s disease Quetiapine and risperidone have a higher risk of orthostatic hypotension (a significant factor in fall risk) Olanzapine has the highest risk factor for obesity, hyperglycemia, and dyslipidemia Aripiprazole, quetiapine, and risperidone have a risk factor of QT prolongation (dangerous heart arrhythmias) 11

12 Atypical Prescribing & Decision Making The American Psychiatric Association (APA) currently recommends that selection of an antipsychotic medication should be based on a patient s previous responses to the drug and its side-effect profile. 12

13 FDA Approved Non-Schizophrenia Related Conditions Bipolar disorder (some as monotherapy & some as adjunct) Tourette s syndrome Nausea, vomiting, and hiccups Major depressive disorder (adjunctive with antidepressants) Short-term treatment of generalized non-psychotic anxiety Management of manifestations of psychotic disorders 13

14 Antipsychotics: Off-label Prescribing Off-label: a drug company does not have FDA approval to market or advertise a medication to treat a specific disorder or condition Physicians can prescribe drug off-label to treat any condition, disorder, or diagnosis Physicians will normally prescribe within the currently accepted standards and principles found in medical literature In dementia care, there are no current medications available to treat the behavioral and psychological symptoms of dementia (BPSD) 14

15 Antipsychotics are NOT Approved to Treat Dementia 15

16 FDA Black Box Warning: Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. 16

17 Alzheimer s vs. Dopamine Pathway 17

18 Understanding Dementia Symptoms of dementia depend on the location of damage in the brain: Frontal Lobe The Hippocampus Occipital Lobe Temporal Lobe Parietal Lobe 18

19 Dementia Disease Process Permanent degenerative changes in the brain Lack of acetylcholine presence Beta-amyloid plaques causing inflammation and brain cell death Tau protein tangles causing brain cell dysfunction and cell death The psychosis-like symptoms seen in dementia are unlike the psychoses in chronic mental illness (e.g. schizophrenia) Disturbances arise from short-term memory/recall problems causing disorientation to time, place, and environment 19

20 Advanced Stages of Dementia Confusion of surroundings (disorientation) Inability to communicate or find the words to express unmet needs Wandering or pacing Sleep-wake cycle disturbances Emotional distress Disrobing or dressing inappropriately in public places 20

21 Advanced Stages of Dementia Delusions Hallucinations (auditory and/or visual) Agitation (irritability, restlessness, anxiety) Aggression (lashing out, verbal outbursts or cursing, resisting care, sexually inappropriate behaviors) 21

22 Dilemmas of Dementia BPSD is troublesome, irregular, disturbing, and difficult to manage 80% of dementia residents will develop neuropsychiatric symptoms over the course of the disease Behavioral disturbances cause caregiver stress, burden, possible injury Behavioral disturbances can worsen the functioning of other residents or the resident themselves 22

23 The strongest people are not those who show strength in front of us, but those who win battles we know nothing about. -Unknown 23

24 Antipsychotic Challenges Behavioral disturbances tend to be episodic and can diminish spontaneously Antipsychotics are likely to be prescribed with comorbid conditions and many medications Antipsychotics are more likely to be prescribed for those already on psychotropic medications Over time, antipsychotics are barely more effective than placebo 24

25 Prescribing Precautions: Advanced Age Less muscle mass, less body weight, and are prone to malnutrition affecting drug transport and drug distribution Less liver and kidney capacity to metabolize and excrete medications, along with dehydration, urinary retention, and urinary infections, can cause drugs to build up in the body 25

26 Prescribing Precautions: Advanced Age All medications have the potential to interact with other medications or medical conditions Adverse reactions can resemble symptoms of acute illness which may be overlooked Polypharmacy (9 or more meds*) with comorbid conditions put individuals at higher risk for adverse events and status decline * CMS SOM Appendix PP 26

27 CATIE-AD Project When atypical antipsychotics are prescribed in dementia care, they are risky and are only modestly effective Side effects can cause both direct and indirect factors that contribute to decreased health and well being Steady and significant declines in both cognition and functional ability can increase the need for care, and can diminish overall quality of life. 27

28 Antipsychotics Risks Worsening or complications with dysphagia Increased risk of aspiration pneumonia and upper respiratory infections Increased risk of urinary tract infections Contribute to the risk of developing delirium Increased risk for pressure ulcers 28

29 Antipsychotics Risks Declines with decision-making capability ( think about safety awareness) Increased risk of falls Decreased ability to be understood/understand Declines in functional ability and independence 29

30 Burdens on Quality of Life: Cognitive Decline Decreased ability to self-report illness and infection Decreased ability to communicate pain/discomfort Decreased recognition of the need for toileting May be unaware of thirst or unable to communicate the need for drink (dehydration risk) or food (weight loss) possible decreases in socialization with other residents, staff, family & friends 30

31 Burdens on Quality of Life: Functional Decline Decreased independence (this can increase staff burdens) Decreased mobility (ability to walk properly or selfpropel) Decreased ability to reposition oneself properly or in a timely manner Possible physical changes in functional eating & drinking Decreased enjoyment due to sedation/drowsiness 31

32 Avoidable Re-Hospitalizations Individuals with dementia on antipsychotics either 6 months before or after hospital admission were more likely to be readmitted back to the hospital than those without an antipsychotic in their drug regimen Reference: L.A. Daiello, et al. Archives of Gerontology and Geriatrics, July-August

33 CMS Approved Diagnoses Chronic conditions Schizophrenia Delusional disorder Tourette s disorder Schizo-affective disorder Mood disorders Huntington s disease 33

34 CMS Approved Diagnoses Acute conditions Psychosis in the absence of dementia Medical illness with psychotic symptoms and/or treatment related psychosis or mania Hiccups Nausea and vomiting with cancer/chemotherapy 34

35 End-of-Life Care Off-label as a comfort measure in end-of-life care This is not CMS or FDA approved, but during hospice the goals are to promote sedation, stabilize the individual, and maintain comfort 35

36 Warnings When antipsychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective. The problematic use of medications, such as antipsychotics, is part of a larger growing concern. This concern is that nursing homes and other setting (i.e. hospitals, ambulatory care) may use medications as a quick fix for behavioral symptoms or as a substitute for a holistic approach that involves a thorough assessment of underlying causes of behaviors and individualized person-centered interventions. 36

37 Avoid Antipsychotics with BPSD Antipsychotics should only be used when clinically necessary to treat targeted behaviors that are causing harm or significant distress to others or the resident themselves. Antipsychotics should be used at the lowest dose and for the shortest period of time to treat specific targeted behavior(s), and are subject to gradual dose reduction. Non-pharmacological interventions and therapeutic approaches are considered first-line therapy for BPSD. 37

38 Pre-psychotropic Assessment and Care Planning Target the behavior as a problem/risk in the care plan Discuss interventions and approaches with all members of the interdisciplinary team and obtain input from family members Document individualized person-centered nonpharmacological interventions and therapeutic approaches in the care plan Implement those interventions and approaches across various disciplines 38

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40 Recognize Disturbances Early Rule out potential medical & psychiatric causes first Behaviors are commonly triggered by the actions, inactions, or the reactions of others Behaviors can arise from frustrations that are caused when choices or personal preferences limit independence Recognize harmful or significantly distressing behaviors, as opposed to the behavioral and psychological disturbances 40

41 Problem Solving Requires New Approaches Insanity: Doing the same thing over and over again, and expecting different results. -Albert Einstein 41

42 Become a Detective Are there any physical or functional limitations that can be remedied? Promote independence with cueing, repositioning, or simple adjustments may be needed What is the resident seeing, hearing, smelling, touching, or tasting that may be leading to behaviors? Review environmental considerations 42

43 Become a Detective Does the resident need emotional support? If they are seeking reassurances, they probably need more emotional support (medication may not be needed) Do the activities offered match the cognitive and functional abilities of the individual? Structure them to promote meaningful active participation 43

44 Address Depressive Symptoms Depression Highly prevalent in the nursing home setting Can worsen cognition and functioning potentially leading to an acceleration of the dementia disease process Can worsen the experience of pain and discomfort can precipitate ruminating thoughts of worry 44

45 Address Depressive Symptoms Antidepressants (SSRIs and SNRIs) Therapy is often necessary with extended use, but only at the lowest dose needed to treat depression Avoid the use of multiple antidepressants unless clinically indicated Caution: fall risk is highest during the first 2 weeks of initiation or with increasing dosages 45

46 Serial Trial Intervention Approach Individuals may not be able to express that they are having pain and discomfort Behaviors can be easily misconstrued and treated with psychotropic medications The STI recognizes that routine mild analgesia should be started as a comfort measure when behaviors are exhibited Monitor for a response such as decreased behaviors and improved mood If analgesia is successful, don t forget to continue other non-pharmacological interventions 46

47 CMS Definition of Monitoring "The ongoing collection and analysis of information (such as observations and diagnostic test results) and comparison to baseline and current data in order to ascertain the individual's response to treatment and care, including progress or lack of progress toward a goal. Monitoring can detect any improvements, complications or adverse consequences of the treatments; and support decisions about adding, modifying, continuing, or discontinuing any interventions. -RAI Manual 47

48 Monitoring Psychotropic Medications Target specific behavior(s) and linking them with treatment of a specific medication At least daily, monitor (shift-by-shift is suggested) for presence of targeted behavior(s) Document non-drug interventions implemented for targeted behavioral occurrences Periodically evaluation (quarterly, but more often is recommended) of targeted behavior(s), effectiveness of non-drug interventions and/or drug therapy with considerations for gradual dosage reductions 48

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50 Reducing Unnecessary Antipsychotic Medications Gradual Dosage Reduction: GENERAL GUIDELINES Monitor dosages regularly; consider adverse reactions, resident s response and level of functioning Review and trend behavior from monitoring system Titrate drug reduction slowly Monitor behavior stabilization 50

51 Reducing Unnecessary Antipsychotic Medications Gradual Dosage Reduction The physician may order dosage titrations downward at 1 to 2 week intervals. Everyone must know titration is happening to increase surveillance Keep documentation- what s working and what s not working Allow intervals of adjustments and continue to perform non-pharmacological interventions. 51

52 Care Planning Recognition or identification of the problem/need (target) Ongoing assessment (root-cause analysis & triggers) Identification of a diagnosis/cause Development of management techniques and/or treatments (non-pharmacological interventions / adjunct medications) Monitoring the efficacy and adverse consequences of those techniques and treatments Periodic reviewing, re-evaluating, and revising those techniques and treatments 52

53 It s not that caregivers have so much time, it s that they have so much heart. -Elizabeth Andrew 53

54 What s the Bottom Line? Identify ALL residents on antipsychotic medications Determine which antipsychotic medications are clinically appropriate Implement gradual dose reduction as needed/indicated Manage unmet needs (behaviors) through improved dementia care using person-centered care 54

55 Changing the Culture of Prescribing in Dementia Care 55

56 Change Starts with Asking Questions Does the interdisciplinary team question why the antipsychotic was initiated? Was it for an acute behavioral or psychological reason which may no longer be present? Does the interdisciplinary team recognize the actual number of occurrences of the behavior(s), or could they be recalling the severity of just a few distant behaviors when making decisions about dosage reductions (subjective views may be influencing opinions more than actual objective documentation from behavior monitoring)? If the targeted behavior is no longer present, or the resident is stable with non-drug interventions, or the behavior is no longer harmful to self or others, then ask why haven t dosage reductions been attempted? Is the drug kept unnecessarily? Does the staff have any preconceived notions which need to be addressed regarding attempted dosage reductions such as they have gone poorly in the past (the staff may be projecting those feelings with making requests for future attempts)? Are these behaviors distressing to family members who are unable to cope with the disease s progression? Do family members have unrealistic notions about antipsychotics such as they are used to improve dementia? Is the family hesitant about trying a dosage reduction due to the severity of distant behaviors? Are psychotropic drugs seen as a positive by the staff, to be utilized as the only solution for treating behavioral problems? It has become ingrained in our society that medications are the solution to all our woes. We seek them out, yet we rarely address their long-term consequences. 56

57 Changing the Culture of Prescribing in Dementia Care 57

58 Changing the Culture of Prescribing in Dementia Care 58

59 Changing the Culture of Prescribing in Dementia Care 59

60 Changing the Culture of Prescribing in Dementia Care 60

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62 Changing the Culture of Prescribing in Dementia Care 62

63 Elizabeth McManamy, RPh Pharmacist Quality Monitor Jennifer Wills, BSN, RN Nurse Manager DADS Quality Monitoring Program

64 Objectives At the conclusion of the presentation, the participate will be able to Describe at least two negative outcomes associated with the use of antipsychotic medications to manage pain related behaviors in elderly persons with dementia. Explain the three types of pain 64

65 Objectives Explain at least three common causes and related manifestations of pain in elderly persons with dementia Explain three best practice pain management strategies for elderly persons with dementia 65

66 Consequences of Antipsychotic Use Increased risk of stroke and death Side effects tremors, rigidity, restlessness, muscle spasms, drowsiness, dizziness, blurred vision, rapid heartbeat Can lead to immobility, decline in ADLs, decreased socialization, sleep disturbances, decreased appetite, depression, increase in behaviors 66

67 Untreated PAIN psychological 67

68 Consequences of Untreated Pain Immobility pressure ulcers, incontinence, circulatory and respiratory problems, falls Increased functional limitations decline in ADLs, decreased socialization Sleep disturbances, decreased appetite Depression and anxiety Agitation and aggression Inappropriate use of antipsychotics to treat pain related behaviors 68

69 OUCH! striking out 69

70 Impact of Dementia on Pain Estimated 35 million people worldwide have dementia 71% of Texas nursing home residents 65 y.o. and older have diagnoses of Alzheimer s, dementia or cognitive impairment 45-80% of nursing home residents with dementia experience pain on a daily basis Generally persons with dementia receive less pain medication than those who are cognitively intact 70

71 What is Pain? Pain is an unpleasant sensory or emotional experience Pain is present whenever a person says it is Pain may be acute or chronic/persistent 71

72 What is Pain? Nociceptive pain results from actual or potential tissue damage Neuropathic pain results from a disturbance of function or pathologic change in the peripheral or central nervous system Unspecified or Mixed pain results from unspecified or mixed mechanisms and includes both nociceptive and neuropathic pain 72

73 What Causes Pain? Degenerative joint disease Low back disorders Rheumatoid arthritis Gout Headaches Fibromyalgia Neuropathies Peripheral vascular disease Vertebral compression fractures 73

74 What Causes Pain? Post-stroke syndromes Oral or dental pathology Cancer Gastrointestinal conditions Renal conditions Immobility, contractures Pressure ulcers Surgical procedures Falls, other injuries 74

75 Pain is such an uncomfortable feeling that even a tiny amount of it is enough to ruin every enjoyment. - Will Rogers 75

76 Is it Pain? Frowning, grimacing Fearful facial expressions Grinding of the teeth Fidgeting, restlessness Striking out, increased agitation Sighing, groaning, crying Breathing heavily 76

77 Is it Pain? Decreasing activity levels, socialization Resisting certain movements Inability to participate in activities of daily living Depression, anxiety Changes in gait Eating or sleeping poorly 77

78 Pain Assessment Should be conducted on admission, quarterly and with a change in condition In a language the person understands According to the person s cognitive and verbal abilities Using a validated pain scale(s) 78

79 Validate Pain Scales Self-reporting pain intensity scales allow the resident to rate his/her pain Note: Wong-Baker Faces Scale is not recommended for use in the geriatric population Behavioral pain scales allow the licensed nurse to observe for behaviors which might suggest pain is present 79

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81 Self-reporting Pain Intensity Scales Numeric Rating Scale (NRS) Verbal Descriptor (VDS) Faces Pain Scale Revised (FPS-R) 81

82 Behavioral Pain Scales Pain Assessment in Advanced Dementia (PAINAD) Pain Assessment Checklist for Senior with Limited Ability to Communicate (PACSLAC) Discomfort Scale for Dementia of the Alzheimer s Type (DS-DAT) 82

83 Behavioral Pain Scale: PAINAD 5 observational indicators Breathing Negative Vocalization Facial Expression Body Language Consolability 83

84 Behavioral Pain Scale: PAINAD Score Breathing Independent of vocalization Normal Occasional labored breathing. Short period of hyperventilation Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations Negative Vocalization None Occasional moan or groan. Low level speech with a negative or disapproving quality Repeated troubled calling out. Loud moaning or groaning. Crying Facial expression Smiling, or inexpressive Sad. Frightened. Frown Body Language Relaxed Tense. Distressed pacing. Fidgeting Consolability No need to console Distracted or reassured by voice or touch Facial grimacing Rigid. Fists clenched, Knees pulled up. Pulling or pushing away. Striking out Unable to console, distract or reassure TOTAL 84

85 Mildred 85

86 Behavioral Pain Scale: PAINAD Score Breathing Independent of vocalization Normal Occasional labored breathing. Short period of hyperventilation Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations Negative Vocalization None Occasional moan or groan. Low level speech with a negative or disapproving quality Repeated troubled calling out. Loud moaning or groaning. Crying Facial expression Smiling, or inexpressive Sad. Frightened. Frown Body Language Relaxed Tense. Distressed pacing. Fidgeting Consolability No need to console Distracted or reassured by voice or touch Facial grimacing Rigid. Fists clenched, Knees pulled up. Pulling or pushing away. Striking out Unable to console, distract or reassure TOTAL 86

87 Behavioral Pain Scale: PAINAD Score Breathing Independent of vocalization Normal Occasional labored breathing. Short period of hyperventilation Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations 1 Negative Vocalization None Occasional moan or groan. Low level speech with a negative or disapproving quality Repeated troubled calling out. Loud moaning or groaning. Crying Facial expression Smiling, or inexpressive Sad. Frightened. Frown Body Language Relaxed Tense. Distressed pacing. Fidgeting Consolability No need to console Distracted or reassured by voice or touch Facial grimacing Rigid. Fists clenched, Knees pulled up. Pulling or pushing away. Striking out Unable to console, distract or reassure TOTAL 87

88 Behavioral Pain Scale: PAINAD Score Breathing Independent of vocalization Normal Occasional labored breathing. Short period of hyperventilation Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations 1 Negative Vocalization None Occasional moan or groan. Low level speech with a negative or disapproving quality Repeated troubled calling out. Loud moaning or groaning. Crying 2 Facial expression Smiling, or inexpressive Sad. Frightened. Frown Body Language Relaxed Tense. Distressed pacing. Fidgeting Consolability No need to console Distracted or reassured by voice or touch Facial grimacing Rigid. Fists clenched, Knees pulled up. Pulling or pushing away. Striking out Unable to console, distract or reassure TOTAL 88

89 Behavioral Pain Scale: PAINAD Score Breathing Independent of vocalization Normal Occasional labored breathing. Short period of hyperventilation Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations 1 Negative Vocalization None Occasional moan or groan. Low level speech with a negative or disapproving quality Repeated troubled calling out. Loud moaning or groaning. Crying 2 Facial expression Smiling, or inexpressive Body Language Relaxed Tense. Distressed pacing. Fidgeting Consolability No need to console Sad. Frightened. Frown Facial grimacing 2 Distracted or reassured by voice or touch Rigid. Fists clenched, Knees pulled up. Pulling or pushing away. Striking out Unable to console, distract or reassure TOTAL 89

90 Behavioral Pain Scale: PAINAD Score Breathing Independent of vocalization Normal Occasional labored breathing. Short period of hyperventilation Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations 1 Negative Vocalization None Occasional moan or groan. Low level speech with a negative or disapproving quality Repeated troubled calling out. Loud moaning or groaning. Crying 2 Facial expression Smiling, or inexpressive Body Language Relaxed Tense. Distressed pacing. Fidgeting Consolability No need to console Sad. Frightened. Frown Facial grimacing 2 Distracted or reassured by voice or touch Rigid. Fists clenched, Knees pulled up. Pulling or pushing away. Striking out Unable to console, distract or reassure 2 TOTAL 90

91 Behavioral Pain Scale: PAINAD Score Breathing Independent of vocalization Normal Occasional labored breathing. Short period of hyperventilation Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations 1 Negative Vocalization None Occasional moan or groan. Low level speech with a negative or disapproving quality Repeated troubled calling out. Loud moaning or groaning. Crying 2 Facial expression Smiling, or inexpressive Sad. Frightened. Frown Body Language Relaxed Tense. Distressed pacing. Fidgeting Consolability No need to console Distracted or reassured by voice or touch Facial grimacing Rigid. Fists clenched, Knees pulled up. Pulling or pushing away. Striking out Unable to console, distract or reassure TOTAL 8 91

92 Mildred 92

93 Comprehensive Pain Assessment Predisposing factors Onset of pain Location of pain Frequency of pain Duration of pain Description of pain 93

94 Comprehensive Pain Assessment Aggravating factors Relieving factors Validated pain scale(s) utilized Acceptable level of pain Current and previous treatment and results of both Impact of pain on individual s physical and psychosocial functioning ADLs and behaviors 94

95 Pain Re-evaluations Pain re-evaluations should be conducted for persons on routine medications or other nonpharmacological interventions based on the severity and chronicity of the pain. At least daily for response when starting a new medication At least weekly when well managed 95

96 Pain Re-evaluations Pain re-evaluations should be conducted before PRN pain medications are administered and after at peak effect of treatment. Peak effect of treatment: Timing when a person experiences the highest level of pain relief from a given intervention. 96

97 Pain Management Interventions Interdisciplinary team approach: Education Frequent assessment with consistent use of validated pain scales Pain medications and adjunct medications Non-pharmacological interventions Physician notification/communication 97

98 Analgesic Trials Serial Trial Intervention (STI) STI serves as a guideline for analgesic use when non-pharmacological interventions and other approaches have not been effective. 98

99 Non-Pharmacological Interventions Physical therapy Routine exercise Activities Massage TENS Aromatherapy Spiritual therapy Comfort foods Hot/cold therapies Music therapy Cryotherapy Diathermy/ ultrasound 99

100 Improving Outcomes One good thing about music, when it hits you, you feel no pain. - Bob Marley 100

101 Improving Outcomes Goal: Relief and control of pain. Outcomes consistent with evidence-based best practice: Implement the individualized interventions identified in the care plan Monitor and evaluate the individualized interventions for effectiveness 101

102 Evidence-based Best Practice Summary Assessment Recognize each person s cognitive and verbal abilities Use a language the person understands Complete comprehensive pain assessments on admission/readmission, change in condition and quarterly Re-evaluate the person s needs based on the severity and chronicity of their pain 102

103 Evidence-based Best Practice Summary Care Plan Process Identify the source(s) of the pain Develop measurable goals based on the assessment Develop individualized interventions Outcome Implement the individualized interventions identified in the care plan Monitor and evaluate the individualized interventions periodically for effectiveness 103

104 Knowing My Pain - by Kathy Pain-racked and unstable, Still, somehow, You see me as able. You see my cane as a toy, Used, not for need, But for ploy. You are not in my body, My pain you cannot feel. How dare you tell me My pain is less real? You may have pain, Others have pain as well. Pain is dealt with In many different ways. For some merely existing Can be a living hell. So, think ere you tell me There's something I can do, Because you don't know The pain I'm going through, You're not me And I certainly am not you! 104

105 Resources Agency for Healthcare Research Quality Centers for Medicare and Medicaid Services Food and Drug Administration Reference: Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: a systematic review Dallas P. Seitz, et al. Int Psychogeriatr. Feb 2013; 25(2): Cheryl L.P. Vigen, Ph.D. et al. Cognitive Effects of Atypical Antipsychotic Medications in Patients with Alzheimer s Disease: Outcomes from CATIE-AD. Am J Psychiatry August ; 168(8):

106 Resources The association of psychotropic medication use with the cognitive, functional, and neuropsychiatric trajectory of Alzheimer s disease P. B. Rosenberg, et al. Int J Geriatr Psychiatry. Dec 2012; 27(12): State Operations Manual Appendix Guidance/Guidance/Manuals/downloads/som107ap_pp_gu idelines_ltcf.pdf Nursing Home Compare: Use of Antipsychotics among Older Residents in Veterans Administration Nursing Homes WF Gellad, et al. Med Care Nov; 50(11):

107 Pain Management References American Medical Directors Association, American Society for Pain Management Nursing, American Geriatrics Society, International Association for the Study of Pain, American Academy of Pain Medicine, American Academy of Pain Management, Geriatric Pain: 107

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109 Additional trainings: Alzheimer s Disease & Dementia Care Seminar Virtual Dementia Tour Texas Taking the Next Step: Dementia in Long Term Care and Community Settings (Geriatric Symposium) August 20, 2015 in Austin TRAIN Big Bang Conference (not an official title) November & December 2015 in 5 locations around the state For more information: 109

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