Behaviour Units: Understanding what they can offer Older Patients with Dementia

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1 Behaviour Units: Understanding what they can offer Older Patients with Dementia David K. Conn Baycrest Centre and University of Toronto 2013 Mount Sinai Geriatrics institute

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3 Outline Alice s journey continues BPSD in LTC brief overview Definition of Behaviour Support Units Studies of specialized units Optimal elements for success in these units

4 Alice s Journey Despite treatment of her pneumonia and CHF she remained agitated at times with episodic physical aggression towards staff and labile emotions. Symptoms of delirium improved but she did not return to baseline. After another week in hospital arrangements were made for a transfer to a Behaviour Support Unit in a local LTC Home

5 Neuropsychiatric Clusters in Dementia Aggression Agitation Apathy Aggressive resistance Physical aggression Verbal aggression Withdrawn Lack of interest Sad Amotivation Tearful Hopeless Low self-esteem Anxiety Guilt Depression Hallucinations Delusions Misidentifications Walking aimlessly Pacing Trailing Restlessness Repetitive actions Dressing/undressing Sleep disturbance Psychosis Adapted from McShane R. Int Rsychogeriatr 2000, 12(Suppl 1):147-54

6 AD patients with behaviours present (%) Neuropsychiatric Symptoms by Severity of AD 100 Mild (MMSE scores 21 30) Severe (MMSE scores 0 10) Moderate (MMSE scores 11 20) Adapted from Cummings and Back, 1998

7 A total of 74 studies examining the prevalence of psychiatric disorders and psychological symptoms in LTC populations were identified including: 30 studies on prevalence of dementia 9 studies on behavioural symptoms in dementia 26 studies on depression Int Psychogeriatrics, Nov. 2010

8 Prevalence of Dementia 30 studies 13 from N. America 12 from Europe 2 from Middle East 1 from Africa 1 from Asia 1 from Australia/ NZ 16 different diagnostic instruments

9 Range The estimated prevalence of dementia in nursing homes varied between 12.0% (Van den Berg, Spijker et al. 1995) and 95% (Serby, Chou et al. 1987) with a median prevalence of dementia of 58% from all the studies.

10 Prevalence of BPSD A total of 9 studies reporting the prevalence of behavioural symptoms in LTC resident with dementia or cognitive impairment were identified 6 from Europe, 2 from N. America, 1 from Australia

11 Range The prevalence of any behavioural symptom in LTC residents with dementia varied between 38% (Wancata, Benda et al. 2003) and 92% (Brodaty, Draper et al. 2001). The median prevalence of any behaviour symptom in dementia in LTC residents from the 9 studies was 78%.

12 Range. The prevalence of major depression in LTC ranged from 4% (Teresi, Abrams et al. 2001) to 25% (McSweeney and O'Connor 2008) the prevalence of depressive symptoms varied between 29% (McSweeney and O'Connor 2008) to 82% (Lin, Wang et al. 2007).

13 Prevalence of BPSD in Community and Nursing Home (Lyketsos et al, Brodaty et al, 2001) Overall Prevalence Clinically Significant Community (%) Delusions Hallucinations Nursing Home (%) Depressed Mood Aggression / Agitation

14 Possible Etiologies of Aggression / Agitation Caregiver related Environment related Manifestation of a medical disorder r/o pain / discomfort Psychiatric comorbidity Delirium Medication side effects Neurotransmitter changes Cohen-Mansfield J et al. Int Psychogeriatr. 1992;4(2): Mintzer JE, Brawman-Mintzer O. J Clin Psychiatry. 1996;57(7):55-63.

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16 Brodaty et al, MJA, in press (2003;178(4)) Brodaty et al, MJA, 2003: 178:

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22 Principles that promote and support mental health for all LTC residents (CCSMH, 2006) individualized, person-centred care; respect for family ties; a biopsychosocial care planning framework; a culture of caring that prioritizes quality of life; a social and physical environment that is responsive to changing needs; a focus on early intervention and prevention as well as treatment; and staff training and development

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25 Behavioural Support System: Essential Elements

26 Behavioural Support Units (MOHLTC, 2007) Specialized treatment units located in selected LTC homes that focus on the treatment and stabilization of individuals with aggressive behaviours Do not rquire a hospital inpatient unit but they are not ready to return to a normal LTC home environment Transitional - a LHIN resource

27 Behavioural Support Unit (BSU) Recommendations (2007) BSUs be created as a regional resource Staffing ratio of regulated to unregulated ranging from 40:60 to 50:50 rather than 20:80 Staffing levels of allied HPs be increased to include a range of providers. Regular access to pharmacist Maximum of 15 to 20 residents

28 Behavioural Support Unit (BSU) Recommendations - cont. (2007) Support patient choice BSUs should be affiliated with a LTC home or another facility Admissions managed by CCAC in cooperation with PG team Regular priority review of admissions & discharges Highly specific admission & discharge criteria

29 Behavioural Support Unit (BSU) Recommendations - cont. (2007) Residents being transferred to a LTC setting should have assistance from a PG Outreach team BSUs must be funded from outside the current resident classification system Referrals to PG Outreach team mandatory if resident has potential for aggression

30 Longitudinal study comparing residents of SCUs versus those in traditional NHs Nobili et al Alz Dis Assoc Disord (2008) 349 res in 35 SCUs vs. 81 res in 9 NHs Res admitted to SCUs were younger, less cognitively and functionally impaired but had more behavioural problems Over 18 months SCU residents had less hospitalization, less use of physical restraints and had a higher rate of withdrawal from antipsychotics

31 Cross-sectional study of 28 SCUs compared with traditional care in Germany Weyerer et al. Int J Ger Psych (2010) 594 res in SCUs vs. 573 res in usual care After controlling for confounding variables: In SCUs. - More social contact to staff - More involvement in activities - More volunteer involvement - Fewer physical restraints - More use of psychiatrists - Less antipsychotics, more antidepressants

32 Special Care Units & Outcomes: National NH Survey 2004 Luo et al The Gerontologist Residents of SCUs more likely to receive specialized dementia care and behavioural management vs. residents in regular units or in NHs without an SCU. They were less likely to have bed rails, use catheters, more likely to have toilet plans, bladder training Less likely to have pressure ulcers, be hospitalized, or have weight loss More likely to have falls. In general residents in SCUs had better care processes.

33 Are Special Care Units better for individuals with behavioural problems? Cochrane Review 2009, Lai CK et al. No RCTs 4 studies available with extractable data Studies suggested a small improvement in NPI scores favouring SCUs & less use of physical restraints Authors concluded that there is no strong evidence of benefit from a SCU. They suggest the implementation of Best Practices is most important!

34 Principles that promote and support mental health for all LTC residents (CCSMH, 2006) individualized, person-centred care; respect for family ties; a biopsychosocial care planning framework; a culture of caring that prioritizes quality of life; a social and physical environment that is responsive to changing needs; a focus on early intervention and prevention as well as treatment; and staff training and development

35 Environmental design Fleming and Purandare (2010) recently reviewed 57 studies and synthesized the evidence with respect to environmental design in LTC Recommendations Re: - Spaces - Security - Single Rooms - Sight lines - Stimulation - Small, homelike, engage in ADLs, outside spaces

36 CCSMH: Assessment & Detailed Investigation We recommend Core elements of a detailed investigation should include history and physical exam, with follow up laboratory and psychological investigations, investigations of the social and physical environment, and diagnostic tests as indicated by the results of the history and physical exam, and treatment history and response. [C] It is important to consider all contributing factors. Investigation of potentially contributing factors (e.g., delirium, chronic pain) should refer to clinical practice guidelines for these conditions where available. [D]

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39 Assessment Scales The Cohen-Mansfield Agitation Inventory (CMAI) Long Form 2 Assesses frequency of 29 agitated behaviours rated by the caregivers on a 7 point scale The Neuropsychiatric Inventory (NPI) and NPI-NH assesses 12 items: frequency (1-4) multiplied by severity (1-3) delusions hallucinations agitation/aggression depression anxiety elation/euphoria apathy disinhibition irritability aberrant motor beh nighttime beh appetite/eating 2. Cohen-Mansfield J. J Am Geriatr Soc 1986; 34: 722 7

40 Behavioural Symptoms: Psychological and Social Interventions We recommend Social contact interventions should always be considered, especially where the goal is to minimize sensory deprivation and social isolation, provide distraction and physical contact, and induce relaxation. [C] Sensory/relaxation interventions (e.g., music, snoezelen, aromatherapy, bright light) should be considered where the goal is to reduce behavioural symptoms, stimulate the senses and enhance relaxation. [B/D] Consider the need for promoting structured activities that engage the resident. [C] Individualized behaviour therapy should be considered where the goal is to manage behaviour symptoms (e.g., contextually inappropriate, disturbing, disruptive or potentially harmful behaviours). [C]

41 Non-Pharmacological Interventions (Beck & Shue, 1994) Behavioural techniques / staff training Environmental modifications Group programs (e.g. exercise, dancing ) Light Therapy Music Therapy Social Interaction / Psychosocial activities Multimodal Approaches Pet Therapy

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44 Included Studies Total number of studies N=40 Total number of participants: 3,519 Sample size: median 80 (range ) Median age participants: 84 years Gender distribution: 78% female Cognitive impairment: MMSE = 5 10 Study duration: median 12 weeks (range of 1 52 weeks)

45 Efficacy of Interventions 16 of 40 (40%) studies reported statistically significant benefits for nonpharmacological intervention : Staff training N=3 (McCaillion, 1999; Chenoweth, 2009; Testad, 2010) Mental health assessment N= 2 (Rovner, 1996; Cohen- Mansfield, 2007) Psychosocial activities N=2 (Toseland, 1997; Lichtenberg, 2005) Exercise N=3 (Alessi, 1999; Landi, 2005; Williams, 2007) Music N=2 (Sung, 2006; Raglio, 2008) Other sensory stimulation N=4 (Ballard, 2002; van Weert, 2005; Woods, 2005; Hawranik, 2008)

46 Montessori Approach Cameron Camp, Gail Elliot Places emphasis on the environment, including activities designed for each individual s level of ability, based on interests and needs AND provides necessary cueing to support memory loss Emphasis is placed on assigning meaningful roles & routines When fully engaged behavioural challenges are eliminated

47 Memory Boxes Aids in the recollection of details about someone's life. Can prevent anxiety, frustration and agitation. Memory boxes need information about items displayed in the case to support declarative memory loss. Before After

48 Memory Boards: Let s Know our Residents

49 Washrooms (BSU) Contrast: Walls are now a different colour than the items hung on the wall Before After Where is the paper towel dispenser?? Where is the paper towel dispenser?? Contrast

50 Shower Room Where would you prefer to Before shower? After

51 Behavioural Management Approach Cognitive Assessment Behavioural Assessment (ABC Analysis) Staff Perceptions Utilize Extinction, Reinforcement, Prompting Staff Stress Innoculation Rewilak, 2001

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53 Remembering the forgotten: psychotherapy groups for the nursing home resident. Ken Schwartz Int J Group Psychother Oct;57(4): Weekly groups Co-facilitated by social worker from the unit An integrated model utilizing developmental, cognitive-behavioral, and psychodynamic approaches

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55 Questions to be asked in evaluating any drug use in a NH Avorn & Gurwitz, 1995 What is the target problem being treated? Is the drug necessary? Are nonpharmacologic therapies available? Is this the lowest practical dose? Could discontinuing therapy with a medicine help to reduce symptoms? Does this drug have adverse effects that are more likely to occur in an older pt.? Is this the most cost-effective choice? By what criteria, and at what time, will the effects of therapy be assessed?

56 Good Drugs or Bad Drugs? (more good than harm or more harm than good) Let s Vote re: older adults in LTC Antidepressants Benzodiazepines with a long half life (e.g. diazepam) Benzodiazepines with a short half life (e.g lorazepam) Antipsychotics Cholinesterase Inhibitors (e.g. Aricept)

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58 Medication Use in 2004 National Nursing Home Survey Participants and Estimates in U.S. Nursing Home Population NNHS Sample Estimates for U.S. Nursing Home Population Total Number Age 65 years 11,940 1,317,292 Any Antidepressant, N (%) 5,567 (46.6) 603,691 (45.8) Any Antipsychotic, N (%) 2,890 (24.2) 324,771 (24.7) Any Benzodiazepine, N (%) 1,498 (12.5) 158,147 (12.0)

59 Medication Use in 2004 National Nursing Home Survey participants: rates of use of cholinesterase inhibitors National Nursing Home Survey (n=5866) U.S Nursing Home Population (N=665,217) Any ChEI No ChEI Any ChEI No ChEI Total Number of Individuals with Dementia (%) 1696* (28.9) 4170 (71.1) 199,296* (30.0) 465,921 (70.0) Total Num Receiving ChEIs (%) Donepezil Rivastigmine Galantamine 1192 (20.3) 237 (4.0) 268 (4.5) ,649 (21.3) 26,986 (4.1) 30,833 (4.6) Seitz et al. JAGS, 2009

60 Mental Health Care System in LTC Facilities Intrinsic Provided by the frontline staff of the facility Extrinsic Mental Health and other professionals (usually visiting consultants or outreach teams)

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63 Quality of the educational input Individual motivation Nature, complexity and acceptability of the proposed change initiative Receptivity of the care environment and its organizational context

64 Conclusions Literature on the effectiveness of Behavioural Support Units / SCUs is sparce. No RCTs. Some studies suggest less use of physical restraints and more optimal use of medications in SCUs vs usual care. Little data on staffing levels. Clear need for significantly higher levels with a full complement of health disciplines. Several models for mental health service provision exist. Clear need for involvement of staff with high levels of expertise. Education & training of staff is essential.