COMFORT AS THE NEW MEDICINE: Reducing Psychotropic Medications. Tena Alonzo, MA Beatitudes Campus

Transcription

1 COMFORT AS THE NEW MEDICINE: Reducing Psychotropic Medications Tena Alonzo, MA Beatitudes Campus Learning Objectives: Describe three specific techniques that promote comfort for people with dementia. Define and describe at least three positive outcomes from initiating comfort for people with dementia. DISCLOSURE OF COMMERCIAL SUPPORT Tena Alonzo, MA does not have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and /or provider(s) of commercial services discussed in this presentation. 1

2 Comfort as the New Medicine: Reducing Reliance on Antipsychotic Medications for People with Dementia Tena Alonzo, MA Vice President, Education & Research Director, Comfort Matters Beatitudes Campus Beatitudes Campus Session objectives Describe three specific techniques which can be used to promote comfort for people with dementia Identify and describe at least positive outcomes from initiating comfort for people with dementia 2

3 I did then what I knew how to do. Now that I know better, I do better. Maya Angelou Why worry about antipsychotic medications? 1. Why do people with dementia receive this type of medication 2. Is there anyway to improve dementia care without using antipsychotic medications? 3. What is a reasonable and practical alternative? FDA Black Box Warning 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 seventeen placebocontrolled trials (model 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 come characteristic(s) of the patients is not clear. 3

4 Antipsychotic risks Analyses of 17 placebo controlled trials -modal duration of 10 weeks Majority of patients were taking atypical antipsychotic drugs, and had a risk of death in the drug treated group of between 1.6 to 1.7 times that seen in placebo treated patients. (death rate 2.6% in placebo / 4.5% in drug 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. Translating the risk Strong belief in pharmacology as a solution Numerous studies show very modest improvements At best only 20-30% showed even marginal improvement in behavior or function Thus 70-80% did not respond! Calculating the risk For every 53 dementia patients treated with these drugs one will die For every 9-25 that benefits one will die Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebocontrolled trials. JAMA, Oct ; 294(15): Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Atypical antipsychotic drugs and the risk of sudden cardiac death. NEJM, Jan ; 360(3): CMS Initiative to Improve Dementia Care and Reduce Antipsychotic Use Launched in March 2012 Seeks to reduce antipsychotic use in nursing homes currently at 19.8% nationally Focus on non-pharmacologic measures and gradual dose reduction of medication (GDR) New guidelines include a mandate to reduce antipsychotics further 4

5 How does Beatitudes Campus measure up The family connection Recognizing strength for people with dementia People with dementia are experts on their own comfort Emotions are intact-so we can change how a person feels even if we can t change how they think Information about the world around us can get into our brain through our 5 senses When verbal communication is compromised we communicate through our behavior/actions 5

6 I have dementia. Medication doesn t work-now what? The answer is comfort Merriam-Webster s definition 1. To give strength and hope to 2. To ease the grief or trouble of Synonyms: assure, cheer, console, reassure, soothe Antonyms: Distress, torment, torture, trouble The clinical definition for comfort Comfort care that is holistic in nature and includes interventions which address symptom control, psychological needs of patients and families, quality of life, dignity, safety, respect for personhood, and an emphasis on the use of intact patient abilities and manipulation of the environment. Kovach, Wilson & Noonan,

7 Barriers to comfort at Beatitudes Campus Everyone but the person with dementia didn t understand why comfort was so important Most staff and families have unrealistic expectations for the person with dementia Comfortable living is confused with end-of-life circumstances Evolution of care models Traditional Model All people used physical restraints All people received an antipsychotic and anxiolytic 25-40% weight loss every month Strict adherence to therapeutic diets Spent $18,000 annually on supplements Most people were resistive/selfprotective with care Sleep/wake were staff-driven Everyone showed symptoms of sundowning Total focus on medical needs Comfort Model No physical restraints Antipsychotic use is 2.7% and anxiolytic use is 2.7% Weight loss is less than 2% monthly NO therapeutic diets NO supplements used Resisting care/service is rare People sleep, wake & eat as they desire NO ONE shows signs of sundowning Total focus on mind, body, spirit Understanding a comfort culture Comfort is the goal for everything and is nonnegotiable Comfort is unique to each individual People with dementia are experts on their comfort Comfort is achievable for everyone regardless of circumstances Comfort is not just for end of life 7

8 What should comfort in longterm care look like? What makes sense to the person Sleep when s/he wants to Eat what s/he wants to Engages in what s/he wants to ADLs on her/his terms Everything that would make the person her/his best Dementia-related behavior What types of dementia- related behavior do you see? Resisting care/service Refusing medication and treatment Calling out Peer altercations Disrobing Exit Seeking Pacing The great myth People with dementia display dementia-related behavior and there s NOTHING we can do about it. 8

9 Human Behavior & Communication Since birth we communicate our needs through our behavior Our message can be subtle or not so subtle Humans interpret the meaning of words using behavior and we don t have to think about it People with dementia continue to make sense out of behavior even when they can t understand verbal language How dementia impacts human behavior-moderate Dementia Difficulty with short and long term memory. Struggles to learn new things Difficulties with understanding and being understood Knows comfort and discomfort Can t self regulate emotions Often easily upset or frustrated Can become fearful May misinterpret the actions of others How dementia impacts human behavior-advanced Dementia Limited/no short and long-term memory-the person lives in the moment Unable learn new information or pick up new routines Unable to carry on meaningful conversation May appear withdrawn and can have difficulty interacting or responding to surroundings 9

10 Road Maps What s a Road Map? How do you use it? Who should develop/use Road Maps? Resists Care/Service Road Map Dementia-specific behavior What is the person communicating? Possible remedies Resists care/service Physical pain Pain medication, repositioning, bed rest, ambulation Fearful Doesn t want to Slow down, soft approach, back off, Don t reason or confront Identify personal routine, back off Road Map Case Study Patricia, who has moderate dementia, recently moved to the nursing home. She rejects the staff attempts to help her bathe and at times she doesn t smell very good. Patricia has a history of spinal stenosis and two back surgeries. She has taken pain medication for the past 15 years but her physician recently discontinued it because she no longer complains of pain. During the bathing experience, Patricia strikes at the staff, yells you/re hurting me. When the staff report what s happening to Patrice s husband he asks for a medication to stop the behavor 10

11 Comfort Road Map - Patrice Dementia-specific behavior What is the person communicating? Possible remedies Final thoughts Human behavior is a legitimate form of communication Comfort is non-negotiable for people with dementia Comfortable people with dementia don t need antipsychotic medication Identifying the meaning of dementia-related behavior and what staff can do to create comfort improves quality of life for people with dementia and staff Thank you! Contact Information Tena Alonzo talonzo@beatitudescampus.org (602)