Behavioural and Psychological Symptoms and Medications Presentation

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3 Vover s research indicated that antipsychotic med are frequently used for individual presenting with disruptive behaviours. This often combined with physical restraints Efficacy of use not justify use. Effects are undesirable anticholinergic effects and extra-pyramidal effects 3

4 Research found the use of these drugs in residents with dementia increases the risk of mortality. These residents will have shorter life spans than their non drugged counterparts 4

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6 Auditor General Report May

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9 Antipsychotic medications are used to treat a variety of symptoms in psychotic disorders, delusional depression and dementia. In order to identify a change, close monitoring i and documentation ti of behaviors is needed before and during use. Since these medications are not free of side effects, it is important to review the inventory of target behaviors prior to commencing the medication and on a regular basis after the drug treatment is initiated. Step 1: Initial Screen EVERY box on the BSMT must be completed with either a Y for yes or N for no. Absence of documentation ti (empty boxes) can not be interpreted t making review and evaluation of behaviour extremely difficult Section A must be completed for every client as part of a screening process. It is a tool to identify patients suitable to receive antipsychotics and documentation of that decision making process. **Note: For new admissions already on antipsychotic agents, start with Step 1 then skipping to Step 3. Current residents should have step 1 completed to establish a base line for behaviours. Rule Out Other Causes: Any of these clinical or environmental causes may be contributing to the behaviors and can likely be managed by other means than drug therapy. Check accordingly and review any identified possible causes to determine if applicable in this situation. Non-Drug Interventions. Due to risk of complications of medication, behavioural interventions should always be trialed completely and consistently prior to the consideration of any medicinal interventions. Document responses in comments section. 9

10 Medications have often been prescribed to manage behaviours for which it may have little or no effect. 10

11 Section B: Define and Describe Behaviour This section is to guide the health care professional in deciding if the behaviour may or may not be treatable with medication. A clear understanding of behaviour will facilitate this process. WILL NOT RESPOND To Antipsychotics. Medications have often been prescribed to manage behaviours for which it may have little or no effect. MAY Respond to Antipsychotics. In addition to indicating which behaviours are occurring, a narrative description is required to further ensure that the medication is being considered for the appropriate reason and could be feasibly managed by medication. 11

12 Wandering, Insomnia, Impaired memory, Lack of social behaviour skills, Poor self care practices, Fidgeting or nervous twitching, Inappropriate eliminations, Indifference to surroundings, Resists care, Hoarding, Restless pacing, Inappropriate Vocalizations Non pharmacological treatments fall into categories: safety focused care,-electronic wander monitoring, physical restraint i.e. broda chairs due to agitation/aggression resident education, - involves explanations to residents and families re symptoms and treatment behaviour focused care, supportive/comfort therapies, activity therapies, and environmental modification 12

13 Recent work by Kverno e tal state that in advanced dementia treatment goals shift from prolonging life to maximizing quality of life, dignity and comfort Delusions- theft, paranoia, false beliefs Hallucinations Hearing or seeing things, sensory, Picking Aggression grabbing/hitting, biting/spitting, swearing/screaming, temper outbursts, sexually aggressive Anxiety negative attitude, repetitive questions, tearful/guilt, restless/ unsettled, sleep patterns Agitation Elopement attempts, constant requests, interfering behaviour, pacing, shadowing Describe behaviour- Physically treatens staff when doesn t get her way. A narrative description of the behaviour is required to ensure that the medication is being considered for the appropriate reason and that the behaviour could be managed by that medication 13

14 It is strongly recommended that two weeks of behavior mapping be documented prior to initiating any drug therapy to serve as a baseline. The mapping will consist of completing Part A: Behaviour and Part B: Baseline Status. Mapping should be initiated by nursing upon identification of a behavioural concern in order to facilitate any required treatment regimes. After two weeks of behavior mapping, the situation will be reviewed by the physician to determine if the presenting behaviors are still within the treatment parameters and the plan for initiating drug therapy should go forth. A section has been designated for the physician and pharmacist to sign on a weekly basis. In a challenging unpredictable situation a physician may be visiting on a weekly basis although it is acknowledged that this is not a requirement. The physician may review the data at the end of the initial two weeks via fax or phone rather than on-site. **Note: Resident and staff safety should not be compromised in order to complete two weeks of behaviour mapping if initiation of medication sooner is clinically indicated. In this situation, at least one column of Step 2 should be completed retrospectively while proceeding with Step 3. Step 2 mapping is divided into two sections: Behaviours. Documentation of y for yes or n for no is required. This answer should best summarize the preceding 24hour time period. Severity and frequency documentation is not required here as that should be captured under either more detailed mapping or in the narrative progress record. Reportable Side Effects. The purpose is to provide an easy to follow guide to assess for the more common side effects of the drug therapy. Place a Y or N in the corresponding column to indicate if the side effect has been observed. 14

15 Decision making occurs after 2 weeks of behaviour mapping on page 2 15

16 Right Medications for the Right Reason The health care team will review the mapping and current status 16

17 Section C: Decision Making Should be completed by the Physician Medical Risks & Considerations. This section is designed to trigger a review of any medical condition(s) that may increase the risk of adverse events for the patient. The physician, upon reviewing the existing medical conditions will determine if the risks preclude the use of antipsychotics. Due to the potential for significant adverse effects, clear documentation of consent is required. Discussions surrounding usage should occur between the physician and resident/family. It is likely that this section may be completed at a later date than the initial screen once a more thorough assessment has been completed. The assessment data will likely include the initial behaviour mapping. 17

18 Step 3: Assessment Response to Medication The purpose of this step is to document an ongoing assessment of the patient following the commencement of drug therapy. Step 3 mapping should commence as soon as any drug therapy has begun and continue daily for a minimum of 2 weeks or longer as further medication adjustments are made, until the behavior is resolved or drug therapy is deemed ineffective. Again, Step 3 is divided into two sections. See Step 2 instructions with the exception of part B (Side Effects) where the assessor is asked to look at change in baseline to assist in determining if side effects are present. Upon completion of the trial, the attending physician, professional nurse and clinical pharmacist will review the behavior mapping and clinically assess the effectiveness of the drug therapy to determine if this drug therapy will be continued. **Note: An observed change in any of these side effects should be reported to physician. 18

19 - Extrapyramidal (Parkinsonian) effects which include tremor (pill rolling), stiffness in limbs (cog- wheel rigidity), idit shuffling gait, drooling, stooped or leaning posture, acute dystonias (often of the neck). These symptoms may be a warning of the possible development of tardive dyskinesia, especially if they occur early in the course of treatment. Tremors, drooling, cogwheeling "Tardive Dyskinesia is a frequent, often irreversible, side effect of antipsychotic agents. Tardive dyskinesia presents as a combination of one or more of the following: - involuntary movements of the face, jaws, mouth, lips and eyes; -movements may be accompanied by uncontrolled grunting, groaning and/or lip smacking - involuntary movements of the limbs (which may lead to gait disturbance) Tardive dyskinesia is usually a complication of long term antipsychotic use (months to years of therapy) but may occasionally develop after only a few months of continuous use. Other side effects include: - Akathisia - increased restlessness which usually worsens with increasing doses of medication -Increased ddrowsiness/sedation d -Dehydration contributing to constipation and dry mouth -Weight gain in the presence of diabetes -Excessive or unnecessary disability 19

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21 Step 4: Maintenance Record Documentation of the ongoing monitoring is tracked here. This will provide the physician with information to complete the required monthly assessment. This section is a continuation of Step 3 and the items being assessed are exactly the same. One new item to be measured it the number of PRNs used in the time period being assessed. This shall be entered as a numeric value. Note: The scoring has changed. (It is no longer Y or N ) It will be scored as behavior that best reflects the frequency of behaviors and side effects occurring over the 30 days prior to the day being scored 0 behavior/side effect did not occur. 1 behavior/side effect occurred once 2 behavior/side effects present more than once but less than every day 3 behavior/side effects present daily 4 behavior/side id effects present more than once daily Enter a numeric value from 0 through 4 in EVERY box. *Documentation of the presence of a particular behavior or side effect on the BSMT does not replace regular documentation in the progress record. Complete documentation of assessments is still required. One column should be dated and completed each month. The BSMT and all other mapping tools used will become part of the patient s resident s permanent record. 21

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25 Given the side effects of these drugs, it is important to keep length of exposure to antipsychotic medications to a minimum when they are used for BPSD. Once success has been achieved, consideration of a gradual decrease in medication dose, again in the presence of behaviour mapping, is indicated. Initiate medication reductions after the behaviours have been successfully resolved for six months. 25

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