Caring for the Dementia Patient: Evidence Based Practice

• Lisa Krier

The population of elderly people in society is continually increasing, which places demands on the health care system. Drugs are extensively used in the elderly, and when the patients have dementia, this raises their level of vulnerability (Jedenius, Johnell, Fastbom, Stromqvist, Winbald & Andreasen, 2011). The administration of psychotropic drugs to dementia patients experiencing out of character responses has become increasingly controversial. Many of these drugs come with black-box warnings from the FDA, have not been approved for use in patients with dementia and are not recommended for the elderly. Many of these drugs have shown to be harmful in the elderly, decreasing quality of life and even leading to death, and have adverse effects (Azermai, Elseviers, Petrovic, Van Bortel, & Vander Stichele, 2011). Nurses have two options when dementia patients experience out of character responses, 1) administer a psychotropic medication to calm the resident, or 2) use a therapeutic approach to calm the patient without the potential of adverse side effects that medications pose (Logsdon, McCurry, & Teri, 2007).

Change Model Overview

The John Hopkins Nursing Evidence-Based Practice Process consists of defining the practice question, gathering, appraising, and synthesizing the available evidence, and then translating the plan into the clinical setting. Nurses with various levels of education have been able to use this process successfully with mentors assisting and the support of their organizations. Nursing professionals find this process beneficial in understanding the elements of nursing intervention and implementing the evidence found into their practice setting (Dearholt & Dang, 2012)

Practice Question

Step 1: Identify an EBP question

The population involved in this evidence-based practice question is dementia patients who experience out of character responses. The intervention being utilized is the use of therapeutic approaches to calm the dementia patient, compared with the use of psychotropic drugs to calm the dementia patient suffering an out of character response. The desired outcome is to see a decrease in the number and severity of out of character reactions in the patients, along with fewer adverse side effects that psychotropic medications may have (Jeste et al., 2008).

Step 2: Scope of practice question

The population of elderly in the United States is steadily increasing and many of these elderly will require the services of a long-term care facility sometime in their life (Harris-Kojetson, Sengupta, Park-Lee, & Valverde, 2013). It is estimated that 69% of residents in long-term care facilities were taking at least one psychotropic medication (Galik & Resnick, 2013). Out of character reactions are common in patients with dementia, but there is no FDA approved drugs to deal with these responses in the dementia patient. The unlabeled use of psychotropic medications is commonly used, even though many of these drugs come with black-box warnings from the FDA. These drugs can cause postural hypotension, sedation, falls, and even mortality, especially with the use of atypical antipsychotics (Jeste et al., 2008). The cost of fall related injuries are estimated to be between $16 and $19 billion annually for nonfatal injuries and around $170 million for deaths resulting from falls, adding additional demands on an already stressed health care system (Currie, 2008).

Steps 3, 4, and 5: Team

The team members involved in this pilot project consist of the Memory Support Coordinator, the Life Enrichment Coordinator, the night shift nursing supervisor, the day shift nursing supervisor, two Certified Nursing Assistants from the day shift and one Certified Nursing Assistance from the night shift. All of the selected participants have direct patient contact and work in the Memory Support Unit with all of the patients having a diagnosis of dementia. The Memory Support Coordinator will be the project’s bridge to the facility’s administration. The chosen team members will be trained in therapeutic approaches to maintain a calming environment and to utilize when any of the patients experiences an out of character response.

Evidence

Steps 6 and 7: Internal and external search for evidence

The quantitative research that was obtained for this projected consisted of three peer-reviewed research articles and one systematic review. One of the peer-reviewed research articles that was utilized for this project was of high evidence, with the other two peer-reviewed research articles containing good evidence. The systematic review that was used consisted of several randomized controlled trials. All of the articles used for this project did make recommendations based upon the evidence cited in the research.

Steps 8 and 9: Summarize the evidence

One of the peer-reviewed research articles that was obtained was of high strength and evidence. It consisted of a randomized study, a large sample size, a control group, and detailed the physical outcomes of dementia patients receiving psychotropic medications. The study recommends that careful consideration of the adverse effects of psychotropic medication used in the elderly along with further longitudinal studies is necessary to fully explore the impact these medications have on the elderly (Galik & Resnick, 2013). The other two peer-reviewed research articles that were obtained were of good evidence and strength. One of the articles consisted of a systematic review of randomized clinical trials and discussed behavioral treatments that were successful in treating behavioral disturbances in dementia patients (Logsdon, McCurry, & Teri, 2007). The third peer-reviewed research articles utilized for this project was a randomized study to discuss the prevalence of psychotropic medications used in nursing homes in relation to patient’s behaviors. The article consisted of a randomized study with a large sample size, but the study did not have a control group. Several recommendations were cited, including the withdrawal of psychotropic therapy in the elderly population (Azermai, Elseviers, Petrovic, Van Bortel, & Stichele, 2011). The final research that was used for this project was a systematic review of randomized, controlled trials that had adequate sample sizes and control groups. This article discusses the two approaches used in treating dementia patients with behavior disturbances, pharmacological and behavioral. The articles discuss what is known and what is not known in regards to the two approaches and make several clinical and research recommendations (Jeste et al., 2008).

Step 10: Recommendations for change

All of the articles used in this project discussed the adverse effects of psychotropic medication use in this population and the fact that these medications are not effective in treating behavior disturbances in the dementia patient. When psychotropic medications are used to treat out of character responses in the elderly, they are being prescribed off-label as the FDA has not approved any of these medications for treating behavioral disturbances in the dementia patient. Also, many psychotropic medications come with black-box warnings from the FDA and have been proven to have many adverse effects, especially in the elderly population (Jeste et al., 2008). Two of the articles discuss the success of the use of therapeutic approaches in calming the dementia patient experiencing an out of character response. What makes the use of therapeutic approaches exciting is that there are no adverse physical effects associated with them and the quality of life is not diminished, and may possibly be enhanced, in the dementia patient (Logsdon, McCurry, & Teri, 2007).

Translation

Steps 11, 12, and 13: Action plan

This pilot study will take place in the Memory Support Unit, which is home to approximately 36 residents, all of whom have a diagnosis of dementia. The eight faculty members that will be participating in this study will all attend a three-day training seminar on how to recognize the early signs of residents who are becoming anxious, and implementing therapeutic approaches for these patients to calm them rapidly and efficiently without the use of medication. After the training seminar, the staff will meet on a biweekly basis and carefully review each resident’s life story to become familiar with their history and likes or dislikes to design therapeutic approaches that are appropriate for the individual patient, as well as thoroughly examine the behavioral monitoring sheets of each resident who experiences out of character responses. The primary emphasis for the team will be to maintain a calm, quiet environment to prevent the onset of out of character responses, and decrease the number and severity of these behavioral disturbances. This project will be evaluated during each biweekly meeting, to see if the therapeutic approaches being used are effective for the individual residents by reviewing their behavioral monitoring sheets. Any changes to the resident’s individual care plan will take place during these meetings. The pilot study will be evaluated after the first six months to review the effects of any dosage reductions in psychotropic medications for individual residents and the efficacy of any therapeutic approaches utilized to manage their out of character responses. The Memory Support Coordinator will report the results to the administration of the facility and will discuss the findings at the weekly department head meetings.

Steps 14 and 15: Evaluating outcomes

It is the objective of this pilot study to see dosage reductions in any psychotropic medications being used, and eliminated altogether if possible, and to see the number and severity of out of character responses decreased without the use of psychotropic medication. Residents in the Memory Support Unit who receive psychotropic medications have their records reviewed by the pharmacist on a quarterly basis and recommendations for dosage reductions of these medications are then forwarded to the physician. Residents in the Memory Support Unit have detailed behavioral sheets where any behavioral disturbances are noted, how many times these disturbances occur per shift, any therapeutic interventions utilized before the administration of a prn medication, the efficacy of the intervention utilized, and any side effects noted from the administration of psychotropic medications. The behavioral sheets will be monitored on a weekly basis by the Memory Support Coordinator to see if there have been changes in any of the categories previously mentioned. Therapeutic approaches that have proven to be effective for individual residents will be added to their care plans. The individual results for each resident will be discussed at the biweekly meetings attended by the pilot study staff and the Memory Support Coordinator will forward this information on to the administration of the facility.

Steps 16, 17, and 18: Implementation

As there are dementia residents in every part of the facility, they also have behavioral monitoring sheets where the same information is recorded as those patients residing in the Memory Support Unit. After the initial pilot study staff have been trained and are utilizing therapeutic responses with all of the individuals in the Memory Support Unit, the entire staff in the Unit will be trained and coached by the pilot study staff. After the training has been completed in the Memory Support Unit, staff in the other areas of the facility will be trained and coached by the Memory Support Unit staff and will begin implementing the appropriate therapeutic approaches for their individual patients. The implementation of gradual dose reductions of psychotropic medications, unless clinically contraindicated, is mandated by CMS guidelines, as well as individualized approaches to person-centered care (CMS, 2013). This ensures that the implementations set forth in this pilot study will become permanent. The behavioral sheets for every resident with a diagnosis of dementia and/or receive psychotropic medications will continue to be monitored and discussed at the risk meetings that are attended by all department supervisors on a weekly basis. The results of this study will be entered into a database for forwarded to the home office, to be shared with all of the facilities in the organization.

Conclusion

The administration of psychotropic medications to elderly patients, especially those suffering from dementia, has been increasingly controversial. Currently there are no medications approved by the FDA for use in dementia patients suffering from behavioral disturbances, and if these drugs are being utilized, they are being prescribed for off-label use (Jeste et al., 2008). Psychotropic medications have shown to have negative effects on the physical function of elderly patients (Galik & Resnick, 2013), even leading to mortality (Azermai, Elseviers, Petrovic, Van Bortel, & Vander Stichele, 2011). Guidelines from the CMS mandate that gradual dose reductions be attempted for all psychotropic medications, unless clinically contraindicated, and individualized approaches to person-centered care are utilized (CMS, 2013). After thoroughly examining the evidence from the research articles, the pilot study staff will be trained in the use of therapeutic approaches to deal with resident experiencing out of character responses. As the pilot staff becomes comfortable with implementing these approaches, the staff in the rest of the facility will be trained. The behavioral sheets for each resident will be monitored, and the therapeutic approaches that have proven to be effective for each resident will be added to their individual care plan. The behavioral sheets will be reviewed each week at the risk meetings attended by all department supervisors, and any appropriate changes will be made to the resident’s individualized care plans. The goal of this pilot study is to decrease the dangerous effects of psychotropic drug use in the elderly (Azermai, Elseviers, Petrovic, Van Bortel, & Vander Stichele, 2011), as well as improve their quality of life with the use of therapeutic approaches specifically tailored to their individual needs and wants (Logsdon, McCurry, & Teri, 2007).

References

Azermai, M., Elseviers, M., Petrovic, M., Van Bortel, L., & Vander Stichele, R., (2011). Geriatric drug utilization of psychotropics in Belgian nursing homes. Human Psychopharmacology, 26, 12-20.

Center for Medical & Medicaid Services. (2013). Center for clinical standards and quality survey & certification group. Retrieved from http://www.google.com/url?sa=t&rct=j&q=&eloading="lazy" src=s&source=web&cd=1&ved=0CB4QFjAA&url=http%3A%2F%2Fwww.cms.gov%2FMedicare%2FProvider-Enrollment-and-Certification%2FSurveyCertificationGenInfo%2FDownloads%2FSurvey-and-Cert-Letter-13-35.pdf&ei=6g1xVO4V6YmxBMW8gdgE&usg=AFQjCNH-POJP2PwdaIXyFpIGmzHN-vDrKw

Currie, L. (2008). Fall and injury prevention. In R. Hughes (Ed.). Patient safety and quality: An evidence-based handbook for nurses. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK26531

Dearholt S. L., & Dang, D. (2012). John Hopkins nursing evidence-based practice: Model and guidelines (2^nd ed.). Indianapolis, IN: sigma Theta Tau International.

Galik, E., & Resnick B. (2013). Psychotropic medication use and association with physical and psychosocial outcomes in nursing home residents. Journal of Psychiatric and Mental Health Nursing, 20, 244-252.

Harris-Kojetson, L., Sengupta, M., Park-Lee, E., & Valverde, R. (2013). Long-term care services in the United States: 2013 overview. Hyattsville, MD: National Center for Health Statistics.

Jedenius, E., Johnell, K., Fastbom, J., Stromqvist, J., Winbald, B, & Andreasen, N. (2011). Dementia management programme in a community setting and the use of psychotropic drugs in the elderly population. Scandinavian Journal of Primary Health Care, 29, 181-186.

Jeste, D. V., Blazer, D., Casey, D., Meeks, T., Salzman, C., Schneider, L., … Yaffe, K. (2008). ACNP white paper: Update on use of antipsychotic drugs in elderly persons with dementia. Neuropsychopharmacology, 33, 957-970.

Logsdon, R. G., McCurry, S. M., & Teri, L. (2007). Evidence-based psychological treatments for disruptive behaviors in individuals with dementia. Psychology and Aging, 22(1), 28-36.