Elisabeth Antifeau, RN, MScN, GNC(C)

Community Integration Health Services

Practice Lead, Complex/Special Populations

and Palliative Care/End of Life.

Interior HealthNelson, BC

Disclosure - Elisabeth Volunteer Director on the BC Psychogeriatric Association

Board since 2006 – currently holding the Practice Supports Portfolio

June 2014 – Received an honorarium from Medical Pharmacies Group Ltd. to deliver an unrestricted educational event for residential nursing staff on the topic of NON-pharmacological interventions for BPSD.

Within my IH role, I am the representative for Interior Health on various provincial and cross agency working groups addressing dementia, behaviours and system level supports.

Dementia, Behaviours and DilemmasElisabeth

Getting on the same page about dementia, behaviours (BPSD) and dilemmas

How big a problem is it?

Principles of caring for people with BPSD

What can be done? Approaches and tools…

Highlights of the BPSD Algorithm www.bcbpsd.ca

Janice:

Behavioural Support Planning

Clinical example(s)

Questions and Answers – both presentations

Dementia – DSM-V

Mild to Major Neurocognitive Disorder due to:

Alzheimer Disease

Lewy Body Disease

Frontotemporal lobar degeneration

Vascular Disease

Parkinson’s Disease etc.

With/Without Behavioural Disturbance

“Behavioural Disturbance”

A behavioural continuum ranging from mild to severe that includes the following characteristics:

Dangerous

Distressing

Damaging

Disturbing

Persistent

What is BPSD?BPSD = Behavioural and Psychological Symptoms of Dementia are the neuropsychiatric symptoms that arise from advancing dementia:

Symptoms can include:

Behaviours = wandering, verbal and physical aggression, sexually or socially inappropriate, resisting care etc.

Psychiatric = depression, delusions, psychosis, apathy

Symptoms will vary with the type and stage of dementia.

Terminology reflects the lens: paradigm shift is needed

“Challenging”, “Difficult” vs. “Responsive” Behaviours

How common is BPSD?Evidence Source

~30-35% of community-dwelling people with dementia

(Lyketsos et al, 2000);

RAI-HC data indicates 7% of HCC clients trigger behavioural CAP, not daily behaviours.Focus is prevention.

RAI CAP manual (2009), pg. 65-72

~80-90% of resident-dwelling people with dementia

Margallo-Lana et al, 2001

RAI-2.0 data indicates 10% of residents trigger daily behaviours.

Focus is to reduce the occurrence. (1/3 will improve in 90 days when care plan in place).

RAI CAP manual (2009), pg. 65-72

Why is BPSD Important? Quality of Life issue

Continuum of Behavioral Escalation/cycling

Resident/Visitor/Staff Safety

Staff continuity/sustainability

Core Behavioral Principles

Behaviours are one of the 4 red flags in dementia care that always needs further assessment: pay attention to changes in behavior, function, thinking

and mood;

ALL Behaviour has meaning – sleuth it out

Presume changes are reversible until proven otherwise

Avoid diagnostic overshadowing

Core Behavioral Principles

Don’t take behaviour personally

Target one behaviour at a time

Target Antecedents<<BEHAVIOUR>>Consequences

Be realistic: success is measured by decreases in intensity, frequency and duration of behaviours, rarely extinguishment.

Behavioural principles – cont’d

Integrated, wholistic, and person-centred approaches are needed**:

Non-pharmacological

Pharmacological

**Not a linear relationship

Tools and ApproachesApproaches

PIECES

Gentle Persuasion Approach (GPA)

Eden Alternative

Others

Tools

BC BPSD Algorithm (2014)

Behavioural Support Plan

Guidelines and Protocols

Never underestimate the therapeutic use of self

BC BPSD Algorithm - History and background

2007-2009 –antipsychotic use in residential care is problematic

2011 – Ministry of Health provincial review = increased use of antipsychotic drugs in res care

2001/02 = was 37%

April 2010 to June 2011 – rose to 50.3%

2012 – Ministry Res Care/BPSD guidelines developed

2013 - Provincial Working Group was struck to achieve provincial consensus on all content within the algorithm.

2014 – electronic version released via the BC Patient Safety and Quality Council website. Purchased domain “BC BPSD”

BC BPSD Algorithm Highlights: The interactive algorithm is compatible

with multiple devices:

http://bcbpsd.ca/

BC BPSD Algorithm Highlights…

PDF vs. JPEG formats Branded vs. No Logo

BC BPSD Algorithm Highlights:

Opening Message

Two Parts

Tool bars:

• Screen Corners

• Screen Bottom

Part One: Interdisciplinary Decision Support for BPSD

Assessment

Problem Solving

Care Planning & Evaluation

(focus on non-pharmacological interventions)

Part Two: Reassessment with GP/NP

Assessment

Medication Options

Care Planning & Evaluation

(focus on layering in appropriate pharmacological interventions)

Summary

Behaviour is…

• Responsive

• Multifactorial

• Complex

• Quintessentially and

uniquely part of

being human

Addressing BPSD skillfully can improve quality of life.