The management of BPSD in an Alzheimer Special Care Unit

Annalisa Bonora

Psychologist

Centro Integrato Servizi Anziani

Mirandola (Modena), Italy

21st Alzheimer Europe Conference Warsaw 6-8 October 2011

Alzheimer Care Unit

Hospitals

Psycho-geriatric Consulting

Family physician Employment

Exchange (for caregivers)

Social Worker

Nursing-Home: Residential

and Day Centers

Bonora A. Italy

Integrated Services of our area (North Province of Modena)

The Alzheimer Special Care Unit -15 people, 8 temporary - diagnosis of Dementia and BPSD (ICD-10)

- Person Centered Care (Kitwood T., 1997) - Protesic Environment (Gentlecare, Jones M., 1996)

8 professional carers (Annarita, Nadia, Franca, Massimo, Selina, Cornelia, Rosanna, Elena). 1 professional nurse (Bellodi C.) 1 Occupational Therapist (18 hrs weekly) (Fedele T.) 1 Psychiatric Therapist (18 hrs weekly) (Menabue G.) 1 Psychologist (10 hrs weekly) (Bonora A.) 1 MD Geriatrician (10 hrs weekly) (Turci M.)

-formal: professional carers -informal: relatives

- Pharmacological - Psychosocial: O.T., multi-sensory stimulation (Room and Bath), ROT,…

Bonora A. Italy

ADMISSION CRITERIA

1) Severe BPSD= difficulty to manage at home, despite the use of multiple

pharmacological or non pharmacological attempts: high NPI scores (>

28/144, or NPI single item=12, except for depression and apathy)

2) Extreme difficulty and burden for the family= deriving by the

management of the patients (RSS 16-30);

3) Moderate-severe cognitive impairment (MMSE 18/28).

Bonora A. Italy

The living room: the main room Bonora A. Italy

The “Care Individual Project”: actions to achive an integrated care!

Patient and

Family

Psychiatric Therapist

Professional Carers

Occupational Therapist MD

Geriatrician

Psychologist

Check at different moments: 1. Entry (± after 15 days) 2. Intermediate Check (± after 60 days) 3. Final Check (discharge)

Equipe meeting:

Topics of the C.I.P.: •Residual abilities: manteinance! •BPSD: reduction or containment! •To stimulate “Psychosocial interventions” •Psychoeducational interventions= export our experience to relatives or other formal caregivers!

Bonora A. Italy

Aims

•for Patient → to test new care’s strategies to improve the quality of life •for Relatives→ psychological and care support

An example of “individual care project”: a single case MS

Bonora A. Italy

GOALS ACTIONS WHO WHEN PERIOD OUTCOMES

Personal hygiene without stress

•Soft and easy to wear suits •Quiet moment •Training of the family assistant

Nurse Unit manager

Every days when the patient was available

Untill next verification.

Minumum:1 day change with two nurses.

BPSD control •Material to be handled safety •Dedicated spaces •Drug-therapy revision after day and night monitoring •Snoezelen Room •Wandering alone in garden or dedicated spaces.

Nurse Geriatrician Psychiatric Therapist Occupational Therapist

Every day Garden: no during the hot afternoons

Untill next verification.

NPI reduction on specific items: aggression, aberrat motor behavior and sleep disorders.

Come back in home

•Search of the assistant •Training of the assistant to learn personal hygiene strategies •Psychological consult •Home site inspection for the environmental adaptation

Family and assistant Psychologist Geriatrician Nurse

•As soon as possible •Every days •Every 15 days •As soon as possible

Untill next verification.

Reduction of the caregiver burden and long lasting successful home care.

Bonora A. Italy

TREATMENTS FOR BPSD EVIDENCE BASED (1)

Livingstone G. et al.

The multisensory stimulation in Snoezelen Room

“…Adopting a non-directive and enabling approach, snoezelen encourages people with reduced cognitive functions to engage with sensory stimuli in a positive and non-stressful environment”… “as a ’sensory cafeteria’ or ’multi-sensory environment’ because of its use of a variety of sensory-based materials and equipment…” (Chung JCC et al., The Cochrane, 2002).

http://www.isna.de/index2e.html

Bonora A. Italy

Psychosocial Treatments

http://www.isna.de/index2e.html

TREATMENTS FOR BPSD EVIDENCE BASED (2)

Bonora A. Italy

“O.T. improved patient’s daily functioning and reduced the burden

on the caregiver, despite the patients’ limited learining ability”.

The Occupational Therapy

•To maintain and stimulate the residual abilities •To favour group activities and socializing •To support the self-esteem •To encourage the fruits and vegetables consumption •“To cool” BPSD

Purpose:

•cook (vegetable and fruit season, home-made pasta, cake with home-made marmalade, make tomato sauce,…)

•take care of environment (clean up, personal launder) •Take care of garden and plants •painting and making decoupage (material recycle)

Main activities:

•Staff: O.T. in collaboration with 1professional care •Method: person centered-projects; positive reinforcement •Modality: small groups of people or one to one •Time: every days (morning and afternoon)

Procedure:

Bonora A. Italy

Psychosocial Treatments

Study on the consumption of fruits and vegetables during the meal after Occupational Therapy

Lunch: vegetables cooked

Lunch: fruits

Control group 51 % 70%

Sperimental group (15 p.) 82% 85%

Defference between conditions 31% 15%

Psychosocial Treatments

The Snoezelen Room: measures of effectiveness

Bonora A. Italy

1. Physiological changes: Hearth Rate (pulse oximetry)

2. Behavioral changes: Goal Attainment Scaling (after each treatment)

Psychosocial Treatments

EFFECT OF MULTISENSORY STIMULATION ON HEART RATE IN A GROUP OF PEOPLE WITH ALZHEIMER DISEASE

AND BEHAVIORAL DISORDERS

77 70

505560657075808590

TO T1

Heart Rate

70 68 505560657075808590

T1 T2

Heart Rate

77 68

505560657075808590

T0 T2

Heart Rate

* P

Bonora A. Italy

http://www.marson-and-associates.com/GAS/GAS_index.html

Levels of Predicted Attainment

Objective 1: Wandering

Objective 2: Diet

Objective 3: Insomnia

-2 Much less than

expected outcome

Sit for15 min 1 2 3 4 5 6 7

Dont’ eat 1 2 3 4 5 6 7

Don’t sleep 1 2 3 4 5 6 7

-1 Less than

expected outcome

Sit for 20 min 1 2 3 4 5 6 7

Eat partially and spoon-feed

1 2 3 4 5 6 7

Frequent wake up and agitantion

1 2 3 4 5 6 7

0 Expected outcome

Sit for 30 min 1 2 3 4 5 6 7

Eat all and spoon-feed

1 2 3 4 5 6 7

Few wake up and no agitation (stay in bed)

1 2 3 4 5 6 7

+1 More than

expected outcome

Sit for40 min 1 2 3 4 5 6 7

Eat by itself one dish 1 2 3 4 5 6 7

Few wake up and sleep again 1 2 3 4 5 6 7

+2 Much more than

expected outcome

Falll asleep 1 2 3 4 5 6 7

Eat by itself all dishes 1 2 3 4 5 6 7

Sleep all night 1 2 3 4 5 6 7

An exmple of GAS measure: a single case SC

The temporary project: from october 2008-present

Demographic and Clinical Features Admission

N 55

CIRS (severity, mean score)

16,20 (+5,50)

Age (yrs), SD 81 (+6,10)

Sex (M; F) 17 (33%); 37 (67%)

MMSE (mean score ±SD)

9 (+6,30)

Tinetti (mean score ±SD)

18,25 (+6,45)

Admission lenght Mean (±SD) Days (n) 110,52 (67,84)

Bonora A. Italy

Disharge p

went back home (n) 43 (80%)

CIRS severity ((mean score ±SD) 16,91 (+5,20) =0,053

MMSE (mean score ±SD)

7 (+6,79) =0,018**

Tinetti (mean score ±SD)

17,15 (+7,6) =0,087

BEHAVIOURAL DISORDERS: main outcomes

Bonora A. Italy

44 30

01020304050

ADMISSION DISCHARGE

Neuropsychiatric Inventory

123456789

101112

ADMISSION DISCHARGE

Single items

Glogal scores * p=0,000

Bonora A. Italy

4.8 5.29

11.5

22.5

33.5

44.5

55.5

6

ADMISSION DISCHARGE

NUMBER OF DRUGS

PHARMACOLOGICAL THERAPIES: main outcomes

DRUGS ADMISSION DISCHARGE

Benzodiazepine (n) 11 8

Antidepressants (n) 13 13

Antipsychotics typical (n) 11 6

Antipsychotics atypical (n) 19 20

Achel/Memantina (n) 16 11

CONCLUSION

Temporary Alzheimer Care Unit: seems to be useful, based on an effective model of care for persons with dementia and BPSD and their relatives, particularly during acute BPSD.

The Care Individual Project: Seems to be useful to define long term care goals and strategies in a person centered model of care, involving relatives.

Psychosocial therapies: - Seems to be useful to reduce and to contain BPSD - Seems to be useful to sustain and to promote new care strategies

Bonora A. Italy

The management of BPSD�in an Alzheimer Special Care UnitIntegrated Services of our area�(North Province of Modena)The Alzheimer Special Care UnitADMISSION CRITERIAThe living room: the main roomThe “Care Individual Project”:�actions to achive an integrated care!An example of “individual care project”:�a single case MSTREATMENTS FOR BPSD EVIDENCE BASED (1)The multisensory stimulation�in Snoezelen RoomTREATMENTS FOR BPSD EVIDENCE BASED (2)The Occupational TherapyStudy on the consumption of fruits and vegetables during the meal�after Occupational TherapyThe Snoezelen Room:�measures of effectivenessSlide Number 14Slide Number 15Slide Number 16The temporary project:�from october 2008-presentBEHAVIOURAL DISORDERS:� main outcomesPHARMACOLOGICAL THERAPIES:� main outcomesCONCLUSION