Elizabeth McManamy, RPhPharmacist Quality Monitor

Jennifer Wills, BSN, RNNurse Manager

DADS Quality Monitoring Program

Objectives

1.Summarize the pharmacology of the antipsychotic

drug class

2.Describe how the use of antipsychotic medications

burden the quality of life in the elderly

3.Explain the CMS appropriate use of antipsychotic

medications in the long-term care setting

4.Describe the dementia disease process

5.Describe strategies to monitor and target behaviors in

the long-term care population

2

What’s the Big Deal?

Antipsychotics are:

• extensively used in nursing homes

• prescribed for the off-label for dementia-related illnesses where effectiveness is little and use is unsupported

3

Antipsychotic Mechanism of Action Block neurotransmitters in the brain at dopaminergic,

histaminic, cholinergic, and serotonergic receptors in the brain

A specific antipsychotic drug may be prescribed over another due to varying activity at these brain receptor sites

The main action is to block dopaminergic pathways to reduce the core symptoms of psychosis: hallucinations, delusions, and paranoid ideation

4

Treatment for Schizophrenia-Related Disorders

Antipsychotics have been the first-line treatment since the 1950’s with first-generation antipsychotics (i.e. the typical antipsychotics)

The down-side risk of blocking dopaminergic receptors is the occurrence of extrapyramidal side effects (EPS)

5

Common Typical Antipsychotics

Haloperidol (Haldol®)

Chlorpromazine (Thorazine®)

Fluphenazine (Prolixin®)

Perphenazine (Trilafon®)

Thioridazine (Mellaril®)

Thiothixene (Navane®)

6

Atypical Antipsychotics

Second-generation antipsychotics were developed in the 1980’s with the first being Clozapine (Clozaril®)

Atypicals commonly seen in the long-term care setting:

Aripiprazole (Abilify®) Lurasidone (Latuda®)

Olanzapine (Zyprexa®) Paliperidone (Invega®)

Quetiapine (Seroquel®) Ziprasidone (Geodon®)

Risperidone (Risperdal®)

7

Atypical Antipsychotic DesignAlong with treating hallucinations and delusions these newer drugs have a better side effect profile and greater effects on other symptoms seen in schizophrenia:

› emotional withdrawal/blunted affect

› suspiciousness or persecution

› grandiosity

› hostility

› poor impulse control

› active social avoidance

› anxiety

› somatic concerns

Reference: http://effectivehealthcare.ahrq.gov/ehc/products/146/1054/CER_63_Antipsychotics%20in%20Adults_08-20-121.pdf

8

Antipsychotic Side Effects

sedation; drowsiness/dizziness; disorientation

confusion; memory or functional impairment

risk of delirium

fall risk; orthostatic hypotension (sudden drop in blood pressure when standing)

constipation, urinary retention, dry mouth; blurred vision

restlessness; inability to sit still; anxiety; sleep disturbances

9

Antipsychotic Side Effects

tremor; slowed movements; muscle rigidity; strong muscle spasms (neck, tongue, face, or back); drooling

tardive dyskinesia

low white blood cell count; irregular heart rate; seizures; metabolic issues; neuroleptic malignant syndrome; increased risk of sudden cardiac death

10

Atypical Prescribing Considerations

Quetiapine and aripiprazole cause the least amount of extrapyramidyl side effects (EPS). Quetiapine or aripiprazole are often a choice in Parkinson’s disease

Quetiapine and risperidone have a higher risk of orthostatic hypotension (a significant factor in fall risk)

Olanzapine has the highest risk factor for obesity, hyperglycemia, and dyslipidemia

Aripiprazole, quetiapine, and risperidone have a risk factor of QT prolongation (dangerous heart arrhythmias)

11

Atypical Prescribing & Decision Making

“The American Psychiatric Association (APA) currently recommends that selection of an antipsychotic medication should be based on a patient’s previous responses to the drug and its side-effect profile”.

12

FDA Approved Non-Schizophrenia Related Conditions

Bipolar disorder (some as monotherapy & some as adjunct)

Tourette’s syndrome

Nausea, vomiting, and hiccups

Major depressive disorder (adjunctive with antidepressants)

Short-term treatment of generalized non-psychotic anxiety

Management of manifestations of psychotic disorders13

Antipsychotics: Off-label Prescribing

Off-label: a drug company does not have FDA approval to market or advertise a medication to treat a specific disorder or condition

Physicians can prescribe drug off-label to treat any condition, disorder, or diagnosis

Physicians will normally prescribe within the currently accepted standards and principles found in medical literature

In dementia care, there are no current medications available to treat the behavioral and psychological symptoms of dementia (BPSD)

14

Antipsychotics are NOT Approvedto Treat Dementia

15

16

FDA Black Box 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 17 placebo-controlled trials (modal 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 some characteristic(s) of the patients is not clear. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124830.htm

Alzheimer’s vs. Dopamine Pathway

17

Understanding Dementia

Symptoms of dementia depend on the location of damage in the brain:

Frontal Lobe

The Hippocampus

Occipital Lobe

Temporal Lobe

Parietal Lobe

18

Dementia Disease Process Permanent degenerative changes in the brain

Lack of acetylcholine presence

Beta-amyloid plaques causing inflammation and brain cell death

Tau protein tangles causing brain cell dysfunction and cell death

The “psychosis-like” symptoms seen in dementia are unlike the psychoses in chronic mental illness (e.g. schizophrenia)

Disturbances arise from short-term memory/recall problems causing disorientation to time, place, and environment

19

Advanced Stages of Dementia

Confusion of surroundings (disorientation)

Inability to communicate or find the words to express unmet needs

Wandering or pacing

Sleep-wake cycle disturbances

Emotional distress

Disrobing or dressing inappropriately in public places

20

Advanced Stages of Dementia

Delusions

Hallucinations (auditory and/or visual)

Agitation (irritability, restlessness, anxiety)

Aggression (lashing out, verbal outbursts or cursing,

resisting care, sexually inappropriate behaviors)

21

Dilemmas of Dementia

BPSD is troublesome, irregular, disturbing, and difficult to manage

80% of dementia residents will develop neuropsychiatric symptoms over the course of the disease

Behavioral disturbances cause caregiver stress, burden, possible injury

Behavioral disturbances can worsen the functioning of other residents or the resident themselves

22

“The strongest people are

not those who show strength

in front of us, but those who

win battles we know nothing about.”

-Unknown

23

Antipsychotic Challenges

Behavioral disturbances tend to be episodic and can diminish spontaneously

Antipsychotics are likely to be prescribed with comorbid conditions and many medications

Antipsychotics are more likely to be prescribed for those already on psychotropic medications

Over time, antipsychotics are barely more effective than placebo

24

Prescribing Precautions: Advanced Age

Less muscle mass, less body weight, and are prone to malnutrition affecting drug transport and drug distribution

Less liver and kidney capacity to metabolize and excrete medications, along with dehydration, urinary retention, and urinary infections, can cause drugs to build up in the body

25

Prescribing Precautions: Advanced Age

All medications have the potential to interact with other medications or medical conditions

Adverse reactions can resemble symptoms of acute illness which may be overlooked

Polypharmacy (9 or more meds*) with comorbid conditions put individuals at higher risk for adverse events and status decline

* CMS SOM Appendix PP26

CATIE-AD Project

When atypical antipsychotics are prescribed in dementia care, they are risky and are only modestly effective

Side effects can cause both direct and indirect factors that contribute to decreased health and well being

Steady and significant declines in both cognition and functional ability can increase the need for care, and can diminish overall quality of life.

27

Antipsychotics Risks

Worsening or complications with dysphagia

Increased risk of aspiration pneumonia and upper respiratory infections

Increased risk of urinary tract infections

Contribute to the risk of developing delirium

Increased risk for pressure ulcers

28

Antipsychotics Risks

Declines with decision-making capability ( think about safety awareness)

Increased risk of falls

Decreased ability to be understood/understand

Declines in functional ability and independence

29

Burdens on Quality of Life: Cognitive Decline

Decreased ability to self-report illness and infection

Decreased ability to communicate pain/discomfort

Decreased recognition of the need for toileting

May be unaware of thirst or unable to communicate the need for drink (dehydration risk) or food (weight loss)

possible decreases in socialization with other residents, staff, family & friends

30

Burdens on Quality of Life: Functional Decline

Decreased independence (this can increase staff burdens)

Decreased mobility (ability to walk properly or self-propel)

Decreased ability to reposition oneself properly or in a timely manner

Possible physical changes in functional eating & drinking

Decreased enjoyment due to sedation/drowsiness31

Avoidable Re-Hospitalizations

Individuals with dementia on antipsychotics either 6 months before or after hospital admission were more likely to be readmitted back to the hospital than those without an antipsychotic in their drug regimen

Reference: L.A. Daiello, et al. Archives of Gerontology and Geriatrics, July-August 201432

CMS Approved Diagnoses

Chronic conditions

Schizophrenia Schizo-affective disorder

Delusional disorder Mood disorders

Tourette’s disorder Huntington’s disease

33

CMS Approved Diagnoses

Acute conditions

Psychosis in the absence of dementia

Medical illness with psychotic symptoms and/or treatment related psychosis or mania

Hiccups

Nausea and vomiting with cancer/chemotherapy34

End-of-Life Care

Off-label as a comfort measure in end-of-life care

This is not CMS or FDA approved, but during hospice the goals are to promote sedation, stabilize the individual, and maintain comfort

35

Warnings

“When antipsychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective.”

“The problematic use of medications, such as antipsychotics, is part of a larger growing concern. This concern is that nursing homes and other setting (i.e. hospitals, ambulatory care) may use medications as a “quick fix” for behavioral symptoms or as a substitute for a holistic approach that involves a thorough assessment of underlying causes of behaviors and individualized person-centered interventions.”

36

Avoid Antipsychotics with BPSD

Antipsychotics should only be used when clinically necessary to treat targeted behaviors that are causing harm or significant distress to others or the resident themselves.

Antipsychotics should be used at the lowest dose and for the shortest period of time to treat specific targeted behavior(s), and are subject to gradual dose reduction.

Non-pharmacological interventions and therapeutic approaches are considered first-line therapy for BPSD.

37

Pre-psychotropic Assessment and Care Planning

Target the behavior as a problem/risk in the care plan

Discuss interventions and approaches with all members of the interdisciplinary team and obtain input from family members

Document individualized person-centered non-pharmacological interventions and therapeutic approaches in the care plan

Implement those interventions and approaches across various disciplines

38

39

Recognize Disturbances Early

Rule out potential medical & psychiatric causes first

Behaviors are commonly triggered by the actions, inactions, or the reactions of others

Behaviors can arise from frustrations that are caused when choices or personal preferences limit independence

Recognize harmful or significantly distressing behaviors, as opposed to the behavioral and psychological disturbances

40

Problem Solving Requires New Approaches

‘Insanity:

Doing the same thing

over and over again, and

expecting different results.’

-Albert Einstein

41

Become a Detective

Are there any physical or functional limitations that can be remedied? Promote independence with cueing, repositioning, or simple adjustments may be needed

What is the resident seeing, hearing, smelling, touching, or tasting that may be leading to behaviors? Review environmental considerations

42

Become a Detective

Does the resident need emotional support? If they are seeking reassurances, they probably need more emotional support (medication may not be needed)

Do the activities offered match the cognitive and functional abilities of the individual? Structure them to promote meaningful active participation

43

Address Depressive Symptoms

Depression

Highly prevalent in the nursing home setting

Can worsen cognition and functioning potentially leading to an acceleration of the dementia disease process

Can worsen the experience of pain and discomfort

can precipitate ruminating thoughts of worry

44

Address Depressive Symptoms

Antidepressants (SSRIs and SNRIs)

Therapy is often necessary with extended use, but only at the lowest dose needed to treat depression

Avoid the use of multiple antidepressants unless clinically indicated

Caution: fall risk is highest during the first 2 weeks of initiation or with increasing dosages

45

Serial Trial Intervention Approach

Individuals may not be able to express that they are having pain and discomfort

Behaviors can be easily misconstrued and treated with psychotropic medications

The STI recognizes that routine mild analgesia should be started as a comfort measure when behaviors are exhibited

Monitor for a response such as decreased behaviors and improved mood

If analgesia is successful, don’t forget to continue other non-pharmacological interventions

46

CMS Definition of Monitoring

"The ongoing collection and analysis of information (such as observations and diagnostic test results) and comparison to baseline and current data in order to ascertain the individual's response to treatment and care, including progress or lack of progress toward a goal. Monitoring can detect any improvements, complications or adverse consequences of the treatments; and support decisions about adding, modifying, continuing, or discontinuing any interventions.“ -RAI Manual

47

Monitoring Psychotropic Medications Target specific behavior(s) and linking them with treatment

of a specific medication

At least daily, monitor (shift-by-shift is suggested) for presence of targeted behavior(s)

Document non-drug interventions implemented for targeted behavioral occurrences

Periodically evaluation (quarterly, but more often is recommended) of targeted behavior(s), effectiveness of non-drug interventions and/or drug therapy with considerations for gradual dosage reductions

48

49

Reducing Unnecessary Antipsychotic Medications

Gradual Dosage Reduction: GENERAL GUIDELINES

Monitor dosages regularly; consider adverse reactions, resident’s response and level of functioning

Review and trend behavior from monitoring system

Titrate drug reduction slowly

Monitor behavior stabilization

50

Reducing Unnecessary Antipsychotic Medications

Gradual Dosage Reduction

The physician may order dosage titrations downward at 1 to 2 week intervals.

Everyone must “know” titration is happening to increase surveillance

Keep documentation- what’s working and what’s not working

Allow intervals of adjustments and continue to perform non-pharmacological interventions. 51

Care Planning Recognition or identification of the problem/need (target)

Ongoing assessment (root-cause analysis & triggers)

Identification of a diagnosis/cause

Development of management techniques and/or treatments (non-pharmacological interventions / adjunct medications)

Monitoring the efficacy and adverse consequences of those techniques and treatments

Periodic reviewing, re-evaluating, and revising those techniques and treatments

52

“It’s not that caregivers have

so much time, it’s that they

have so much heart.”

-Elizabeth Andrew

53

What’s the Bottom Line?

Identify ALL residents on antipsychotic medications

Determine which antipsychotic medications are clinically appropriate

Implement gradual dose reduction as needed/indicated

Manage unmet needs (behaviors) through improved dementia care using person-centered care

54

Changing the Culture of Prescribing in Dementia Care

55

56

Change Starts with Asking Questions

Does the interdisciplinary team question why the antipsychotic was initiated? Was it for

an acute behavioral or psychological reason which may no longer be present?

Does the interdisciplinary team recognize the actual number of occurrences of the

behavior(s), or could they be recalling the severity of just a few distant behaviors when

making decisions about dosage reductions (subjective views may be influencing

opinions more than actual objective documentation from behavior monitoring)?

If the targeted behavior is no longer present, or the resident is stable with non-drug

interventions, or the behavior is no longer harmful to self or others, then ask “why

haven’t dosage reductions been attempted”? Is the drug kept unnecessarily?

Does the staff have any preconceived notions which need to be addressed regarding

attempted dosage reductions such as “they have gone poorly in the past” (the staff may

be projecting those feelings with making requests for future attempts)?

Are these behaviors distressing to family members who are unable to cope with the

disease’s progression? Do family members have unrealistic notions about

antipsychotics such as “they are used to improve dementia”? Is the family hesitant

about trying a dosage reduction due to the severity of distant behaviors?

Are psychotropic drugs seen as a “positive” by the staff, to be utilized as the only

solution for treating behavioral problems? It has become ingrained in our society that

“medications are the solution to all our woes”. We seek them out, yet we rarely address

their long-term consequences.

Changing the Culture of Prescribing in Dementia Care

57

Changing the Culture of Prescribing in Dementia Care

58

Changing the Culture of Prescribing in Dementia Care

59

Changing the Culture of Prescribing in Dementia Care

60

61

Changing the Culture of Prescribing in Dementia Care

62

Elizabeth McManamy, RPhPharmacist Quality Monitor

Jennifer Wills, BSN, RNNurse Manager

DADS Quality Monitoring Program

ObjectivesAt the conclusion of the presentation, the participate will be able to…

Describe at least two negative outcomes associated with the use of antipsychotic medications to manage pain related behaviors in elderly persons with dementia.

Explain the three types of pain

64

Objectives

Explain at least three common causes and related manifestations of pain in elderly persons with dementia

Explain three best practice pain management strategies for elderly persons with dementia

65

Consequences of Antipsychotic Use

Increased risk of stroke and death

Side effects – tremors, rigidity, restlessness, muscle spasms, drowsiness, dizziness, blurred vision, rapid heartbeat

Can lead to immobility, decline in ADLs, decreased socialization, sleep disturbances, decreased appetite, depression, increase in behaviors

66

Untreated PAIN

psychological67

Consequences of Untreated Pain

Immobility – pressure ulcers, incontinence, circulatory and respiratory problems, falls

Increased functional limitations – decline in ADLs, decreased socialization

Sleep disturbances, decreased appetite

Depression and anxiety

Agitation and aggression

Inappropriate use of antipsychotics to treat pain related behaviors

68

OUCH!

striking out69

Impact of Dementia on Pain Estimated 35 million people worldwide have

dementia

71% of Texas nursing home residents 65 y.o. and older have diagnoses of Alzheimer’s, dementia or cognitive impairment

45-80% of nursing home residents with dementia experience pain on a daily basis

Generally persons with dementia receive less pain medication than those who are cognitively intact 70

What is Pain?

Pain is an unpleasant sensory or emotional experience

Pain is present whenever a person says it is

Pain may be acute or chronic/persistent

71

What is Pain? Nociceptive pain – results from actual or

potential tissue damage

Neuropathic pain – results from a disturbance of function or pathologic change in the peripheral or central nervous system

Unspecified or Mixed pain – results from unspecified or mixed mechanisms and includes both nociceptive and neuropathic pain

72

What Causes Pain? Degenerative joint disease

Low back disorders

Rheumatoid arthritis

Gout

Headaches

Fibromyalgia

Neuropathies

Peripheral vascular disease

Vertebral compression fractures 73

What Causes Pain? Post-stroke syndromes

Oral or dental pathology

Cancer

Gastrointestinal conditions

Renal conditions

Immobility, contractures

Pressure ulcers

Surgical procedures

Falls, other injuries 74

“Pain is such an uncomfortable feeling that even a tiny amount of it is enough to

ruin every enjoyment.”

- Will Rogers

75

Is it Pain? Frowning, grimacing

Fearful facial expressions

Grinding of the teeth

Fidgeting, restlessness

Striking out, increased agitation

Sighing, groaning, crying

Breathing heavily76

Is it Pain? Decreasing activity levels,

socialization

Resisting certain movements

Inability to participate in activities of daily living

Depression, anxiety

Changes in gait

Eating or sleeping poorly77

Pain Assessment

Should be conducted on admission, quarterly and with a change in condition

In a language the person understands

According to the person’s cognitive and verbal abilities

Using a validated pain scale(s)

78

Validate Pain Scales

Self-reporting pain intensity scales

– allow the resident to rate his/her pain

Note: Wong-Baker Faces Scale is not recommended for use in the geriatric population

Behavioral pain scales

– allow the licensed nurse to observe for behaviors which might suggest pain is present

79

80

Self-reporting Pain Intensity Scales

Numeric Rating Scale (NRS)

Verbal Descriptor (VDS)

Faces Pain Scale – Revised (FPS-R)

81

Behavioral Pain Scales

Pain Assessment in Advanced Dementia (PAINAD)

Pain Assessment Checklist for Senior with Limited Ability to Communicate (PACSLAC)

Discomfort Scale for Dementia of the Alzheimer’s Type (DS-DAT)

82

Behavioral Pain Scale: PAINAD

5 observational indicators

• Breathing

• Negative Vocalization

• Facial Expression

• Body Language

• Consolability

83

Behavioral Pain Scale: PAINAD0 1 2 Score

Breathing

Independent of

vocalization

Normal Occasional labored

breathing.

Short period of

hyperventilation

Noisy labored breathing.

Long period of hyperventilation.

Cheyne-Stokes respirations

Negative

Vocalization

None Occasional moan or groan.

Low level speech with a

negative or disapproving

quality

Repeated troubled calling out.

Loud moaning or groaning.

Crying

Facial

expression

Smiling, or

inexpressive

Sad. Frightened. Frown Facial grimacing

Body Language Relaxed Tense.

Distressed pacing. Fidgeting

Rigid. Fists clenched, Knees

pulled up.

Pulling or pushing away.

Striking out

Consolability No need to

console

Distracted or reassured by

voice or touch

Unable to console, distract or

reassure

TOTAL84

Mildred

85

Behavioral Pain Scale: PAINAD0 1 2 Score

Breathing

Independent of

vocalization

Normal Occasional labored

breathing.

Short period of

hyperventilation

Noisy labored breathing.

Long period of hyperventilation.

Cheyne-Stokes respirations

Negative

Vocalization

None Occasional moan or groan.

Low level speech with a

negative or disapproving

quality

Repeated troubled calling out.

Loud moaning or groaning.

Crying

Facial

expression

Smiling, or

inexpressive

Sad. Frightened. Frown Facial grimacing

Body Language Relaxed Tense.

Distressed pacing. Fidgeting

Rigid. Fists clenched, Knees

pulled up.

Pulling or pushing away.

Striking out

Consolability No need to

console

Distracted or reassured by

voice or touch

Unable to console, distract or

reassure

TOTAL86

Behavioral Pain Scale: PAINAD0 1 2 Score

Breathing

Independent of

vocalization

Normal Occasional labored

breathing.

Short period of

hyperventilation

Noisy labored breathing.

Long period of hyperventilation.

Cheyne-Stokes respirations1

Negative

Vocalization

None Occasional moan or groan.

Low level speech with a

negative or disapproving

quality

Repeated troubled calling out.

Loud moaning or groaning.

Crying

Facial

expression

Smiling, or

inexpressive

Sad. Frightened. Frown Facial grimacing

Body Language Relaxed Tense.

Distressed pacing. Fidgeting

Rigid. Fists clenched, Knees

pulled up.

Pulling or pushing away.

Striking out

Consolability No need to

console

Distracted or reassured by

voice or touch

Unable to console, distract or

reassure

TOTAL87

Behavioral Pain Scale: PAINAD0 1 2 Score

Breathing

Independent of

vocalization

Normal Occasional labored

breathing.

Short period of

hyperventilation

Noisy labored breathing.

Long period of hyperventilation.

Cheyne-Stokes respirations1

Negative

Vocalization

None Occasional moan or groan.

Low level speech with a

negative or disapproving

quality

Repeated troubled calling out.

Loud moaning or groaning.

Crying2

Facial

expression

Smiling, or

inexpressive

Sad. Frightened. Frown Facial grimacing

Body Language Relaxed Tense.

Distressed pacing. Fidgeting

Rigid. Fists clenched, Knees

pulled up.

Pulling or pushing away.

Striking out

Consolability No need to

console

Distracted or reassured by

voice or touch

Unable to console, distract or

reassure

TOTAL88

Behavioral Pain Scale: PAINAD0 1 2 Score

Breathing

Independent of

vocalization

Normal Occasional labored

breathing.

Short period of

hyperventilation

Noisy labored breathing.

Long period of hyperventilation.

Cheyne-Stokes respirations1

Negative

Vocalization

None Occasional moan or groan.

Low level speech with a

negative or disapproving

quality

Repeated troubled calling out.

Loud moaning or groaning.

Crying2

Facial

expression

Smiling, or

inexpressive

Sad. Frightened. Frown Facial grimacing 2

Body Language Relaxed Tense.

Distressed pacing. Fidgeting

Rigid. Fists clenched, Knees

pulled up.

Pulling or pushing away.

Striking out

Consolability No need to

console

Distracted or reassured by

voice or touch

Unable to console, distract or

reassure

TOTAL89

Behavioral Pain Scale: PAINAD0 1 2 Score

Breathing

Independent of

vocalization

Normal Occasional labored

breathing.

Short period of

hyperventilation

Noisy labored breathing.

Long period of hyperventilation.

Cheyne-Stokes respirations1

Negative

Vocalization

None Occasional moan or groan.

Low level speech with a

negative or disapproving

quality

Repeated troubled calling out.

Loud moaning or groaning.

Crying2

Facial

expression

Smiling, or

inexpressive

Sad. Frightened. Frown Facial grimacing 2

Body Language Relaxed Tense.

Distressed pacing. Fidgeting

Rigid. Fists clenched, Knees

pulled up.

Pulling or pushing away.

Striking out

2

Consolability No need to

console

Distracted or reassured by

voice or touch

Unable to console, distract or

reassure

TOTAL90

Behavioral Pain Scale: PAINAD0 1 2 Score

Breathing

Independent of

vocalization

Normal Occasional labored

breathing.

Short period of

hyperventilation

Noisy labored breathing.

Long period of hyperventilation.

Cheyne-Stokes respirations1

Negative

Vocalization

None Occasional moan or groan.

Low level speech with a

negative or disapproving

quality

Repeated troubled calling out.

Loud moaning or groaning.

Crying2

Facial

expression

Smiling, or

inexpressive

Sad. Frightened. Frown Facial grimacing

2

Body Language Relaxed Tense.

Distressed pacing. Fidgeting

Rigid. Fists clenched, Knees

pulled up.

Pulling or pushing away.

Striking out

2

Consolability No need to

console

Distracted or reassured by

voice or touch

Unable to console, distract or

reassure 1

TOTAL 891

Mildred

92

Comprehensive Pain Assessment

Predisposing factors

Onset of pain

Location of pain

Frequency of pain

Duration of pain

Description of pain

93

Comprehensive Pain Assessment

Aggravating factors

Relieving factors

Validated pain scale(s) utilized

Acceptable level of pain

Current and previous treatment and results of both

Impact of pain on individual’s physical and psychosocial functioning – ADLs and behaviors

94

Pain Re-evaluations

Pain re-evaluations should be conducted for persons on routine medications or other non-pharmacological interventions based on the severity and chronicity of the pain.

• At least daily for response when starting a new medication

• At least weekly when well managed

95

Pain Re-evaluations

Pain re-evaluations should be conducted before PRN pain medications are administered and after at peak effect of treatment.

Peak effect of treatment: Timing when a person experiences the highest level of pain relief from a given intervention.

96

Pain Management Interventions

Interdisciplinary team approach:

Education

Frequent assessment with consistent use of validated pain scales

Pain medications and adjunct medications

Non-pharmacological interventions

Physician notification/communication97

Analgesic Trials

Serial Trial Intervention (STI) www.geriatricpain.org

STI serves as a guideline for analgesic use when non-pharmacological interventions and other approaches have not been effective.

98

Non-Pharmacological Interventions

Physical therapy

Routine exercise

Activities

Massage

TENS

Aromatherapy

Spiritual therapy

Comfort foods

Hot/cold therapies

Music therapy

Cryotherapy

Diathermy/ ultrasound

99

Improving Outcomes

“One good thing about music, when it hits you, you feel no pain.”

- Bob Marley

100

Improving Outcomes

Goal: Relief and control of pain.

Outcomes consistent with evidence-based best practice:

Implement the individualized interventions identified in the care plan

Monitor and evaluate the individualized interventions for effectiveness

101

Evidence-based Best Practice SummaryAssessment

• Recognize each person’s cognitive and verbal abilities

• Use a language the person understands

• Complete comprehensive pain assessments on admission/readmission, change in condition and quarterly

• Re-evaluate the person’s needs based on the severity and chronicity of their pain

102

Care Plan Process• Identify the source(s) of the pain

• Develop measurable goals based on the assessment

• Develop individualized interventions Outcome

• Implement the individualized interventions identified in the care plan

• Monitor and evaluate the individualized interventions periodically for effectiveness

Evidence-based Best Practice Summary

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Knowing My Pain - by Kathy

Pain-racked and unstable, Still, somehow, You see me as able. You see my cane as a toy, Used, not for need, But for ploy.

You are not in my body, My pain you cannot feel. How dare you tell me My pain is less real?

You may have pain, Others have pain as well. Pain is dealt with In many different ways. For some merely existing Can be a living hell.

So, think ere you tell me There's something I can do, Because you don't know The pain I'm going through, You're not me And I certainly am not you!104

Resources www.AHRQ.gov. Agency for Healthcare Research Quality

www.CMS.gov. Centers for Medicare and Medicaid Services

www.fda.gov. Food and Drug Administration

Reference: “Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: a systematic review” Dallas P. Seitz, et al. Int Psychogeriatr. Feb 2013; 25(2): 185–203.

Cheryl L.P. Vigen, Ph.D. et al. “Cognitive Effects of Atypical Antipsychotic Medications in Patients with Alzheimer’s Disease: Outcomes from CATIE-AD”. Am J Psychiatry. 2011 August ; 168(8): 831–839.

http://www.nursinghometoolkit.com/#!clinical/c7ax105

Resources

“The association of psychotropic medication use with the cognitive, functional, and neuropsychiatric trajectory of Alzheimer’s disease” P. B. Rosenberg, et al. Int J Geriatr Psychiatry. Dec 2012; 27(12): 1248–1257

State Operations Manual Appendix PP @ https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

http://www.nursinghometoolkit.com/#!clinical/c7ax

Nursing Home Compare: www.medicare.gov

“Use of Antipsychotics among Older Residents in Veterans Administration Nursing Homes” WF Gellad, et al. Med Care. 2012 Nov; 50(11):954-60. 106

Pain Management References American Medical Directors Association,

www.amda.com American Society for Pain Management Nursing,

www.aspmn.org American Geriatrics Society,

www.americangeriatrics.org International Association for the Study of Pain,

www.iasp-pain.org American Academy of Pain Medicine,

www.painmed.org American Academy of Pain Management,

www.aapainmanage.org Geriatric Pain: www.geriatricpain.org 107

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Additional trainings:

Alzheimer’s Disease & Dementia Care Seminar

Virtual Dementia Tour

Texas Taking the Next Step: Dementia in Long Term Care and Community Settings (Geriatric Symposium) –August 20, 2015 in Austin

TRAIN Big Bang Conference (not an official title) –November & December 2015 in 5 locations around the state

For more information: www.texasqualitymatters.org

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