I Graduated from the University of Victoria with a BScN in 2007- in my fourth year and the year after graduation, I specialized into geriatrics and palliative care

I was hired at Castleview soon after graduation and quickly thrived in the environment

I especially enjoy entering into relationship with residents and families; providing safe and ethical care; and most omportantly, having the privilege and honor of supporting residents and families as death draws near

In the Spring of 2012 I took over the Director of Care role

I realized there where changes needing to be made-moving away from the medical model and towards family centered nursing care, the core theme of current nursing education

I was able to quickly make changes at Castleview the entire management team too believed these changes would be of great benefit to our residents quality of life

Currently antipsychotics are used as a first line to manage behaviors of residents. "In 2001, more than 70 percent of U.S. atypical antipsychotic prescriptions were written for off-label indications such as dementia, and atypical antipsychotics accounted for 82 percent of antipsychotic prescriptions written for older patients in Canada in 2002

Winter 2012: as part of a quality improvement initiative, I choose to conduct a perspective analysis on the use of antipsychotics at Castleview

After careful and lengthy research I came to a decision: “antipsychotics were being used as a chemical restraint” at Castleview

PharmaNet data indicates that 50.3 percent of PharmaCare Plan B (residential care) patients were prescribed an antipsychotic between April 2010 to June 2011 These data, however, do not provide information about how long each medication was used, or the condition for which these drugs were prescribed.

AIM: Objective: To reduce the amount of residents on antipsychotics MEASURE: Outcome Measure/ Indicator: There will fewer

residents on antipsychotics by the fall of 2012. Current Performance: 39% of residents—February 5,

2012 Performance Goal 2012/2013: To reduce the amount

of antipsychotic (under 20%) Priority: To target residents on antipsychotics who

are experiencing negative side effects

Improvement Initiative: Stage 1: Audit all the MARs Stage 2: Research antipsychotic uses Stage 3: Prior to discontinuing the medications

outline daily behaviors Stage 4: Discuss with Pharmacist and doctors

about new proposed action for decreasing the use of antipsychotics at Castleview.

Stage 5: Implement policy for all new residents coming to facility; targeting those who arrive on antipsychotics, finding a documented reason for the prescription

February 2012: 39% of the residents are on antipsychotics (considered average)

By reviewing the MAR, and critically looking at antipsychotic use at Castleview:

We were able to decrease the use by 12% with-in 6 weeks, the first residents to be tapered off medications were those prescribed the medication for an “inappropriate behavior”

look at those residents who were being treated with antipsychotics for any of the following reasons:

Wandering Hiding &Hoarding Vocally disruptive Repetitive Activity

Inappropriate (un)dressing Inappropriate voiding Tugging at restraints

Eating inedible objects Pushing wheelchair bound Resident

Carol Ward MD Sept. 20,

2008

Looking how long, who/where prescribed and if there was any documented reason. At Castleview I had many residents on antipsychotics and I was unable to find any documentation as to why.

Behavioral Care Planning Using the model from, Sandra Psiurski,

Castleview created a system of educating staff about behavioral care planning. Staff were able to see residents as individuals with differing pasts, searching pasts has become an interest to many

How do we figure out the behaviours? We take a trip down memory lane. We remember our residents grew up and

lived in a different time then the staff who care for them

We understand how a residents past shapes who they are today. We take into account how past experiences influence how residents respond to their current demands of life.

By investigating fully who a resident was and is, a tailored successful care plan for behaviors can be created.

1) What are the residents strengths and successes-list of what the resident can do, helps create a care plan

2) Define the behaviour (What, when, where)-looking critically at the behavior, if a resident is yelling, is there a trigger-looking for patterns, times and charting these behaviors in an inventory

3) Describe what has been done in responsive to these behaviors: once the behavior is defined, trying multiple interventions, if a resident needs toileting, nutrition, or pain management for example

The most important part of this is to communicate to all members of the health care team and families.

* Families are a wealth of information *At Castleview if a resident is being physically

abusive and resistive to care the first course of action is to stop providing care immediately.

*Families need to know the procedures of this, if they come for a visit and their family member is not up for the day.

*Letting families know we are working on it, we have some techniques that do work but ultimately their loved one still has a choice

This is vital! When nursing explains the situation in a manner

families understand, they are able to participate in the decision making process:

- your father wants to sleep in, your mother has chosen at this time to not get dressed, your sister does not want to get out of her chair right now

-your family member has lost almost all of their ability to make choices, he/she is still a strong willed adult with the right to choose

-the biggest question is: Would your loved one or would you want to be forced or restrained

At Castleview we constantly talk to staff and families about quality of life. This is an ongoing conversation, it needs to happen as soon as the resident comes through the front door

Quality of Life includes: autonomy, comfort, control over life, dignity, respect and engagement in meaningful activities and relationships

We investigate residents tirelessly before involving the doctor in interventions. If a doctor is involved, we attempt to source out medical reasons for the behavior; medications of other classes are tried first (pain, depression)

Staff and families realize how an antipsychotic can be a

chemical restraint, and will ultimately sedate the resident. Once sedate their ability to enjoy any part of life is seriously compromised.

This part of the care planning process is time consuming but very rewarding for all staff members:

monitor staff interaction while a resident is experiencing a time of a behavioral challenge; watching multiple times, chart what works and does not work, finding the pattern

make a 5-7 step care plan to manage a specific behavior, staff know once created this is the plan to follow

***this process can take hours, and days***

All but 2 residents are tapered and taken off antipsychotics.

Other residents with behavioral challenges have been

investigated, triggers found, care plans created Staff still leave some residents at times, residents

still have the right to choose the direction of the day Staff are recognizing the negative side effects suffered

by residents from antipsychotic use: sedation, increased falls and unfortunately we have three residents with TD (tardive dyskinesia)One being 101 on Risperidone last year for wandering

A new male resident hits the care-aides during brief changes every time, I have many incident reports on my desk. Care aides are refusing to do care, the wife has tried to be present he still lashes out. His wife comes everyday to visit and assist with lunches. By monitoring care, speaking with wife and speaking to direct care staff I discover:

He was in Europe during WWII, he yells during care to stop hurting him, he has said out loud to the staff he was abused by male German soldiers when he was nine, distraction only works sporadically, having a male in the room makes him very tense

I was able to tailor a care plan with only a soft calming female voice speaking, this works 99% of the time. He is not sedated and he gets to enjoy his wife’s visits

We started monitoring care on an aggressive resident-looking for at least 10 interactions

I had non-stop incident reports of aggression, she was left in bed often, as the staff could not approach, she made the choice but we continued to look for a trigger to the aggression, at what point in care did she get upset? There seemed to be no aggression during monitoring by nurses-but the staff insist she hits every time

So, guess what? As long as a staff member is silently monitoring her with a clip board she is not aggressive. It is really that simple? Yes! Outside of the box but simple

Currently there are two residents (4%) on antipsychotics:

both have been tapered and failed, both have a diagnosed mental illness

that was present prior to the onset of dementia.

In no way am I saying Castleview will never use antipsychotics again, I am saying we are committed to using them after tireless investigation, when all else fails and when the benefits will out weigh the risk

IT IS BETTER TO SPEND TIME NOW TO GET THE RESIDENT TO BE SUCCESSFUL THAN TO FIGHT THEM FOR THE REST OF THEIR LIFE

Sometimes getting a resident to do

something different and be successful, opens up a new world to them , and for you....

So, if everyone agrees it is about quality of life, what do we do as a multi-disciplinary team and family when it is evident a resident is no longer participating in life?

This is where residential care needs to step up, become comfortable taking about death, supporting families with letting go and most importantly providing an environment for dignified, respectful and easy passing. Help families remember the good times, let go of the bad and tell them you are honored to be part of the process. There is guilt associated with this decision, advocate for families to advance care plan (living will) so their own children will not have to make this difficult decision

Looking at the mission and vision for residential care, creating attainable, personal goals with each resident and family. Be present, be supportive and be honest!

(H. C. Kales, K. Zivin, H. M. Kim, M. Valenstein, C. Chiang, R. Ignacio, D. Ganoczy, F. Cunningham, L. S. Schneider, F. C. Blow. Trends in Antipsychotic Use in Dementia 1999-2007. Archives of General Psychiatry, 2011; 68 (2): 190 DOI: 10.1001/archgenpsychiatry.2010.200

A REVIEW OF THE USE OF ANTIPSYCHOTIC DRUGS IN BRITISH COLUMBIA RESIDENTIAL CARE FACILITIES http://www.health.gov.bc.ca/library/publications/year/2011/use-of-antipsychotic-drugs.pdf

Accommodating and Managing Behaviours in Dementia Decisional and Practice Support for BPSD 28 February

2012 Behaviour Management and Care Planning: Power point

by Psiurski, Sandra