Transcript Module IV Interventions - Massachusetts Senior Care

Interventions
Objectives
 Implement changes to address unmet needs and
prevent disruptive behavior
 Utilize de-escalation techniques
 Utilize non-pharmacologic interventions
Review
 All behavior has…
 All behavior is an attempt to …
 Our first question is NOT
HOW DO I GET THEM TO STOP? but
Review
 Primary Objective is Prevention
 Anticipating needs
(Maslow)
 Addressing unmet needs
(Cohen-Mansfield)
 Changing our own behavior (STAR)
 Secondary Objective is avoiding use of antipsychotics
 Morbidity/Death
 Limited effectiveness
Maslow’s Hierarchy of Needs
MEANING
ESTEEM & SELF RESPECT
BELONGING & AFFECTION
SAFETY AND SECURITY
PHYSIOLOGIC INTEGRITY
 Trying to meet these needs drives human behavior, including many
of the behaviors of individuals with Alzheimer’s Disease
Conflict Between Residents
What happens?
Prevention
 Person-centered care plans
 Identify needs, strengths
 Anticipation
 Vigilance
 Debriefing
Intervention: De-escalation
 De-escalation techniques
 Signal breath
 Body language and tone of voice
 Monitor proximity
 Ask, don’t tell
 Listen actively
 Make sense of communication
 Address underlying problem
 Offer immediate and/or interim solution
 Insert pleasurable activity (divert or distract)
Intervention
 Address underlying problem
 Learning Circle
 Loneliness
 Boredom
Addressing the underlying problem
Loneliness
Boredom
What are the risks?
What are the benefits?
Psychotropics
 Anti-anxiety
 Anti-depressants
 Anti-psychotics
 Mood stabilizers
 Sedative-hypnotics
Problem of medications
 No “anti-agitation/anti-aggression” medication
 Miss the point
 Off-label use ‘OK’
 risk/benefit equation more critical
 Antipsychotics 
  mortality
  stroke
Anti-Psychotics
• Side effects
– Sedation
– Restlessness
– Stiffness
– Dry mouth
– Blurred vision
– Weight gain
 Risks




Falls
Failure to thrive
Pressure ulcers
Diminished quality of life
 Akithesia
 Neuroleptic malignant syndrome
(NMS)
 Tardive dyskinesia (TD)
 In dementia


STROKES
DEATH
Anti-Psychotics
 Target
 Hallucinations
 Delusions
 Disorganized thinking
 Negative symptoms
 Behavioral symptoms of dementia IF AND ONLY IF



Meeting unmet needs a la Maslow doesn’t work AND
Non-pharmacological interventions haven’t worked AND
Benefits strongly outweigh risks
Approach to medication use
 Does benefit justify risk?
 What is my target? Are there alternatives? Have I given
alternatives a fair trial?
 How will I know if it works?
 When will I stop if it is not working?
 How long will I keep going if it is working?
What helps us NOT Use Medication
 Changing our practices: New paradigm
 Not just symptoms
 Communication
 Not the task
 Prevention not intervention

Address loneliness, helplessness, boredom
What helps us NOT Use Medication
 Tools
 Individualized, strength-based care planning
 Anticipating needs
 Addressing unmet needs
 Engaging strengths, wishes
 Engaging family, community
 Huddle and analyze disruptive behaviors
What helps us NOT Use Medication
 Changing our behavior
 De-escalate, not escalate
 Shift to relationship building as “the job”
 The tasks are not the job
 Monitoring own fear response
 Monitor environment
Successful Interventions
 Environment
 Eden Alternative (loneliness, helplessness, boredom)
 Music
 (Massage)
 Recreation
 (Aromatherapy)