Transcript Improving Mental Healthcare in Nursing Homes

IMPROVING MENTAL
HEALTHCARE IN
NURSING HOMES
Brenda K. Keller, MD,CMD, Cameo Rogers, CTRS, CDP, Jennifer Medlin
Hannah Fillman, Thomas M. Magnuson, MD
Goal of Project


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To teach non-pharmacological interventions for
management of behavioral problems in dementia to
nursing home staff.
To test the effectiveness of these educational efforts.
To reduce the overall prn and scheduled
psychotropic use by introducing nonpharmacological methods into daily resident care.
Part I: Education
Methods
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All staff at 120 bed facility received two- hour
long sessions focused on non-pharmacological
behavioral management and use of activities to
prevent behaviors.
Tip sheets group- learned about aggression,
wandering, and disruptive vocalizations
Activities group- learned how to use activities as a
proactive measure for behavior management and
lead and adapt small group activities for multiple
ability levels
Lectures with case
examples
testing
Tip sheets placed on MAR
/ activity guides on units
Weekly Small
groups/DVD sessions
testing
Mental Health Topics
General Principles
Aggression
Wandering
Disruptive vocalizations
Depression treatments
Anxiety
Relaxation techniques
Insomnia treatments
Activity Guides / DVD
Assessment Tools
Knowledge
Attitudes
Participants
N=40*
Results
Dementia Knowledge Questionnaire Results for Tip Sheets Group
Pre-Test
Post-Test
X2
P-value
Basic
Sub-Category
2.87
3.00
2.04
0.179
Epidemiology
Sub-Category
0.91
1.09
0.87
0.357
Cause
Sub-Category*
3.74
4.61
7.45
0.012
Symptom
Sub-Category
7.17
7.00
0.14
0.670
Test Total
14.70
15.70
2.47
0.108
*significant data
Difference Between Pre and Post Test Scores
for Tip Sheets Group
Basic SubCategory
Epidemiology
Sub-Category
Cause SubCategory
Symptom
Category
Test Total
CNA (N=11)
0.09
0.27
1.64*
-0.54
1.46
MA (N=4)
0.50
0.00
0.00
0.75
1.25
LPN (N=4)
0.00
0.00
0.25
0.25
0.50
RN (N=3)
0.00
0.33
0.33
-0.66
0.00
Activities (N=1)
0.00
0.00
0.00
0.00
0.00
*X2 = 8.77 p < 0.05
CNA participants improved their knowledge of the causes of dementia
Part II: Resident
Outcomes
Methods
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Measured the percent of residents on routine
antidepressants, antipsychotics, anxiolytics, and hypnotics
each month.
Measured the number of residents using prn doses of
psychotropic drugs more than twice monthly.
Measured the number of incidents of behavior problems
affecting other residents monthly. (MDS)
Measured the percent of residents feeling more depressed
and the percent with depression without treatment monthly.
(MDS)
Used data from November 2009 to April 2010 to calculate
the 6 month historical average for comparison.
Historical Ave: 48.5
Months
New ave =49.3
Stdev= 3.2
Resident Antipsychotic Drug Use
P
e
r
c
e
n
t
New Average 8.125
STD 1.73
Percent
Resident Antianxiety Drug Use
New Average= 8.25
Stdev=2.12
Percent
Resident Hypnotics Drug Use
New average= 4.85
Stdev=0.83
14
PRN Psychotropic Use
N with > 2 prns used monthly
12
10
8
6
4
2
0
chotropic Use
His
tori
cal
A…
Jul
y
Au
g
Se
pt
12
8
7
8
Oct
No
v
De
c
Jan
Fe
b
8
6
5
3
6
Ne
w
Av
e
std
de
v
7
1.77
Resident Behavior Affecting Others
14
12
10
Percent
8
6
4
2
0
2
Historical
Ave
June
July
Aug
Sept
12.5
12.1
8.1
7.8
12.7
+Intervention Began: June 18, 2010
* P < 0.05
Limitations
Low participation 40/152 in survey may
minimize the true effect of educational
intervention on patient outcomes.
 Change in MDS mid intervention allows for only
3 months of f/u of behaviors
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Conclusions
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The tip sheets lecture overall helped increase the CNAs’
knowledge of dementia etiology.
The lectures did not significantly affect the knowledge and
confidence of the participants, however an overall increase in
both areas was observed.
The percent of residents using routine antipsychotics,
anxiolytics, and hypnotics showed a trend toward decrease
following the intervention but did not reach statistical
significance.
The percent of residents using prn psychotropic medications
used decreased significantly during the intervention
The percentage of resident behaviors affecting others
significantly decreased during the of intervention.
Unanticipated outcomes
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Lectures now part of new staff orientation at test
site
Tip sheets and Activities DVD to be incorporated
into education policies and procedure for Vetter
Health Services, owner/operators of 32 long-term
care facilities in Nebraska, Kansas, Iowa, Missouri
and Wyoming
Tip sheets available at:
http://www.unmc.edu/intmed/geriatrics/nursing_ho
me_personnel.htm
Thanks
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AMDA Foundation/Pfizer for support of this project
Staff and Administration at Brookestone Village
Cameo Rogers, CTRS, CDP
Jennifer Medlin, M1 supported by AFAR
MSTAR program
Hannah Fillman, supported by the UNMC
Student Undergraduate Research Program
Thomas M. Magnuson, MD