Transcript sylvia - The Hotel Network

Reinvention of the CADE units: An
individual approach to the care of people
with dementia
Annaliese Blair
Katrina Anderson
Michael Bird
Sarah MacPherson
Funded by NSW Ministry of Health MHDAO
Older Persons Mental Health Policy Unit
T-BASIS model
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Medical Director - Part-time geriatrician or psychogeriatrician
Integrated outreach/inpatient service – ensuring:
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most cases treated in situ, and capacity building takes place
most admissions are appropriate and planned
follow-up after patients’ discharge
Weekly multi-disciplinary case reviews
All staff involved in developing and implementing care plans
24 hour nurse and medical coverage
Main population at least moderate BPSD
Median length of stay 8 -12 weeks
Regular staff training.
Broad Evaluation Questions
 Are
the units adhering to the
guidelines and adopting the
model?
 Are
the units clinically effective?
Number of patients with primary
diagnosis (N=118)
Alzheimer’s disease
Vascular dementia
LBD
Alcohol Related Dementia
FTD
Other dementia or dementia unspecified
Mixed Dementia
Parkinson’s Dementia
Affective disorder
Psychotic disorder
Delirium
Other
Missing
% with medical co-morbidities
% with psychiatric co-morbidities
% with moderate to severe dementia (CDR)
35
18
6
6
4
26
6
4
5
3
3
1
1
94.72%
55.79%
71.96%
Behaviour
Physical aggression
Verbal aggression
Wandering
Sexual disinhibition/ inappropriate
Intrusiveness
Agitation
Absconding
Hallucinations
Poor medication compliance
Delusions
Tearfulness
Self-Neglect/Living in Squalor
Respite
Repetitive behaviours
Resistive to care
Alcohol withdrawal
Pacing
Awaiting placement
Calling out
Behavioural assessment
Medical review
Delirium
Confusion
No. of patients admitted for behaviour
19
11
10
9
8
8
7
6
6
5
5
5
5
4
4
4
3
3
2
2
2
2
1
Mean number of behaviour incidents in
first two weeks after admission
30
25
20
15
10
5
0
Unit 1
(n=12)
Unit 2
(n=15)
Unit 3
(n=15)
Unit 4
(n=14)
Unit 5
(n=11)
How behaviours were responded to (%)
100
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
0
Unit 1 (n=12)
Unit 2 (n=15)
Unit 3 (n=15)
Unit 4 (n=14)
Unit 5 (n-11)
Figure 1. Psychosocial
Admission
Discharge
Unit 1 (n=12) Unit 2 (n=15) Unit 3 (n=15) Unit 4 (n=14) Unit 5 (n-11)
Figure 2. PRN medication
‘What would you have done if there
wasn’t a T-BASIS unit?’
Number and Percentage
(n=27)
Used sedation
11 (40.70%)
Asked the GP to review medications
5 (18.50%)
Referred to the Psychogeriatric Unit
5 (18.50%)
Taken them to the Emergency Department
2 (7.40%)
Involved the Mental Health Team
2 (7.40%)
Increased staffing levels
2 (7.40%)
Case example
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Admitted to hospital after a fall at home – she was
not given any pain relief
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Multiple physical co-morbidities
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Continuously wandered into other patients’ rooms
and got into bed with them and frequently had to be
removed by security staff
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She was given Valium and Haloperidol, restrained
using manacles, and specialled for 7 consecutive
days.
Case example (cont.)
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No incidents of aggression or inappropriate
behaviour in the first 48 hours and few thereafter
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The design of the T-BASIS units means that doors
can be locked but the main ‘treatment’ was
redirection by staff
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Haloperidol, Temazepam and Valium was ceased
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She was given substantial pain relief
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Remained on Risperidone
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Discharged to residential care after 12 weeks.
Average number of behavioural incidents per
patient at admission and discharge by unit
30
25
20
Admission
15
Discharge
10
5
0
Unit 1 (n=12)
Unit 2 (n=15)
Unit 3 (n=15)
Unit 4 (n=14)
Unit 5 (n=11)
Reason for discharge (%)
Discharge reason
1
(n=30)
2
(n=21)
3
(n=25)
4
(n=22)
5
(n=20)
Behaviour settled
76.7
61.9
52.0
59.0
75.0
Acute physical illness
0.0
9.5
0.0
4.5
0.0
Moved due to increase in behaviours
0.0
4.8
0.0
0.0
0.0
Physical deterioration
13.3
4.8
12.0
0.0
0.0
Died
0.0
4.7
4.0
4.5
0.0
Still in unit
0.0
9.5
20.0
31.8
15.0
Other
3.3
0.0
0.0
0.0
0.0
Missing data
6.7
4.8
12.0
0.0
10.0
Readmissions
2
3
1
2
2
Where did they go?
Discharge to
Percentage of patients
(N=103)
Residential care
73.79%
Home
3.88%
Still in unit
8.74%
Other in-patient facility
3.88%
Mental Health Ward
0.97%
Missing
0.97%
Feedback
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Families
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I’ve got my mum back. I’m so grateful to them for getting
mum better; it was a God-send
… the staff took mum's behaviours in their stride and
worked with her in a really caring and sensitive way
The social worker was astronomical: she was so attentive to
him [the patient] and she conversed with him as well as with
me.
Residential Facilities
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RACF staff were asked to rate their satisfaction with the
service on a scale of 1 = extremely dissatisfied to 5=
extremely satisfied.
M Score = 3.86 (SD = 0.90).
Acknowledgements
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The Nursing Unit Managers and staff who welcomed us so warmly and who
also welcomed the fact that there was going to be an evaluation so they could
assess their progress.
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The families of patients in the T-BASIS units who gave us permission to look at
the medical files, and some of whom allowed us to interview them about quality
of care.
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Richard Fleming and John Bowles, whose commitment to improving the care of
people with dementia and challenging behaviour in health services led to the
development of the original CADE units.
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The NSW Ministry of Health which funded the evaluation and is committed to
further improvement of the model and the care of older people with dementia