Successful initiative reducing anti-psychotic medication expands to more LTC sites
A shift in the culture of care at long-term care sites was in the offing. In Quebec, between 40 and 60 per cent of residents in CHSLDs are prescribed anti-psychotic (APs) medications to manage their behaviour. In many cases, they had not undergone a psychiatric assessment.
So pervasive was the practice that the provincial health ministry took action, with OPUS-AP. The program was launched in 24 CHSLDs across the province to study the effectiveness of alternative interventions in limiting problem behaviours.
Kastner 3, a nursing unit at Donald Berman Jewish Eldercare (DBJ), took part in the first phase of the project. Dubbed the “Behaviour Unit”, Kastner 3 is home to residents with behavioural and psychological symptoms of dementia, which may be expressed aggressively.
“We were very lucky to have been chosen to take part in OPUS-AP at these early stages,” says Jodie Little, the Nursing Educator leading the project on Kastner 3. Prior to the start of the program, 63 per cent of residents on Kastner 3 were given anti-psychotics. As the reliance on medication to manage behaviours dropped, that number declined to 41 per cent. “The OPUS-AP project has been a win-win-win for residents and their families, as well as staff,” attests Ms. Little.
The results of the de-prescription of anti-psychotics at DBJ mirrored the success of similar programs in long-term care centres across Quebec, as well as other provinces. Alternative measures in managing agitated residents brought no increase in behaviour problems, and staff recorded a slight decrease in falls. As an additional benefit, family members reported their loved ones were less drowsy and more cognitively alert.
“We’ve been hearing positive feedback from families during the transition,” Ms. Little says. “They’ve told us, ‘He recognizes me now!’, and ‘It’s the first time in a long time she’s said my name’. In that respect, the families were a rich source of information. It was very helpful to have them as partners.”
To ensure the safety and well-being of residents, the removal of the medication coincided with a shift in approach by the staff who care for them. The team leaders on Kastner 3, Bertha Désir and Irlande Jean-Charles, were trained to assess different behaviours and respond appropriately. They helped coach staff on the floor and modeled the approach for their colleagues.
“The key is to conduct a more thorough assessment before we administer medication,” Ms. Désir points out. “We try to determine the resident’s needs and understand their unique preferences.”
“It’s like an organigram,” Ms. Jean-Charles adds. “First you consider whether the resident’s basic needs are met. Is the person tired, hungry, or do they need to be changed? If their needs aren’t met and can’t be communicated, that can impact on the resident’s mood and lead to disruptive behaviours like wandering or aggression. So we keep an eye out.”
Staff were trained to personalize interventions based on the personal history of each resident, which is collected at the time of admission and supplemented in a family meeting. For instance, information regarding routine or habits, such as whether a resident prefers sleeping in or waking early, guided the staff in enhancing the resident’s comfort and maintaining the quality of life to which they were accustomed.
The Kastner 3 multidisciplinary team took the following steps in carrying out the OPUS-AP program:
1) Staff initially met with family members to learn more about the resident and discuss potential triggers and causes for their behaviours
2) The therapeutic nursing plan was modified based on the cause of the behaviour and feedback from the resident’s family
3) A meeting was held the following week to discuss how the resident is reacting to the change in approach
4) Anti-psychotic medications were reduced incrementally, by 25 per cent weekly
Ms. Little reassured staff who had concerns about a potential increase in violent behaviour by sharing encouraging results from other provinces. “The data showed that when APs were reduced, there were fewer falls, and that meant fewer incident reports for staff to write,” she says. “Also, residents were more alert and better able to participate in their own care.”
Phase 2 of the OPUS-AP project will expand to other long-term care facilities within the CIUSSS. All units at DBJ will be taking part, along with all units at Saint Margaret Residential Centre and three units at Donald Berman Maimonides. The second phase is expected to run from March through December 2019.
For staff who are poised to begin the second phase of the OPUS-AP project, Ms. Jean-Charles points to the positive results they witnessed after reducing the use of AP medications among their residents with behaviour problems. “You need to believe and try,” she urges colleagues. “It’s all in the approach. Good communication becomes the basis for care.”
“If we succeeded with this program, anyone can!” affirms Ms. Désir.