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Alternatives to Chemical Restraints in the Long Term Care Setting

— August 31st, 2012

This two part series will challenge perceptions about alternatives to chemical restraints in the long term care setting for residents with Alzheimer’s or other types of dementia.

There are four basic keys to utilizing alternatives to chemical restraints with this unique population. Understanding, Communication, Attitude, and Willingness. Each area needs to be addressed to achieve successful outcomes.

Understanding

Understanding, is critical: understanding the diagnosis that increases the potential for adverse, agitated, even combative behavior; understanding role delineation with nursing and therapy regarding chemical restraint reduction; understanding the triggers for the behavior; understanding that behavior is a form of communication often times resulting from an unmet need; understanding adverse behavior occurs when the demand on a person exceeds the person's ability at any given time; understanding the importance of resident centered approach strategies.

Communication

Communication can be the basis for implementing resident specific approach strategies. Communication is as important among direct care staff, nursing, dietary, therapy, physician, social services, and other departments, as it is with the resident and family members. Communication is effective when each member of the interdisciplinary treatment team has the opportunity to provide feedback throughout the entire day. This resident centered care approach empowers all staff to take ownership and share strategies to decrease the risk of adverse behavior.

Attitude

Attitudes can negatively, as well as positively, affect the work place. "When people look at the past, they feel regret. When they look at the future, they feel anxiety and pessimism. In the moment they're bound to find something unsatisfactory. They are suffering from automatic negative thoughts, ANTS, which are cynical, glooming, and complaining thoughts A "Can-do", positive attitude is critical to the success of any organization, effecting all departments.

Willingness

Willingness is the key to changing our understanding of resident specific triggers. Willingness is the key to always challenging, while striving to improve our understanding of residents entrusted to our care. Willingness helps to improve our communication with each other, with our residents, families. Willingness ties to ongoing staff training and trying new approaches including interdisciplinary treatment team regular weekly meetings. This treatment team may consist of the medical director, consultant, pharmacist, director of nursing, unit nurse manager, MDS nurse, social services and therapy representative.

The focus of this team is to review each dementia resident on antipsychotic medications to determine if the need still exists. Resident concerns and adverse drug reactions - negative side effects should be discussed, along with recommendations to reduce or discontinue the use of psychotropic drugs, while ensuring that each psychotropic drug used has a specific diagnosis linked to it.

While psychotropic medications can decrease the need for physical restraints, they aren't the only or necessarily the first treatment strategy. It is effective to incorporate intervention strategies including therapy, effective communication, environmental modifications to manage the behavior, instead of medicating the behavior to fit in the environment. Look to identify the cause of the behavior, first, and then determining how to proceed.

--You have it easily in your power today, to increase the sum total of this world happiness, now. How, by sharing a few words of sincere appreciation, to someone who is lonely or discouraged. Perhaps tomorrow, you will have forgotten the kind words you said today, but the recipient will cherish them for a lifetime." Dale Carnegie.

--You CAN make a difference in the care and life of the person with dementia!

Below are recommendations that afford the opportunity to use alternatives to chemical restraints with this unique population.

1. Approach is everything...make the resident your focus, determine what he/she likes as a reward.

2. Build rapport; help resident to recognize you as a person who is friendly and supportive.

3. Modify the environment- eliminate distractions to increase focus, know the residents personal, cultural history.

4. Work closely with staff; know what works, and what doesn't.

5. Use multi-sensory cues.

6. Use positive statements and praise for efforts leading to completion of task.

7. Do not use terms of endearment; honey, sweetie, sugar, or dear.

8. Problem solve with caregivers to find effective strategies.

9. Use non-threatening body language.

10. Use calm, audible voice, use one step requests, avoid giving too much information, don't ask yes or no questions...the answer most of the time will be "no".

11. Realize your thoughts are real, and automatic negative thoughts - ANT's - don't always tell the truth.

12. Train your thoughts to be positive and hopeful.

13. Replace the negative with the positive.

14. Psychotropic medications are among the most frequently prescribed agents for elderly nursing home residents.

15. Older people, and people suffering from a dementing illness are susceptible to overmedication and negative reactions from a combination of drugs.

16. To get the needed results, doctors can't always eliminate the side effects. You and your doctor must work closely to achieve a balance.

17. Ask what side effects to watch out for, and communicate what you see.

18. The focus should be to eliminate the underlying cause of the behavior rather than medicate the behavior.

19. In cases where medication cannot be eliminated, the focus should be to; maximize the resident’s potential and wellbeing, and minimize the hazards associated with medication side effects.

20. Increase understanding of non-medication treatment, and approach strategies.

21. Change the approach, redefine the problem, if the behavior doesn't cause harm, don't medicate the behavior.

22. Ask yourself, "What's my goal," this is to improve resident’s quality of life.

23. Ask resident "What is troubling you, and how can I help"... if you find you are getting impatient or angry, leave.

24. Remind caregivers they can make a difference.

25. Decide how to respond, rather than react, to the behavior., don't take behavior personally.

26. Be confident, yet flexible in your approach, avoid frustration and negativity.

27. Think safety first.

28. Staff training regarding antipsychotic medications is key to any efforts to reduce drug use in long term care.

29. Resident quality care improves with staff empowerment.

30. We can't change the person, so we have to change our approach.

"Antipsychotic medications pose a great risk for elderly residents, especially those with dementia. They can increase the risk of death in these residents and may put elders with dementia at greater risk for a stroke. They also have many negative side effects such as weight gain, agitation, sleepiness, gastrointestinal problems, dry mouth, worsening cognitive problems, and fatigue to name a few.

These drugs must help stabilize or improve the person's clinical outcomes, quality of life, and functional capacity. The FDA regulations indicate that these drugs cannot be used simply for behaviors of wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia, unsociability, fidgeting, nervousness, uncooperative behavior, verbal outbursts, and behaviors that don't endanger the resident or others.

They should be used to treat an enduring condition only when target behaviors are clearly and specifically identified and monitor, and usage must be documented over time. The behavioral issues must be re-evaluated periodically to determine if medication dose reduction or discontinuation are viable options."

Article by Tom Conrad, OTA/L, is a Clinical specialist for Cognition and Behavioral Approach strategies for HealthPRO Rehabilitation. In addition to providing daily treatment for clients with dementia and other psychiatric disorders, he develops and delivers continuing education seminars nationwide.

From July 2012 issue of Provider; The Troubling Role of Antipsychotics. Solving The Mystery, Providers are finding alternatives to antipsychotics by doing some old fashioned detective work. by Joanne Kaldy

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