“Challenging Behaviours”,or is it Behaviours that Challenge us?

Presentation byDuncan Robertson

Senior Medical Director Seniors’ Health SCN

toChallenging Behaviours Meeting

Corbett Hall. University of Alberta 2012-11-21

How AHS Seniors’ Health SCN will collaborate in addressing this challenge.

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Overview

• Strategic Clinical Networks (SCN) in AHS

• Seniors’ Health “Platforms” 3-5 years

• Initial Projects for 2013-14

• Questions

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Challenging behaviour – defined

"culturally abnormal behaviour of such intensity, frequency or duration that the physical safety of the person or others is placed in serious jeopardy, or behaviour which is likely to seriously limit or deny access to the use of ordinary community facilities" and may be exhibited by people with developmental disabilities, dementia, psychosis and by children.

- Emerson E 2001 ISBN 9780521794442

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Behaviours that challenge us in the context of dementing illnesses

• Angry (aggressive) behaviour • Excessive walking (wandering behaviour)• Repetitive behaviours • Vocally disruptive behaviours• Disinhibited behaviours

http://www.dementiapartnerships.org.uk/workforce/learningpathway/step-3/1-challenging-behaviours/

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What are Strategic Clinical Networks (SCNs) ?

• Collaborative clinical teams (with a strategic mandate)• Led by clinicians and driven by clinical needs• Comprised of:

• Front-line Clinicians• Zone and Other Clinical Operations / Clinical Support

Service Leaders • Researchers• Content Experts• Public / Patients• Alberta Health & other external partners

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Six SCNs Launched in 2012

• Obesity, Diabetes and Nutrition• Bone and Joint Health• Cardiovascular Health and Stroke• Addiction and Mental Health• Cancer Care• Seniors’ Health

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Ogden Nash (1902-1971)

Crossing the Border 

“Senescence begins And middle age ends  The day your descendents Outnumber your friends.”

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• Today, 1 in 9 Albertans is over 65 years of age• In 25 years, 1 in 5 Albertans will be a senior• 47% of Alberta seniors have a health condition that

limits their everyday activities• Alberta seniors visit emergency departments at twice

the rate of non-seniors• Alberta seniors are admitted to an inpatient unit at 5

times the rate of non-seniors.• Dementia and delirium are major contributors to LOS,

ALC days and admissions to LTC

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What is the Provincial Mandate of SCNs?

• To:– Improve population health– Ensure continuous quality improvement– Incorporate research that impacts patients– Focus on patient outcomes– Design more accessible care– Develop & implement appropriate clinical practices– Make patient safety a priority– Ensure value for money

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(Projected)

Alberta Seniors Population Growth 2005-2020

• Today: Seniors make up 10.6% of Alberta’s Population

• Seniors make up 14.6% of the Population

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Non-sustainable healthcare cost increases in Canada:

Canada 1975 to 2010• Expenditure increases = 3.5 fold• Population increases = 1.5 fold

23.4M people

34.2 M people

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Seniors Health SCN Platform 1

Aging Brain Care:

Aging Brain Care Pathway incorporates:• Healthy Brain Aging• Prevention, diagnosis, treatment, and

management of co-morbidity• Advance care planning and issues for

individuals and caregivers• EOL care

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Seniors Health SCN Platform 2

Healthy Aging and Seniors Care:

• Health Promotion and Prevention• Development of a Care Pathway to guide

citizens, families and caregivers, practitioners and others on the patient journey of the frail elder across the care continuum.

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Initial Project: Elder Friendly Care 1/2

What is the problem? • One-third of frail seniors develop new

functional disabilities in hospitals as a result of delirium, immobility, falls, prolonged catheter use and infections.

• Result is longer LOS, discharges to higher level of care, loss of independence and reduced well-being.

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Initial Project: Elder Friendly Care 2/2

What is the solution?• Multiple interventions to prevent unintended

outcomes of hospitalization

• Start in hospital sector and move to other parts of continuum

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Elder Friendly Care Strategies

• Delirium Prevention, Detection & Management• Preventing Functional Decline (through mobility)• Continence Management (reduced use of catheters)• Nutrition & Hydration• Comfort Rounds (being evaluated in Calgary Zone)

– Scheduled nursing rounds at least q2h to improve inpatient care safety and quality

– Includes communication, toileting, positioning, nutrition, hydration, & pain management

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Why Elder Friendly Care?• AHS/AH Priority - HQCA Ministerial Directive to reduce

ALC days and occupancy in hospitals; Destination Home • Builds on successful delirium screening component of

Bone & Joint Hip Fracture Pathway• Builds on Zone priorities:

- Calgary Zone: Elder Friendly Care Project in hospitals already underway; Destination Home in Home Care- Central Zone: priority on improving elder care in Red Deer

Regional Hospital- Edmonton Zone: alignment with Care Transformation Project

in acute care hospitals

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Elder Friendly Care - Appropriate Use of Catheters

What is the problem? • Unnecessary use of catheters leads to high

infection rates, antimicrobial resistance, immobility, delirium, falls, longer LOS and poor patient experience

• Risk is highest for seniors in emergency and inpatient units, especially those with dementia

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Elder Friendly Care - Appropriate Use of Catheters

What is the solution?

• Guidelines for insertion of catheters (“7 reasons only”)

• Nurse-led protocol for removal, checked daily

• Reminder system

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Philippus Theophrastus Aureolus Bombastus von Hohenheim (1493-1591 alias Paracelsus )

Alle Ding' sind Gift und nichts ohn' Gift; allein die Dosis macht, dass ein Ding kein Gift ist.

“all things are poison and nothing is without poison, only the dose permits something not to be poisonous."

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Initial Project :Appropriate Use of Antipsychotics

What is the problem?

• Over 1 in 4 residents in Long-Term Care (LTC) facilities in Alberta

receive antipsychotics for management of behaviours

associated with dementia

• Evidence exists for harm when used

inappropriately and for long periods of time – including loss of

mobility, loss of cognition, stroke, falls, death

Prevalence of Antipsychotic Drug Use in Absence of Psychotic and Related Conditions (%) - April 2011 - March 2012

North Zone Edmonton Zone

Central Zone

Calgary Zone South Zone Alberta Rest of

Canada

34.4 27.3 33.3 26.4 35.4 28.1 32.5

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US Initiatives on Antipsychotic Use in Care Facilities 1/2

• 1987 OBRA Act (Implemented 1990)• Appropriate Diagnosis• Target Symptoms• 24-Hour Dose Guidance• Monitoring• Concurrent Behavioral treatment• Attempt to Reduce d/c in 6 Months

http://www.rimed.org/medhealthri/2010-12/2010-12-372.pdf

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US Initiatives on Antipsychotic Use in Care Facilities 2/2

• 2007 Iteration of OBRA– If used, must document 2 attempts at GDR* at least 1

month apart in 1 year– If used over 1 year must document:

• Worsening of Sx when D/C• MD opinion why no further D/C attempt

• 2005 FDA “Black Box Warning”

* Gradual dose reduction

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Appropriate Use of AntipsychoticsIn Collaboration with A&MH SCN

What is the solution?

- Use antipsychotics only when required according to guidelines

- Identify non-pharmacological approaches for challenging behaviours

- Educate on behaviour management practices- Engage families, government and advocacy groups

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Why Appropriate Use of Antipsychotics?

Alignment:

• Alberta Health Continuing Care Health Service Standards• Accreditation Canada Standards• American Geriatric Society’s Updated Criteria (2012) for

Potentially Inappropriate Medication Use in the Older Adults.

• AHS Seniors Health Medication Management Initiative and Cognitive Impairment Strategy

• Public, government and media concerns• Zone Priorities: All Zones Participating

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