NON PHARMACOLOGICAL NON PHARMACOLOGICAL APPROACHES TO APPROACHES TO

REDUCING THE USE OF REDUCING THE USE OF ANTIPSYCHOTICSANTIPSYCHOTICS

Presented byPresented byWanda Raby Spurlock, DNS, RN-BC, Wanda Raby Spurlock, DNS, RN-BC, CNE, FNGNACNE, FNGNA

Associate Professor, Southern University and Associate Professor, Southern University and A&M CollegeA&M College

School of NursingSchool of Nursing

PSYCHOSIS: KEY PSYCHOSIS: KEY POINTSPOINTS

HallucinationsHallucinations Perceptions without stimuliPerceptions without stimuli Can occur in any sensory modalityCan occur in any sensory modality

DelusionsDelusions Fixed or false perceptions or Fixed or false perceptions or

beliefs not in keeping with realitybeliefs not in keeping with reality Unfounded ideas that can be Unfounded ideas that can be

suspicious (paranoid), grandiose, suspicious (paranoid), grandiose, somatic, self-blaming, etc.somatic, self-blaming, etc.

Not the result of religious or Not the result of religious or cultural normscultural norms

Psychosis in the Psychosis in the ElderlyElderly

Commonly used to describe a severe mental illness in which delusions and hallucinations are prominent

Can be seen in a wide range of conditions

Psychotic symptoms of acute onset are usually the result of a delirium secondary to a medical condition, drug misuse, and drug-induced psychosis

Increased Risk of Psychosis in Increased Risk of Psychosis in Elderly Persons: Contributing Elderly Persons: Contributing

FactorsFactors

Age related deterioration of Age related deterioration of frontal and temporal corticesfrontal and temporal cortices

Social isolationSocial isolation Sensory deficitsSensory deficits Age related pharmacokinetic Age related pharmacokinetic

and pharmacodynamic and pharmacodynamic changeschanges

PolypharmacyPolypharmacy

Parkinson’s Disease and Parkinson’s Disease and HallucinationsHallucinations

Anti-Parkinson Anti-Parkinson medications improve medications improve motor disorder but motor disorder but may also induce may also induce psychotic symptoms, psychotic symptoms, namely visual namely visual hallucinationshallucinations

Examples of Medical Examples of Medical Conditions that May Cause Conditions that May Cause

Psychotic SymptomsPsychotic Symptoms Cerebrovascular Cerebrovascular

diseasedisease CNS traumaCNS trauma Fluid or electrolyte Fluid or electrolyte

imbalanceimbalance Hepatic diseaseHepatic disease Hypo-Hypo-

hyperthyroidismhyperthyroidism NeoplasmsNeoplasms

Metabolic conditionsMetabolic conditions Hypoxia, Hypoxia,

hypoglycemiahypoglycemia Normal pressure Normal pressure

hydrocephalushydrocephalus Vitamin deficiency Vitamin deficiency

(B(B1212)) Huntington’s diseaseHuntington’s disease

Four Common Types of Four Common Types of Misidentifying Delusion in Misidentifying Delusion in

Persons with Alzheimer’s #1 Persons with Alzheimer’s #1

The Capgras TypeThe Capgras Type

False belief that previously known people (e.g. wife or caregiver) have been replaced by impostersSpouse or caregiver is an

imposter

Four Common Types of Four Common Types of Misidentifying Delusion in Misidentifying Delusion in

Persons with Alzheimer’s #2 Persons with Alzheimer’s #2

Phantom Boarder Phantom Boarder SymptomSymptom

False belief that guests are living in the person’s house

Four Common Types of Four Common Types of Misidentifying Delusion in Misidentifying Delusion in

Persons with Alzheimer’s #3Persons with Alzheimer’s #3

The Mirror The Mirror SignSign

Person misidentifies his or her own mirror image as someone else

Four Common Types of Four Common Types of Misidentifying Delusion in Misidentifying Delusion in

Persons with Alzheimer’s #4Persons with Alzheimer’s #4

The TV SignThe TV Sign

Misidentification of TV images as real

Points to RememberPoints to Remember

Hallucinations and delusions that Hallucinations and delusions that do not cause distress do not require do not cause distress do not require pharmacological interventionpharmacological intervention

Correcting auditory and visual Correcting auditory and visual deficits may improve symptomsdeficits may improve symptoms

Late-onset schizophrenia is a Late-onset schizophrenia is a rarerare disorderdisorder

Paradigm Shift in Dementia Care

Biomedical ModelBiomedical Model

Defined in terms of pathological changes

Inevitable decline; incurable Progressive cognitive and

functional decline Centered around deficits -

expectation of loss of competency

As communication and cognitive functioning are affected by the disease progression, care is aimed at meeting basic biologic needs

Person-Centered CarePerson-Centered Care

Knowledge of individual’s personal history, life-long patterns, standing personality traits, and coping patterns

Aimed to maximize existing strengths Abilities oriented care – retained

abilities; prevention of excess disability

Modification of environment to support and enhance safety

Adaptation of environment to meet changing needs

Social engagement Personal preferences, likes,

dislikes

The Progressively Lowered Stress Threshold (PLST) Model

Major premises: internal and environmental stressors

beyond a person’s threshold for coping lead to increased disability Examples: fatigue; adverse effects of medications; noise; pain; multiple competing stimuli

environmental modifications will reduce environmental stressors and prevent or lessen behavioral symptoms

(Smith, Gerdner, Hall, & Buckwalter, 2004)

Needs Driven Dementia Compromised Behavior

Provides a different way of viewing behaviors

Examines source of behaviors Expression of unmet needs Unmet needs manifest in behavioral symptoms

Key is to identify root cause of behavior All behavior is meaningful Triggers Focus on treating, reducing, eliminating or modifying

factors that cause or contribute to behaviors

(Algase et al., 1996)

Behavioral TriggersBehavioral Triggers

Environmental Environmental

Poor lighting Poor lighting with with shadowing shadowing effect, glareeffect, glare

Excessive Excessive noisenoise

ClutterClutter Uncomfortable Uncomfortable

temperaturestemperatures

PsychologicalPsychological

AngerAnger FearFear LonelinesLonelines

ss Boredom Boredom FrustratioFrustratio

nn

• Hunger• Pain • Thirst• Constipati

on• Fatigue• Infection

Physical

Communication Communication Validation vs Reality Validation vs Reality

OrientationOrientation Don’t argue with, attempt to convince or Don’t argue with, attempt to convince or

force person to accept reality force person to accept reality Use a matter of fact approachUse a matter of fact approach More effective to address the person’s More effective to address the person’s

feelings in relation to what they perceive feelings in relation to what they perceive as realityas reality

Responding to the emotional content of what the person is saying, rather than presenting “factual reality” is more beneficial and less likely to result in increased agitation or a catastrophic reaction.

Prior to Using Prior to Using Antipsychotic Drugs: Antipsychotic Drugs:

ChecklistChecklist Rule out medication side Rule out medication side

effect effect Underlying medical Underlying medical

condition condition Social and physical Social and physical

environmentenvironment sensory overloadsensory overload sensory deprivationsensory deprivation

Result of unmet needResult of unmet need Life-long personality traitsLife-long personality traits Use of non-pharmacological Use of non-pharmacological

interventions as interventions as front-line front-line approachapproach

DopamineDopamine

Antipsychotics and Dopamine

Parkinson’s Disease and Dopamine

Target SymptomsTarget Symptoms Target symptoms should be Target symptoms should be

clearly identified prior to clearly identified prior to antipsychotic treatment and antipsychotic treatment and carefully monitored over the carefully monitored over the course of treatmentcourse of treatment

Medication intervention for Medication intervention for poorly defined eccentricities poorly defined eccentricities provide limited clinical benefit provide limited clinical benefit and unnecessary exposure to and unnecessary exposure to medication risks and poor medication risks and poor health outcomeshealth outcomes

Antipsychotic Drugs and Antipsychotic Drugs and Inappropriate Treatment Inappropriate Treatment

Targets Targets UnsociabilityUnsociability Poor self-carePoor self-care RestlessnessRestlessness Impaired memoryImpaired memory Inattention or Inattention or

indifference to indifference to surroundingssurroundings

WanderingWandering UncooperativenessUncooperativeness

https://www.healthcare.uiowa.edu/IGEC/IAAdapt/document/Antipsychotic_Prescribing_Guide_Both.pdf

Antipsychotic Drugs and Antipsychotic Drugs and Inappropriate Treatment Inappropriate Treatment

Targets Targets Mild anxietyMild anxiety Verbal expression Verbal expression

or behaviors not or behaviors not representing a representing a danger or threat danger or threat to othersto others

Nervousness Nervousness FidgetingFidgeting

https://www.healthcare.uiowa.edu/IGEC/IAAdapt/document/Antipsychotic_Prescribing_Guide_Both.pdf

Atypical Antipsychotics and Atypical Antipsychotics and

FDA Black Box WarningsFDA Black Box Warnings In 2005 the FDA issued a black-box warning of In 2005 the FDA issued a black-box warning of

increased risk of death associated with use of atypical increased risk of death associated with use of atypical antipsychotics in the elderly population with dementiaantipsychotics in the elderly population with dementia

“Increased Mortality in Elderly Patients with Dementia-Related Psychosis – Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Analysis of seventeen placebo-controlled trials (modal duration of 10 weeks) in these patients revealed a risk of death in the drug-treated patients of between 1.6 to 1.7 times that seen in placebo –treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5% compared to a rate of 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infections (e.g., pneumonia) in nature. [this drug] is not approved for the treatment of patients with dementia related psychosis. “ (p. 4)

Example of a Boxed Warning

Levinson, D. (2011). Medicare atypical antipsychotic drug claims for elderly nursing home residents. Department of Health and Human Services. Office of the Inspector General. OEI-07—8-00150

Black Box Warning Extended Black Box Warning Extended to Conventional Antipsychoticsto Conventional Antipsychotics

The FDA extended the black box The FDA extended the black box warning to conventional warning to conventional antipsychotic drugs in 2008antipsychotic drugs in 2008 Elderly persons with dementia-related Elderly persons with dementia-related

psychosis treated with antipsychotic psychosis treated with antipsychotic drugs (conventional or atypical) are at drugs (conventional or atypical) are at ↑risk of death↑risk of death

Neither class of drugsNeither class of drugs is FDA approved is FDA approved for use in treatment of dementia related for use in treatment of dementia related psychosispsychosis

Office of Inspector General Office of Inspector General (OIG)(OIG)

May 2011 Report May 2011 Report Evaluation requested regarding use of atypical Evaluation requested regarding use of atypical

antipsychotics in elderly NH residentsantipsychotics in elderly NH residents Atypicals approved by FDA for use in treatment of Atypicals approved by FDA for use in treatment of

schizophrenia and/or bipolar disorderschizophrenia and/or bipolar disorder Concern regarding use for off-label conditions Concern regarding use for off-label conditions

(i.e., conditions other than schizophrenia and/or (i.e., conditions other than schizophrenia and/or bipolar disorders) and/or for residents with the bipolar disorders) and/or for residents with the condition specified in the FDA boxed warning condition specified in the FDA boxed warning (i.e., dementia).(i.e., dementia).

Side effect of atypical drugs include increased risk of death in elderly

persons with dementiaLevinson, D. (2011). Medicare atypical antipsychotic drug claims for elderly nursing home residents. Department of Health and Human Services. Office of the Inspector General. OEI-07—8-00150

Other Adverse Side Other Adverse Side EffectsEffects

CardiovascularCardiovascular Hypotension

Orthostatic hypotension Cardiac arrhythmias

prolongation of QT intervall

Central Nervous SystemCentral Nervous System Sedation Reduction in

seizure threshold

EndocrineEndocrine• Nausea• Diarrhea• Constipation

GastrointestinalGastrointestinal• Weight gain• Diabetes

mellitus

• Cholestatic jaundice• ↑transaminase enzyme

activities

LiverLiver

Potential Antipsychotic Potential Antipsychotic DrugsDrugs

Side EffectsSide EffectsExtrapyramidalExtrapyramidal

Akathisia Drug induced

Parkinsonism Dystonia

Acute dystonic reaction

Tardive dyskinesia

AnticholinergicAnticholinergic Dry mouth, blurred

vision Glaucoma Constipation Urinary

hesitancy/retention Impairment in

cognitive functioning and hallucinations

Extrapyramidal Side Effects Extrapyramidal Side Effects (EPSEs)(EPSEs)

Side Effect

Nursing Considerations

Akathisia • Most often with high potency antipsychotics• Hallmark symptoms: inability to sit still, pacing, squirming • Critical to distinguish between ↑ anxiety or psychotic agitation

Drug induced Parkinsonism

• 3 major hallmark symptoms: tremors, rigidity, and bradykinesia• Mental effects: bradyphrenia and cognitive impairment• ↑ susceptibility to aspiration or to injury due to falls

Acute Dystonias

• Early recognition of hallmark symptoms: tightening of jaw, stiff neck, swollen tongue• Later signs: Severe and bizarre muscle contractions i.e. oculogyric crisis , torticollis, opisthotonos, glossopharyngeal constrictions• Painful and very frightening • Accurate observation promotes prompt recognition and treatment

Example of objective EPSE assessment tool: The Abnormal Involuntary Movement Scale (AIMS)

Sensory Enhancement Sensory Enhancement MeasuresMeasures

ExamplesExamples Landscaped outdoor

gardens Soothing environmental

sounds such as singing birds, waterfall, soft music

Pleasing odors that stimulate the senses (baking smells, fresh brewed coffee, tea, fresh flowers)

Provide for periods of exposure to natural lighting when possible

Incorporate items in environment that stimulate the 5 senses: visual (memory books and scrap books containing family pictures, different textures such as cotton balls, perfumes, citrus odors from fruits such as lemons and oranges, smells from plants such as lavender, and roses)

Measures to Prevent Sensory Measures to Prevent Sensory OverloadOverloadExamplesExamples

Decrease environmental stimuli ( noise generated from equipment, TVs, stereos and background noise from loud conversations

Keep use of overhead paging at a minimum

Avoid use of large mirrors

Use appropriate level of lighting to prevent casting of shadows in environment

Comfortable room temperature

Assess for unmet physical needs such as toileting, hunger, thirst, pain, constipation

Utilize therapeutic communication strategies to prevent catastrophic reactions

Maintain a calm, non-hurried approach to care

Allow for periods of rest between challenging activities

Resistance to Care During BathingResistance to Care During BathingNursing ApproachesNursing Approaches

Person-Centered Care Approaches

Communication Strategies

Environmental Modifications

• Requires knowledge of lifelong bathing preferences, individual rituals surrounding bathing, and awareness of cultural considerations

• “See” through the eyes of the person with dementia

• Focus is on “individual” not the task being performed

• Avoid hurried movements

• Allow participation in care to the degree possible

• Calming voice• Simple, step by

step, directions and instructions

• Avoid use of “elderspeak”

• Engage in “pleasant” conversations on topics of interest

• Verbal cueing, sequencing, gesturing, priming, or mirroring

• Never scold; Offer praise and unconditional regard

• ↓ extraneous noise

• Soft, relaxing, preferred music

• Avoid bright lights, glare or shadows

• Maintain comfortable room and water temperature

• Remove clutter and items that could be distracting or frightening

Examples of Stage Related Symptoms

and Non-Pharmacological Interventions

Stage

Symptoms Interventions

Mild Forgetfulness Generalized anxiety Restlessness, pacing Isolation or withdrawal from usual activities Apathy Depression

Memory books Reminiscence therapy Meaningful structured activity/ exercise Indoor/outdoor gardening Music therapy (individual preferred)

*Note: Interventions from either stage can be used based on individualized needs/response

Examples of Stage Related Symptoms

and Non-Pharmacological Interventions

Stage Symptoms Interventions*Moderate

Shadowing ↑ restlessness and

pacing Wandering Physical aggression; agitation Sundowning More severe diurnal

or circadian rhythm

disruptions Suspiciousness,

accusatory paranoia Delusions,

hallucinations

Simulated presence therapy Individualized, preferred music; soothing music Validation therapy White noise Pet therapy Aromatherapy, message therapy Video-respite

*Note: Interventions from either stage can be used as appropriate based on individualized needs/response

Examples of Stage Related Symptoms

and Non-Pharmacological Interventions

Stage Symptoms Interventions*

Severe

Repetitive vocalizations Screaming, yelling, crying out, moaning 

Soft, calming music Snoezelen® (multisensory) Simulated presence therapy

*Note: Interventions from either stage can be used based on individualized needs/response

Benefits of SleepBenefits of Sleep

Brain tissue restorationBrain tissue restoration Body restoration Body restoration Energy conservationEnergy conservation Memory reinforcement Memory reinforcement Regulation of immune functionRegulation of immune function Metabolism and regulation of certain Metabolism and regulation of certain

hormoneshormones ThermoregulationThermoregulation

A Single Normal Sleep A Single Normal Sleep PatternPattern

Non Drug Measures to Non Drug Measures to Promote SleepPromote Sleep

Warm milk, soothing, preferred music, aromatherapy, light message

Eliminate intake of caffeine in late afternoon and evening, offer opportunity for toileting prior to retiring for sleep

Encourage periods of interaction between family and staff during daytime

Engage in meaningful individual and/or group activities

Reduce levels of environmental stimuli (i.e. sounds and images from TVs kept playing in room during evening and night-time hours)

Proper lighting in room to avoid shadowing effect

Honors importance of keeping the “Person” at the center of care planning and decision making

Promotes choice, purpose and meaning in daily life of the “Person”

“Person” supported in achieving a maximal level of physical, mental and psychosocial well-being

Premium placed on active listening to and observingthe “Person”

REMEMBER: A “Person”-Centered Approach Builds on Individual Strengths and Abilities

to Maximize and Promote Independence

The End