Recreation Therapy For Dementia

Introduction

Patients/Residents residing in LTC homes with behavioral and psychological symptoms of dementia (BPSD) or (responsive behaviors) often receive treatment with antipsychotic medication to alleviate these symptoms as they are the standard of care (Borisovskaya, Pascualy, & Borson, 2014). BPSDs are often seen as challenging for staff working with the aging population and the use of antipsychotic medication is often used for the benefit of the staff and not for the benefit of the older adult. With an aging population and an increasing number of older adults in Canada a greater proportion of persons with dementia will follow. Based on projections using data from the Canadian Study of Health and Aging (Canadian Study of Health and Aging Working Group, 1994), the Alzheimer Society of Canada estimated that there would be 564 000 Canadians living with dementia in 2016. They also expected the number to rise to 937 000, an increase of 66% (Alzheimer Society of Canada, 2016). The Canadian Foundation of Healthcare Improvement (CIHI) in collaboration with interRAI created the RAI 2.0 indicator for appropriate use of antipsychotics, approximately 57% of all LTC facilities in Canada provide routinely collected and reported data to calculate this indicator (CIHI, 2018). Using the number of individuals who do not meet exclusion criteria and who are receiving an antipsychotic on 1 or more days within the 7 days preceding their most recent LTC assessment, divided by the total number of individuals in the facility or region (CIHI, 2018). The exclusion criteria for the RAI 2.0 indicator are individuals with schizophrenia, Huntington’s disease, those with active delusions or hallucinations, and those at the end of life (all potential indications for antipsychotics). heterogeneity in underlying clinical populations, differences in age, severity of dementia (as measured by the Cognitive Performance Scale), and agitation (HQO, 2015) require adjustments to be made to compare rates across facilities or regions (CIHI, 2018). Ontario, Alberta, British Columbia, and the Yukon, with partial reporting in Newfoundland, Nova Scotia, and Manitoba long term care facilities currently have provincial rates of the RAI 2.0 indicator publicly reported which creates a troubling discrepancy across jurisdictions concerning the use of antipsychotics in LTC facilities with patients/residents without a diagnosis of psychosis. CIHI using the RAI 2.0 indicator estimated that 27.5% of long term care patients/residents throughout Canada are prescribed antipsychotic medication without a diagnosis of psychosis (CIHI, 2018). If antipsychotic reduction programs were to be put in place nationwide it would benefit over 100,000 people every year and save $5.2 Billion healthcare dollars over the next 30 years (CFHI, 2018).There is an alternative for treatment for BPSDs in the form of non-pharmacological interventions which are strategies used for preventing, reducing or eliminating behaviors without the use or in conjunction with pharmaceutical agents based on the needs, preferences, and functional abilities of patients/residents residing in long term care facilities (Cohen-Mansfield, Libin, & Marx, 2007), (Janzen, Zecevic, Kloseck, & Orange, 2013).

Other provinces and health regions in Canada have started new comprehensive programs to reduce inappropriate use of antipsychotics. The most comprehensive program in Canada to date is the Appropriate us of Antipsychotics initiative in Alberta (AHS, 2016). The program started in 2011 and included both policy and regulatory approaches involving a provincial clinical guideline (AHS, 2016) and program implementation including staff education, use of person-centered approaches to reduce BPSD, and Monthly interdisciplinary team meetings to support discontinuation of antipsychotics (AHS, 2016). The goal of the AUA project was to lower the RAI 2.0 indicator for appropriate use of antipsychotics from 26.8% to 20% or below by 2018, this goal was achieved by Alberta as they currently have the lowest provincial average for antipsychotic prescriptions in long term care facilities for geriatric patients/residents with an inappropriate antipsychotic prescribing rate of 18% resulting in improved quality of life and social engagement for the patients/residents, improved job satisfaction and no increase in staff requirements (CIHI, 2018).

Other initiatives currently under way in Canada include the Canadian Foundation for Healthcare Improvement antipsychotic reduction collaborative, involving more than 200 LTC facilities across Canada (CIHI, 2018), the Call for Less Antipsychotics in Residential Care program in British Columbia (BCPSQC, 2016), and the Ontario Ministry of Health and Long-Term Care Appropriate Prescribing Demonstration Project in Ontario (HQO, 2015), (HQO, 2018). In 2014-2015, 56 long-term care facilities across seven provinces and one territory in Canada received help from the CFHI antipsychotic reduction collaborative to lower antipsychotic drug use for their residents with dementia who were inappropriately prescribed the medication. The collaborative established 15 teams to implement more patient/resident-centered, team-based and data-driven approaches to managing BPSDs associated with dementia. The collaborative’s early results from a sample of 416 patients/residents from the facilities showed that 54% of patients/residents had antipsychotics discontinued or significantly reduced (18% reduced; 36% complete eliminations). The same patients/residents had a reduction in falls of 20%, reduction in verbally abusive behavior of 33%, reduction of physically abusive behavior of 28%, a reduction of socially inappropriate behavior of 26%, and a reduction in resistance to care by 22%. Although a potential increase in aggressive behavior is a common major concern in the removing of antipsychotic medication the initiative showed this concern to be negligible (CFHI, 2018). Scaling the results of the CFHI initiative nationally in the first five years were estimated to: reduce or discontinue antipsychotic the use of antipsychotics in 35,000 LTC residents per year, an avoidance of 25 million antipsychotic prescriptions altogether, prevention of 91,000 falls, prevention of 19,000 ER visits (8% decline), prevention of 7000 hospitalizations (8% decline), and $194 Million saved in direct health care costs after cost of implementation of the initiative are accounted for (CFHI, 2018).

Although there is emerging evidence that many non-pharmaceutical strategies can reduce inappropriate antipsychotic use in dementia, several areas require further research and evaluation. The optimal rate of antipsychotic use in dementia has not been determined. Based on changes in prescribing rates observed in which widespread initiatives for reducing antipsychotics have been implemented (such as the United States and Alberta), rates of inappropriate antipsychotic prescribing below 20% are likely feasible in many regions provided that similar processes to support reductions are available. Health Quality Ontario has proposed a provincial benchmark of 19% for performance on the RAI 2.0 indicator (Kirkham et. al. 2017).

Conceptual framework for understanding BPSD

Behavioral and psychological symptoms of dementia (BPSDs) are considered the most troublesome and problematic symptoms of dementias. They include agitation, aberrant motor behavior, anxiety, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes (Cerejeira, Lagarto, & Mukaetova-Ladinska, 2012). The percentage of persons living with Dementia that experience just one BPSD is 97%, the most common being apathy, depression, irritability, agitation, and anxiety (Steinberg et al., 2008). The social and physical environment can influence changes in the brain resulting in BPSDs which is explained in the following three complementary conceptual models. Competence-environmental press theory (CEPT) states that environmental stressors influence an individual’s psychological state which challenges their cognitive capacity which can provoke a behavioral response (Lawton & Nahemow, 1973). A patient/resident living with dementia receiving care might perceive it as uncomfortable may strike out instead of communicating discomfort through words. The progressively lowered stress threshold model (PLST) expands the concept of press, suggesting that environmental factors produce stress, which is met by a coping response that is influenced by the progressive impact of dementia causing responsive behavior when environmental demands exceed stress tolerance (Hall & Buckwalter, 1987). The needs-driven dementia-compromised behavior model (NBD) conceptualizes BPSDs as an attempt to communicate an unmet need. A resident living with dementia responds to their environment or social stimuli based on their personal characteristics which includes there cognitive and functional status causing BPSDs (Algase et al., 1996). The NBD model sees BPSDs including apathy, pacing, and physical aggression as meaningful expressions to express ones needs. An individual living with dementia might express the feeling to leave a situation causing anxiety by wandering or eloping (Kovach, Noonan, Schlidt, & Wells, 2005). Understanding the causes of BPSDs aided in the development of non-pharmaceutical interventions to reduce or eliminate those symptoms. Non-pharmaceutical interventions are needed to reduce the use of antipsychotic medications used in the population of geriatric patients as there is little evidence to support their benefit (Sink, Holden, & Yaffe, 2005). In the population of geriatric patients, the use of antipsychotic medication is associated with higher risk of myocardial infraction (Pariente et al., 2012), stroke (Douglas & Smeeth, 2008), and mortality (Kales et al., 2012). The retrospective cohort study conducted by Kales and his colleagues showed that haloperidol was associated with the highest mortality rates, followed by risperidone, olanzepine, valproic acid and its derivatives, and quetiapine (Kales et al., 2012). Regulations recommend antipsychotic medications should only be used when an individual symptom present a danger and only after all possible causes have been identified and addressed (CMS, 2013). Antipsychotic medication has also been indicated to increase the risk of falling (Pretorius, Gataric, Swedlun, & Miller, 2013). The leading cause of injury-related hospitalizations are falls among the elderly population, resulting in 20-30% of seniors falling each year (Public Health Agency of Canada, 2014).Current recommended practices to address BPSDs should be influenced by broader dementia care principles such as simplifying tasks, clear and calm communication with sufficient time for the individual to respond, individualized activities aligned with preferences and cognitive capacity, and engagement in simplified environments that are free from clutter and distractions, (Gitlin, Kales, & Lyketsos, 2012).

Nonpharmacological practices to treat BPSDs should be person-centered, reflect environmental factor and individual stress and coping reactions, address the individual’s unmet needs, and include readily accessible evidence-based protocols (Fazio, Pace, Flinner, & Kallmyer, 2018). There is little literature that has specifically examined the outcomes of individualized practices creating a need for systems to be put in place to evaluate the effectiveness of practices and allow for adaptations or changes to be made as needed. A new system developed by Kales, Gitlin, & Lyketsos in 2014 entitled DICE (Describe, Investigate, Create, Evaluate) is an effective process of selecting and monitoring practices to evaluate their individual effectiveness (Kales, Gitlin, & Lyketsos, 2014). A similar process is used to follow best practices in therapeutic recreation called APIED (Assess, Plan, Implement, Evaluate, Document), and is viewed as an accountability model to guide the design of programs and services that specifically focus on patient’s objectives (Peterson & Stumbo, 2000). This systematic approach allows for recreation and leisure programs to be developed and implemented to best meet the patients/resident’s needs and enables progress towards predetermined goals (ATRA, 2018). The approaches follow’s a step by step process assessing a patients/resident’s needs, strengths, limitations and personal interests, planning a personalized intervention plan with adaptions or modifications to assist in the patients/resident’s ability to participate, implementing and monitoring the response to the intervention, evaluating the outcomes and effectiveness of the intervention, and documenting behavioral observations and recommendations for future practices (ATRA, 2018). Current practices of non-pharmaceutical interventions for BPSDs lack evidence-based protocols to implement them leaving care teams with a lack of guidance implement the interventions. Creating a tool kit for evidence-based non-pharmaceutical interventions for BPSDs will give care teams the proper guidance to implement the interventions to help improve the quality of life of patients/residents living with dementia.

During my internship here at Kenneth E. Spencer home I developed a wing based program for C wing to support patients/residents participating in the AUA initiative (appropriate use of antipsychotics). The program aimed to align with AUA initiatives goals by implementing person-centered non-pharmaceutical approaches to manage BPSDs and reduce the use of antipsychotic medication amongst patients/residents living with dementia residing in long term care facilities in Canada. The goal of the program was to develop 5 person-centered individualized and group activities with evidence to support their rational of use to reduce BPSDs that could be implemented by the care team at Kenneth E. Spencer Memorial Home. The activities were chosen based on the assessment of the patients/resident’s cognitive impairment using the Mini-Mental State Exam (MMSE) and their personal leisure interests using the Farrington Leisure Interest Inventory (FLII). The implementation of the activities was planned providing adaptations or modifications to assist the patients/residents in their ability to participate. During the implementation process engagement was encouraged and responses were monitored. The activities were then evaluated on their successfulness of elevating BPSD in the patients/residents participating in the activities and the evaluations were then documented with recommendations for future practices.

The following outlines the wing based program for C wing implementing 5 activities following the systematic approach of APIED to create an activity toolkit to be used as part of a new initiative to reduce the use of antipsychotic medications at Kenneth E. Spencer memorial home.

Assessment

15 residences were assessed on c-wing for their cognitive impairment using the Mini-Mental State Exam (MMSE), the MMSE is a test to rate cognitive functioning in individuals living with dementia, the test takes 10 minutes to administer and is scored out of 30, scores between 24 and 30 show no cognitive impairment, scores between 20 and 23 show mild cognitive impairment, scores between 11 and 19 show moderate cognitive impairment, and scores of 10 or less show severe cognitive impairment (Folstein, Folstein, & McHugh, 1975). The patients/resident’s personal leisure interests were measured using the Farrington Leisure Interest Inventory (FLII) which is a questionnaire used to gather past and current recreation and leisure activity personal interests, previous work history, where the patient/resident grew up, their favorite food, type of music and their favorite activity they enjoy the most doing (Smith, Buckwalter, Buettner, & Seydel, 2010). Assessment of cognitive impairment using MMSE resulted in 1 resident having severe cognitive impairment, 8 having moderate cognitive impairment, 2 having mild cognitive impairment, and 4 having normal cognition. The FLII provided information on residence work history, where they grew up, favorite foods, favorite types of music, and personal recreation and leisure activity interests under the categories of sports/games, social, outdoors, and cultural.

Plan

The residence were divided into two groups based on cognitive impairment, the 8 residence with moderate cognitive impairment were grouped with the 1 resident with severe cognitive impairment, and the 2 residence with mild cognitive impairment were grouped with the 4 residence with normal cogitation. Activities were chosen based on cognitive impairment, personal recreation and leisure activity interests, and evidence of improving (BPSD).

Activities considered were sensory activities, reminiscence activities, social activities, and structured activities.

Sensory activities stimulate one or more of the five senses which can correct a sensory imbalance (i.e. sensory overload or sensory deprivation) which leads to a lower stress threshold (Chung, Chan, & Lee, 2007). Sensory activities are suitable choices for low functioning older adults living with dementia because the sensorimotor area of the brain maintains capabilities long after other abilities are gone (Fitzsimmons, Barba, Stump, 2014). Sensory activities include music, simple pleasure activities that consist of multilevel sensorimotor age-appropriate activities, handwashing, aromatherapy, and message.

Reminiscence activities are a way to recapture the memories of the past and focus on them to enrich our daily lives (Cappeliez, & O'Rourke, 2006). Person centered care and knowing the residence history and leisure/recreational activity are important when using reminiscence activities and can prevent recollection of past events that call upon grief, anger, or fear (Fitzsimmons, Barba, Stump, 2014). person-centered care has been shown to reduce symptoms of BPSDs which requires that professional caregivers have full knowledge of each resident’s cultural and family values, personal life story, previous interests and skills, likes and dislikes (e.g., food, activities, personal care), and physical well-being (IPA, 2012). A pilot study in Sweden found that when participants remembered, they made associations and had positive interactions with each other and their caregivers (Holm, Lepp, & Ringsberg, 2005). A meta-analysis of reminiscence therapy for older adults with dementia statistically significant results included increased cognition, mood, and behavior among the participants and also showed a significant reduction in stress amongst their caregivers (Woods, Spector, Jones, Orrell, & Davies, 2005). When an older adult expresses anxiety, sadness, or mild agitation, a short reminiscing session helps replace the negative thoughts with positive ones (Fitzsimmons, Barba, Stump, 2014).

Structured activities are activities that have the goal to develop and/or stimulate the social, cognitive and physical abilities of persons with dementia and to reduce boredom. Structured activities may include tasks (eg, flower arrangement, coloring with markers), reading stimuli (eg, being presented with a large-print magazine), individualized activities matched to the individual’s past preferences or identity, work like activities (eg, stamping envelopes, folding towels), and manipulative stimuli (eg, a tetherball, building blocks), a significant positive impact on BPSDs where found using each type of stimuli and activity (Cohen-Mansfield et. al. 2010). Task, reading, and self-identity (ie, person centered relating to patient/resident’s personal interests and history) activities was found to have the greatest impact on both physical and verbal agitation symptoms of BPSD, while work activities and manipulative stimuli only significantly impacted physical agitation (Cohen-Mansfield et. al. 2010).

Social interactions have been shown to have a definite impact on BPSDs by producing a positive mood/affect through reducing the feeling of boredom and social isolation felt by patients/residents living with dementia (Cohen-Mansfield et. al. 2010). There are various dimensions of social interactions and they were thoroughly analyzed in a study by Cohen-Mansfield et al, the dimensions analyzed included: human vs nonhuman (ie, animal), realistic vs not realistic (eg, a doll that looks like a baby vs a doll that looks like a doll), animated (eg, a robot with movement) vs not animated, and alive (eg, real human or real cat) vs not alive (eg, video, doll, or robot) (Cohen-Mansfield et. al. 2010). Human, animated, realistic, and live stimuli where shown to be advantages in promoting engagement, attention, and a positive attitude when compared to the other forms of social interactions, however engagement with a non-living stimulus such as a robotic cat, may provide longer engagement with a patient/resident (Cohen-Mansfield et. al. 2010).

Activities chosen

Nature Lovers (Dixon, & Daphne, 2005)

Shopping Scavenger Hunt (Dixon, & Erkstrom, 1999)

Table Ball Game (Buettner, & Greenstein, 1997)

Google Earth Armchair Travel (wills, 2012)

Question Ball (Dixon, & Irving, 2007)

Implementation

The first activity I choose to implement was “Nature Lovers”, an activity used to elicit positive emotions in patients/residents and encourage communication with patients/residents by providing a focal point for discussion. The activity involves using 5 photographs of images in each of the following 5 categories: babies, animals. Inspiration, nostalgia, and nature. The images are used to elicit positive emotions in a one-to-one or small group setting. Residents who participated were Irene, Joan, David N, Harry, peter, and Margaret.

Irene and Joan participated together in a small group. Irene and Joan were sitting at a table in the common area of C-wing at Kenneth E. Spencer Memorial home, they were not interacting with each other and displayed passive emotions. They both enjoyed the photographs of animals and babies which prompted a noticeable increase in mood and communication. The photographs elicited smiling, laughing and commenting each photograph amongst the two patients/residents. The activity prompted Irene and Joan to tell stories about pets they use to have and when their children were babies and what it was like to be a mother. The activity created a positive communication with the staff implementing the activity and both patients/residents asked the staff implementing the activity to share any photographs in the future when they would have more.

Harry participated by himself, when staff approached him he was in his room reading a book displaying passive emotions. Harry enjoyed all the photographs but particularly enjoyed the nostalgia photographs the most. The pictures elicited positive emotions such as smiling and laughing. The pictures prompted Harry to share stories of his past such as where he lived, where he worked, what cars he liked and drove, and stories about his children. The staff implemented this activity could relate with Harry as he told the staff he used to live in Campbellton NB and owned a department store there for 20 years. The staff implementing this activity is from Campbellton NB so he could relate and share his own stories of Campbellton as well. The staff implementing this activity had prior interactions with Harry but never like this, usually only one word or two-word sentences. The photographs really brought harry up in his mood and confidence or desire to communicate. Harry thanked the staff for sharing the photographs and asked the staff to come by anytime to visit.

David N participated by himself, when staff approached him he was in his room communicating concern about his stuff missing and the staff had taken his stuff from him. Staff recalled from previous notes that David N had been showing signs of agitation and had been wondering at night getting very little sleep. David N was pleased to have a visitor and someone to talk to, when presented one photograph at a time he made comments and elicited positive emotions in the form of smiling and laughter. The photographs lowered his level of agitation and worry about his stuff acting as a positive distraction from these feelings. The photographs prompted David N to share stories about where he used to work, his love for news and reading the newspaper every day, where he grew up and use to live, where he traveled selling cosmetics as his line of work, what pets his to have, and other stories of his past experiences. David N thanked the staff implementing this activity for visiting and told him to come back any time. David N’s level of agitation and worry had de-escalated and he went to sit at a table in the common room of C-Wing and began to socialize with the other patients/residents.

Peter and Margret participated together as a small group, they are married so they often participate in activities together. The staff approached peter and Margret while they were sitting in their room they share, they were watching tv quietly and not engaging in much conversation. Peter and Margret both enjoyed each category of images presented to them in the photographs. The photographs elicited positive emotion in the form of smiling and laughter and created a discussion about the photographs between the staff member, Peter, and Margret. The photographs prompted peter and Margret to share stories of their past, what it was like raising their children, pets they use to have, places they use to work, and places they visited throughout their lives. Peter and Margret thanked the staff for coming by and sharing the photographs and told the staff member to stop by anytime. Peter and Margret seemed less passive and more ambitious, positive and communicating between each other more as the staff was getting ready to leave.

The second activity I choose to implement was “Shopping Scavenger Hunt” which is a fun interactive game used to elicit cognitive engagement, positive social interactions, and visionary/tactile sensory interactions. The activity can improve mood, give a sense of accomplishment, provide a distraction from things causing agitation or sadness, relieve boredom and loneliness, and create positive social connections amongst the patients/resident’s peers. Patients/residents who participated where: Don, Joan, Irene, David M, and Regina.

Don, Joan, Irene, David M, and Regina participated in a large group. The staff implementing the activity explained to residents that today’s activity was going to be a scavenger hunt activity using sales advertisements and a list of items commonly found in sales advertisements. The staff then brought each patient/resident to a table in the common room of C-Wing where they would be playing the game with other patients/residents the staff then handed each participant a shopping scavenger hunt check list that had a list of 20 items commonly found sales advertisements, scissors, and plastic Ziploc bags, and a stack of sales advertisements. The staff then explained that the object of the game was to use the list provided finding each item on the list in the sales advertisements provided and cutting them out with the scissors provided and placing the cut-out items into their Ziploc bags provided to keep the item collected safe. The staff then explained that there would be a 20-minute time limit to the game and at the end of the game a count of the items collected will be taken from each participant and that the person with the most items at the end of the game wins. The participants were encouraged to share or trade adds they found with each other to complete the list. Don, David M, and Regina where excited to play and began to look at the list and start looking through the sales advertisements provided to find the items on the list to cut out. Irene and Joan’s first reaction were that they found the game was childish and did not want to participate, however Don asked them for their help to complete his list by helping him cut out items that he found. Irene and Joan then became interested as they wanted to help Don and they did not mention any negativity towards the game or that the game was childish throughout the remainder of the game. Prior to the activity each Don, Regina, and David M were in their rooms showing signs of passiveness, boredom and possibly loneliness. Prior to the game Irene and Joan were showing signs of agitation, anxiety possibly caused by boredom and loneliness. During the game all five residents were fully engaged, communicating socially with each other, having fun, and showing signs of positive emotions in the form of smiling and laughter. Once the game was finished each patient/resident counted the items they cut out, David M had 8, Regina had 14, and Don with the help of Irene and Joan were the winners with 18 items. The patients/residents showed excitement and joy from participating in the activity. The patients/residents elicited a positive mood through smiling and laughing. Each resident was proud of the accomplishment they had made, and there was no fighting or signs of feeling left out if the patient/resident wasn’t the winner. The patients/residents were encouraged to save the items they cut out to put them up on their walls in their rooms or create a collage out of them. The patients/residents thanked the staff implementing the activity and asked him to bring more activities or games for them to play in the future. While the staff was getting ready to leave the patients/residents choose to stay at the table and socialize amongst themselves showing positive emotions in the form of smiling and laughter.

The third activity I chose to implement was “Table Ball Game” a game using an elevated table with target holes and 3 tennis balls to promote reach, grasp and release skills, visual tracking, run repetitive movements, and a sense of achievement. This activity can help relieve agitation or anxiety in individuals who wonder, display passive behaviour or boredom, or are fixated on particular things creating the emotions of agitation or anxiety. Patients/Residents who participated were Harry, Regina, David M, and David N.

The staff implementing this activity brought the Table Ball Game to C-Wing and placed it on one of the tables in the common room. The staff then brought a picture of the game to different residents on C-Wing, explained that the object of the game was to roll a tennis ball so that it bounces gently off the side of the game and rebounds into one of the target holes, and asked each patient/resident if they wanted to participate in the game. Harry, Regina, David M, and David N all chose to come try the game out and participate. Prior to starting the game Harry, Regina and David M were in their rooms showing signs of passiveness, boredom and possibly loneliness. David N was showing signs of agitation, wondering and was fixated on who took his stuff from his room. The staff demonstrated how the game was played by saying “here is three tennis balls we are going to use, we are going to each take a turn with the three balls rolling one ball at a time gently to try and bounce it off the game so it rebounds into one of the target holes. The staff and the participants agreed upon how many points each hole was worth and that we would play 10 rounds each and the person with the highest score wins. Each patient/resident were excited to participate in the game and showed positive emotions through smiling and laughter while participating in the game. The patients/residents told me the game was fun, challenging, and entertaining. After playing 10 rounds Regina was the winner and the other patients/residents were happy for her for winning. The patients/residents asked if we could play another 10 rounds in which I agreed to. The patients/residents continued to display positive emotions, had fun, and showed a sense of achievement each time they would get a ball in one of the target holes. After the second 10 rounds of playing the residents said how fun and exciting it was to play and asked me to come back anytime to play again. Regina, Harry, and David M showed more ambition and liveliness and continued to socialize with each other after the game had ended. David N showed no signs of agitation, wondering, anxiety, or being fixated on where his stuff went in his room. David N also stayed to socialize with Regina, Harry, and David M after the game had ended.

The next game I chose to implement was “Google Earth Armchair Travel” which is an activity using Google Earth via the internet to provide a positive distraction to illicit positive emotions and reduce passiveness, aggressiveness, agitation, or anxiety. This activity provides sensory experience and allows the opportunity to reminisce or social engagement. This activity takes participants to faraway places without leaving home. Participants can visit their original homes, there children’s or grandchildren’s homes, as well as different countries and landmarks. The patients/residents who participated in this activity were Peter and Margret.

The staff implementing this activity knocked on Peter and Margret’s room door, introduced himself and asked if they were interested in participating in activity using Google Earth via the internet that would allow them to visit places they have been or want to see, and that the places would be visually displayed on their tv and they could explore each place they choose. Peter and Margret were excited to participate and to see what it was I was talking about looked like. The staff then plugged his computer into the patients/residents tv via an HDMI cable and brought up Google Earth on his web browser via the internet. The staff then asked Peter and Margret if there was a place they have lived before or have been to that they would like to see, or a place they have never been to that they would like to see. Peter and Margret told the staff they wanted to see where they used to live in the UK in the city of Portsmouth. Using Google Earth, the staff could show them the house they lived in, the downtown area where they used to shop, the Portsmouth historic dockyard, and the naval base where Peter used to work. Using street view on Google Earth, the staff could make the experience life like as if the Patients/Residents were there in person. This sensory life like experience prompted Peter and Margret to reminisce and share stories of the time they lived there. The patients/residents lived there throughout world war 2 and the time after, they both shared their experience of what it was like to live through these hard times and what types of bombs were dropped and the sound they would make if they were coming. The time the experienced during World War 2 may have seemed terrifying but sharing this experience did illicit negative emotions or create agitation or anxiety in the patients/residents. The patients/residents then asked if they could see the countries of Australia and New Zealand as they have visited those places in the past. The staff brought up each location one at a time and showed them the different areas of the countries they wanted to see and again created a life like experience using street view Via Google Earth. The experience of seeing Australia and New Zealand again prompted the patients/residents to reminisce and discuss their experiences visited these places in the past and how wonderful their experiences were. This activity elicited positive emotions in the form of smiling, laughter, ambition and liveliness. This activity gave the patients/residents the experiencing of visiting different parts of the world without leaving the comfort of their room and prompted reminisce of good times they had in the past which gave them a positive distraction which reduced the patients/residents level of passiveness, boredom and possibly loneliness.

The last activity I chose to implement was called “Question Ball” an activity that uses hand-eye coordination and physical activity to illicit cognitive and social engagement, as well as to reminisce. This activity provides an enjoyable quality interaction amongst the patients/residents promoting positive emotions, a sense of happiness and improved wellbeing. This activity can help with patients/residents showing passive behavior, boredom, or loneliness. This activity can also help residents who are showing aggressive behavior, agitation, anxiety and wondering behavior. The patients/residents who participated in this activity were Irene M, David N, Anne M, and Jaqueline C.

The staff implementing this activity created a question ball out of a beach ball and wrote various questions on it to prompt meaningful social interactions and reminiscence amongst the patients/residents participating. The staff brought the ball to C-Wing and explained the concept of the game to patients/residence on the wing and asked them if they wanted to participate in the game. Irene M, David N, and Anne M all showed interest and excitement to participate, Jaqueline C did not want to participate but wanted to stay and watch. Prior to the game Anne M and Jacqueline C where sitting at the table showing passiveness, boredom and longlines. Irene M and David N were roaming around the wing and showing signs of agitation, anxiety and boredom. The staff demonstrated how the game as played by throwing the ball to himself and reading the question that his right thumb was touching to the group, answered the question, and gave time for other participants to comment or answer as well. The staff then explained that he was going to toss the ball to another participant and that participant was going to read and answer the question that there right thumb was touching and then allow time for participants to answer or comment on the question before tossing the ball to another participant. The staff tossed the ball to David N who answered the question “what is your favorite food” and showed positive emotions, laughing and smiling while catching the ball and answering the question. The other patients/residents answered and made comments on David N’s question and the entire group reminisced about what foods they like and what foods they have eaten in the past. David N then passed the ball to Irene M who laughed and smiled as she caught the ball and answered the question “what is your favorite subject in school”. The other patients/residents answered and commented on the question. Irene M told stories of when her children went to school and what subjects they enjoyed in school. Irene M then tossed the ball to Anne M who tried to catch the ball but lost her grip, the staff then gently tossed the ball in the air so Anne M could catch it. Anne M. then smiled and laughed as she caught the ball and answered the question “what is your favorite kind of music”. The other residents answered the question and commented on it as well, and all the patients/residents chose country/western music so the staff asked the patients/residents who was there favorite country/western music star or group. The patients/residents all discussed their favorite country/western music stars and groups and reminisced about the times they first heard these stars and groups. Anne M then tossed the ball to David N who answered the question “do you prefer cats or dogs”. David N smiled and laughed and told a story of a dog he used to have. The other Patients/residents shared stories of their past pets they had while laughing and smiling about the things the pets used to do. The activity continued in a similar fashion improving the patients/resident’s mood, happiness and wellbeing. When the activity ended David N and Irene M showed no signs of agitation or anxiety and continued to sit at the table and socialize with Anne M and Jaqueline C. Anne M showed no signs of passiveness, boredom or loneliness after the activity and continued to socialize, smile and laugh with other patients/residents. Although Jaqueline did not participate in the game through catching the ball or answering or commenting on questions, she showed decreased signs of passiveness during and after the activity, showed signs of engagement during the activity through listening and watching the other patients/residents, and continued to show less passiveness, more liveliness and assertiveness to engage with the group. The group thanked the staff as he got ready to leave and asked him to bring more games around to play. The game created an enjoyable quality social interaction involving hand-eye coordination and reminiscing amongst the patients/residents, elicited positive emotions, decreased passive and anxious behavior and improved overall happiness and wellbeing amongst the patients/residents who participated.

Evaluation

The evaluation of the outcomes of the activities implemented was purely observational without the use of any evaluation tools. From the observations the staff member experienced the activities were all successful in reducing BPSD and passive behavior in the patients/residents who participated in the Program and elicited positive emotions, improved mood and overall wellbeing amongst the patients/residents who participated in the program. The use of evidence based pre-existing evaluation tools commonly used in the assessment of the effectiveness of non-pharmacological interventions used to reduce BPSD in individuals living with dementia are highly valuable and effective: below are the most common used evaluation tools used in the assessment of the effectiveness of non-pharmacological interventions used to reduce BPSD in individuals living with dementia.

The Cohen-Mansfield Agitation Inventory CMAI is an evaluation tool that rates the frequency of 29 individual behaviors (e.g., hitting, calling out) in the previous two weeks amongst individuals living with dementia displaying BPSD. The agitated behaviors include wandering, aggression, inappropriate vocalization, hoarding items, sexual disinhibition and negativism, and are rated on a seven-point scale of frequency. The CMAI is useful for the assessment of agitation in residents of nursing and residential homes (Cohen-Mansfield, Marx, Rosenthal, 1989).

The Neuropsychiatric Inventory NPI rates the frequency and severity of a broader range of psychopathology than other evaluation tools used to measure BPSD. It may help distinguish between different causes of dementia, records severity and frequency separately, and takes 10 minutes to administer. The NPI assesses ten domains: delusions; hallucinations; dysphoria; anxiety; agitation/aggression; euphoria; disinhibition; irritability/lability; apathy; and aberrant motor behavior. It is scored from 1 to 144 and severity and frequency are independently assessed. The NPI has been translated into many languages and it is now used widely in drug trials (Cummings, 1997).

The BEHAVE—AD evaluation tool takes 20 minutes to administer and was designed particularly to be useful in prospective studies of BPSD and in pharmacological trials to document BPSDs in patients living with Dementia. The BEHAVE—AD is the original behavior rating scale in Dementia. It is in two parts: the first part concentrates on symptomatology, and the second requires a global rating of the symptoms, on a four-point scale of severity. The domains covered are paranoid and delusional ideation; hallucinations; activity disturbances; aggression; diurnal variation; mood; and anxieties and phobias (Reisberg et al, 1987).

The Manchester and Oxford Universities Scale for the Psychopathological Assessment of Dementia (MOUSEPAD) is an evaluation tool that takes 15-30 minutes, most items being given a three-point severity score (Allen, Gordon, Hope, & Burns,1996). The main indication for use of the scale is the measurement of BPSDs in patients with dementia.

The Revised Memory and Behavior Problems Checklist is an evaluation tool used to assesses BPSD in individuals living with dementia, taken from care team reports (Teri et al, 1992). It is a 24-item list that provides one total score and three sub scores for memory-related problems, depression and BPSD, assessing both the frequency of the BPSD and the care team’s reaction.

the Passivity in Dementia Scale (PDS) (Colling, 1999). an observational scale consisting of 40 behaviors: 11 passive items scored in the negative and 29 active items scored in the positive. Lower scores indicate greater passivity.

Documentation and Recommendations

The development of a new initiative to reduce the use of antipsychotic medications at Kenneth E. Spencer memorial home should follow protocols for best practices when treating individuals Living with Dementia living in long term care facilities who are suffering from BPSD, the following protocols should be considered for creating a new initiative.

Involve patients/residents and family members or alternative decision makers in the treatment, assessment and intervention plan for the patients/residents with BPSD

Proper identification and description of the BPSD concerning the patients/residents involved and consideration of the impact of the responsive behavior on all involved including other patients/residents, staff and family/alternative decision maker

Tracking and monitoring of the frequency and severity of BPSDs with patients/residents to identify triggers and/or medical causes or conditions provoking responsive behaviors of BPSD

If a new patient/resident is admitted to long term care facility with a previous prescription to an antipsychotic medication a collaborative meeting with the care team, patient/resident and family members or alternative decision makers to determine the reason why the antipsychotic medication was initiated and confirm diagnosis

Creation, implementation, and documentation of person-centered care plans to identify underlying causes of BPSDs and reduce BPSDs in patients/residents

Non-pharmacologic approaches and interventions are utilized and integrated as a major part of the person-centered care plans implemented

Continued tracking and monitoring of the frequency and severity of BPSDs with patients/residents to determine outcomes of the various approaches that are trialed. For each behavior scenario documented details should include: time of behavior, what activity the patient/resident was doing prior to behavior, what interventions were used by staff, the response of the resident to the intervention, and the outcomes of the intervention

Antipsychotic medication is no longer to be used as the first intervention considered. Activities of daily living modifications, recreation therapy activities, existing physical and mental health complications, side effects of exciting medications used, and effective pain management are to be considered ahead of medication use

Additional recreation activity coordinators should be hired to help facilitate the new movement towards non-pharmacological interventions to treat BPSDs

Prescription of antipsychotic medication are to follow proper clinical indications for prescribing such medication which include: confirmed mental health diagnosis, symptoms of psychosis that reduce the quality of life in the patient/resident, and behavior that acutely puts patient/resident or others at risk of injury

A consent form to be made for the prescription of antipsychotic medication to ensure a meeting will take place with the patient/resident, family and care team before prescribing an antipsychotic medication for a patient/resident to discuss care approaches the have been tried and the outcome of those interventions, risk and benefits of the antipsychotic medication, the intended goal of the treatment, and the smallest does of the antipsychotic medication should be used for the trial period

A medication review with the care team, patient/resident and family to be conducted to assess the need for continued use of the antipsychotic medication within two weeks of the medication initiation and/or change. Medication reviews should assess efficacy, significant side effects, and change in behavior

Monthly medication reviews to assess the continued need for antipsychotic medication, if medication is deemed not necessary and to be discontinued, the dose of the antipsychotic medication should be tapered down before discontinuing, and the discontinuation of PRN use of antipsychotic medication after three months of non-use of antipsychotic medication

Maintain continuity of care when possible by not rotating staff of the care team through various units and shift to allow staff to develop relationships with patients/residents, get to know their preferences and routines, and approaches that work with the patient/resident

To promote continuity and consistency in the approaches used to assess monitor and treat BPSD by implementing a 24 hour, seven-day-a-week communication tool to be used by front line care givers, nurses, dietary staff, and recreation staff

Dedicated staff education about the initiative and support for RA’s, LPN’s in their decision making should be implemented along with weekly planning meetings with the care team and the director of care to update and personalize care plans for all patients/residents – particularly those with BPSD, and consideration of providing training of staff of the care team in non-violent crisis interventions

Collaboration with local health authorities and mental health teams should be considered to help troubleshoot BPSD in patients/residents

Possible consideration of having psychiatrists start patients/residents on PRN (as needed) dosing of anti-psychotics rather than regular scheduled doses

Implementing a new initiative to reduce the use of antipsychotic medications to treat individuals living in long term care facilities who are suffering from BPSD comes with barriers of implementation. These barriers include staff-related barriers, such as denial of unmet need, refusal to provide for a need, or lack of access to a physician; family-related barriers, such as unavailability or lack of cooperation in providing information about the person’s past or memorabilia to help devise appropriate interventions; and environmental barriers, such as uncomfortable surroundings (Mahoney, Trudeau, Penvack, Macleod, 2006). These barriers of implementation create a demand for an algorithmic approach toward assessment and management of BPSD to effectively implement an initiative to reduce the use of antipsychotic medications and treat individuals living in long term care facilities who are suffering from BPSD without running into these barriers of implementation.

In Detroit, Michigan, in fall 2011 a multidisciplinary expert panel was sponsored and convened at the Johns Hopkins Alzheimer’s Disease Research Center and Center for Innovative Care in Aging collaborated with the University of Michigan Program for Positive Aging. Three objectives were created for the multidisciplinary expert panel to achieve: 1. define critical elements of care for BPSDs in dementia; 2. construct an approach describing the sequential and iterative steps of managing BPSDs in real-world clinical settings that can be used as a basis for integrating nonpharmacological and pharmacological approaches; 3. discuss how the approach generated could be implemented in research and clinical care (Kales, Gitlin, & Lyketsos, 2014). Clinical and research expertise in managing BPSDs in dementia were characteristics found in each panel member. The expert panel developed the DICE approach (Describe, Investigate, Create, Evaluate). The DICE approach can be integrated into diverse practice settings and is an evidenced based person-centered and care team centered structured approach. The DICE approach offers clinical reasoning to more efficiently and effectively choose optimal treatment plans and enables the care team and family members or alternative decision makers to consider conjointly the role of nonpharmacological, medical, and pharmacological treatment. enhanced clinical practice and outcomes and promotion of advanced research is an attribute the DICE approach is capable of eliciting (Kales, Gitlin, & Lyketsos, 2014).

The DICE approach assumes that a BPSD has been identified and brought to the care teams attention.

Step 1. Describe

Describing the presenting behavior to provide an accurate description of the BPSD and the way in which it occurs is the first step in the DICE approach. The BPSD that is occurring should be discussed with the care team and the individual with dementia (if possible) through implementing a meeting. This step should include asking the care team to recall the patient/resident, care team and environmental factors leading up to the BPSD, and an accurate description of what the care team witnessed as the BPSD. Basic problem-solving approaches identify precursors, specific details of the BPSD, and describes ramifications to discover the circumstances in which the BPSD occurred and potential hidden modifiable patterns or contributory factors. Prior documentation of tracking and monitoring notes recorded by the care team can be a useful tool in to uncover these modifiable patterns or contributory factors. The viewpoint of the patient/resident with dementia should be obtained, and the care team should examine to determine what the patient/resident can describe about the BPSD. It is important to understand what aspect of the symptom is most afflictive or ambiguous for the patient/resident, care team and the treatment goal. Obtaining this information helps to evaluate the care team’s knowledge of dementia and leads to specific treatment strategies (Kales, Gitlin, & Lyketsos, 2014).

Step 2. Investigate

The care team should review, omit, and identify possible implicit and underlying causes once the BPSD is well defined and understood. Thorough assessment of underlying causes is the key to managing BPSD. Patients/residents with dementia often have pain and undiagnosed illnesses such as urinary tract infection and anemia more often than those without, resulting in undiagnosed health issues as a major contributing factor that may cause BPSD (Hodgson, Gitlin, Winter, Czekanski, 2011), (Hodgson, Gitlin, Winter, Hauck, 2014), (Kales, Gitlin, & Lyketsos, 2014).

Individual considerations: current medications (side effects, interactions, other over the counter drugs and supplements) undetected medical conditions or pain (urinary tract and other infections, constipation, dehydration and pain), blood work ( blood glucose, electrolytes, complete blood count with differential), urinalysis, prior psychiatric comorbidity, limitations in functional abilities, severity of cognitive impairment, poor sleep hygiene, sensory changes, boredom, feelings of inadequacy, helplessness, and fear of being a burden should be considered when investigating the cause of the BPSD elicited from the patient/resident (Kales, Gitlin, & Lyketsos, 2014).

Care team Considerations: the patient/resident and the care teams historical and current quality of the relationship should be evaluated. The care team may not fully understand the link between dementia and BPSDs and believe the individual is at fault or purposely doing the behavior. The Care team’s communication styles, expectations, misunderstanding of the patients/resident’s abilities, and their own stress and depression may unintentionally provoke behaviors. The dynamics of the long-term care facilities cultural context is also very important. Beliefs will affect the behaviors of the care team and the patient/resident with dementia differently (Kales, Gitlin, & Lyketsos, 2014).

Environmental Considerations: With decreased ability to process stimuli, the stress threshold of the patient/resident with dementia becomes lower and the potential for higher levels of frustration increases; if unabated, serious anxiety and severe agitation can develop. Stress may be caused by changes in routine, too many competing or misleading stimuli, lack of stimuli, physical and social environmental changes, and demands that exceed the functional ability of the patient/resident (Smith, Hall, Gerdner, & Buckwalter, 2006). Safety factors in the long-term care facility such as the ability for patient/resident to leave the home, access of dangerous objects, negativity safety from one room to the next, access of grab bars or other equipment used to create adaptations (labels, adequate task lighting) that can be used to compensate for functional difficulties should be considered (Kales, Gitlin, & Lyketsos, 2014).

Step 3. Create

A treatment plan is to be created and implemented involving a collaboration between the care team, and the patient/resident with dementia (if possible). First response should be given to physical problems detected in the investigative step i.e. prescribing antibiotics for a urinary tract infection, giving fluids to a dehydrated patient/resident, and managing constipation. Discontinuing medications that have the potential to cause BPSDs is to be assessed and evaluating whether other medication side effects may be contributing to BPSDs. The role of effective pain management is also an important factor for reducing the inappropriate use of anti-psychotic medication (Husebo, Ballard, Sandvik, Nilsen, & Aarsland. 2011). Psychotropic regiments for underlying psychiatric conditions predating the diagnosis of dementia amongst patients/residents should be optimized by monitoring and discontinuing medications that are ineffective or not tolerated. Proper sleep hygiene protocols should be instituted, and sensory impairments (hearing, vision) should be addressed. Brainstorming approaches with the care team, and the patient/resident with dementia (if possible) should be implemented to aid in creativity. In Brainstorming approaches the care team can address any active problems, utilize problem solving, and provide recommendations. The Behavioral and environmental strategies used during this step can be categorized as generalized or targeted. Generalized strategies are non-behavior specific and involve enriching the environment and improving care team’s skills and well-being. Targeted strategies are directed at eliminating a specific BPSD (e.g., wandering) (Gitlin, Kales, & Lyketsos, 2012). A specific group of Four domains of generalized strategies provide the greatest probability for success and require the least resources: 1. enhancing effective communication between the care team and the patient/resident with dementia, 2. providing education to the Care team on proper protocols to care for patients/residents living with Dementia and eliciting BPSD, 3. Provide resources for the care team to implement meaningful activities for the patients/residents living with dementia, 4. Providing protocols to simplify tasks and establish structured routines for the care team (Kales, Gitlin, & Lyketsos, 2014).

Step 4. Evaluate

This step is used to assess whether recommended strategies were attempted and effective. If an intervention was not implemented, it is important to understand why and brainstorm solutions. If an intervention was attempted, it is important to evaluate whether it was implemented effectively, whether the BPSD improved, and whether the care team distress was reduced. Sometimes interventions cause unintended side effects or consequences; a behavioral intervention may make a behavior worse or have unintended consequences, which is why it is important to assess the reaction of the patients/residents with dementia to the intervention(s). The assessment of the reaction of the patients/residents living with dementia to the intervention(s) can help the care team can better understand whether the negative outcome is a consequence of the intervention or whether the intervention was not implemented as intended. It is important to consider a trial of dose reduction or discontinuation of anti-psychotic medication to ensure that the medication continues to be evaluated as a necessary as part of the overall treatment. The removal of interventions, especially medications, should be considered on an ongoing basis along with ongoing monitoring of behaviors, because BPSD can change and fluctuate over the course of dementia ((Kales, Gitlin, & Lyketsos, 2014).).

In conclusion, a new initiative to reduce the use of antipsychotic medications at Kenneth E. Spencer memorial home should be implemented following the protocols recommended, using the algorithmic guideline of the DICE approach as a guide to properly assessment and management of BPSD through clinical reasoning to more efficiently and effectively choose optimal treatment plans. The non-pharmaceutical approaches in the form 5 activities under the categories of sensory activities, reminiscence activities, social activities, and structured activities implemented in the wing based program for C-Wing can be used as an activity toolkit to aid in the reduction of the use of antipsychotic medication as part of the new initiative for Kenneth E. Spencer Memorial Home. The recommendations for the initiative align with the goals and philosophy of the AUA initiative in Alberta, the Canadian Foundation for Healthcare Improvement antipsychotic reduction collaborative across Canada, the Call for Less Antipsychotics in Residential Care program in British Columbia, and the Ontario Ministry of Health and Long-Term Care Appropriate Prescribing Demonstration Project in Ontario. The recommendations for the initiative also aligns with Competence-environmental press theory (CEPT), The progressively lowered stress threshold model (PLST), and the needs-driven dementia-compromised behavior model (NBD). Future non-pharmaceutical interventions in the form of recreation and leisure activities being trialed to show the effectiveness of the effectiveness of the activities to reduce BPSDs in patients/residents living with dementia should always follow the systematic approach of APIED using the MMSE and FLII to assesses which residence should participate in each activity using a person-centered approach while implementing the activities, and use one or more of the pre-existing evidence based evaluation tools available such as the NPI, BEHAVE—AD, MOUSEPAD, CMAI, PDS, or the Revised Memory and Behavior Problems Checklist. With the rising aging population, the proven financial and health benefits of Antipsychotic reduction programs amongst the aging population, the proven efficacy of non-pharmaceutical interventions, and the pre-existing overuse of antipsychotic medication in patients/residents living with dementia residing in long term care facilities I believe Kenneth E. Spencer Memorial home should lead the way in New Brunswick by starting this proposed initiative.

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