Reducing antipsychotic medications? Try these behavioral interventions

With the recent focus on reducing antipsychotics in long-term care and substituting behavioral interventions, facilities may be left wondering what interventions to use and how to implement them. Here are ideas on how to prevent, investigate and monitor agitation on your units and address staffing needs to ease the transition from antipsychotic medication.

PREVENTION: BORROW FROM THE PSYCHIATRIC HOSPITAL

In a psychiatric hospital, the focus is on creating an emotionally healing environment—a therapeutic milieu. In long-term care, the focus is on providing high-quality physical healthcare and the frequently neglected therapeutic milieu can contribute to resident agitation. Take some time to walk your units and evaluate the emotional environment. This is what residents, and especially those with dementia, are reacting to and small changes can make a big difference. 

Evaluate and adjust the physical environment. Is it disturbingly bright or so dark that older eyes can’t see who’s approaching? Is it very loud, with excessive overhead paging, chair alarms and shouting staff and residents? Is it too cold or too warm? Make environmental changes so that an older version of you wouldn’t mind spending time in the day room.

Provide appropriate programming. Are residents crammed together in a small area for long periods of time, creating the sensation of being trapped? Is the main activity a blaring television set? A therapeutic milieu is all about engaging the residents in appropriate activities with a pleasant flow through the day. Pursuits for residents with dementia can include music, baking, tactile and visual stimulation, etc. Providing activities off the unit offers additional stimulation to those who can tolerate it and lessens crowding in the day room. It can also offer a healthy diversion for cognitively intact residents.

Calm residents before they get agitated. The time for staff to act is when interactions between residents start to become tense, rather than waiting until an argument has broken out. Interventions such as distraction, redirection and a face-saving move to another location can be remarkably effective. Attending to individuals at early signs of distress can prevent episodes of full-blown agitation.

Use customer service techniques. Well-trained staff can often prevent agitation from occurring. Units can be transformed by charge nurses who speak to residents and staff alike in calm, respectful tones, address needs immediately and expect the aides working with them to do the same.

Staffing recommendations:  

• Train all your staff in customer service techniques.
• Offer special workshops for nurses, aides and recreation therapists on providing care and activities for residents with dementia.
• Consider hiring nurses with psychiatric experience who understand how to maintain a therapeutic milieu.

INVESTIGATE: PUT ON YOUR SHERLOCK HOLMES HAT

If a resident is agitated despite environmental changes, look for underlying causes.  Residents with dementia are often unable to speak through words, so they use other methods. Sometimes it takes a bit of sleuthing to figure out what they’re saying.

Assess for pain. A major cause of agitation is pain, which is still undertreated in long-term care. Agitated residents should be assessed for pain either by direct questioning or by using a facial recognition test.

Address physical needs. Residents might not be in pain, but may be hungry, thirsty or physically uncomfortable. Agitated residents, whether or not they are cognitively impaired, can often be calmed by attention to their physical needs, especially when this is provided in a warm, supportive manner.

Evaluate triggers. Observe the agitated individual throughout the day to see if there are particular times or situations that trigger episodes of agitation. Discuss observations as a team, including family members to form an action plan. For example, perhaps a resident becomes agitated around the busy change of shift—the family might bring in a CD player with favorite soothing music that the staff could put on before the shift changes.

Staffing recommendations:

• Use the change of shift report to communicate behavior changes in addition to the physical observations generally reported.
• Identify agitated residents and initiate an observation period to assess triggers and potential remedies. 
• Use your consulting psychologist for staff training on behavioral observations and for suggestions of behavioral interventions for specific residents.

MONITOR: STRENGTHEN YOUR MENTAL HEALTH TEAM

The LTC mental health team is made up of social workers, psychiatrists and psychologists, with trained recreation therapists as adjunct members. A strong mental health team can work with the nursing staff to monitor and prevent agitation. 

Social workers. As the liaison for the families, social workers gather important information about residents’ prior and current behavior and can offer observations about interpersonal interactions on the unit that might escape the attention of medically focused staff.

Psychiatrists. Regular visits from the psychiatrist can reassure staff that psychotropic medications are available if needed, and residents whose psychotropic medications are being reduced can be monitored closely.

Psychologists. Psychologists can provide cognitively intact residents the opportunity to address concerns before they result in agitation, offer techniques to manage moods and social interactions and monitor the need for psychotropic medication.

Recreation therapists. A reasonable amount of structure is vital to good mental health and therapeutic recreation can offer not only a pleasant diversion but also a way to create meaning out of life in long-term care. Changes in activity attendance or level of participation often reflect mental health issues.

Staffing recommendations:

• A fully staffed well-trained social work department allows social workers to move beyond discharges and admissions to attend to the mental health of the residents.
• Consider the use of telehealth in areas without access to a psychiatrist.
• Psychologists, who are often skilled in establishing a therapeutic milieu, can offer staff training.

In conclusion, with training and attention, shifting from psychotropic medications to behavioral interventions can benefit not just residents with dementia, but all those in the community through creation of a therapeutic milieu.

Eleanor Feldman Barbera, PhD, author of The Savvy Resident's Guide, is a speaker and consultant on psychological issues in long-term care.  For more information, visit Dr. Barbera's website, www.mybetternursinghome.com.

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