The most effective ways to achieve change with challenging behaviors involve using no antipsychotics at all.
Perhaps the most pernicious and widespread misconception in post-acute care is that antipsychotics are the best answer to the problem of challenging resident behaviors, and that the Centers for Medicare & Medicaid Services (CMS) crackdown on the use of antipsychotics is a well-intended, but misguided endeavor.
Nothing could be further from the truth. The fact is that antipsychotics are not the best way to respond to most unwanted behaviors in a skilled nursing facility (SNF), and there is no medication that can hone in on and eliminate a particular behavior.
Are medications the easiest answer? For sure. But the negative impact to residents that results from the widespread use of such powerful medications is profound in terms of overall impact on quality of life.
For many SNF residents, the challenges confronting them upon admission will represent the fight of their lives, and their chances of success should never be undermined by the use of antipsychotics unless those medications are absolutely necessary.
Fortunately, they typically are not, because nonpharmacologic interventions are more effective than antipsychotics at producing lasting behavior change, even among residents with dementia.
Here are best practices that facilities employ to successfully manage unwanted behaviors without the use of antipsychotics.
The Right Environment
The facility creates an environment that is not conducive to angry, disruptive, or disturbing behavior. The lighting and sound levels are more subdued, and appropriate to the time of day. There are quiet areas where residents can go when the first signs of agitation become apparent.
The facility staff allow each resident as much choice and self-determination as reasonably possible in terms of their daily schedules and preferences. Staff understand that the culture and climate of their building is an important element in proactively preventing disturbed behavior and that it is infinitely easier, and better for all involved, to prevent unwanted behavior than it is to be constantly having to put out fires.
Stable Staffing Key
The facility maintains stable staffing patterns. The certified nurse assistant (CNA) is the most important person in the daily life of many SNF residents. Age, infirmity, and pain often lead to a restricted world view that reduces to one’s immediate surroundings—the nursing unit, the regular staff, and, particularly, the CNA who helps residents with the most basic elements of life.
Disruptions to these relationships can have a cataclysmic impact on residents, so these facilities are careful before changing assignments that would separate CNAs from residents they have developed positive alliances with.
On a related note, the facility is careful about room assignments, always seeking to pair residents based on personalities, habits, schedules, and other preferences. One of the side effects of maintaining a positive environment for residents is that staff members benefit as well. They look forward to going to work, they are proud of the fact that they work in a CMS Five-Star-rated SNF, and they are much less likely to leave.
Making Training A Priority
The facility trains staff to manage mental health issues and respond appropriately to unwanted behaviors. The prevalence of psychiatric issues and dementia-related behaviors is now so high in SNFs that it would not be inaccurate to describe them as mental health facilities in which the direct caregivers have received little or no training with respect to responding to them.
SNFs were not designed to care for these populations, and although there are multiple exceptions, training has generally not kept pace with the changes in population, so staff can feel overwhelmed by behaviors they haven’t been taught to manage. A best practice is to provide training that gives staff members the education they need to understand, communicate effectively, and de-escalate agitated behaviors.
Addressing Root Causes
The facility tries to identify the underlying source of unwanted behavior and address the cause, as opposed to merely trying to suppress the behavior itself. The facility staff construe unwanted behaviors as expressions, albeit inappropriate, of residents’ unmet needs or internal mood states.
There is no reason to assume that Mrs. Jones’ aggressive behavior is precipitated by anything resembling the cause of Mr. Smith’s. While both behaviors may be temporarily subdued with an antipsychotic, going deeper to understand the unique underlying dynamics and issues that are driving a particular resident’s behavior will provide a long-term solution that doesn’t require an all-out behavior management plan, much less an antipsychotic.
Medications Not Always Necessary
The facility does not blindly accept the idea that the medications the resident is taking upon admission are necessary. Newly admitted residents often enter facilities with a litany of psychotropics on board. Some may be part of a long-standing regimen prescribed by multiple community-based prescribers in response to the demands of family caregivers, others may have been added recently during the hospital stay that preceded SNF admission.
For example, some SNF residents are maintained on an antipsychotic that was prescribed in a hospital as a result of a brief episode of delirium. Every resident’s current psychiatric condition and diagnosis should be thoroughly evaluated upon admission, and any psychotropics prescribed should be based on the resident’s current diagnosis and observable symptoms, not on past prescribing practices.
Employ Other Interventions
The facility views antipsychotics as a last resort, not a first line intervention. For years, antipsychotics were the default response to unwanted behavior in some SNFs, a practice that eventually led to the strong response from CMS that facilities are now struggling to comply with.
And those facilities that have not yet developed a strong program of nonpharmacologic interventions find themselves in an untenable position. They can either remain out of compliance in terms of antipsychotic use or watch the climate of their facility—and their Five-Star rating—deteriorate because their building is full of residents displaying aggressive, inappropriate, and other unwanted behaviors.
Facilities following best practices know that antipsychotics become necessary only after psychotherapy, behavior management plans, family therapy, targeted recreation therapy activities, and environmental interventions have not proved successful. And they also know that being able to report these interventions to the state surveyor who wants to know why Mr. Smith is still receiving Risperdal puts them in a much better position for survey success.
The facility creates individualized behavior management plans for each resident that needs one. Just as there is no medication that targets individual behaviors, there is no behavior management strategy that works across the board for all residents. Again, the underlying cause of any behavior is different across residents, and so are the strategies that should be employed to reduce or eliminate the behavior.
The psychologist’s interview, medical assessment, family history, and feedback from nursing are all considered in a behavior management process that leads to an understanding of the unexpressed needs, goals, and communications that are driving the unwanted behavior. These data are then used to create a plan that is unique to each resident. The well-considered plan is then documented in the medical record and revisited frequently with the entire team to monitor its effectiveness and make ongoing changes, if required.
Consistent Response Imperative
The facility ensures that all team members respond to unwanted behavior in a consistent fashion. Once a behavior management plan is created, these facilities understand how imperative it is that all team members act in accord with it each time that behaviors are observed. In most SNFs, an unwanted behavior is responded to in a well-intended but essentially random manner by the staff member who happens upon it. This paradigm guarantees that the behavior will continue indefinitely, because some staff responses will inevitably, although inadvertently, reinforce the unwanted behavior.
Best practice means that all team members understand that behavior change will only occur when unwanted behaviors are consistently met by specific, individualized and well-considered staff responses that have been agreed upon and spelled out in the plan. Even the occasional deviation from the designated response can be enough to derail the plan’s effectiveness.
Long-term behavior change requires great consistency and communication from staff. This paradigm is particularly true in dealing with residents with dementia, who require a higher number of repetitions for new learning to sink in and new, pro-social behaviors to take hold.
Beefing Up the GDR Process
The facility should incorporate behavior management planning and other nonpharmacologic approaches into their Gradual Dosage Reduction (GDR) process. Some SNF GDRs are doomed to failure. Such a process can be expressed like this: “Let’s cut back or eliminate the medication that has been suppressing an unwanted behavior, and without doing anything else to address the behavior, let’s just hope that it doesn’t return.” When it does, the facility documents a failed GDR and returns to the prior dosage.
Best practice means that facilities understand that when an antipsychotic is reduced or eliminated, it is predictable that the behaviors it was prescribed for may return, and they plan for it.
The psychiatrist and the psychologist work together in discussing the timing of the GDR. That gives the psychologist ample time to support and educate the staff, and prepare them to respond to the potential re-emergence of unwanted behaviors. That’s an integrated care approach that leads to far greater success for these facilities’ GDRs and leads to much lower utilization of antipsychotics.
Article Author: Richard Juman, PsyD
Richard Juman, PsyD, is national director of psychological services at TeamHealth, Knoxville, Tenn. He can be reached at: firstname.lastname@example.org.