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Running head: EFFECTS OF NON-PHAMACOLGICAL MANAGEMENT OF NPS 1

Effects of Non-pharmacological Management of NPS in Persons with Dementia

Emlyne St. Helen

Virginia Commonwealth University, School of Nursing

DNP project Chair: Pamela Biernacki, RN, DNP, NP-C-

DNP project Committee Member: Anthony Caterine, MD

Dawn Martinez, RN, DNP, AGPCNP-BC

Date of Submission: December, 05th, 2018

EFFECTS OF NON-PHAMACOLGICAL MANAGEMENT OF NPS 2

Introduction

Background and Relevance

Neuropsychiatric symptoms (NPS) commonly called behavioral symptoms or behavioral

disturbances, occur in almost all persons with dementia, thus treatment of NPS is a major

concern in caring for persons with dementia. Nearly one in every three seniors who die each year

has Alzheimer's dementia or other dementia. In 2014, approximately 5 million people in the

United States lived with Alzheimer’s and other related dementias (Centers of Disease Control

and Prevention [CDC], 2018). Dementia is the sixth leading cause of death in Virginia since

2013, and the Medicare cost of dementia in Virginia is $866 million (Alzheimer’s Association,

2016). Dementia with its disabling decline in memory and cognitive function, led to an increase

in the number of patients in long-term care facilities and specialized memory care units. The cost

of caring for those with Alzheimer’s dementia and other related dementia in the United States

was estimated to be a total of $236 billion in 2016, and this was expected to increase to $1.1

trillion in the mid-century (Alzheimer’s Association, 2016). This is very alarming and drastic

measures must be taken in managing NPS in persons with dementia.

In 2011, the Office of the Inspector General (OIG) reported of the 2.1 million nursing

home residents in the United States, 304,983 had at least one Medicare claim for atypical

antipsychotic medication use (Levinson, 2011). Of the 8.5 million claims for Medicare

beneficiaries, about 20% were claims from nursing home residents; which amounts to

approximately $309 million (Levinson, 2011). Eighty-three % of the atypical antipsychotic

medications prescribed for nursing home residents were without the United States Food and

Drug Administration (FDA) indication (Levinson, 2011). An estimated 88% of the claims were


residents with dementia. The excessive antipsychotic medication use is associated with an

increased risk of mortality as defined in the FDA black box warning (Levinson, 2011).

The Center of Medicare and Medicaid Services (CMS) initiated strategies to improve

dementia care in nursing homes by increasing the use of non-pharmacological behavioral health

interventions with the intent to reduce the use of unnecessary psychotropic medication (Lucas &

Bowblis, 2017). Further, regulations implementing the federal Nursing Home Reform Law

attempt to limit the use of antipsychotic drugs (Medicare Advocacy, 2010).

The National Partnership to Improve Dementia Care set a new goal of a 15% reduction of

antipsychotic medication by the end of 2019 for long-stay residents in nursing home (Paltc.org

2018). In practice, antipsychotic medications are typically used after a comprehensive

assessment of a resident. The long-term care facilities responsibility is to ensure residents

without a history of antipsychotic medication use are not prescribed this drug class without an

appropriate documented diagnosis. Further, the facility must assure residents’ antipsychotic

medication prescription includes a gradual dose reduction and behavioral interventions, unless

clinically contraindicated (Medicare Advocacy, 2010). With the stringent regulations by CMS,

health care providers are tasked with a more active approach in the development of behavioral

interventions that will benefit patients.

Through the recommendations of the OIG report, the CMS launched the National

Partnership to improve dementia care in nursing homes in (CMS, 2012). The importance of the

appropriate use of behavioral interventions in nursing home patients with dementia is a national

initiative. The primary focus of this quality improvement project is to decrease the frequency of

antipsychotic medications use in nursing home residents by implementing behavioral

interventions that will lead to effective dementia care.


Problem Statement

Antipsychotic medications are viewed as extremely dangerous in older adults, because of

the severe adverse effects and increased mortality in elderly persons with dementia (Medicare

Advocacy, 2010). This led to the development of regulations by CMS to govern the utilization of

antipsychotic medications in long-term care facilities. CMS also placed emphasis in the

utilization of non-pharmacological intervention as first-line approach in the management of NPS

of dementia. In the area of dementia caregiving, there are over 200 proven behavioral

interventions for caregivers, yet only 3% has been submitted for translation into real practice

setting (Gitlin & Czaja, 2016). The overuse of antipsychotic medications is related to the

difficulty in establishing quality behavioral interventions in long-term care facilities. There is a

gap in practice as it relates to the treatment and management of behavioral symptoms of

dementia with non-pharmacological interventions, in long-term care settings.

PICOT-D

This project will examine the treatment of neuropsychiatric symptoms (NPS) in elderly

patients with dementia. An exploration of the use of behavioral interventions in the management

of NPS for patients with dementia in nursing home settings will be undertaken, with the goal of

decreasing the need for antipsychotic medications. Therefore, the question guiding this work is:

Does the implementation of an evidence based educational program for staff regarding

behavioral interventions for treatment of NPS lead to a reduction in antipsychotic medication and

increase job satisfaction in six months?

Purpose

The purpose of this quality improvement project is to utilize best practice evidence to

implement and evaluate an initiative to effectively manage NPS in patients with dementia,


leading to a reduction in antipsychotic medication use. By using best practice educational

programs and behavioral interventions, the quality initiative will empower care staff with tools

for the management of NPS in elderly patients.

Site Analysis

The quality improvement initiative will be implemented at a health system with a lifelong

health and aging department, which oversees multiple long-term care facilities. The facilities

include three assisted living facilities, four memory care facilities, and eight convalescent

centers. Currently, there is one memory care unit with a behavioral program. Care staff in the

memory care unit still have challenges in implementing appropriate behavioral interventions in

the treatment of NPS. Due to a limited number of beds in the memory care units, the majority of

patients with dementia are cared for in the convalescent centers.

The convalescent centers in this health system exceed the state and national average for

antipsychotic medication use (Nursing Home Compare, 2018). The current benchmark for

antipsychotic medication utilization in each convalescent center is 20%; however in 2019, the

objective of CMS is to reduce antipsychotic medication use to 15% in long-term care facilities.

Virginia (14.5%) is below the national state average (15%) for antipsychotic medication use in

all nursing homes (Nursing Home Compare, 2018). Out of the seven convalescent centers in this

health system, one of the convalescent center is close to the national average with antipsychotics

medication use at 15.2%; all other facilities exceed the national and state averages. This health

system requires a purposeful plan to reduce antipsychotic medication usage to comply with

national standards for antipsychotic medication use stipulated by CMS.


Facility A

Facility A is a 60-bed short and long-term convalescent rehabilitation center located in a

rural community in Virginia. Key staff and stakeholders impacted by this project include, the

administrator, Director of Nursing (DON), assistant director of nursing (ADON), nurse educator

(NEd), registered nurse (RN) supervisor, minimum data set coordinator (MDS), licensed

practical nurse (LPN), certified nursing assistant (CNA), social worker (SW) and activity

coordinator (AC). From July 2018 to September 2018, records show the facility had

approximately 46 patients, including five short-stay patients and 41 long-stay patients

(Pointright, 2018). Out of the 41 long stay-patients, 13 were prescribed antipsychotic

medications. Minimum data set (MDS) according to CMS quality measures indicate that Facility

A long-stay rate for antipsychotic use is 26.9%, which is at the 92nd national percentile (see

Appendix H and figure 1). The long term care MDS is a health status screening and assessment

tool used for all residents of long term care nursing facilities certified to participate in Medicare

or Medicaid, regardless of payer (ResDAC.org, 2018). Facilities with ≥ 75% are a red flag for

CMS. An urgent need exists for the implementation of a quality improvement initiative leading

to a reduction in antipsychotic medication use in long-term care patients at Facility A. To comply

with CMS regulations the goal of this project is to achieve a ≤ 15% reduction in antipsychotic

medication use facility-wide.


Figure 1. Trend graph- Antipsychotic use for Facility A

Stakeholders

Key stakeholders identified are nurse executive (NE), the director for lifelong health and

aging, the practice manager, the quality improvement team leader, DON for both facilities,

facility administrators and providers. Other stakeholders that can benefit from this quality

improvement project include patients, direct care staff, NS and NEd, clinical pharmacist,

behavioral therapist, SW, MDS coordinators, patient family members, activity therapist, and

CMS.

One of the leading stakeholders is the NE, who leads the quality improvement teams for

the long-term care facilities. The NE is instrumental in mobilizing other key stakeholders such as

the DON and administrators in the implementation of quality improvement projects. The DNP

student discussed plans for QI project with the NE and QI team leader. The DNP student elicited

feedback from the NE and QI team leader. The NE recommended Facility A as a suitable site for

the implementation of QI project.


Project Facilitators and Barriers

The planning of this quality improvement initiative involved the assessment of, the

strengths, weaknesses, opportunities, and threats (SWOT) that facilitate or hinder the

intervention of this project (see figure 2). There are several identified internal factors facilitating

project implementation, including support from administrative staff and highly skilled nursing

staff, knowledgeable psychiatric providers, an on-site and clinical pharmacist. External factors

influencing the project goals include the standards and regulations from the CMS, and local

health department. CMS has formulated specific regulations to guide the use of antipsychotic

medications in patients with dementia. Nursing home participating in Medicare and Medicaid

services are required to undergo annual review by the federal government for recertification.

State surveyors from the health department review antipsychotic medication use to determine

appropriateness per CMS regulations during the annual survey. These regulating bodies’ drives

the need to integrate behavioral interventions into practice to decrease antipsychotic medication

use.

The potential barriers to the project include finances, high rate of staff turnover and a

shortage of direct care staff. The finances must be considered when planning a quality

improvement initiative; lack of funding can impede the implementation process and affect the

overall success of the project. Another potential barrier is the high rate of staff turnover; new

hired nursing staff may lack the knowledge of behavioral interventions used in treatment of NPS.

Finally, a shortage of direct care staff can result in inappropriate implementation of behavioral

interventions due to increased workload. To overcome these barriers effective planning will be

done; sources of financial funding will be identified. The NEd will ensure that newly hired staff


are educated and trained in specific behavioral interventions used in the management of NPS in

persons with dementia.

Figure 2. SWOT Analysis

Project Description

The IOWA Model

The IOWA Model of Change, developed by Marita G. Titler, will guide the

implementation of this quality improvement initiative (see Appendix G). This model was first

published in 1994 and was revised in 2001 based on changes in the healthcare system and

feedback from users (Brown, 2014). The IOWA Model of Change focuses on translating

research and other evidence into practice to improve outcomes for patients (Brown, 2014). The

components of the IOWA includes: 1) identify either a problem-focused trigger or a knowledge-

focused trigger, 2) determine if the problem is priority for the team and determine a plan, 3) form

a team, 4) gather evidence, assemble relevant research and gather literature, 5) critique and

synthesize the evidence, 6) determine the validity and appropriateness of the evidence, 7) pilot


change, 8) determine if the change is appropriate for practice, 9) implement, and 10) disseminate

results (Brown, 2014).

PLST Model

The Progressively Lowered Stress Threshold (PLST), a model developed by Hall and

Buckwalter (1987), will be used as the framework to guide the development of the educational

program and to evaluate the intervention. The PLST (see figure 3 and appendix D) provides the

foundation for psychoeducation interventions in understanding behaviors and planning care for

persons with dementia (Buckwalter, 2017). The model addresses three main dimensions of

dementia: losses associated with cognitive decline and accompanying symptoms; behavioral

states; and, stage of the disease process. Losses related to cognitive decline are further clustered

into four groups:1) intellectual losses; 2) affective or personality losses; 3) conative planning

losses; and 4) a progressive lowered stress threshold.

The PLST model places major emphasis on the assumption that progressive cerebral

pathology is accompanied by a progressive decline in the stress threshold (Buckwalter, 2017).

Therefore, according to the PLST model, behavioral symptoms occur due to a reduced stress

threshold. As the stress threshold declines with disease progression, normative behaviors in

response to stress will decline and gives rise to anxious and dysfunctional behaviors

(Buckwalter, 2017). The PLST model takes into consideration that there is an underlying cause

for all behavioral symptoms of stress in persons with dementia because all behaviors have

meaning (Hall & Buckwalter, 1987).

An additional concept of the PLST model consists of six factors (see appendix D). The

six factors contribute to stress in patients with progressive cerebral pathology and include: 1)

physical stressors such as pain and infection; 2) misleading stimuli or inappropriate stimuli; 3)


change of environment, caregiver or routine; 4) internal or external demands that exceed

functional capacity; 5) fatigue and; 6) affective response to perception of loss (Hall, Gerdner,

Zwyart-Stauffacher, & Buckwalter, 1995).

Figure 3. Example of PLST Model of Behavior in Dementia.

Needs Assessment

To comply with CMS regulations; the administrative staff, executive nurse, quality team

and director of nursing want to implement a more robust behavioral intervention plan for the

treatment of NPS in patients with dementia resulting in a reduction of antipsychotic medication

use. Information from the minimum data set (MDS) obtained from Pointright indicates that

Facility A has a high rate of antipsychotic medications utilization, see site analysis above. To

comply with CMS regulations the goal is to achieve a ≤15% reduction at Facility A. The NE and

DNP student discussed the need to implement a strategy that will lead to a reduction in

antipsychotic medication utilization at Facility A. The NE expressed the need to educate staff at

Facility A in non-pharmacological approaches for managing NPS in patients with dementia. To


assess the educational need and job satisfaction, a pretest will be sent out to all nursing staff and

clinicians at Facility A.

Project Design

The IOWA model of change will be used as the framework for this project. This program

will be implemented in two nursing homes in the health system.

1. Identify the problem: To reduce antipsychotic medication use in geriatric patients in

long-term care settings. There is a need to keep up with CMS regulations dictate the goal

of antipsychotic use of < 15%. The need to utilize effective non-pharmacological

interventions as the first-line approach in the treatment of NPS in persons with dementia

is imperative to decreasing antipsychotic medication use.

2. Determine if the problem is a priority for the organization: As stated earlier in the

needs assessment, there is a need to implement a QI initiative to address the excessive

utilization of antipsychotic medications. Many of the nursing homes in the health system

exceed 15% use of antipsychotics medications.

3. Form a team: Based on recent observations and recommendations, stakeholders who

will be impacted by or benefited from this quality initiative were identified. The DNP

student, project committee, NE and NEd at the facility will be responsible for,

researching and designing an educational program that will educate staff in non-

pharmacological interventions for the management of NPS.

4. Gather relevant evidence: Research of the evidence performed in major databases such

as CINAHL, PsychINFO and Pubmed. Search terms utilized for this review include

Dementia, NPS, Behavioral programs, pharmacological and non-pharmacological

treatment of dementia. An initial search of the evidence returned a total of 4282 articles;


however, only studies done in patients with dementia in nursing home and memory care

units were included. Studies performed on patients with dementia in the home setting or

community settings were excluded. Two hundred and seventy-six articles were

considered after adjusting for year of publication ranging from 2012 to 2018. A total of

80 articles were excluded after screening for duplication. Sixty-three and 83 full-text

articles were assessed for eligibility, and 67 were omitted. Eventually, a total of 16

articles were included in this review. Areas reviewed include treatment of NPS in

dementia, treatment of patients with dementia in nursing home and memory care units

and behavioral therapy of NPS in dementia. The evidence strongly supports using a

planned behavioral intervention program compared to psychotropic medication use,

effects NPS in nursing home patients with dementia over a six month period.

5. Review, critique, and synthesis related literature and use into practice: Evidence

supporting the implementation of the non-pharmacological intervention in the treatment

of NPS in dementia obtained (refer to summary in section titled State of the Evidence).

The evidence supports the implementation of the behavioral intervention in managing

NPS as a first-line approach. The PLST model to educate caregivers of persons with

dementia is an evidence-based tool that helps guide the development of behavioral

interventions in the management of NPS of dementia (Buckwalter, 2017).

State of the Evidence: Many guidelines recommend the use of non-pharmacological

treatment as the first-line approaches in the treatment of NPS except in severe cases

where behavioral intervention is ineffective (Gitlin et al., 2016). The use of

nonpharmacological intervention in the treatment of NPS conceptualizes behavioral

symptoms as an expression of unmet needs. The goal of treatment is to prevent, reduce,


manage or eliminate behavioral symptoms. Some interventions include activities, care

provider education, and support, communication, simplified environment, and tasks.

Non-pharmacological treatment of dementia is underutilized. Empowering dementia care

providers through education and training programs will help in the overall improvement

of dementia care (Karlin, Young, & Dash (2016). Designing care programs by combining

educational programs with interventions can be used in the management of NPS. The

program can utilize a 5 step approach - evaluation of psychotropic drug use (PDU),

detection, analysis, treatment and evaluation of NPS (Van Duinen- Van Den, 2018).

6. Determine the validity and appropriateness of the evidence: The evidence obtained

from the literature review was analyzed, synthesized and reviewed for appropriateness

and relevance to current practice. Many of the articles had consistent findings to support

the QI project. The evidence supports the use of non-pharmacological interventions as the

first-line approach in the treatment of NPS in patients with dementia (refer to section

titled State of the Evidence). The evidence supports educational programs for care staff

and clinicians in the management of NPS.

7. Pilot change: This project will be implemented over a 6 month timeframe in one

convalescent center with high utilization of antipsychotics medications in geriatric

patients. All care staff and clinicians will be included in the educational program to

enhance their knowledge of behavioral interventions as first-line treatment of NPS in

patients with dementia. See timeline in Appendix B

8. Determine if the change is appropriate for practice: The plan was discussed with the

NE; she supports the need to implement a quality improvement initiative that will lead to

the reduction of antipsychotic medications use in patients with dementia. Based on the


needs assessment, more effective behavioral interventions in the treatment of NPS in

persons with dementia would improve care. The educational program will empower staff

in the use of appropriate behavioral intervention for the treatment of NPS in patients with

dementia. An evaluation of initial change will be implemented to allow for modifications

to be made, based on data collected, to align the facilities for best according to practice

guidelines.

9. Implement change: Refer to the timeline and the implementation section below.

10. Disseminate Results: Frequent evaluation of results will be performed and updated, refer

to section titled Data Analysis and Evaluation. The DNP student will meet with NE and

care team during and after the QI project to review data. The DNP student will also

present QI project results to other departments in health system. The DNP student will

participate in a poster presentation at the Virginia Commonwealth University and will

submit final article for publication.

Plan for Implementation

The primary purpose of this DNP project is to implement an evidence-based behavioral

program that will lead to a reduction of antipsychotic medication use in geriatric patients with

dementia. Patients will include nursing home residents, age 65 years or older, who are prescribed

an antipsychotic medication and are currently being followed by a geropsychiatric team. Patients

will have a diagnosis of a specific type of dementia (Alzheimer’s dementia, Lewy body

dementia, Parkinson’s dementia and vascular dementia) with behavioral disturbances according

to the International Classification of Diseases-10 (ICD-10). The goal is to reduce the percentage

of antipsychotic medication use to ≤ 15%, during the six months quality improvement project.

Evidence-based behavioral interventions using a systematic individualized approach will be


utilized as the first-line approach in the treatment of NPS in patients with dementia (see sample

behavioral management plan in appendix F).

The QI plan was discussed with the NE and the QI team leader. The successful

implementation and sustainability of this QI relies on identifying key team members who will

lead and influence change at Facility A such as the NEd, NS and DON. The NEd, NS and DON.

The NEd and DON will ensure that staff members are notified of upcoming educational

secessions and they will remind staff to complete the pre-test survey.

SMART Goals for Implementation

For the successful planning and implementation of the quality improvement project the

aim has to be specific, measureable, achievable, relevant and time-bound (SMART). The aim of

this project includes: 1) improvement of dementia care by effectively managing NPS in patients

with dementia; 2) ≤ 15% reduction in antipsychotic medication use in patients with dementia in

long-term care facilities; 3) implement non-pharmacological interventions in management of

NPS in patients with dementia; and 4) increase job satisfaction. The outcome measures for this

project is firstly, increase staffs knowledge in management of behavioral symptoms of dementia

through educational sessions. A pre-test survey (see appendix C) will be sent out one week prior

to first educational session. The pre-test will guide development of educational program. The

educational content will be analyzed by a panel of experts on education; the NE, the NEd at the

facility, the professor at the DNP student’s university, and the committee members on the

project. The pre-test will also assess staffs current job satisfaction rating. Staff will start

implementing behavioral interventions into practice one week after the first education session.

The NE or the nursing supervisor will observe and guide staff in the application of appropriate

behavioral interventions. The post-test will be sent out two weeks after the first educational


session, this will assess knowledge acquisition from the first educational session. A final post-

test survey will be sent out six months after implementation to assess knowledge retention and

job satisfaction. Thirdly, the overall usage of antipsychotic mediation for Facility A will be

measured before QI intervention and six months post intervention. Interventions for this project

will be implemented in the spring of 2019. Evaluation, and the data collection process will begin

in the summer of 2019, and will culminate in the spring of 2020. By the summer of 2020 policies

will be developed to in cooperate this QI into practice, throughout the health system.

Implementation

Two educational sessions will be held for providers, clinicians and direct care staff

(CNA, and professional nursing staff). The NE along with DNP student will post flyers up at the

facility to notify staff of upcoming education session. Free gifts such as mugs with Alzheimer’s

Association logo, and finger foods will be provided to encourage attendance. A pre-test survey

will be sent out to all participants via email two weeks prior to educational session. The pre-test

results will determine educational content to be covered at the first session. The pre-test will also

evaluate participants’ job satisfaction. The single global rating method will be used by simply

asking one question related to job satisfaction. The education session will be presented during

work hours to facilitate participation. The DON, NS and NE will be instrumental in reminding

staff of the training sessions.

The DNP student will present a one and a half hour, educational session at Facility A for

two days to target morning and evening staff. Educational packets will be disseminated to each

participant. The packet will include, a copy of PowerPoint presentation and a handout with

behavioral interventions that can be utilized according to the six principles of the PLST model

(see appendix D). The educational session will involve PowerPoint presentations, video clips,


case-study discussions, and role play with time allotted for questions and answers. To assess

knowledge acquisition a post-test will be sent out two weeks after the first educational session.

Post-test results will assess knowledge acquisition and determine educational content that will be

addressed in second educational session. The second educational session will be held for one and

a half hour and will occur three months after first education session. Post-test results will be

reviewed and direct care staff engagement will be elicited by obtaining feedback on behavioral

interventions implemented. A final post-test will be sent out six months after implementation of

intervention. The final post-test will assess knowledge retention and job satisfaction.

For this project the Dementia Observational System tool (DOS) tool will be used to

assess behavioral trends and evaluate the interventions used in managing behaviors (see

appendix E). The DOS tool is used to assess a person’s behavior over a 24 hour cycle for up to 7

days to determine the occurrence, frequency, and duration of behaviors of concern. The DOS is

also instrumental in helping care givers begin to determine reasons for behaviors by looking at

trends .This tool can be used for: 1) whenever there is a change or concern about the patients’

behaviors; 2) one week prior to a reduction in antipsychotic medications to determine a baseline;

3) on the second week after an antipsychotic medication has been reduced or discontinued to

determine effectiveness.; 4) to evaluate the effectiveness of a planned intervention on the care‐plan that is addressing specific target behaviors, e.g., has there been a change in the duration or

frequency of the behavior (Registered Nurses Association of Ontario [RANO], 2018).

The nurse and the CNAs are responsible for completing the DOS tool. Results of DOS

for all patients will be kept in one binder at nursing station. Appropriate behavioral intervention

according to PLST model (see appendix D) will be implemented to target specific NPS for each


patient as noted in DOS tool. The DOS tool will be utilized daily to assess effectiveness of

behavioral interventions that is targeting specific NPS after implementation.

The CNA and nurse on duty are responsible for implementing appropriate behavioral

interventions in the management of NPS in the patients (see sample behavioral management plan

in appendix F). The CNA will inform nurse of successful or unsuccessful implementation of

behavioral interventions observed through direct or indirect care. Shift updates will be done in

the form of huddles at every shift change. This will involve all direct care staff. Pertinent

information about patients will be discussed to include, effective or ineffective implementation

of behavioral interventions. The nurse will be responsible for documentation of NPS, and

behavioral intervention applied. The nurses will record detailed behavioral summaries in nurses’

progress notes in the patients chart using well‐defined, neutral terms. This will address:

1. What behavior was observed?

2. Where did the behavior occur?

3. Why / what has happening just before the behavior occurred?

4. How / what interventions were used – how were they implemented?

5. Outcome ‐ how did the resident respond

As part of normal work flow interdisciplinary team (DON, ADON, NE, SW, AC and RN

supervisor) meetings will be held weekly to review behavioral disturbances and behavioral

treatment plans for patients. The DNP student will evaluate antipsychotic medication use at least

every two months as part of normal work flow by performing chart reviews on routine patients.

As part of chart reviews providers' notes will be reviewed in detail to assess the continual use of

antipsychotic medications for long-term, and acute treatment of NPS as well as any gradual dose

reduction (GDR) performed. The chart review will also focus on detailed behavioral summary in


the nurses’ progress notes. The DOS will be reviewed to assess and evaluate effectiveness of

behavioral interventions before and after implementation. If behavioral interventions are

successful in the management of NPS, caregivers will be encouraged to use this method for

future episodes. Per organization protocol, the clinical pharmacist and providers will continue to

assess the need to perform GDR of antipsychotic medications.

Timeline

The timeline for this project will facilitate, the designing, implementation, and evaluation

of intervention in a timely and effective manner for the actual timeline (Appendix B). The

professional presentation of this proposal will be presented to the DNP team in November of

2018. After proposal presentation and acceptance, Internal Review Board (IRB) application will

be submitted. The team will continue to gather pertinent data that can influence the project. After

proposal approval and IRB confirmation, the team will start to mobilize participants. The NE and

DON will notify staff of upcoming educational sessions (refer to timeline in appendix B for

details).

Cost-Benefit/Analysis Budget

The DNP student salary and time spent in research and designing this project are not

included in this cost analysis (See appendix A). Resources such as handouts, mugs, food, pens,

and surveys will be accounted for; the total cost is $880.00. The educational program will be

carried out as a mandatory in-service and will have continuing education credit, therefore, the

facility will compensate staff for their time. Total staff compensation for Facility A is $1337.50

To perform the cost-benefit analysis for Facility A: the direct care staff such as the

CNAs, LPNs, and RN compensation should be considered. Stressors related to caring for patients

with NPS has contributed to staff turnover and absenteeism from work. The exact figure cannot


be provided at this time; however, this cost will be analyzed and included in the actual cost-

benefit of this project implementation.

An indirect cost to consider is staff recruitment and orientation due to the high rate of

staff turnover. If the staff is empowered to manage NPS in patients with dementia effectively,

this will lead to an improvement in job satisfaction; hence, there will be a reduction in staff

absenteeism due to work-related stressors. Furthermore, this will lead to a decline in staff

turnover, which will eventually lead to a reduction in the overall cost of recruitment and

overtime pay.

Another potential saving is a reduction in compensation for antipsychotic medications by

payers such as Medicare and Medicaid. The patients will also benefit, because on average

antipsychotics mediations cost $150-200 monthly. Facility-wide this can also be cost-effective as

this can result in the reduction of total uncompensated cost of medications.

Evaluation

Data Analysis

Evaluation of providers, clinicians, and direct care staff before and after the educational

session is necessary to determine effectiveness. To facilitate data collection, a pre and post-test

will be administered in the form of a questionnaire to assess participants’ knowledge of

dementia, ability to identify NPS of dementia, and behavioral approaches used in the treatment

of NPS. Pre-test results will guide the development of the educational program and assess

current job satisfaction of all participants. First post-test will be administered via email in the

form of an online survey to all participants two weeks after the educational session. This survey

will test knowledge acquisition of participants after first educational session and will also guide

development of second educational program. A final post-test will be administered six months


after implementation of interventions. Post-test results ≤ 70% indicates that further evaluation

and modification of interventions is necessary. The final post-test will also evaluate whether

enhancement of staff knowledge in non-pharmacological interventions in treatment of NPS of

dementia led to improved job satisfaction six months after implementation of interventions. To

facilitate data analysis an excel spread sheet will be used to record pre and post-test results (see

Table 1).

Data obtained from the MDS report in Pointright will be used to evaluate Facility’s A

overall percentage use of antipsychotic medications before and after implementation of the QI

project. The current report shows that Facility A has antipsychotic medication use of 26.9%

(refer to figures in section titled Site Analysis). Six months after implementation of the QI

project the MDS report will be reviewed to assess Facility’s A antipsychotic medication use.

Ideally the goal is to achieve a ≤ 15% reduction rate facility-wide however, achieving a small

reduction in the use of antipsychotic medications facility-wide through the implementation of

this QI initiative will be considered significant.

Table 1- Pre and Post-test results and Job satisfaction survey results


Sustainability

To ensure sustainability the team leader will have weekly follow up calls or face to face

meetings with NS, and NE. To mobilize staff with the integration of non-pharmacological

interventions as first-line treatment of NPS, a behavioral champion will be selected monthly. The

champion will receive a certificate and gift card; along with his/her name and photograph placed

on the champion wall of fame. The NE will post reminders at nursing stations to remind staff to

utilize non-pharmacological approaches first. Gentle reminders will be sent out to staff daily via

general text, Facebook group and Tweeter. The nurses on duty and CNAs will observe and guide

each other in the application of appropriate non-pharmacological interventions in the

management of NPS in patients similarly to that done in the interventions.

Ethical Consideration/ Protection of Human Subjects

The Virginia Commonwealth University in Richmond, Virginia and the Riverside Health

System in Newport News, Virginia IRBs’ will exempt this quality improvement project before

initiation. Additionally, the DNP student and project team will not be collecting information on

care staff participants or patients in the facility. Therefore, there will not be any employee or

patient identifiers used.

This quality improvement initiative is within the scope of practice of the DNP student

who is a practicing psychiatric mental health nurse practitioner. Improving the care of geriatric

patients with dementia by limiting the use of antipsychotic medication is an evidence-based

approach to care. The participants in this project will not be at risk as the patients will be

receiving the standard of care for dementia. Any electronic file which contains identifiable

information will be password protected.


Practice Implications

Short term Implications

This QI initiative will provide the QI team an opportunity to observe the utilization of

non-pharmacological interventions in the management of NPS in patients with dementia nursing

home facilities. In the short term this quality improvement will lead to an increase utilization of

the DOS for assessing and observing behavioral patterns in patients with dementia and to

evaluate interventions used to treat behaviors in nursing home settings. Through the application

of the DOS, a systematic individualized plan of care will be implemented for patients with

dementia. This project will lead to improvement in dementia care through the utilization of non-

pharmacological interventions. Another short term implication is a reduction in the prescription

of antipsychotic medications through the application of non-pharmacological approaches as first-

line treatment. There will be improved job satisfaction because, staff will be able to efficiently

apply behavioral interventions into practice. The facilities will benefit because the QI initiative

will lead to improvement in quality measures per CMS stipulations.

Long term Implications

This project provides the opportunity to utilize the DOS tool system wide, thus it will be

important to incorporate the DOS tool into the electronic mediation record (EHR). Integrating

the DOS tool into the EHR will facility data collection, thus enable more efficient evaluation of

interventions. The project will influence the development of behavioral programs to manage

behavioral symptoms in the entire system. This QI project will result in a decline in staff

turnover rate in nursing homes thus, it will lead to a reduction in recruitment and hiring

expenses. The governing bodies such as CMS and insurance payers will benefit from this QI

project because, it will lead to a reduction in compensation cost for antipsychotic medications.


Conclusion

Reducing the use of antipsychotic medication in persons with dementia is a national

initiative supported by CMS. There is a need for implementation of behavioral programs as the

first-line approach in dementia care. The purpose of this quality improvement initiative is to

empower providers, and caregivers through a robust educational program on dementia care. This

QI project will show that well planned educational programs will lead to an increase in the

utilization of non-pharmacological interventions and increased job satisfaction. This project will

lead to a reduction in the use of antipsychotic medications used in management of NPS

experiences for persons with dementia.


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Appendix

Appendix A

Cost Analysis/ benefit

Item Facility A

Designing project DNP Student -free

Project design and Implementation- for both facilities

Ink andPrinting cost $0.10 per paper x 200= $20Paper $10.00Food $ 200.00Mugs $10.00 x 60 = $600.00Pens 150 = $ 50.00

Total= $ 880

Staffing per hour.This class will take 1.5 hours first sessionSecond session 1 hour

Director of Nursing $45 1 112.5

Assistant director of nursing $40 1 100

MDS Coordinator $30 1 75

Social Worker $26 1 65

Nurse Educator $30 1 75


LPN $20 8 x 400

CNA $12 15 x450

Activity Coordinator $25 1 62

Total $1339.5

cost of overtime for facilities- LPN RN CNAProject benefits- empower staff in dementia

care thus relieve caregiver burden and stressorsStaff Orientation and recruitment

Average yearly saving5 year saving

Other benefits

-Benefit to insurance or payer (Medicare) - can lead to reduction in compensation for

antipsychotics as these medications are very expensive.

-Can be beneficial to patients- antipsychotics cost an average $150-200 monthly

-Beneficial to facilities which may have to cover for uncompensated medications.

Appendix B

Timeline

Time Activity

Week 1 Send out pre-test to all participants via email.Review pretest results and develop educational program based on pretest results


Week 2 Present first educational session at facilities A

Week 4 Send out post-test survey to all participants via email. Review Post-test results and prepare for second education session

Week 5 onwardsContinue with normal work flow- monitor antipsychotic medication use, review nurses notes. Review behavioral interventions utilization. Review DOS.

3 months Second Educational Session- review post-test results staff engagement, review implementations of interventions elicit feedback from direct care staff.

6 months Send out final post-test, compare results with pre-test and first post-test.Assess staffs’ job satisfactionAnalysis of antipsychotic use in from data obtained from Pointright.comPerform statistical analysis and interpretation of data.

Appendix C

Survey/ questionnaire

Pre-Test: Assessment for Knowledge of dementia Care

This questionnaire is designed to collect basic data and assess your knowledge of dementia. Please fill out to the best of you knowledge. Thank you.

1. Select Profession/ or role in current Healthcare Facility


a. Provider

b. Social worker

c. RN

d. LPN

e. CNA

f. Activity Coordinator

2. In your practice do you care for patients with dementia?

YesNo

3. How long have you been caring for patients with dementia?

< 1 year 1-5 years 5- 10 years > 10 years

4. All of these are behavioral symptoms of dementia except

Yelling out repetitive phrasesWandering Resistance to careAmbulating unassisted

5. Do you use non-pharmacological interventions to manage behavioral symptoms

are your current practice?

a) Yesb) No, if no why not?

6. Briefly explain in your own words the behavioral intervention you will use in

managing an aggressive and combative patient who is resisting care.

7. A patient is constantly pacing the hallway, what can this indicate? Explain the behavioral intervention you will use to manage this behavior?


8. Do you find it difficult or time consuming to implement behavioral interventions in management of behavioral disturbances in patients with dementia?

a) Yes, if yes please explain b) No

NEW QUESTI

9. Over all how satisfied are you with your current job?• Not satisfied • Neutral • Somewhat satisfied • Satisfied • Very Satisfied

10. If less than satisfied what would you change and why?

Appendix D


Appendix E


Dementia Observational System (DOS) Tool

Purpose:

The DOS tool is used to assess a person’s behavior over a 24 hour cycle for up to 7 days

to determine the occurrence, frequency, and duration of behaviors of concern. The DOS is also

instrumental in helping care givers begin to determine reasons for behaviors by looking at trends.

When to use the DOS tool:

1. Whenever there is a change or concern about the person’s behaviors. 2. One week prior to a reduction in antipsychotic medications to determine a

baseline. 3. On the second week after an antipsychotic medication has been reduced or

discontinued to determine effect. 4. To evaluate the effectiveness of a planned intervention on the care‐plan that is

addressing specific target behaviors, e.g., has there been a change in the duration or frequency of the behavior.

Directions:

1. Fill out in detail, the behavior you are tracking. Do not use vague terms such as

“verbal or physical aggression”, “restless”, etc. Use descriptive terms that so that everyone

tracking the

behavior understands exactly what they are monitoring (ex: spitting, slapping,

punching, kicking, calling out, “help me”, sleeping in bed, sleeping in chair, awake,

restlessness, pacing, verbal aggression, physical aggression, exit seeking, wandering,

psychosis [visual, auditory hallucination, paranoia, delusions]).

2. Do not try to track more than 3 (max 4) behaviors at a time.

3. Ensure the behaviors you are tracking are those that place the resident or others

at risk.

4. Record the behavior in 30 minute intervals for the duration of up to 7 days to

determine trends.


5. Throughout the week record behaviors of concern on the progress notes, using

well‐defined, neutral terms. Include:

• What behavior was observed?

• Where did the behavior occur?

• Why / what has happening just before the behavior occurred?

• How / what interventions were used – how were they implemented?

• Outcome ‐ how did the resident respond.

6. To interpret results, use color codes to assist in identifying patterns. Assign a

different color for each behavior you are tracking, and then color each 30 minute square for each

24 hour cycle where the behavior appears.

7. At the end of the 7 days, the multidisciplinary team should convene to review the

results of the DOS and the Integrated Progress Notes. For each 24 hour column, calculate the

number of hours spent in sleep, calmness, restlessness, and concerning behaviors. Look for

trends that may identify clues as to the reason for the behavior (ex: getting the resident up too

early in the morning, shift change causing disruption, etc.).

9. As a team, create a care plan to address the issues that you’ve discussed and

document your plan in the Integrated Progress Notes. Adjust the electronic care plan to reflect

the new plan of care.


Adapted from the P.I.E.C.E.S. (2008) Resource Guide: A Model for Collaborative Care

and Changing Practice, pages 88‐92


Appendix F

Behavioral plan for management of NPS in Dementia

Step 1. Assess for NPS symptoms (use DOS tool) - is the behavior present, is the patient

on antipsychotics for NPS (aggression, agitation, psychosis, wandering, repetitive statements,

anxiety etc.)

If no- continue to monitor and follow with PCP or geropsychiatric provider, continue

with weekly care plan meeting. Assess the need to perform GDR of antipsychotic.

Step 2. If yes- What does the NPS symptoms look like- is it acute?

Rule out (R/O) medical causes such as UTI. Manage pain and discomfort. Review

medication. Treat dehydration and nutrition.

Is there any safety concerns?

Caregiver distress? – educate care givers

Step 3. What are the causes of NPS – are there any triggers?

- Are causes modifiable?

Step 4. Treatment plan- address acute episodes (distress symptoms) and safety concerns

first.

- Use behavioral interventions as the first-line approach according to PLST model

(see appendix A) to manage NPS.

- If behaviors are unmanageable with behavioral interventions, refer to PCP or

geropsychiatric provider

Step 5. Evaluate behavioral interventions and implementation (use DOS)

- Was it effective? If so, continue behavioral interventions and share with team members,

continue to utilize intervention for management of NPS.


- If it was ineffective- was it implemented? Was it performed appropriately – if so why

wasn't it implemented, what are the barriers to implementation? Revise plan of

implementation and determine or modify strategy for implementation.

Step 5. Are new behaviors emerging?

-Continue to monitor and utilize effective behavioral interventions

- Continue to follow up with PCP and geropsychiatric providers.

-Continue to document in nursing notes. Reassess behavioral interventions used.

-Assess the need to GDR off antipsychotics.


Appendix G


Appendix H

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