Vol. 40, No. 3, pp. 244–254 Improving Management of ... · PDF fileImproving Management...

Nurs Admin QVol. 40, No. 3, pp. 244–254Copyright c© 2016 Wolters Kluwer Health, Inc. All rights reserved.

Improving Management ofBehavioral and PsychologicalSymptoms of Dementia inAcute CareEvidence and Lessons Learned FromAcross the Care Spectrum

Eleanor S. McConnell, PhD, RN, GCNS-BC;Michele J. Karel, PhD, APBB

As the prevalence of Alzheimer disease and related dementias increases, dementia-related be-havioral symptoms present growing threats to care quality and safety of older adults across caresettings. Behavioral and psychological symptoms of dementia (BPSD) such as agitation, aggression,and resistance to care occur in nearly all individuals over the course of their illness. In inpatientcare settings, if not appropriately treated, BPSD can result in care complications, increased lengthof stay, dissatisfaction with care, and caregiver stress and injury. Although evidence-based, non-pharmacological approaches to treating BPSD exist, their implementation into acute care hasbeen thwarted by limited nursing staff expertise in behavioral health, and a lack of consistentapproaches to integrate behavioral health expertise into medically focused inpatient care settings.This article describes the core components of one evidence-based approach to integrating behav-ioral health expertise into dementia care. This approach, called STAR-VA, was implemented inVeterans’ Health Administration community living centers (nursing homes). It has demonstratedeffectiveness in reducing the severity and frequency of BPSD, while improving staff knowledgeand skills in caring for people with dementia. The potential for adapting this approach in acute caresettings is discussed, along with key lessons learned regarding opportunities for nursing leadershipto ensure consistent implementation and sustainability. Key words: behavioral interventions,dementia, evidence-based practice, hospitals, interprofessional care, symptom management

Author Affiliations: Geriatric Research, Educationand Clinical Center, Department of Veterans AffairsMedical Center, and Duke University School ofNursing, Durham, North Carolina (Dr McConnell)and Mental Health Services, US Department ofVeterans Affairs (VA) Central Office, Washington, DC(Dr Karel).

This material is based upon work supported by MentalHealth Services and Office of Mental Health Operations,US Department of Veterans Affairs (VA) Central Office.The authors acknowledge the contributions of Officeof Nursing Services Mental Health Field Advisors KerriWilhoite, DNP, RN, and Elizabeth Czekanski, DNP, RN;Office of Geriatrics and Extended Care Operations, Di-rector of Facility Based Care Lisa Minor, RN, MSSL; theentire interdisciplinary STAR-VA training team for their

P EOPLE with dementia and those whocare for them often experience high

levels of distress related to both cognitive

dedication to implementing STAR-VA in VA CommunityLiving Centers; and Dr Linda Teri for collaborating inthe adaptation of her evidence-based STAR program forcaring for Veterans with dementia.

The opinions expressed in this manuscript are those ofthe authors and do not necessarily reflect policy of theDepartment of Veterans Affairs.

Correspondence: Eleanor S. McConnell, PhD, RN,GCNS-BC, Duke University School of Nursing, 307 TrentDr, Durham, NC 27710 ([email protected]).

DOI: 10.1097/NAQ.0000000000000167

Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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mailto:Eleanor.mcconnell@dukeglobal advance �reakcnt @ne penalty -@M .edu

mailto:Eleanor.mcconnell@dukeglobal advance �reakcnt @ne penalty -@M .edu

Improving Management of BPSD in Acute Care 245

and behavioral changes that characterize thisdisease, particularly when hospitalized.1-3

Dementia refers to a group of age-related,chronic, progressive neurological disordersthat impair cognition in multiple domainsand interfere with daily function. In additionto declines in memory, language, visual-perceptual, and/or executive functioning,individuals with dementia almost universallyexperience behavioral or psychological symp-toms of dementia (BPSD) that include, amongothers, apathy, agitation, aggression, andresistance to needed personal care.4,5 As thepopulation ages, the prevalence of dementiais growing in the United States,6 affecting anestimated 14.7% of those older than 70 years.7

On average, people with Alzheimer disease,the most common cause of dementia, live10 years following their diagnosis, and theyare 2 to 3 times more likely than thosewithout dementia to be hospitalized.8 Thus,hospital staff will care for increasing numbersof patients with dementia and will face sub-stantial challenges unless behavioral healthexpertise is integrated into care.

Behavioral or psychological symp-toms of dementia often worsen during ahospitalization,1-3 due to challenges facedby people with memory loss, impairedexecutive functioning, and reduced impulsecontrol when confronted with an unfamil-iar environment, disruption of routines,procedures that may cause discomfort, anddifficulty communicating needs to unfamiliarcaregivers. In addition, coexisting acuteillness may precipitate delirium, a syndromedistinct from dementia, yet more commonlyoccurring in people with dementia thatresults in altered attention, disorganizedthinking, and fluctuating cognitive function.9

Both delirium and poorly controlled BPSDduring hospitalization can lead to increasedpatient distress, interruptions in therapy,likelihood of complications, increased lengthof stay, patient and staff safety risks, andfamily distress.1,10

A growing body of evidence from stud-ies conducted in community and residen-tial long-term care settings suggests that

BPSD should most often be managed withnonpharmacological approaches.5,11 Antipsy-chotic and sedative/hypnotic medications,the traditional mainstay of treatment for BPSD,have limited efficacy and a high risk of ad-verse side effects. These include increasedrisk of falls, and, for antipsychotics, an in-creased risk of stroke, and death.5,12 Suc-cessful implementation of nonpharmacolog-ical therapies requires that caregiving staffmodify their care techniques to help theperson with dementia compensate for cog-nitive deficits,12-14 using person-centered ap-proaches to care. Although nonpharmacologi-cal approaches to BPSD have not been studiedextensively in acute care, the core elements ofthese approaches, if implemented with an un-derstanding of the unique attributes of acutecare,15 hold great potential for improving out-comes for people with dementia who requirehospitalization.

This article describes the core componentsof 1 evidence-based approach to integrat-ing behavioral health expertise into demen-tia care implemented in Veterans Health Ad-ministration (VHA) community living centers(CLCs) (nursing home care). These programshave demonstrated effectiveness in reducingthe severity and frequency of BPSD, while im-proving staff knowledge and skills in caringfor people with dementia. This approach wasadapted specifically for the VHA from the StaffTraining in Assisted living Residences (STAR)program16,17 and is known as STAR-VA. Wealso discuss the potential for adapting this stafftraining approach to acute care.

UNDERSTANDING THE COMPLEXITYOF BPSD

A complex set of contributors typicallyunderlies BPSD. Therefore, successful assess-ment and management require an interpro-fessional approach that integrates nursing,medical, and behavioral health expertise withknowledge of dementia. In addition to mem-ory loss, people with dementia suffer froma variety of neurocognitive impairments, in-cluding difficulties in higher-order thinking


246 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2016

such as setting goals, following complexinstructions, problem solving, and exercis-ing judgment. They also develop difficultieswith basic abilities needed to interpret visualand auditory stimuli, have impaired ability tocommunicate their needs, and difficulty con-trolling impulses. Behavioral or psychologicalsymptoms of dementia are a consequence of1 or more interrelated factors: neuronal de-generation affecting the range of functionsjust described; additional intrapersonal med-ical or psychological factors that the personwith dementia may have difficulty communi-cating, such as illness-related discomfort orfear; caregiver factors that affect communica-tion with the person with dementia; and en-vironmental factors that may cause stress.5,18

Caregivers who do not recognize the effectsof dementia on communication, behavior, andfunction may fail to recognize unmet needs,further contributing to BPSD. Moreover, care-givers may actually trigger symptoms by us-ing caregiving approaches that frustrate orfrighten the person with dementia by over-whelming his or her cognitive or functionalabilities, or by inadvertently stimulating neg-ative emotions related to fear or discomfortduring caregiving tasks.13,18,19 Understandingfactors that influence BPSD is essential knowl-edge for acute care staff so they can developan effective, nonpharmacological treatmentplan.

Specific challenges in acute care

The acute care environment presentsparticular challenges for older adults withdementia, owing to their diminished abilityto communicate20 and their reduced abilityto process and interpret stimuli from newenvironments.18 Features of acute care thattend to worsen BPSD include an environmentthat presents high levels of auditory and visualstimulation, demands to interact with manydifferent staff in the process of receiving care,interruptions in customary routines, andchallenges interpreting meaning of medicalor nursing care interventions. In addition, thetendency for highly specialized medical careto focus narrowly on the admitting diagnosis,

rather taking into account complex comorbidillness and social situations that influence thehealth status of the person with dementiaand their family, sets the stage for staff tooverlook important contributors to BPSDduring the hospital stay.21

Illustrative case example

Consider the experience of a personwith moderate-stage Alzheimer disease who,among her cognitive limitations, has difficultywith language comprehension and expres-sion. When she is hospitalized and experi-ences pain, either due to a chronic problem,such as osteoarthritis, or due to an acute prob-lem such as urinary retention, the only meansshe may have of communicating her pain is toyell out, to speak in a manner that is seeminglyincoherent, or to resist care. These are all com-mon BPSD. Under traditional models of care,when staff members lack an understandingof the factors that underlie BPSD, or lack thenecessary expertise to investigate and treatthe underlying causes, they typically interpretthese behaviors as psychiatric symptoms (ag-itation) to be suppressed with psychoactivemedicine. The patient may then continue tosuffer from pain, perhaps more quietly or withless disruption to care routines, but withoutneeded pain relief. In contrast, when staff rec-ognize the patient’s BPSD as signifying one ormore unmet needs, they can conduct a moresystematic assessment of the patient, directedat identifying and treating the root cause.21

The patient is then likely to experience morelasting relief of multiple symptoms withoutthe risk of side effects from unnecessarymedication.

Evidence-based management of BPSD

Although to date there has been limited re-search examining the efficacy of treatmentstrategies for BPSD in acute care settings,careful analysis of research outcomes fromthe large and growing literature on nonphar-macological interventions in community andlong-term care settings can be used to gener-ate an evidence-informed set of approaches



for acute care. Considering evidence devel-oped in alternative care settings is consistentwith Centers for Medicare and Medicaidpriorities to focus on person-centered ap-proaches to care that provide consistencyacross the care spectrum.22

Systematic reviews of nonpharmacologicalintervention studies find variable evidenceof efficacy and effectiveness. Evidence-basednonpharmacological approaches fall into 2major categories: (1) simple interventions de-signed to promote comfort and cooperationwith care and (2) multicomponent behavioralintervention approaches. Some simple inter-ventions, such as the use of comforting touchin combination with encouragement to eat,or use of hand massage along with relaxingmusic, have been demonstrated to cause im-provements in important outcomes such asoral intake or agitation.12 These are consis-tent with good basic nursing care approaches.The evidence base is stronger for multicom-ponent behavioral approaches tailored to theperson with dementia’s specific behaviors,personality, level of cognitive function, andpersonal preferences. These approaches typi-cally involve advanced assessment and behav-ioral management skills.12 Although each ofthe multicomponent intervention studies usesa slightly different set of approaches, core el-ements among them include careful assess-ment of behaviors, contributing factors, anddevelopment of an individualized treatmentplan-–in short, a person-centered, systematicapproach to investigating and treating con-tributors to BPSD.

Kales and colleagues5 convened an inter-professional consensus panel that endorseda framework to guide management of BPSD,regardless of care setting. This framework isknown as DICE: Describe, Investigate, Create,and Evaluate.5,23 The model assumes that clin-ical staff understand the interacting factorsthat can contribute to BPSD. Each sequentialstep guides a caregiving team in developingand evaluating a care plan. The first step isto describe the behavior of concern and itscontext in detailed terms. Oftentimes, a teammight say, “we need to deal with this agitated

behavior,” which is not helpful in understand-ing what exactly is happening, when, where,and with whom, and for whom it is a prob-lem. This step is important because not allBPSD are troublesome. For example, in oneprospective study of BPSD in acute care, only17% of the symptoms identified on admissionwere classified as “troublesome.”2

Following a careful description of the be-havior, the next step is to investigate its mul-tiple possible contributors. These may be thepatient (e.g., medical, medication, sleep, un-met needs), caregiver, and environmental fac-tors. The third step entails creating a plan tointervene with the patient, caregiver, and/orthe environment, to modify the suspectedcauses of the BPSD. Finally, staff evaluates towhat extent interventions are effective andmodify the plan accordingly. At each step, theteam may consider psychotropic drug use ifthere are imminent safety concerns, or if treat-ment of underlying psychiatric conditionssuch as depression or psychosis is indicated.

Implementing an interprofessional,evidenced-based BPSD interventionin VHA

Over the past 5 years, VHA has imple-mented an interprofessional, behavioralintervention to reduce BPSD in 68 of its 1341CLCs, adapted from Teri and colleagues’17,24

“STAR” (Staff Training in Assisted LivingResidences) intervention. STAR is a multicom-ponent intervention that includes systematicassessment and individualized approachesto manage and prevent BPSD and is amongthe most extensively studied of the nonphar-macological interventions. STAR has beensuccessfully implemented in diverse caresettings, with consistently positive results ob-tained under both research and “real world”circumstances. STAR-VA development hasbeen guided by principles from implementa-tion science,25 including (1) specifying corecomponents of a research-based interventionto be translated into practice, (2) adaptingthe intervention to be consistent with theorganization’s culture and practices without



altering core components, (3) ensuringalignment with broader organizational goals,(4) conducting training in a manner that isconsistent with evidence-based instructionalapproaches, and (5) monitoring implemen-tation to ensure that each component isdelivered as designed. These processes, par-ticularly aligning the program with leadershipgoals, implementing staff training, and con-ducting program evaluation, provide a usefulexample of how research evidence for BPSDmanagement can be adapted for a new settingof care and sustainably implemented, withpositive outcomes for both patients and staff.

Core components of STAR-VA

The core components of STAR-VA includebehavioral analysis and care planning, withstructured assessment and modification of in-trapersonal, interpersonal, or environmentalactivators of behaviors and consequences thatmay reinforce or worsen those behaviors, alsoknown as the “ABC” approach; integrationof individualized pleasant events into dailycare; and promotion of realistic expectationsof individuals with dementia and the use ofenhanced verbal and nonverbal communica-tion strategies that take into account com-mon impairments associated with dementia,including a technique called “Listen with re-spect, comfort, and redirect.” With this careapproach, residents experience decreased fre-quency and severity of target behaviors, aswell as decreased symptoms of depressionand anxiety, while staff report increased con-fidence and positive program impact.16

Interprofessional staff training tomanage BPSD in STAR-VA

The STAR-VA training program was initi-ated by VHA Mental Health Services in 2010and has been expanded since then in collabo-ration with leaders from 3 program offices:Geriatrics and Extended Care, Nursing Ser-vices, and Mental Health Operations. This isconsistent with national efforts to improveperson-centered dementia care in nursinghomes and to reduce the inappropriate use

of antipsychotic medications.26 The trainingprogram was modeled after the VHA nationalcompetency and evidence-based psychother-apy training programs.27 Those include expe-rientially based training followed by weekly,telephone-based consultation over 6 monthswith expert training consultants during im-plementation of new care techniques. Fourcompetency domains were addressed duringSTAR-VA training:

• Behavioral assessment skills such asidentifying target dementia-related behav-iors, and identifying activators and conse-quences of target behaviors;

• Collaborative development of a behav-ior plan with the team, by promotingrealistic expectations and effective com-munication, incorporating tailored pleas-ant events that are meaningful to the per-son with dementia into daily care, andchanging activators/consequences;

• Teaching other staff members knowl-edge and skills needed to develop andimplement the behavioral care plan,through various training, coaching, andteam communication modalities; and

• Translating the behavior plan into dailypractice, to ensure consistent implemen-tation of the behavior plan, modifying asindicated by the patient’s response.

A STAR-VA leadership team, composed ofa psychologist, psychiatrist, or psychiatricmental-health nurse practitioner who servedas the STAR-VA “Behavioral Coordinator” (BC)and a registered nurse (RN) who served as theSTAR-VA “Nurse Champion,” was recruitedfrom each site. Each dyad attended an inten-sive, 21/2-day clinical workshop that includeddidactic presentations, small group exercisesto practice behavioral assessment and treat-ment planning skills, and interprofessionalteamwork. Training focused on core com-ponents of the intervention and strategiesfor working with the interdisciplinary teamfor implementing the new care approach.Interprofessional collaboration competencieswere emphasized,28 as were strategies forcommunicating and collaborating with localleadership. Training was further supported by



a detailed intervention manual29 and a STARDVD with video clinical vignettes to be usedfor team training.

During the 6-month follow-up consultationperiod, each team completed the STAR-VAintervention with at least 4 veterans, sub-mitting weekly behavioral assessment andcare plans for consultant review. Behavioralcoordinators participated in weekly consul-tation group conference calls (approximately4 participants per group) that were led byan expert psychologist STAR-VA trainingconsultant. Nurse champions met monthlyunder the leadership of STAR-VA nursingfaculty. Consultation calls focused on strate-gies to facilitate engagement of all CLC staffin behavioral assessment, care planning,and implementation, and on acquisition ofSTAR-VA competencies. Consistent withevidence-based approaches to clinical skillacquisition,30 training consultants evaluatedeach participant in their development of in-tervention competencies. They then providedfeedback to facilitate competency attainment.

Feedback obtained regarding veteran andstaff response to this training attests to the

effectiveness of the approach. As has beenpreviously reported, statistically significantand clinically important reductions in fre-quency and severity of targeted symptomswere observed during the 6-month training,along with improvements in depression andanxiety.16 The Figure summarizes changes inseverity and frequency of target symptoms ob-served among veterans during the 2013 and2014 training cohorts.

Target symptoms were diverse in natureand included verbal or physical aggression, re-sistance to care, disruptive vocalization, andwandering. On average, there was a 50% to60% decrease in ratings of severity, and a40% to 45% decrease in ratings of frequency,with effect sizes of 1.0 or greater. In clini-cal terms, on average, severity of symptomsdecreased from “very severe” to “mild” andfrequency was reduced from 3 to 6 timesper week to only 1 to 2 times per week.Likewise, there were improvements in staffoutcomes. As shown in Table 1, trainingwas accompanied by sustained increases instaff self-efficacy in implementing behavioralapproaches.

Figure. STAR VA 2013 and 2014 outcomes: Change in target behavior severity and frequency (n = 71 in2013, n = 72 in 2014).



Table 1. Selected 2014 Trainee Self-efficacy Ratings Prior to In-person Training Workshop,Postworkshop, and Post-6-Month Consultation

Mean (SD)Self-Efficacy Evaluation Item: Traineesself-rated their confidence on eachcompetency using on a scale of 1 =not at all confident to 7 = completelyconfident

Pre-workshop(N = 38)

Post-workshop(N = 36)

Post-consultation

(N = 26)

I can effectively use behavioral approacheswith residents who are demonstratingchallenging dementia-related behaviors.

5.1 (1.0) 6.1 (0.6) 6.3 (0.8)

I can provide Staff Partnersa with a clearand persuasive rationale for utilizing abehavioral approach to addressingchallenging dementia-related behaviors.

4.9 (1.2) 6.2 (0.6) 6.4 (0.9)

I can identify potential activators ofchallenging dementia-related behaviors.

5.1 (1.2) 6.3 (0.6) 6.6 (0.6)

I can develop a behavioral interventionplan to address challengingdementia-related behaviors.

4.6 (1.4) 6.2 (0.7) 6.4 (0.7)

I can teach Staff Partners to use effectivesteps for arranging a patient-centeredpleasant event for residents withchallenging dementia-related behaviors.

4.5 (1.2) 6.1 (0.8) 6.4 (1.0)

I can describe strategies for effectivecommunication with residents who havechallenging dementia-related behaviors

5.0 (1.3) 6.3 (0.6) 6.6 (0.7)

aStaff Partners is a STAR-VA-specific term that refers to members of the care team.

Lessons learned from STAR-VAimplementation

Several lessons learned during STAR-VA im-plementation may inform implementation ofevidence-based BPSD management in acutecare. The first of these is that an interpro-fessional approach to implementation is crit-ical, given the complex web of causationthat underlies BPSD. STAR-VA builds on theincreasingly recognized value of behavioralhealth integration into medical care that lever-ages complementary expertise of behavioraland nursing care experts, and their distinc-tive roles in care as clinicians, teachers, andcoaches of other staff. Behavioral health prac-titioners have advanced expertise in behav-ioral assessment and coaching for behaviorchange. Nursing staff have complementary ex-pertise for offering intimate personal care in

a supportive, nonthreatening manner that isconsistent and predictable. Nurses can benefitwhen coached by an experienced behavioralanalyst. Nurses are also uniquely positionedto observe patients’ response to treatment,which is an essential ingredient for behavioralanalysis and treatment planning. Each pro-fession can achieve much more by workingtogether.

Another lesson concerned the critical im-portance of engaging and empowering frontline staff to implement behavioral interven-tions in inpatient care settings. Staff learnedthat their observations and interactions withpatients are critical to behavioral assessmentand care planning. Furthermore, they sawthat, by developing new skills, they can makean enormous difference in quality of life forveterans with dementia.



In addition, engaging both unit-level andexecutive-level leadership around sharedgoals was critical to ensure that staff had ade-quate time and involvement in learning andimplementing a new care approach. Lead-ership support was also key to integratingSTAR-VA techniques into usual care prac-tices. These included supporting modificationof electronic health record templates to ac-commodate behavioral assessments and careplans, introducing behavioral care planning aspart of usual team and shift change meetings,and making the STAR-VA model of care partof orientation for new staff.

Modifications of the STAR-VA approachfor the acute care setting

STAR-VA and other multicomponent ap-proaches to BPSD have been developed out-side the acute care setting. As shown inTable 2, the core components of the programcan readily be applied to acute care but re-quire modifications to take into account themedical acuity of the population, rapid paceof care, the hospital care environment, andthe availability of mental health profession-als. For example, the training model wouldneed modification in acute medical-surgicalsettings, to accommodate more rapid cycleanalysis of patients’ behaviors and implemen-tation of approaches. Direct care providershave a higher educational level in the acutecare setting and enhanced access to specialtycare. The combination of more rapid turnoverof patients, and the greater fund of knowledgeupon which staff can build would likely accel-erate knowledge and skill acquisition, so thattraining/consultation could be accomplishedover a shorter period of time (1-3 months vus6 months).

DISCUSSION

As the prevalence of dementia increases,acute care staff will find themselves increas-ingly challenged by patients suffering fromBPSD. STAR-VA evaluation data demonstratethe potential for clinically important improve-

ments in BPSD that occur frequently in acutecare when teams composed of registerednurses and behavioral health experts are avail-able to assist direct caregivers in developingand implementing nonpharmacological ap-proaches. Although it is not possible to com-pare these results directly with other stud-ies of nonpharmacological interventions ow-ing to differences in evaluation design andoutcome measures, the impact on BPSD isconsistent with other studies.17,24 Unfortu-nately, cost-effectiveness studies of STAR-VAand similar interventions do not exist butare an important direction for future work.While evidence-based nonpharmacological in-terventions for BPSD have been translated to“real-world” care settings, little research ex-ists to guide implementation of such care ap-proaches in acute medical-surgical care.

Implementation of research findings intopractice requires careful specification of corecomponents of an intervention, use of ac-tive learning approaches to help staff acquirenew care competencies, and a robust strategyfor linking staff to experts so that new skillsare acquired efficiently. It is important thatresources are provided so that, as questionsarise during implementation, staff can clarifyexpectations and technique.25 The STAR-VAtraining approach uses the principles of suc-cessful research implementation to make ad-vanced behavioral health expertise availableto all staff on the units where the behaviorcoordinators and nurse champions practice.By setting the expectation that staff with ad-vanced expertise will model evidence-basedcare approaches, and coach others in theiracquisition and use, even broader impact onstaff competence is achieved. Untapped op-portunity exists for teams of behavioral healthexperts and RNs to acquire needed behav-ioral analysis and treatment planning skills toguide improved management of BPSD in acutecare. Lessons learned from implementation ofSTAR-VA in VHA CLCs can inform adaptationof the approach in the acute care setting.

Although the STAR-VA program was imple-mented in a system that is rich in behavioralhealth resources, the expertise and systems of



Table 2. STAR-VA Intervention Components and Training Applied to Acute Medical CareSetting

STAR-VA Core Component Proposed Adaptation for Acute Care

Realistic expectations andcommunication

Address delirium as a common and important influence oncognitive function

Find ways to reassure and comfort the person with dementiawho is medically ill

Recognize that reality testing or reality orientation are neitherhelpful nor necessary

Make staff aware of individual’s history to inform efforts atcommunicating/redirecting. Actively seek informationabout patient’s background and preferences

Behavioral analysis andidentification BPSD triggers(ABC Model)

Consider signs of pain/discomfort/fear as possible activators ofBPSD

Consider environmental activators to BPSD leading to:overstimulation: alarms, lights, television, orunderstimulation: lack of distracting activity

Pleasant events Engage with family to determine individualized sources ofpleasure or comfort

Provide simple, evidence-based pleasant experiences (e.g.,individualized music, massage, or touch therapies)

Provide tailored activities appropriate for person withdementia, with occupational or recreational therapy support

If sitters or patient safety attendants are used, have themengage patient in pleasant activities in a structured manner

Interprofessional approach,including mental health andnursing partnership

If integrated psychology and/or psychiatry staff are notavailable in acute care, consider collaboration withconsultation/liaison mental health professionals

Engage professionals including occupational therapist,recreation therapist, social worker in implementingnonpharmacological intervention approach

Recognize that physician-to-physician consultation modelsmay be less effective; consider development of team-basedconsultation models to inform nursing care practices

Engaging the entire team Have all staff who interact with patient contribute to care plan(including those doing consults/tests)

Develop centralized method to share behavioral observationsand communicating behavioral care plan (e.g., “all staffshould be aware that patient is comforted when referred toby his nick-name, Sammy”)

Training model Adapt training model to pace of acute care setting andbehavioral expertise available

care needed to improve BPSD managementare available outside the VHA. Prior studieshave shown that expertise in treatment of be-havioral symptoms associated with deliriumcan be obtained through the use of trainingapproaches that build needed skills among di-

rect care staff.1,30 Models to strengthen geri-atrics care or behavioral health have been suc-cessful in many acute care settings, throughthe implementation of evidence-based prac-tice protocols,31,32 psychiatry consultation-liaison models,33 comanagement inpatient



care models,34 and “acute care for the elderly”units.35 Equipping staff with necessary exper-tise will require strong nursing leadership toensure that sufficient attention is paid to thestructures and processes to support staff inacquiring and implementing needed compe-tencies on a consistent basis.

CONCLUSIONS

The growing prevalence of dementia callsfor improved approaches to managementof BPSD in acute care, building on thegrowing evidence-base for nonpharmaco-

logical approaches. The STAR-VA programhas developed a feasible, reproducible,competency-based approach that is associ-ated with improved symptom managementand staff self-efficacy. Adapting this approachto acute care will require modification dueto the rapid pace of care in the hospital andwill require leadership from nurse executivesand behavioral experts. Improved accessto behavioral health expertise in acutemedical-surgical settings holds great promisefor improving the management of BPSD and,in turn, the safety and care outcomes forolder adults hospitalized with dementia.

REFERENCES

1. Galvin JE, Kuntemeier B, Al-Hammadi N, GerminoJ, Murphy-White M, McGillick J. Dementia-friendlyhospitals: care not crisis: an educational program de-signed to improve the care of the hospitalized pa-tient with dementia. Alzheimer Dis Assoc Disord.2010;24(4):372-379.

2. Sampson EL, White N, Leurent B, et al. Behaviouraland psychiatric symptoms in people with dementiaadmitted to the acute hospital: prospective cohortstudy. Br J Psychiatry. 2014;205(3):189-196.

3. NC Department of Health and Human ServicesDoA. Acute hospitalization and Alzheimer’s disease:A special kind of care. https://www.nia.nih.gov/alzheimers/publication/acute-hospitalization-and-alzheimers-disease2008. Accessed December 30,2015.

4. Lyketsos CG, Carrillo MC, Ryan JM, et al. Neuropsy-chiatric symptoms in Alzheimer’s disease. AlzheimerDement. 2011;7(5):532-539.

5. Kales HC, Gitlin LN, Lyketsos CG. Assessment andmanagement of behavioral and psychological symp-toms of dementia. BMJ Clin Res ed. 2015;350:h369.

6. US Department of Health and Human Services. Na-tional Alzheimer’s plan, 2015. https://aspe.hhs.gov/national-plan-address-alzheimer%e2%80%99s-disease-2015-update. Accessed December 12, 2015.

7. Plassman BL, Langa KM, Fisher GG, et al. Prevalenceof dementia in the United States: the aging, demo-graphics, and memory study. Neuroepidemiology.2007;29(1/2):125-132.

8. Phelan EA, Borson S, Grothaus L, Balch S, LarsonEB. Association of incident dementia with hospital-izations. JAMA. 2012;307(2):165-172.

9. First MB. DSM-5 Handbook of Differential Diagno-sis [Electronic Resource]. Washington, DC: AmericanPsychiatric Publishing, a division of American Psychi-atric Association; 2014.

10. Fick DM, Steis MR, Waller JL, Inouye SK. Deliriumsuperimposed on dementia is associated with pro-longed length of stay and poor outcomes in hospital-ized older adults. J Hosp Med. 2013;8(9):500-505.

11. American Psychiatric Association. Choosing wisely:Five things that physicians and patients shouldquestion. http://www.choosingwisely.org/doctor-patient-lists/american-psychiatric-association/.Accessed December 30, 2015.

12. O’Neil M, Freeman M, Christensen V, et al. A System-atic Evidence Review of Non-pharmacological In-terventions for Behavioral Symptoms of Dementia(Internet). Washington, DC: Department of VeteransAffairs Health Services Research and DevelopmentEvidence Synthesis Program; 2011: http://www.ncbi.nlm.nih.gov/books/NBK54978/. Accessed De-cember 30, 2015.

13. Whall AL, Kolanowski AM. The need-drivendementia-compromised behavior model—A frame-work for understanding the behavioral symptoms ofdementia. Aging Ment Health. 2004;8(2):106-108.

14. Logsdon RG, McCurry SM, Teri L. Evidence-based psy-chological treatments for disruptive behaviors in in-dividuals with dementia. Psychol Aging. 2007;22(1):28-36.

15. Clissett P, Porock D, Harwood RH, Gladman JR. Thechallenges of achieving person-centred care in acutehospitals: a qualitative study of people with dementiaand their families. Int J Nurs Stud. 2013;50(11):1495-1503.

16. Karel MJ, Teri L, McConnell E, Visnic S, Karlin BE.Effectiveness of expanded implementation of STAR-VA for managing dementia-related behaviors amongveterans. Gerontologist. 2016;56(1):126-134.

17. Teri L, Huda P, Gibbons L, Young H, van LeynseeleJ. STAR: a dementia-specific training program forstaff in assisted living residences. The Gerontologist.2005;45(5):686-693.


https://www.nia.nih.gov/alzheimers/publication/acute-hospitalization-and-alzheimers-disease2008



http://www.choosingwisely.org/doctor-patient-lists/american-psychiatric-association/

http://www.choosingwisely.org/doctor-patient-lists/american-psychiatric-association/

http://www.ncbi.nlm.nih.gov/books/NBK54978/

http://www.ncbi.nlm.nih.gov/books/NBK54978/


18. Algase DL, Beck C, Kolanowski A, et al. Need-driven dementia-compromised behavior: An alterna-tive view of disruptive behavior. Am J Alzheimer’sDis Other Dement. 1996;11(6):10-19.

19. Kovach CR, Noonan PE, Schlidt AM, WellsT. A model of consequences of need-driven,dementia-compromised behavior. J Nurs Scholarsh.2005;37(2):134-140; discussion 140.

20. Miller CA. Communication difficulties in hospi-talized older adults with dementia. Am J Nurs.2008;108(3):58-66; quiz 67.

21. Kovach CR, Logan BR, Joosse LL, Noonan PE. Fail-ure to identify behavioral symptoms of people withdementia and the need for follow-up physical assess-ment. Res Gerontol Nurs. 2012;5(2):89-93.

22. US Department of health and Human Services, Cen-ters for Medicare and Medicaid Services. CMS QualStrategy. 2016. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html. Accessed January 4, 2016.

23. Kales HC, Gitlin LN, Lyketsos CG. Management ofneuropsychiatric symptoms of dementia in clinicalsettings: recommendations from a multidisciplinaryexpert panel. J Am Geriatr Soc. 2014;62(4):762-769.

24. Teri L, McCurry SM, Logsdon R, Gibbons LE. Trainingcommunity consultants to help family members im-prove dementia care: a randomized controlled trial.The Gerontologist. 2005;45(6):802-811.

25. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyr-iakidou O. Diffusion of innovations in service orga-nizations: systematic review and recommendations.Milbank Q. 2004;82(4):581-629.

26. National Partnership to Improve Dementia Carein Nursing Homes. https://www.nhqualitycampaign.org/dementiaCare.aspx. Accessed December 30,2015.

27. Karlin BE, Cross G. Enhancing access, fidelity, andoutcomes in the national dissemination of evidence-

based psychotherapies. Am Psychol. 2014;69(7):709-711.

28. Interprofessional Education Collaborative. CoreCompetencies for Interprofessional CollaborativePractice: Report of an Expert Panel. Washington,DC: Interprofessional Education Collaborative; 2011.https://ipecollaborative.org/uploads/IPEC-Core-Competencies.pdf. Accessed December 30, 2015.

29. Karlin BE, Teri L, McGee JS, et al. STAR-VA Interven-tion for Managing Challenging Behaviors in VACommunity Living Center Residents With Demen-tia: Manual for STAR-VA Behavioral Coordinatorsand Nurse Champions. Washington, DC: US Depart-ment of Veterans Affairs; 2014.

30. Gelfman LP, Lindenberger E, Fernandez H, et al. Theeffectiveness of the Geritalk communication skillscourse: a real-time assessment of skill acquisitionand deliberate practice. J Pain Symptom Manage.2014;48(4):738-744; e731-e736.

31. Mezey M, Kobayashi M, Grossman S, Firpo A, Ful-mer T, Mitty E. Nurses Improving Care to Health Sys-tem Elders (NICHE): implementation of best practicemodels. J Nurs Adm. 2004;34(10):451-457.

32. Rudolph JL, Archambault E, Kelly B. A delirium riskmodification program is associated with hospitaloutcomes. J Am Med Dir Assoc. 2014;15(12):957;e957-e911.

33. Callaghan P, Eales S, Coates T, Bowers L. A reviewof research on the structure, process and outcomeof liaison mental health services. J Psychiatr MentHealth Nurs. 2003;10(2):155-165.

34. Chen P, Hung WW. Geriatric orthopedic co-management of older adults with hip fracture: anemerging standard. Ann Transl Med. 2015;3(16):224.

35. Fox MT, Sidani S, Persaud M, et al. Acute carefor elders components of acute geriatric unit care:systematic descriptive review. J Am Geriatr Soc.2013;61(6):939-946.


https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html




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