A team approach to dose reduction

The behavior management team (BMT) of the Hollidaysburg Veterans Home, Hollidaysburg, Pennsylvania, one of six state veterans’ homes operated by the Pennsylvania Department of Military and Veterans Affairs, was developed to address the many challenging behaviors exhibited by residents in a nursing care facility. It was decided to convene and collaborate the perspectives of different nursing home disciplines to address these residents’ behaviors and medication regimen throughout the nursing care facility. As a result, a positive overall culture change has been noted in which behaviors are tolerated and managed creatively and psychoactive medications are not considered the only means of addressing behaviors. For example, prn (as needed) medications are no longer used prior to providing care. Instead, specific interventions are used, based on the resident’s customary routines and responses to previous approaches.

The team consists of staff from nine designated nursing units, which include:

• Nursing staff/RNAC

• Social workers

• Activities staff

• Occupational therapists

• Pharmacist

• Quality assurance manager

• Primary physicians

• Certified nursing assistants (CNAs)

With nine nursing home units, the goal of a quarterly review of each unit requires approximately three meetings per month. The primary intention of these meetings is to protect the residents from unnecessary drugs and excessive dosing. The CNAs’ role as the “eyes and ears” of the team is consistently emphasized as their active participation in the meetings is considered essential.

Prior to a scheduled meeting, the pharmacy generates a computerized report on all residents who are ordered one more of the following type of medications: antidepressants, anxiolytics, sedative/hypnotics, antipsychotics, cognitive enhancers, and the anticonvulsants (often used as mood stabilizers). These are the residents that are reviewed during this meeting. Specific materials are gathered such as psychiatric consults, Behavioral Intervention Flow records, Severe Impairment Battery results, and Mood and Behavior reports. The goals for reviews are:

• To monitor and direct the multidisciplinary interventions necessary when an elderly resident may exhibit behavioral symptoms secondary to dementia.

• To identify and ensure accurate documentation of the residents’ behaviors, especially those that pose a danger to themselves or others and/or interfere with care (i.e., target behaviors).

• To collaborate as an interdisciplinary team and emphasize nondrug approaches to addressing target behaviors.

The meeting begins with a review of the minutes and recommendations from the last meeting. The pharmacy report is reviewed for the residents with recent changes in medications since the last review. When any recent medication changes are discovered the medical record is reviewed for the appropriate documentation and care plans. The care plans should address the change and include non-drug interventions. During this meeting the recent psychiatric consults are also reviewed for documentation supporting the diagnosis and use of medication so that the team can confirm that the psychiatric recommendations have been carried out. The Monthly Behavioral Intervention Flow sheets are reviewed to see if the resident’s target behaviors (those that pose a threat to themselves or others or significantly interfere with care) have decreased or, at least, stabilized. If this is the case, a dose reduction recommendation is made to psychiatry or to the primary physician unless contraindicated or there are noted previous failures at dose reduction. If behaviors have developed or increased, changes to the care plan or a psychiatric referral are made. Following each meeting, formal recommendations are noted in each resident’s electronic medical record and included in a report sent to all team members, the consulting psychiatrist, administrator, and medical director. These recommendations and the follow-up are carefully evaluated during the next quarterly review.

Overall effectiveness of this approach at the Hollidaysburg Veterans Home is evidenced by an cultural change that emphasizes the use of non-drug interventions before or in place of medications. This has resulted in increased number of dose reductions, the use of creative and therapeutic nondrug interventions, more comprehensive documentation, and improved awareness of the ethical use of psychoactive drugs in long-term care.

Lisa M. Lego, LSW, is Director of Social Services, Hollidaysburg Veterans Home, Hollidaysburg, Pennsylvania. James M. McConnell, RPh has been Chief Pharmacist at Hollidaysburg Veterans Home, Hollidaysburg, Pennsylvania, since 1990. He has been a Consultant Pharmacist, servicing the long-term care and various institutional settings since 1987. Long-Term Living 2010 October;59(10):48-49

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