Rapid Fire Presentations: Golden Nuggets in BC

A-MOP: An Antipsychotic Medication Optimization Program for Long Term Care

Janice Robinson, NP

January 18, 2013

Janice Robinson, MN, NP(A),GNC(C) Clinical Nurse Specialist/Nurse Practitioner

The Lodge at Broadmead, Victoria, BC

Fiona Sudbury, BScN, MHSc, GNC(C)Director of Care

Fiona.Sudbury@broedmeadcare.com

How low can you go?: Antipsychotics in residential care – the clinical limbo

Objectives

Share a snapshot of The Lodge at Broadmead team’s journey to apply best practice dementia care.

Provide information on a quality improvement initiative to reduce antipsychotic medications.

Stimulate discussion and information sharing regarding the future of medication optimization for frail older adults.

The Lodge at Broadmead

Population served

Many Veterans 65% male Average age 88 50% move in from

hospital ALOS ~ 18 mos ~80% mod - severe

dementia

Care Team Residents & Family Members Health Care Workers Licensed Practical Nurses Registered Nurses Therapy Services Social Workers Nurse Practitioner Family Physicians Consulting Geriatric Psychiatrist

Dignity

Knowing the person Maintain their comfort – this includes

their psychosocial and spiritual comfort Partnering with families Path of Least Resistance

Dementia Care

“Supportive Pathways” Education for all staff

Clinical Program of best practice Behavioural Care Guidelines Person-centered philosophy of care Dementia Friendly environment

Medication Optimization Program

When people move-in & regular review of medication

Beer’s list audits Staff education and

good practice guidelines

Policy development

Antipsychotic Concerns!

A-MOP – QI project

Lodge

Residents

RegularOrder

Regular & PRN

Order PRN Only Total

Total 225 20 31 22 72

% 9% 14% 10% 33%

23%

ResultsContext for the prescriptions

Indication for use: 73% - Dementia (AD, VaD, Mixed) 27% - Other psychiatric diagnoses

Rationale documented for 83% of residents Most common reason - aggression and/or risk to

self or others Care plan review

57% had non-pharmacological strategies identified

Medication history 40% had been trialled on a lower dose in past

As the QI project went along…

During the project time frame - 19 people move in with a prescription for an atypical antipsychotic [38% of new admissions in a 8 month period]

8 current residents had a NEW atypical antipsychotic prescription initiated

Project Outcomes - Prescriptions July 1, 2011 – March 15, 2012

25 residents - drug discontinued 16 residents - dosage reduced 8 residents - dosage increased 8 residents – new order for atypical

antipsychotic drug initiated 14 residents died

Comparison of Atypical Antipsychotic Use – Time 1 & 2

T2 225 12 33 13 58 % 5% 15% 5% 25%

20%

Time

Residents

RegularOrder

Regular & PRN

Order PRN Only Total

T1 225 20 31 22 72

% 9% 14% 10% 33%23%

Project Impacts

Clearer picture of atypical antipsychotic drug use in this care home

Better understanding of which individual “people” are prescribed these medications and why

Increased team awareness of the risks and good practice principles for use of atypical antipsychotics

Made us look at what our assessment and care planning

Can we get lower?

Auto stop for PRNs not used Continued assessment of the person –

health status and unmet needs Provide non-pharmacological

interventions including using the path of least resistance with personal hygiene

Start using other medications classes?

How low is low enough?

A 50% decrease will be 12-15% at TLAB [33 residents]

Will those people be the folks who require these medications or will in just be a “number” to look at – who are the numbers

Are we treating people or are we trying to met a numbered benchmark?

Final thoughts - Dignity

Is it dignified to have a person in psychiatric distress or experiencing an un/under treated psychosis related to brain disease from dementia?