>>Systems Integration

This section of the toolkit is focused on system-wide implementation of non-pharmacological approaches (NPA). The National Institutes of Health defines implementation as "the use of strategies to adopt and integrate evidence-based health approaches and change practice patterns within specific settings."¹ Accordingly, this section addresses the techniques and resources that have been found to affect a positive influence upon the quality of care and quality of life of the nursing home resident, and uptake of alternatives to anti-psychotic use.

Nursing homes are complex systems comprised of people (residents, families, administrators and staff), who learn and relate to each other and the environment in a nonlinear way.² Providing creative and individualized care for nursing home residents requires an organizational commitment to "looking at the whole picture," i.e., all the factors that influence how the resident feels, functions, and responds to care. These factors include intrapersonal characteristics (e.g., resident's health and cognitive status); interpersonal influences (e.g., resident's relationship with staff, degree of family engagement, staff knowledge and attitudes); physical and social environment (comfort, functionality, and capacity to "cue" the person with cognitive impairment); and policies (e.g., those related to staffing, communication, care evaluation, and decision-making).^3-5

The organizational leadership (Administrator, Director of Nursing, Medical Director) plays a critical role in supporting resident well-being and quality-of-life, which includes clinically appropriate, responsible, and humane use of anti-psychotic medication. To that end, their initial steps in catalyzing change to a new paradigm of care include:

• Articulating the vision of resident-centered care and incorporating the vision into strategic planning;
• Identifying one or more champions; and
• Facilitating the development of a quality team that will steer the initiative. 5 Members ideally include representatives from all disciplines/all levels of staff (including direct care staff), residents, and families.

Table 1 contains a blueprint for organizational strategies. These strategies are organized to address the "social-ecological"³ factors that influence the resident's well-being, and offer examples and resources to support the goal of providing safe and effective alternatives to antipsychotic use for Behavioral and Psychological Symptoms of Dementia (BPSD).

• Table 1. Blueprint for Organizational Strategies



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>>Education & Leadership

In this section of the Toolbox, staff programs that address use of non-pharmacological interventions, reduction of antipsychotic medication use in the nursing home, general dementia care education when it included either of the above, and leadership development for professional staff are identified. Programs that are easily accessible to facilities were selected; where there is a cost for the program this information is provided.

There are four databases associated with this section of the Toolbox:

• Table 1. Educational programs for implementing non-pharmacological interventions;
• Table 2. Leadership opportunities for professional staff;
• Table 3. Educational resources available on the Portal of Geriatric Online Education (POGOe) website and;
• Table 4. Geriatric certification opportunities.

>>Assessment

One of the first steps in managing behaviors through pharmacological or nonpharmacological treatment strategies is to detect their occurrence. There is growing consensus that early and on-going assessment of behavioral symptoms can lead to their more effective management. For example, the AMA Performance Dementia Measurement Set recommends that health providers systematically screen for behavioral symptoms once a year minimally using a standardized assessment tool. It is unclear however which assessment tool to use and whether there are sufficient standardized approaches to on-going behavioral detection from which effective treatment plans can be derived.

To evaluate the state-of-science concerning behavioral assessments, we conducted a comprehensive review of available published measures and summarized their psychometric properties. A final set of 44 measures were identified with most having adequate psychometric properties. The majority of measures (n=15) covered a broad range of behavioral symptoms and were developed for use in dementia care or in nursing homes. Measures were also found for specific neuropsychiatric symptoms including agitation, apathy, aggression, depression, anxiety, sleep, and wandering, though these were less likely to be specific for a dementia population. There were no specific measures identified, separately from the general measures that addressed behaviors such as euphoria, hallucinations, irritability apart from aggression or anxiety, and motor and verbal disturbances.

• Table 1 lists all 44 measures and their essential properties.
• Table 2 summarizes the number of measures for each behavioral category considered.
• Table 3 compares the 44 measures in terms of settings, number of Items and behavioral Categories included.

>>Non-Pharmacological Intervention

The Non-pharmacological Approaches (NPA) subgroup was charged with reviewing pertinent literature in order to determine which approaches were most effective in reducing the behavioral and psychological symptoms (BPSD) of dementia exhibited by persons residing in nursing homes. NPA are the first line therapy for responding to BPSD, due to the high risks and limited effectiveness of antipsychotic medications for treating BPSD. As a result, there is an urgent need to equip nursing home providers with readily accessible tools for identifying and implementing NPA.

We begin by presenting information that will help staff understand behavioral symptoms. We also provide information on clinical decision support approaches and practical guidance for providers.

Realizing the challenges nursing home providers encounter when faced with the realities of responding to BPSD in a resource-challenged environment, experts are increasingly calling attention to the need to address both the feasibility and efficacy of NPA in nursing home settings. Among the common resource challenges faced by nursing home providers are limited access to staff with advanced training in dementia care, limited resources and high rates of turnover. The goal of this guide is to assist nursing home providers in identifying the optimal evidence-feasibility fit for their residents and facility. We defined feasibility using Seitz and colleagues guidelines: high feasibility approaches require fewer resources, less cost of supplies, less complexity of the activity, minimal staff training, and less need for additional personnel and less specialized personnel.

To help providers overcome some of these challenges, two tables are provided: Table 1, a succinct review of the evidence for different NPA and Table 2, practical guidance for providers that integrates both the efficacy and feasibility of different NPA.