Expert panel on Agitation and Aggression in Dementia
Quality Standards and Clinical Handbook
AGHPS Summit
November 13, 2015
Health Quality Ontario
The provincial advisor on the quality of health care in Ontario
www.HQOntario.ca
Project Scope
Population and topic in scope
• Individuals with agitation and aggression in the context of
Dementia being cared for in the following settings: Emergency
Department, Inpatient Hospital, LTCF
• Transitions between these 3 environments
Population and topics out of scope
• Individuals with agitation and aggression in Dementia in the
Community (non-LTCF)
• Individuals with Dementia where agitation and aggression is not
an area of clinical concern
• Clinical issues related to the care of individuals with Dementia
that are not specific to agitation and aggression
www.HQOntario.ca
1
Methods: Review of Evidence
For each prioritized key area:
Summary of relevant
recommendations and
guidance statements
Evidence review
Establishment
of consensus
www.HQOntario.ca
CE will identify recommendations or statements from
relevant guidelines (such as NICE or NICE-accredited
guidelines, guidelines used in current practice, or those
otherwise identified through scoping exercise) that support
potential quality statement development.
If limited or no evidence exists for a key area, the CE will
ideally conduct an evidence review using the most
appropriate review method.
If there is no evidence, the panel may wish to:
• Use expert consensus
• Note prioritized key area for future consideration
2
Methods: Review of Evidence
Identification and Inclusion of Clinical Guidelines
• Identify relevant guidelines covering the population(s) and
setting(s) of interest, with guidance from the medical librarians
and input from the advisory panel
• Use the AGREE II instrument to select 4–5 highest quality clinical
guidelines, including at least 1 contextually relevant (Canadian)
guideline
Appraisal of Guidelines for Research & Evaluation II
1) Scope and Purpose
2) Stakeholder Involvement
3) Rigour of Development
4) Clarity of Presentation
5) Applicability
6) Editorial Independence
www.HQOntario.ca
3
Methods: Drafting of Quality Statements
• 5–10 quality statements will be drafted, based on
either recommendations from relevant guidelines or an
evidence review
• Quality statements are not verbatim restatements of
the relevant recommendations from source
guideline(s)
• One quality statement may map to recommendations
from one or more guidelines, and/or may be derived by
rewording one or more recommendations into a single
statement
www.HQOntario.ca
4
HQO's Expert Advisory Panel on Dementia with
Agitation or Aggression
#
Titl First
Last Name
e Name
Affiliation
Specialization
1
Dr.
Ilan
Fischler
OSCMHS
Geriatric Psychiatrist
2
Dr.
Tarek
Rajji
CAMH
Geriatric Psychiatrist
3
Dr.
Krista
Lanctot
Sunnybrook Health Sciences Centre
PhD Pharmacologist
4
Ms. Vincci
Tang
Ontario Shores Centre for Mental Health Sciences
5
Ms. Saima
Awan
CAMH – clinical pathway support
6
Dr.
Amer
Burhan
Western University (London)
Geriatric Psychiatrist
7
Dr.
Dallas
Seitz
Queen's University Providence Care
Geriatric Psychiatrist
8
Dr.
Evelyn
Williams
Sunnybrook Health Sciences Centre
Head, Division of Long
Term Care
9
Ms. Carrie
Acton
Muskoka Landing LTC - Huntsville
Administrator
10
Ms. Ashley
Miller
Regina Gardens Long Term Care Center
Administrator
11
Ms. Denise
Malhotra
Erie St. Clair Community Care Access Centre (CCAC)
12
Ms. Natasha
Ward
Thunder Bay Regional Health Science Center
13
Dr.
14
Ms. Lori
15
Dr.
16
Dr.
17
Richard
Decision Support Analyst
Nursing
Trillium Health Partners
Geriatric Psychiatrist
Whelan
St. Michael's Hospital
Occupational Therapist
Jenny
Ingram
Kawartha Regional Memory Clinic
Geriatrician
Barry
Goldlist
Mount Sinai Hospital (MSH)
Geriatrician
Ms. Sandi
Robinson
Accalaim Health Alzheimer Services
18
Mr.
Wong
Full-Time Caregiver
19
Ms. Margaret Weiser
Ken
Shulman
Deputy CFO & Director of
IT & Decision Support
Manager, Integrated Care
Pathways Program
Private Practice
Social Worker
Patient Advocate
5
Psychologist
Primary Key Areas
1. Assessment and monitoring
2. Nonpharmacological interventions
3. Pharmacological interventions
4. Physical restraint minimization
5. Provider education and training
6. Caregiver education and training
7. Access to specialty care
8. Physical care environment
9. Consent and decision-making capacity
10. Transition of care
www.HQOntario.ca
6
Examples of possible Quality
Standards
• People with dementia receive a comprehensive
evaluation with the use of appropriate validated tools
or instruments , which includes early identification of
individual risk for behavioural challenges.
• People with dementia and agitation or aggression
receive behavioural interventions that are tailored to
their specific needs and symptoms, as specified in
their care plan. Evidence-based behavioural
interventions include:
–
–
–
–
–
Aromatherapy,
Multisensory therapy,
Therapeutic music and dance therapy,
Pet-assisted therapy
Massage therapy
www.HQOntario.ca
7
Examples of possible Quality
Standards
•
Medication review for dosing reduction and discontinuation is performed
on a regular basis (at least every 3 months) for people with dementia
who receive pharmacological agents for agitation or aggression
•
Physical restraints are only used in people with dementia and agitation
or aggression when behavioural and/or pharmacological measures have
been unsuccessful, and individuals continue to pose an imminent risk of
harm to themselves or others
•
People with dementia and agitation or aggression receive care from
providers with structured specialized training in dementia and its
behavioural symptoms, which are consistent with the provider’s roles and
responsibilities.
www.HQOntario.ca
8
Examples of Possible Quality
Standards
•
Carers of people with dementia and agitation or aggression are informed
of advocacy and support groups and services and how to access them.
•
People with dementia and agitation or aggression receive access to
mental health and behavioural support services from a multidisciplinary
team, which provides specialized care in dementia with behavioural and
psychological symptoms
•
People with dementia and agitation should be assessed and treated in a
physical care environment that is supportive and therapeutic.
•
People with dementia and agitation and/or carers are actively engaged in
the transition preparation process, and receive an up-to-date proactive
care plan that is agreed upon by all providers and considers the changing
needs of the person with dementia.
www.HQOntario.ca
9
The Ontario Shores Approach to
Implementing CPGs
Step 1: Guideline selection
Step 2: Development of Algorithm
Step 3: Gap Analysis
Step 4: Create supporting governance structure
Step 5: Selection of adherence and outcome measures
Step 6: Create Project Charter
Step 7: Utilize informatics – eg. electronic templates,
automated decision support
– Step 8: Realignment of Therapeutic Services
– Step 9: Monitor Adherence and Promote Quality
Improvement
–
–
–
–
–
–
–
10
Key Changes for Dementia Program
– Electronic ABC tracking tool
– Implement Evidence-based non-pharmacologic
interventions:
» Pet therapy, Aromatherapy, Massage Therapy,
Formalized exercise program (already had
multisensory stimulation, music therapy,
reminiscence, etc.)
– New training program for all clinical staff – with a
focus on person-centred care
11
Key Changes for Dementia Program
– New assessment tools to be completed by interprofessional
staff at prescribed times
• PAIN-AD, Cornell, CAM, Prompted voiding trial
assessment, environmental assessment, NPI-NH and
others
– New interprofessional care plan
– New social work psychosocial assessment with a focus on
caregiver assessment and support and relationship with
Long-term care
– New physician assessment tools to standardize family
meetings and follow-up of treatment response
– Incorporate CAMH medication algorithm
12
NPI-NH
13
Integrated Care Pathways
• CAMH Experience with
Agitation and Aggression due
to Alzheimer’s or Mixed
Dementia
14
Treatment Algorithms: Evidence
 Algorithm use in clinical practice associated
with:
 Improved quality of care
 Enhanced patient outcomes
 Reduced health care costs
15 Psychiatry. 59. 1029.
Adli. M et al. 2006. Biological
Pathway
Assessment &
Medications
Discontinuation
NonPharmacological
Cognitive
Enhancers
(AChEI,
Memantine)
Pharmacological
16
Zaraa, 2003
18
Non-Pharmacological Interventions
•
•
•
•
•
Consent
Caregiver education and support
Enhance communication with the patient
Ensure safe environment
Increase or decrease stimulation in the environment
19
Non-Pharmacological Interventions
Allied Health
Professional
Please check
discipline:
Occupational
Therapist
NON-PHARMACOLOGICAL INTERVENTIONS IDENTIFIED
INITIALLY AS MOST APPROPRIATE*
Social Contact
Pet therapy
One-to-one visit
Recreation
Therapist
Social Worker
Sensory
Enhancement/
Relaxation
Hand massage
Purposeful Activity
Exercise group
Helping tasks /
Volunteer role
Indoor/outdoor walks
Other:___________ Individualized Music Inclusion in group
____
programs of
Individualized art
identified interest
Primary Nurse
Sensory modulation Access to outdoors
Name:
Other:___________
____
20
Individual exercise
program
Other:____________
___
Other:___________
____
Sign:
Date:
Physical Activity
Multisensory Snoezelen System
21
Paro
Therapeutic
Robot
22
Pharmacological Interventions
Risperidone
Aripiprazole
Quetiepine
Carbamazepine
Citalopram
For partial responders:
1. Extend the trial
2. Increase the dose
3. Augment with another
agent that showed also partial response
Gabapentin
Prazosin
PRNs:
1. Trazodone
2. Lorazepam
ECT
23
24
Pharmacological Interventions
Combined Total
Patients
Enrolled
(Alzheimer’s
and
Frontotemporal
Dementia)
Combined Total
Patients
Completed
ICP’s
(Alzheimer’s
and
Frontotemporal
Dementia)
21
19
Alzheimer’s/Mixed Vascular
Completed
18
Step One of
Medication
Algorithm
Step Two of
Medication
Algorithm
13
4
Exited
(no meds)
Currently being
treated
1
1
Non-Pharmacological Interventions
Combined Total
Patients (Alzheimer’s
and Frontotemporal
Dementia)
21
Patients Enrolled and
Tolerating
Three or More
NonPharmacological
Interventions (any
selected
combination from
algorithm)
Patients Enrolled and
Tolerating
Two or Less
Non-Pharmacological
Interventions (any
selected combination
from algorithm)
Did Not Respond,
Tolerate or Accept
any NonPharmacological
Interventions
1
5
15
25
Frontotemporal
Dementia
Completed
1
Integrated Care Pathway
• Dr. Amer Burhan
• Dr. Simon
Davies
• Dr. Donna Kim
•
•
•
•
• Dr. Benoit
Mulsant
• Dr. Bruce Pollock
• Dr. Vincent Woo
• Dr. Angela Golas
• Dr. Kaila Rudolph
• Dr. Evan Weizenberg
26
Ms. Rong Ting
Dr. Sawsan Kalache
Ms. Saima Aiwan
Mr. Christopher
Uranis