26th Annual Fall Symposium – New Frontiers in Geriatrics - Arizona Geriatrics Society
COMFORT AS THE NEW MEDICINE:
Reducing Psychotropic Medications
Tena Alonzo, MA
Beatitudes Campus
Learning
Objectives:
● Describe three specific techniques that promote comfort for people with dementia.
● Define and describe at least three positive outcomes from initiating comfort for
people with dementia.
DISCLOSURE OF COMMERCIAL SUPPORT
Tena Alonzo, MA does not have a significant financial interest or other relationship with
manufacturer(s) of commercial product(s) and /or provider(s) of commercial services
discussed in this presentation.
The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of
the Arizona Geriatrics Society.
2014 Arizona Geriatrics Society All Rights Reserved
1
26th Annual Fall Symposium – New Frontiers in Geriatrics - Arizona Geriatrics Society
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Comfort as the New
Medicine: Reducing Reliance
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on Antipsychotic Medications for
People with Dementia
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Tena Alonzo, MA
Vice President, Education & Research
Director, Comfort Matters™
Matters™
Beatitudes Campus
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Beatitudes Campus
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Session objectives
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 Describe three specific techniques which can be
used to promote comfort for people with
dementia
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 Identify and describe at least positive outcomes
from initiating comfort for people with dementia
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of
the Arizona Geriatrics Society.
2014 Arizona Geriatrics Society All Rights Reserved
2
26th Annual Fall Symposium – New Frontiers in Geriatrics - Arizona Geriatrics Society
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“I did then what I knew how to do. Now that I
know better, I do better.”
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Maya Angelou
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Why worry about antipsychotic
medications?
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2.
3.
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Why do people with dementia receive this
type of medication
Is there anyway to improve dementia care
without using antipsychotic medications?
What is a reasonable and practical
alternative?
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FDA Black Box Warning
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WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH
DEMENTIA-RELATED PSYCHOSIS
Elderly patients with dementia-related psychosis treated with antipsychotic
drugs are at an increased risk of death. Analyses of seventeen placebocontrolled trials (model duration of 10 weeks) largely in patients taking
atypical antipsychotic drugs, revealed a risk of death in drug-treated
patients of between 1.6 to 1.7 times the risk of death in placebo-treated
patients. Over the course of a typical 10-week controlled trial, the rate of
death in drug-treated patients was about 4.5%, compared to a rate of about
2.6% in the placebo group. Although the causes of death were varied, most
of the deaths appeared to be either cardiovascular (e.g., heart failure,
sudden death) or infectious (e.g., pneumonia) in nature. Observational
studies suggest that, similar to atypical antipsychotic drugs, treatment with
conventional antipsychotic drugs may increase mortality. The extent to
which the findings of increased mortality in observational studies may be
attributed to the antipsychotic drug as opposed to come characteristic(s) of
the patients is not clear.
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of
the Arizona Geriatrics Society.
2014 Arizona Geriatrics Society All Rights Reserved
3
26th Annual Fall Symposium – New Frontiers in Geriatrics - Arizona Geriatrics Society
Antipsychotic risks
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Analyses of 17 placebo controlled trials -modal
duration of 10 weeks
Majority of patients were taking atypical
antipsychotic drugs, and had a risk of death in the
drug treated group of between 1.6 to 1.7 times that
seen in placebo treated patients. (death rate 2.6% in
placebo / 4.5% in drug group)
Although the causes of death were varied, most of
the deaths appeared to be either cardiovascular
(e.g., heart failure, sudden death) or infectious (e.g.,
pneumonia) in nature.
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Translating the risk
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Strong belief in pharmacology as a solution
Numerous studies show very modest improvements
 At best only 20-30% showed even marginal improvement in
behavior or function
 Thus 70-80% did not respond!
Calculating the risk
 For every 53 dementia patients treated with these drugs – one
will die
 For every 9-25 that benefits – one will die
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Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic
drug treatment for dementia: meta-analysis of randomized placebocontrolled trials. JAMA, Oct 19 2005; 294(15):1934-1943.
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Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Atypical antipsychotic drugs
and the risk of sudden cardiac death. NEJM, Jan 15 2009; 360(3):225-235.
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CMS Initiative to Improve Dementia Care
and Reduce Antipsychotic Use
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Launched in March 2012
Seeks to reduce antipsychotic use in nursing
homes currently at 19.8% nationally
Focus on non-pharmacologic measures and
gradual dose reduction of medication (GDR)
New guidelines include a mandate to reduce
antipsychotics further
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of
the Arizona Geriatrics Society.
2014 Arizona Geriatrics Society All Rights Reserved
4
26th Annual Fall Symposium – New Frontiers in Geriatrics - Arizona Geriatrics Society
How does Beatitudes Campus
measure up
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The family connection…
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Recognizing strength for people
with dementia
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People with dementia are
experts on their own comfort
Emotions are intact-so we can
change how a person feels
even if we can’t change how
they think
Information about the world
around us can get into our
brain through our 5 senses
When verbal communication is
compromised we communicate
through our behavior/actions
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of
the Arizona Geriatrics Society.
2014 Arizona Geriatrics Society All Rights Reserved
5
26th Annual Fall Symposium – New Frontiers in Geriatrics - Arizona Geriatrics Society
I have dementia. Medication
doesn’t work-now what?
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The answer is comfort
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Merriam-Webster’s definition
1. “To give strength and hope to”
2. “To ease the grief or trouble of”
Synonyms:
assure, cheer, console, reassure, soothe
Antonyms:
Distress, torment, torture, trouble
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The clinical definition for comfort
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“Comfort care that is holistic in nature and includes
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interventions which address symptom control,
psychological needs of patients and families,
quality of life, dignity, safety, respect for
personhood, and an emphasis on the use of
intact patient abilities and manipulation of the
environment.”
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Kovach, Wilson & Noonan, 1996
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of
the Arizona Geriatrics Society.
2014 Arizona Geriatrics Society All Rights Reserved
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26th Annual Fall Symposium – New Frontiers in Geriatrics - Arizona Geriatrics Society
Barriers to comfort at Beatitudes
Campus
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Everyone but the person with
dementia didn’t understand
why comfort was so important
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Most staff and families have
unrealistic expectations for the
person with dementia
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Comfortable living is confused
with end-of-life circumstances
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Evolution of care models
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Traditional Model
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All people used physical restraints
All people received an antipsychotic
and anxiolytic
25-40% weight loss every month
Strict adherence to therapeutic diets
Spent $18,000 annually on
supplements
Most people were resistive/selfprotective with care
Sleep/wake were staff-driven
Everyone showed symptoms of
sundowning
Total focus on medical needs
Comfort Model
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No physical restraints
Antipsychotic use is 2.7% and
anxiolytic use is 2.7%
Weight loss is less than 2% monthly
NO therapeutic diets
NO supplements used
Resisting care/service is rare
People sleep, wake & eat as they
desire
NO ONE shows signs of sundowning
Total focus on mind, body, spirit
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Understanding a comfort culture
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Comfort is the goal for everything and is nonnegotiable
Comfort is unique to each individual
People with dementia are experts on their
comfort
Comfort is achievable for everyone regardless of
circumstances
Comfort is not just for end of life
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of
the Arizona Geriatrics Society.
2014 Arizona Geriatrics Society All Rights Reserved
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26th Annual Fall Symposium – New Frontiers in Geriatrics - Arizona Geriatrics Society
What should comfort in longterm care look like?
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What makes sense to the person
 Sleep when s/he wants to
 Eat what s/he wants to
 Engages in what s/he wants to
 ADLs on her/his terms
 Everything that would make the person
her/his best
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Dementia-related behavior
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What types of dementia- related
behavior do you see?
 Resisting care/service
 Refusing medication and
treatment
 Calling out
 Peer altercations
 Disrobing
 Exit Seeking
 Pacing
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The great myth…
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“People with dementia display
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dementia-related behavior and
there’s NOTHING we can do
about it.”
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of
the Arizona Geriatrics Society.
2014 Arizona Geriatrics Society All Rights Reserved
8
26th Annual Fall Symposium – New Frontiers in Geriatrics - Arizona Geriatrics Society
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Human Behavior & Communication
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Since birth we communicate
our needs through our
behavior
Our message can be subtle or
not so subtle
Humans interpret the meaning
of words using behavior and
we don’t have to think about it
People with dementia continue
to make sense out of behavior
even when they can’t
understand verbal language
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How dementia impacts human
behavior-Moderate Dementia
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Difficulty with short and long –term
memory. Struggles to learn new
things
Difficulties with understanding and
being understood
Knows comfort and discomfort
Can’t self regulate emotions
Often easily upset or frustrated
Can become fearful
May misinterpret the actions of
others
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How dementia impacts human
behavior-Advanced Dementia
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Limited/no short and long-term
memory-the person lives in the
moment
Unable learn new information
or pick up new routines
Unable to carry on meaningful
conversation
May appear withdrawn and
can have difficulty interacting
or responding to surroundings
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of
the Arizona Geriatrics Society.
2014 Arizona Geriatrics Society All Rights Reserved
9
26th Annual Fall Symposium – New Frontiers in Geriatrics - Arizona Geriatrics Society
Road Maps
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What’s
a Road Map?
How do you use it?
Who should develop/use Road
Maps?
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Resists Care/Service Road Map
Dementia-specific
behavior
What is the person
communicating?
Possible remedies
Resists care/service
Physical pain
Pain medication,
repositioning, bed rest,
ambulation
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Fearful
Slow down, soft
approach, back off,
Don’t reason or confront
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Doesn’t want to
Identify personal
routine, back off
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Road Map Case Study
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Patricia, who has moderate dementia, recently moved to
the nursing home. She rejects the staff attempts to help
her bathe and at times she doesn’t smell very good.
Patricia has a history of spinal stenosis and two back
surgeries. She has taken pain medication for the past 15
years but her physician recently discontinued it because
she no longer complains of pain. During the bathing
experience, Patricia strikes at the staff , yells “‘you/re
hurting me’. When the staff report what’s happening to
Patrice’s husband he asks for a medication to stop the
“behavor
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of
the Arizona Geriatrics Society.
2014 Arizona Geriatrics Society All Rights Reserved
10
26th Annual Fall Symposium – New Frontiers in Geriatrics - Arizona Geriatrics Society
Comfort Road Map - Patrice
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Dementia-specific
behavior
What is the person
communicating?
Possible remedies
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Final thoughts
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Human behavior is a legitimate form of communication
Comfort is non-negotiable for people with dementia
Comfortable people with dementia don’t need
antipsychotic medication
Identifying the meaning of dementia-related behavior
and what staff can do to create comfort improves quality
of life for people with dementia and staff
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Thank you!
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Contact Information
Tena Alonzo
[email protected]
(602) 433-6182
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The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of
the Arizona Geriatrics Society.
2014 Arizona Geriatrics Society All Rights Reserved
11