Expert panel on Agitation and Aggression in Dementia

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 # Title 1 Dr. 2 First Last Name Ilan Affiliation Specialization Fischler OSCMHS Geriatric Psychiatrist Dr. Tarek Rajji CAMH Geriatric Psychiatrist 3 Dr. Lanctot Sunnybrook Health Sciences Centre Ph. D 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. 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. Shulman Trillium Health Partners 14 Ms. Lori Whelan St. Michael's Hospital 15 Dr. Jenny Ingram Kawartha Regional Memory Clinic Geriatrician 16 Dr. Barry Goldlist Mount Sinai Hospital (MSH) Geriatrician 17 Ms. Sandi Robinson Accalaim Health Alzheimer Services 18 Mr. Wong Full-Time Caregiver 19 Ms. Margaret Weiser Krista Evelyn Richard Ken Private Practice Deputy CFO & Director of IT & Decision Support Manager, Integrated Care Pathways Program Decision Support Analyst Nursing Geriatric Psychiatrist Occupational Therapist 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 Longterm 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 Ø Algorithm use in clinical practice associated with: Ø Improved quality of care Ø Enhanced patient outcomes Ø Reduced health care costs 15 Adli. M et al. 2006. Biological Psychiatry. 59. 1029.

Pathway Assessment & Medications Discontinuation Non. Pharmacological Cognitive Enhancers (ACh. EI, Memantine) Pharmacological 16

Zaraa, 2003

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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 Recreation Therapist Social Worker Primary Nurse Name: Sign: Date: NON-PHARMACOLOGICAL INTERVENTIONS IDENTIFIED INITIALLY AS MOST APPROPRIATE* Social Contact Pet therapy One-to-one visit Other: ______ Sensory Purposeful Activity Enhancement/ Relaxation Helping tasks / Hand massage Volunteer role Individualized Music Inclusion in group programs of Individualized art identified interest Sensory modulation Access to outdoors Other: ______ Other: ______ 20 Physical Activity Exercise group Indoor/outdoor walks Individual exercise program Other: ______

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

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Pharmacological Interventions Combined Total Patients Enrolled Completed (Alzheimer’s and ICP’s Frontotemporal (Alzheimer’s and Dementia) Frontotemporal Dementia) 21 19 18 Alzheimer’s/Mixed Vascular Step One of Step Two of Exited (no meds) Medication Algorithm 13 4 Currently being treated 1 1 Non-Pharmacological Interventions Patients Enrolled and Tolerating Patients Enrolled and Three or More Tolerating Combined Total Non-Pharmacological Two or Less Patients (Alzheimer’s Interventions (any Non-Pharmacological and Frontotemporal selected Interventions (any Dementia) combination from selected combination algorithm) from algorithm) 21 15 1 25 Did Not Respond, Tolerate or Accept any Non. Pharmacological Interventions 5 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 Ms. Rong Ting Dr. Sawsan Kalache Ms. Saima Aiwan Mr. Christopher Uranis • Dr. Angela Golas • Dr. Kaila Rudolph • Dr. Evan Weizenberg 26