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Behaviour Support Units: Staffing, Models of Service Provision Education

Principles that promote and support mental health for all LTC residents (CCSMH, 2006) . individualized, person-centred care; respect for family ties; a biopsychosocial care planning framework; a culture of caring that prioritizes quality of life; a social and physical environment that is responsive to changing needs; a focus on early intervention and prevention as well as treatment; and staff training and development.

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Behaviour Support Units: Staffing, Models of Service Provision Education

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    1. Behaviour Support Units: Staffing, Models of Service Provision & Education David K. Conn Baycrest Centre and University of Toronto

    2. Principles that promote and support mental health for all LTC residents (CCSMH, 2006) individualized, person-centred care; respect for family ties; a biopsychosocial care planning framework; a culture of caring that prioritizes quality of life; a social and physical environment that is responsive to changing needs; a focus on early intervention and prevention as well as treatment; and staff training and development

    3. Mental Health Issues in Nursing Home Care - Expert Meeting Tuesday, 1 September 2009 ? Montréal, Canada Held in Conjunction with the 2009 IPA International Congress

    5. Download from www.ccsmh.ca Summaries Can J. Geriatrics (2006)

    6. Guideline Development Group Members: LTC Homes

    7. A total of 74 studies examining the prevalence of psychiatric disorders and psychological symptoms in LTC populations were identified including: 30 studies on prevalence of dementia 9 studies on behavioural symptoms in dementia 26 studies on depression Int Psychogeriatrics, Nov. 2010

    8. Prevalence of Dementia 30 studies 13 from N. America 12 from Europe 2 from Middle East 1 from Africa 1 from Asia 1 from Australia/ NZ 16 different diagnostic instruments

    9. Range The estimated prevalence of dementia in nursing homes varied between 12.0% (Van den Berg, Spijker et al. 1995) and 95% (Serby, Chou et al. 1987) with a median prevalence of dementia of 58% from all the studies.

    10. Prevalence of BPSD A total of 9 studies reporting the prevalence of behavioural symptoms in LTC resident with dementia or cognitive impairment were identified 6 from Europe, 2 from N. America, 1 from Australia

    11. Range The prevalence of any behavioural symptom in LTC residents with dementia varied between 38% (Wancata, Benda et al. 2003) and 92% (Brodaty, Draper et al. 2001). The median prevalence of any behaviour symptom in dementia in LTC residents from the 9 studies was 78%.

    12. Brodaty et al, MJA, 2003: 178:231-234

    13. Prevalence of Depression A total of 26 studies reported on the prevalence of major depression or depressive symptoms in LTC residents 9 from N. America, 7 from Europe, 4 from Asia, 4 from Australia /NZ, 1 from Africa, 1 from Middle East

    14. Range . The prevalence of major depression in LTC ranged from 4% (Teresi, Abrams et al. 2001) to 25% (McSweeney and O'Connor 2008) the prevalence of depressive symptoms varied between 29% (McSweeney and O'Connor 2008) to 82% (Lin, Wang et al. 2007).

    15. Possible Etiologies of Aggression / Agitation Caregiver related Environment related Manifestation of a medical disorder r/o pain / discomfort Psychiatric comorbidity Delirium Medication side effects Neurotransmitter changes

    17. Behavioural Support Unit (BSU) Recommendations (2007) BSUs be created as a regional resource Staffing ratio of regulated to unregulated ranging from 40:60 to 50:50 rather than 20:80 Staffing levels of allied HPs be increased to include a range of providers. Regular access to pharmacist Maximum of 15 to 20 residents

    18. Behavioural Support Unit (BSU) Recommendations - cont. (2007) Support “patient choice” BSUs should be affiliated with a LTC home or another facility Admissions managed by CCAC in cooperation with PG team Regular priority review of admissions & discharges Highly specific admission & discharge criteria

    19. Behavioural Support Unit (BSU) Recommendations - cont. (2007) Residents being transferred to a LTC setting should have assistance from a PG Outreach team and funds BSUs must be funded from outside the current resident classification system Funded based on 100% capacity not per diem rate Referrals to PG Outreach team mandatory if resident has potential for aggression

    20. Are Special Care Units better for individuals with behavioural problems ? Cochrane Review 2009, Lai CK et al. No RCTs 4 studies available with extractable data Studies suggested a small improvement in NPI scores favouring SCUs & less use of physical restraints Authors concluded that there is no strong evidence of benefit from a SCU. They suggest the implementation of Best Practices is most important !

    21. Cross-sectional study of 28 SCUs compared with traditional care in Germany Weyerer et al. Int J Ger Psych (2010) 594 res in SCUs vs. 573 res in usual care After controlling for confounding variables: In SCUs…. - More “social contact to staff” - More involvement in activities - More volunteer involvement - Fewer physical restraints - More use of psychiatrists - Less antipsychotics, more antidepressants

    22. Longitudinal study comparing residents of SCUs versus those in traditional NHs Nobili et al Alz Dis Assoc Disord (2008) 349 res in 35 SCUs vs. 81 res in 9 NHs Res admitted to SCUs were younger, less cognitively and functionally impaired but had more behavioural problems Over 18 months – SCU residents had less hospitalization, less use of physical restraints and had a higher rate of withdrawal from antipsychotics

    24. Non-Pharmacological Interventions (Beck & Shue, 1994)

    26. Ballard et al. 2009

    28. Behavioural Management Approach Cognitive Assessment Behavioural Assessment (ABC Analysis) Staff Perceptions Utilize Extinction, Reinforcement, Prompting Staff Stress Innoculation Rewilak, 2001

    29. www.bendigohealth.org.au

    30. Remembering the forgotten: psychotherapy groups for the nursing home resident. Ken Schwartz Int J Group Psychother. 2007 Oct;57(4):497-514. Weekly groups Co-facilitated by social worker from the unit An integrated model utilizing developmental, cognitive-behavioral, and psychodynamic approaches

    31. Questions to be asked in evaluating any drug use in a NH Avorn & Gurwitz, 1995 What is the target problem being treated ? Is the drug necessary ? Are nonpharmacologic therapies available ? Is this the lowest practical dose ? Could discontinuing therapy with a medicine help to reduce symptoms ? Does this drug have adverse effects that are more likely to occur in an older pt. ? Is this the most cost-effective choice ? By what criteria, and at what time, will the effects of therapy be assessed ?

    32. Medication Use in 2004 National Nursing Home Survey Participants and Estimates in U.S. Nursing Home Population

    33. Mental Health Care System in LTC Facilities Intrinsic Provided by the frontline staff of the facility Extrinsic Mental Health and other professionals (usually visiting consultants or outreach teams)

    34. Models of mental health services in nursing homes: a review of the literature. Bartels SJ, Moak GS, Dums AR. Psychiatr Serv. 2002 Nov;53(11):1390-6. psychiatrist-centered nurse-centered & multidisciplinary team models Uncontrolled observational studies suggested that mental health services may result in improved clinical outcomes and less use of acute services. However, few well-designed controlled intervention studies have been conducted. The least effective model involved traditional consultation-liaison service in which a lone clinician provided a one-time, written consultation on an as-needed basis.

    35. Snowdon 2010, Int Psychogeriatrics

    37. Moyle et al, Int Psychogeriatrics 2010

    38. Moyle et al, Int Psychogeriatrics 2010

    39. Moyle et al, Int Psychogeriatrics 2010

    40. Quality of the educational input Individual motivation Nature, complexity and acceptability of the proposed change initiative Receptivity of the care environment and its organizational context

    41. Conclusions Literature on the effectiveness of SCUs is sparce. No RCTs. Some studies suggest less use of physical restraints and more optimal use of medications in SCUs vs usual care. Little data on staffing levels. Clear need for significantly higher levels with a full complement of health disciplines. Several models for mental health service provision exist. Clear need for involvement of staff with high levels of expertise. Education & training of staff is essential.

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