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Caring for people with dementia and challenging behaviors in nursing homes: A needs assessment geriatric nursing
Geriatric Nursing 36 (2015) 182e191
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Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Caring for people with dementia and challenging behaviors in nursing homes: A needs assessment geriatric nursing Jeanette M. Daly, RN, PhD a, *, Camden P. Bay, MS b, Barcey T. Levy, PhD, MD a, b, Ryan M. Carnahan, MS, PharmD b a b
Department of Family Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, USA Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, IA, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 November 2014 Received in revised form 29 December 2014 Accepted 5 January 2015 Available online 9 February 2015
An estimated 50% of nursing home residents have a dementia diagnosis. The purpose of this research was to conduct a needs assessment of directors of nursing (DON) in Iowa nursing homes in relation to caring for patients with Behavioral and Psychological Symptoms of Dementia. DON responses were linked to Online Survey Certification and Reporting/Certification and Survey Provider Enhanced Reporting (OSCAR/CASPER) data to examine how facility characteristics may be associated with use of and confidence in non-drug management strategies. From 431 questionnaires mailed to DONs, 160 (37%) were returned. Regression analysis showed that those who were more confident in managing challenging behavior were more likely to have satisfaction with current training on managing challenging behaviors and had a psychiatrist available to visit the facility. Facilities with a larger proportion of patients with challenging behaviors being treated with non-drug approaches instead of antipsychotics had DONs who were more likely to be confident in non-drug management strategies and have knowledge about the FDA antipsychotic medications risks. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Nursing home Director of nursing Dementia Challenging behaviors Antipsychotic medication
Currently, there are more than 15,000 Medicare and Medicaidcertified nursing homes in the United States1 with almost 3.3 million patients receiving care in those nursing homes.2 An estimated 50% of nursing home residents have a diagnosis of dementia3,4 with 13% having dementia or Alzheimer’s disease as their primary diagnosis.5 Neuropsychiatric disturbances occur in 60e98% of people with dementia, frequently triggering nursing home placement and antipsychotic treatment.6 Antipsychotics have been a mainstay of pharmacologic management. In 2006, 25.9% of nursing home residents in the United States received antipsychotics,7 compared to 16.4% just 10 years earlier. Recent estimates place the prevalence of nursing home antipsychotic use around 22%.8 Evidence suggests that antipsychotic use is often suboptimal, based on lack of appropriate indications, inappropriate dosing,9,10 and high variability in usage rates across facilities.10 This is of particular concern since antipsychotics are associated with serious side effects in people with dementia, including an increased risk of mortality
Funding: ARHQ R18 HS19355-01. * Corresponding author. 01290-F PFP, 200 Hawkins Drive, Iowa City, IA 52242, USA. Tel.: þ1 319 384 8995. E-mail address: [email protected] (J.M. Daly). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2015.01.001
which was the reason for a black box warning required by the Food and Drug Administration. In 2014 the Centers for Medicare and Medicaid Services (CMS) launched the National Partnership to Improve Dementia Care initiative to enhance dementia care quality and address antipsychotic overuse, with a goal of reducing antipsychotic use in nursing homes by 30% at the end of 2016.11 Regulatory requirements have facilitated a marked improvement in decreasing the use of antipsychotic medications in nursing homes from 24% in the fourth quarter of 2011 to 20% in the first quarter of 2014.11 The current focus of the initiative is to not only reduce antipsychotics but also to encourage person-centered care and non-drug management of behavioral symptoms of dementia in order to reduce unnecessary antipsychotic use.12 Challenging behaviors for persons with dementia are common and multi-faceted being attributable to the environment, chronic conditions, health, or medications. More than 80% of nursing home residents with dementia exhibit one or more forms of challenging behaviors.13 Examples of challenging behaviors include agitation, anger, depression, disrobing, eating abnormalities, hoarding, inappropriate sexual behavior, irritability, paranoia, physical and verbal aggression, repetition, swearing, and withdrawal. There are situations in which antipsychotic use in dementia patients is considered appropriate by most clinicians as well as CMS, particularly when a patient’s behaviors are dangerous to
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themselves or others.14 Initial therapy for patients with dementia who have challenging behaviors is environmental modifications and non-pharmacologic approaches. However, if that is unsuccessful and antipsychotic use is warranted, an appropriate indication for use of the medication needs to be documented. Once antipsychotic medication is started ongoing monitoring to evaluate its effectiveness and observation for adverse effects is necessary. If the medication is ongoing, the lowest effective dose should be established and maintained. In 2013, the percentage of nursing home residents taking antipsychotic medication ranged from 12.3% in Hawaii to 33.1% in Louisiana with a mean of 24.2% in the U.S. 15 In Iowa the percentage of nursing home residents taking antipsychotic medication was 21.2% in 2012.15 The purpose of this research study was to conduct a needs assessment of directors of nursing (DON) in Iowa nursing homes in relation to caring for patients with dementia and those with challenging behaviors. That is a needs assessment to establish knowledge deficits in which to appropriately care for people with Behavioral and Psychological Symptoms of Dementia (BPSD) and then to best determine how they would like to receive additional training. This needs assessment would help to inform the development of educational materials and tools to help guide care for people with BPSD. In addition, the DON responses were linked to the Online Survey Certification and Reporting/Certification and Survey Provider Enhanced Reporting (“OSCAR/CASPER”) survey and inspection data to provider responses to examine how information on facility operations, patient census and regulatory compliance may be associated with use of and confidence in non-drug management strategies for behavioral symptoms of dementia. Comparison of both resident and facility data allows us to look at the variation and influence of these factors. In particular, we utilized regression modeling to aid in assessing the relationship between the proportion of dementia patients with challenging behavior treated using non-drug approaches and nurse’s knowledge, confidence, and education, family involvement, medical director education, availability of a psychiatrist or nurse practitioner with a dementia/ psychiatric specialty, facility operations, and patient census (see Table 1 for the entire list OSCAR/CASPER Date). Additionally, we wanted to look at nurse’s confidence in managing challenging patient behaviors associated with dementia and non-drug approaches. Methods After institutional review board approval, a mailed survey was sent to Iowa nursing homes. The Medicare nursing home compare website (medicare.gov/NursingHomeCompare) listed 443 nursing homes in Iowa. Of the 443, 12 were hospitals and eliminated from the list because the cover letter read director of nursing and would go to the hospital director and not the nursing home director, leaving 431 nursing homes. All nursing home DONs were invited to participate and questionnaires were mailed in January 2011. DONs were asked to complete the questionnaire while skipping any questions they did not want to answer and mail it back. If no response was given by a DON within three weeks, a second questionnaire was mailed. Following the two mailings, no further mailings or contacts were made. Instrument A 22-item questionnaire (see Appendix 1) entitled, “Needs Assessment: Caring for People with Dementia and Challenging Behaviors” developed by the research team of clinicians, researchers, and education specialists, was used to assess the needs of DONs in regard to caring for individuals with BPSD. To ensure
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content validity, the questionnaire was critique by current or former nursing home employees that were on the research team. Questions included information pertaining to the treatment of dementia patients and the education of nursing home staff and family members about dementia. To better understand current dementia management approaches, DONs were asked about which antipsychotics were most often prescribed (a list of commonly used antipsychotics was provided), satisfaction with current training on managing dementia behaviors, if the nursing staff provides influence on the selection of the antipsychotic medication prescribed, their awareness of the FDA warning on antipsychotics in dementia, and their usage as well as confidence in non-drug treatment approaches for managing BPSD. To gather information related to the education of nursing home staff and family members of dementia patients, DONs were asked how they obtain information about dementia treatment, what dementia topics interest them the most, preferred methods of delivery (such as, CD-ROM, e-mail, handbook, mail, online resources, or pocket guides, poster) for dementia treatment information and what method would be best for communicating about the treatment of dementia symptoms with family members. Information about the medical director and availability of a psychiatrist or dementia specialist nurse consultant to consult or make a visit to the nursing home was collected. DON demographic information was collected and included age, gender, race, ethnicity, total years in practice, and total years employed at the current nursing home. OSCAR/CASPER data OSCAR is an administrative database of the Centers for Medicare and Medicaid Services (CMS). In July 2012, OSCAR data was replaced by the CASPER system. CASPER is a part of a large relational database operating within CMS Automated Survey Processing Environment (ASPEN). Every nursing home in the United States that is certified to provide services under either Medicare or Medicaid is listed in the survey data. The number of variables in a data file depends on the survey process and extensive data is collected for nursing homes. Data are available for download, but new survey data overwrites the previous data. Archived longitudinal data for this study were purchased from Cowles Research Group so the data was current with the survey.16 OSCAR/CASPER data were linked to each nursing home’s DON responding to the questionnaire through the nursing home’s respective National Provider Identifier (NPI). Thirty-two CMS OSCAR/CASPER variable descriptions were retrieved from their respective forms which included: 1) Long Term Care Facility Application for Medicare and Medicaid, 2) Resident Census and Conditions of Residents, 3) Statement of Deficiencies and Plan of Correction (see Table 1). The research team reviewed the forms and determined which variables to include in the data analysis. Data analysis Using the returned questionnaires, basic descriptive statistics for questions of interest were calculated. For any statistics derived from the questionnaires and reported as proportions, missing responses have been removed from the denominator for calculation; any missing data exceeding 10% for a question has been noted in the results. The analysis explored predictors for two of the questions asked on the questionnaire: 1) the proportion of dementia patients who had challenging behavior treated with non-drug approaches instead of medications (questionnaire takers were given five choices: “less than 1/4,” “less than 1/2 but more than 1/4,” “about 1/2,” “more than 1/2 but less than 3/4,” and “more than 3/4”), 2) the
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Table 1 Potential predictors for models. Source
Variablea
Needs Assessment Survey
-
-
-
-
-
Censusb
-
-
Census e Staffing
b
-
Census e Residents
b
-
-
-
a b
Proportion of dementia patients with challenging behavior treated using non-drug approaches (only in confidence model) Confidence in managing challenging dementia patient behaviors with non-drug approaches (only in proportion of dementia patients model) How often family members are involved in decision to use medication for challenging behaviors in dementia patients Awareness of FDA warnings on antipsychotic risks for patients with dementia Medical director specialty/additional training in geriatrics (dichotomous) Board-certified psychiatrist available by phone for help with medication management (dichotomous) Board-certified psychiatrist available through visits for help with medication management (dichotomous) Nurse or nurse practitioner specializing in dementia/psychiatrics available by phone (dichotomous) Nurse or nurse practitioner specializing in dementia/psychiatrics available through visits (dichotomous) Highest nursing education (continuous and categorical) Medical director years in practice Medical director years employed at facility Consulting nurses are used for information or clinical tools regarding challenging behaviors in patients with dementia (dichotomous) Consulting pharmacists are used for information or clinical tools regarding challenging behaviors in patients with dementia (dichotomous) Consulting drug company representatives are used for information or clinical tools regarding challenging behaviors in patients with dementia (dichotomous) Satisfaction with training of yourself and staff regarding management of challenging behaviors in people with dementia Provider category code (skilled nursing facility (dually certified)/skilled nursing facility (distinct part)/skilled nursing facility/ nursing facility) (categorical) Special care unit with beds for Alzheimer’s disease available (dichotomous) Nurse aide training and competency evaluation program (dichotomous) Medical director FTE Other physicians FTE Physician extenders FTE RN director of nurses FTE Nurses with administrative duties FTE Registered Nurse FTE and HPRD (hours per resident per day) Licensed practical/licensed vocational nurses (LPN/LVN) FTE and HPRD Certified nurse aides FTE and HPRD Nurse aides in training FTE and HPRD Registered Nurses þ LPN/LVN þ certified/in training nurse aides FTE and HPRD Medication aides/technicians FTE Therapeutic recreation specialists FTE Social workers FTE Other social service staff FTE Mental health services FTE Proportion of residents with . - documented psychiatric diagnosis (excludes dementias and depression) - dementia or Alzheimer’s disease - behavioral health care needs - behavioral health care needs and an individualized health care plan Proportion of residents receiving . - psychoactive medication - antipsychotic medication - antianxiety medication - antidepressant medication - hypnotic medication Proportion of residents’ dependent or requiring assistance for . - bathing - dressing - transferring - toilet use - eating
Variables were treated as continuous unless otherwise noted in parentheses. Variables from OSCAR/CASPER.
confidence in managing patients with dementia who had challenging behavior with non-drug approaches (question responses were on a 5-point Likert-like scale from “not at all confident” to “totally confident”). These were referred to as the “Proportion of Dementia Patients” model and the “Confidence” model respectively. Separate models were used for the two response questions. Responses to both questions were treated as categorical and collapsed down to three categories in order to simplify interpretation, suggesting that ordinal logistic regression should be utilized. The Proportion of Dementia Patients outcome was collapsed into three levels: 1) Less than 1/2 (n ¼ 39), 2) Approximately 1/2 (n ¼ 31), and 3) More than 1/2 (n ¼ 83). The Confidence outcome
was collapsed into three levels: 1) Not confident (n ¼ 52), 2) Medium confidence (n ¼ 74), and 3) Confident (n ¼ 32). Univariable analysis was performed with predictors of interest from the questionnaire and OSCAR/CASPER data for each response. Predictors with p-values 0.10 were selected for further analysis in a multivariable model (see Table 2). If there was evidence that the proportional odds assumption of the ordinal logistic regression models was not met (score test), multinomial logistic regression was utilized. Multinomial logistic regression requires a different interpretation for odds ratios than ordinal, as it does not assume proportional odds, but still provided relevant information for the investigation.
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Table 2 Candidate predictors selected through univariable analysis for proportion of dementia patients and confidence outcomes. Variablea Outcome: proportion of patients with dementia treated with non-drug approaches How often family members are involved in decision to use medication for challenging behaviors in dementia patients Confidence in managing challenging dementia patient behavior with non-drug approaches Awareness of FDA warnings on antipsychotic risks in dementia Satisfaction with training of yourself and staff regarding management of challenging behaviors in people with dementia Outcome: confidence in managing challenging behaviors of patients with dementia patient with non-drug approaches How often family members are involved in decision to use medication for challenging behaviors in dementia patients Awareness of FDA warnings on antipsychotic risks in dementia Visits from board-certified psychiatrist (dichotomous) Consulting pharmacists are used for information or clinical tools regarding challenging behaviors in patients with dementia (dichotomous) Satisfaction with current training for managing challenging behaviors in dementia patients Medical director years employed at facility Special care unit with beds for Alzheimer’s disease available (dichotomous) a
Odds ratios
90% CI
p-value
1.44 3.29 1.65 1.40
1.13e1.83 2.25e4.80 1.31e2.08 1.07e1.83
0.01 <0.0001 <0.001 0.04
1.44 1.77 2.16 2.12
1.13e1.84 1.40e2.22 1.30e3.57 1.27e3.54
0.01 <0.0001 0.01 0.02
2.61 1.03 2.45
1.95e3.50 1.00e1.06 1.38e4.34
<0.0001 0.09 0.01
All variables were entered continuously, unless otherwise noted.
Through univariable selection of predictors of interest for the Confidence outcome, seven candidate predictors were found for introduction into the full Confidence model. These candidate predictors can be found in Table 2 along with measures of effect. The proportion of dementia patients who had challenging behaviors treated with non-drug approaches was also significantly associated with confidence in non-drug management strategies. However, this was not included as a predictor in the model because it seemed likely that this was an outcome affected by confidence rather than a cause of confidence. It is also possible that a bidirectional relationship exists in which use of non-drug management strategies increases confidence and confidence impacts use of non-drug management strategies, but it was felt excluding this from the model predicting confidence would be most appropriate. For the Confidence outcome, the univariable analysis revealed many potential predictors (Table 2), limiting the interpretation of their independent contributions and risking over fitting, so forward selection was utilized with a reduction in AIC (Akaike Information Criterion) of greater than 1.0 being considered a cutoff for entrance into the full model. Before selection, all predictors were assessed for multi-collinearity using variance inflation factor (VIF), and at each step in the selection process, the model was checked for the proportional odds assumption. For the Proportion of Dementia Patients outcome, forward selection was also utilized to construct a full model. In order to account for all predictors of interest in the two models, OSCAR/CASPER data was linked to each nursing home that responded. Most of the predictors were proportions of the total number of patients in a nursing home, so controlling for size was accomplished. DON letters and questionnaires were mailed on January 3, 2011, and were completed within six weeks, so OSCAR/ CASPER assessments closest in time to this date were chosen for the linkage. The certification date of each nursing home was chosen as the date of assessment as it was found to be at most 43 days away from the start of assessment and 30 days away from the end of an assessment, and it was consistently reported in all OSCAR/CASPER assessment databases used. For all facilities, the difference between certification date and questionnaire mailing was less than nine months. Comparing those DONs who responded from DONs who did not respond, nursing homes that did not have a DON respond were more likely to be for-profit (60% vs. 52%). For size, the nursing homes that did not respond tended to be a little smaller (median of 49 vs. 52 patients). The median was used for both comparisons as the distributions were fairly skewed. All hypothesis testing was performed at a 0.05 significance level and two-tailed unless otherwise noted. Data were analyzed using SAS software, version 9.3 for Windows (SAS Institute, Cary NC). R, version 2.13.0, was used for the boxplot.
Results Of the 431 questionnaires mailed, 160 (37%) were returned. The mean age of the DONs was 45 years. Of the 160 DONs, 154 (99%) were female, 151 (98%) were Caucasian. The DONs had a mean of 20 years in nursing practice and had been employed at their current nursing home a mean of 10 years (see Table 3). The antipsychotics most frequently reported as being used for patients with dementia or delirium across nursing homes were risperidone, quetiapine, and olanzapine. These were also most frequently reported as the most commonly used antipsychotics within individual facilities (see Table 4). Of the DONs, 114 (72%) were not satisfied or neutral with their training on managing challenging behaviors in people with dementia with a mean score of 2.9 (SD 1.0) on a 5-point Likert scale. Ninety-four (63%) of the DONs said it would be helpful for them or their staff to receive training on how to use tools to assess cognition, behavioral symptoms, and movement disorders related to antipsychotics while 56 (37%) were comfortable with available tools. One hundred and seven (68%) DONs reported that nursing staff had little to moderate input into the antipsychotic medication
Table 3 Demographic and work characteristics of directors of nursing. Variable
DONs
Age in years (n ¼ 153) Range Years in practice (n ¼ 156) Range Years employed current nursing home (n ¼ 156) Range Gender (n ¼ 156) Female Male Race (n ¼ 154) American Indian Asian Black Native Hawaiian White Ethnicity (n ¼ 104) Hispanic a Nursing education (n ¼ 156) Associate’s degree Bachelor’s degree Diploma MS PhD
45.4 (9.7) 23e66 20.4 (9.9) 2e44 10.2 (9.4) 0e40 154 (98.7) 2 (1.3) 3 (1.9) 0 0 0 151 (98.0) 0 97 41 14 6 1
(62.2) (26.3) (9.0) (3.9) (0.6)
Values are presented as mean (standard deviation) in the case of continuous variables and frequency (percentage) in the case of categorical variables. a Some subjects fall into multiple categories.
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Table 4 Antipsychotic medications used and predominantly used in the nursing home for persons with dementia or delirium (n ¼ 160). Medication
Risperidone (Risperdal) Quetiapine (Seroquel) Olanzapine (Zyprexa) Haloperidol (Haldol) Aripiprazole (Abilify) Ziprasidone (Geodon) Clozapine (Clozaril) Thioridazine (Mellaril) Fluphenazine (Prolixin, Permitil) Paliperidone (Invega) Trifluoperazine (Stelazine) Chlorpromazine (Thorazine) Thiothixene (Navane) Perphenazine (Trilafon) Asenapine (Saphris) Iloperidone (Fanapt) Other
Used in the NH n (%)
Predominantly used in the NH n (%)
154 146 132 109 88 37 19 7 7 6 6 6 4 2 1 0 5
118 112 75 30 25 5 0 0 0 1 1 0 0 0 0 0 0
(96.3) (91.3) (82.5) (68.1) (55.0) (23.1) (11.9) (4.4) (4.4) (3.8) (3.8) (3.8) (2.5) (1.3) (0.6) (0.0) (3.1)
(73.8) (70.0) (46.9) (18.8) (15.6) (3.1) (0.0) (0.0) (0.0) (0.6) (0.6) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0)
prescribed, with a mean score of 2.7 (SD 1.3) on a 5-point scale from “not at all” to “very much.” A Pearson correlation coefficient between the influence of nursing staff on medication selection and satisfaction with training was found to be 0.25 (p-value < 0.01), suggesting a modest, positive linear association. Sources of information or clinical tools to help DONs or their staff address challenging behaviors were the consulting pharmacist by 96 (60%) respondents, facility in-services by 86 (54%), drug book by 63 (40%), consulting nurse by 62 (39%), and Internet resource by 49 (31%). Respondents wanted to learn more about managing difficult behaviors without medications, caring for difficult patients, and differentiating between dementia and delirium (see Table 5). They preferred the following methods of obtaining new information or clinical tools to help with challenging behaviors with persons who have dementia: facility in-services, pocket guides, e-mail, and an online resource. Table 6 provides DONs preferred and most likely to use tools to address challenging behaviors. One hundred and fourteen (72%) of the DONs reported often or always involving patient family members in decisions to use medications for challenging behaviors for persons with dementia, with a mean 5-point Likert scale score of 4.1 (SD 1.1). The DONs preferred the following information to help communicate with families about medications and non-drug approaches for challenging behaviors: one-page handout, easier-to-read materials, brochures, and booklets. Medical director specialties were reported as 115 (73%) family medicine, 31 (20%) certified in geriatrics, and 16 (10%) internal
Table 5 Information would like to learn more about to care for persons with dementia (n ¼ 159). Information
n (%)
Managing difficult behaviors without drugs Caring for difficult Patients Differentiating between dementia and delirium Tools for family members Types of dementia Measuring pain Medications Staff consistency Dementia in hospice/when to stop medications Other
139 120 88 76 70 70 65 55 55 5
(87.4) (75.5) (55.4) (47.8) (44.0) (44.0) (40.9) (34.6) (34.6) (3.1)
Table 6 DONs preferred and most likely to use tools to address challenging behaviors (n ¼ 159). Source
Preferred n (%)
Most likely to use n (%)
Facility in-service Pocket guides E-mail On-line resource Mail Handbook CD-ROM Short on-line videos Consulting nurse Informational poster Consulting pharmacist Application for other PDA device Screensavers Application for iPhone Facebook Other
126 88 84 82 80 64 53 50 45 45 43 4 2 1 1 4
53 36 34 37 22 31 26 17 13 13 12 1 0 1 0 2
(79.3) (55.4) (52.8) (51.6) (50.3) (40.3) (33.3) (31.5) (28.3) (28.3) (27.0) (2.5) (1.23) (0.6) (0.6) (2.5)
(33.3) (22.6) (21.4) (23.3) (13.8) (19.5) (16.4) (10.7) (8.2) (8.2) (7.6) (0.6) (0.0) (0.6) (0.0) (1.3)
medicine. Fifty (32%) reported that a board-certified psychiatrist was available by telephone for help with medication management. Seventy-three (46%) reported the psychiatrist would make a visit to the nursing home. Eighteen (11%) reported there was a nurse practitioner with a dementia/psychiatric specialization for consultation by telephone and 58 respondents (37%) reported they would make a visit to the nursing home. After forward selection with an AIC cutoff of 1.0, availability of a board-certified psychiatrist for making visits and satisfaction with current training in regard to managing patients with dementia were significant and independent predictors for the Confidence model (Table 7). The awareness of FDA warnings for antipsychotic drugs was also selected, but ultimately removed from the model as it did not have a strong linear relationship with the log odds as seen through highly decreased AIC upon inclusion of polynomial terms. It was also suspected that awareness of warnings would not be a direct cause of confidence in non-drug approaches, but was only associated because of a higher awareness of issues relating to care of dementia behaviors. A Spearman correlation coefficient of 0.31, (p < 0.0001) was found, providing evidence of the presence of an underlying monotonic, increasing relationship. Univariable selection of predictors of interest for the Proportion of Dementia Patients full model revealed four candidate predictors (Table 2). After forward selection, awareness of FDA warnings for antipsychotic drugs and confidence in treating dementia patient with non-drug approaches remained in the model (Table 7). Discussion The majority of DON respondents were middle-aged, female, experienced registered nurses with a work commitment to longterm care nursing by their longevity in the field. Less than a third of the DONs were satisfied with training on managing patients with challenging behaviors and over half said it would be helpful to receive additional training. They preferred to have this additional training mainly through facility in-services. Nursing homes routinely provide in-service education as federal requirements [Code of Federal Regulations, 483.75(e) Subsection 8]. Federal requirements require that the in-service education must be sufficiently intensive to ensure continuing competence of nursing assistants and be at least 12 hours a year.17 The in-services must address areas of staff weakness as determined by performance reviews and any special needs of current residents as determined by facility staff. The curriculum content for staff development is not specified in Federal requirements but there is the caveat that some
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Table 7 Final ordinal logistic regression models. Response
n
Variable
Odds ratio
95% confidence interval
Proportion of dementia patients treated with non-drug approaches
152
2.95
1.87e4.65
Confidence in managing challenging patient behavior with non-drug approaches
156
Confidence in managing challenging patient behavior with non-drug approaches Awareness of FDA warnings on antipsychotic risks in dementia Visits from board-certified psychiatrist Satisfaction with current training for managing challenging behaviors in dementia patients
1.42 2.12 2.58
1.05e1.92 1.14e3.97 1.81e3.66
of the content must deal with cognitive impairment. Since inservice education is part of the nursing home routine, it is an ideal setting for education on antipsychotic medications and management of difficult patient behaviors. Atypical antipsychotics were the predominant antipsychotics for patients with dementia or delirium which is similar to another study of the 65,618 nursing home patients prescribed antipsychotics, 91% were prescribed atypical antipsychotics.18 In this study and the Huybrechts et al,18 study, risperidone, quetiapine, and olanzapine were prescribed most frequently. This is very similar to results from other evaluations of national prescribing trends.8,19 While the use of risperidone and olanzapine are understandable given the evidence supporting limited efficacy in dementia, the frequent use of quetiapine is somewhat perplexing. Five randomized controlled trials have found overall that quetiapine is no better than placebo for management of agitation and psychosis in people with Alzheimer’s or vascular dementia.20 Only one secondary analysis of one trial found that 200 mg/day quetiapine was more effective than placebo for dementia-associated agitation,21 but this dose exceeds the CMS allowable dose for chronic use of quetiapine in nursing home residents with dementia.22 Other flexible dose trials allowed similar doses and showed no beneficial effect of quetiapine.20 One potential explanation for use of quetiapine is that it is a highly sedating antipsychotic,20 so sedation may be confused with efficacy. Less than a third of the DON respondents reported input influencing the selection of the antipsychotic medication that is prescribed. It is important for nurses, physicians, and consulting pharmacists to work together in monitoring the use of antipsychotic medications. Nurses should monitor for over sedation, orthostatic hypotension, unsteadiness, and acute extrapyramidal side effects when administering both conventional and atypical antipsychotic medications and be aware of the black box warnings for all antipsychotic medications.23,24 Each nursing home must employ or obtain the services of a licensed pharmacist.25 The pharmacist must provide consultation on all aspects of the provision of pharmacy services in the nursing home. Part of the consulting pharmacist’s role is to collaborate with nursing home DONs and staff who are responsible for medication administration. Usually the consulting pharmacist visits the nursing home monthly and staff is aware and prepare for the visit. It seems obvious from the responses that about two-thirds of the DONs value the consulting pharmacist’s knowledge and seek information from the pharmacist. The second sought resource, facility inservices, were valued to obtain information on challenging patient behaviors. Responses for information resources indicate that nurses are busy and rely on easy-to-read information that is readily available and quick to access. Confidence as a nurse comes from experience and exposure to as many different patient scenarios and clinical situations as possible. DON respondents had a mean of 20 years practicing nursing and 10 years practicing nursing in the nursing home, yet only one-fifth of them were confident in managing challenging patient behaviors with non-drug approaches. Those who were confident had greater satisfaction with current training on
managing challenging behaviors in people with dementia and were more likely to have access to a psychiatrist who would visit the facility. Greater confidence in non-drug approaches and awareness of the FDA warning on antipsychotics and mortality in dementia were associated with more frequent use non-drug management approaches instead of antipsychotics. Confidence building seems to be a mechanism to improve management of challenging patient behaviors. Suggestions for nurses to improve confidence would be focused education, a mentor such as a psychiatrist or advanced geriatric nurse practitioner, asking questions when unsure of behavior management, and to practice implementing non-drug approaches for managing challenging behaviors. The traditional lecture approach for education regarding the management of problem behaviors is weak in producing changes in practice.26 At the University of Iowa, the Iowa Geriatric Education Center website (https://www.healthcare.uiowa.edu/igec/iaadapt/) provides a training module and toolkit to help clinicians, providers, and consumers better understand how to manage problem behaviors and psychosis in people with dementia using evidencebased approaches. This includes brief lectures, written content, quick reference guides for clinicians and providers, and information for families or patients on the risks and benefits of antipsychotics for people with dementia. Content of the material was based on feedback from providers and nurses in long-term care settings, such as that obtained through this survey. Continuing education credit is provided for prescribers, nurses, and pharmacists.27 About half of the DONs in this study preferred to use online resources and pocket guides. Laminated pocket guides with information on managing dementia behaviors can be ordered through the Iowa Geriatric Education Center website, and pdfs are freely available. Another dissemination mechanism to go along with the pocket guide is the case-based mini-lecture that provides digital presentations presenting a case study that illustrates principles described in the pocket guides.27 Another study identifying through a needs assessment, the learning needs and preferences of nursing home staff providing care for patients with life-limiting illnesses found that the participants preferred to receive training online and at their convenience.28 At the time of the survey, the newer forms of social media, Facebook, and applications for the iPhone were not preferred or not more than likely to be used by the respondents to garner information regarding tools to address challenging behaviors. However, a mobile device application with information from the pocket guides was created and is available through the website. This study has several limitations. Although the response rate of 37% was consistent with prior reports of survey responses29 the results may not be representative of all DONs in Iowa or those in other states. A strength of the study was to use OSCAR/CASPER data, as it is the most extensive data for nursing homes that is available. Also, the nursing home survey process is rigorous whose data provides a rich source of information. There were, however, nursing home characteristics that may have influenced outcomes which we did not consider in this analysis. Univariable testing was used to narrow potential predictors. The large number of tests may have resulted in false positive hypothesis results, and the omission of
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variables based on univariable results may have resulted in exclusion of predictors that would have been significant after adjustment for other important predictors. Similarly, the forward selection procedure utilized to reduce the number of variables is limited in its ability to identify the best subset of all potential predictors. It is notable that among all potential predictors, very few were actually selected for the final models. The focus of this research was on DONs who are not the frontline staff providing direct care to patients in the nursing home. Future research should consider the perceptions and opinions of staff providing direct care, such as nursing assistants, medical assistants, and therapists. In conclusion, the typical DON who was more confident in managing patients with challenging behaviors was more likely to have the availability of a board-certified psychiatrist to make visits to the nursing home and was more likely to be satisfied in their training for managing these behaviors. Confidence in non-drug management strategies and awareness of the FDA warning on antipsychotics in dementia were associated with greater use of non-drug management strategies instead of antipsychotics for management of BPSD. These results suggest that education on managing challenging behaviors and psychiatrist availability may be helpful in promoting confidence and use of non-drug management strategies for management BPSD. The distribution of antipsychotics prescribed also suggests room for improvement, since the best available evidence suggests that quetiapine is not particularly effective for management of dementia symptoms.
References 1. Center for Medicare & Medicaid Services. What is nursing home compare?. Accessed 05.11.14, http://www.medicare.gov/nursinghomecompare/About/ What-Is-NHC.html; Published 2014. 2. Centers for Medicare & Medicaid Services. Nursing home data compendium 2010. Accessed 21.12.12, http://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/DataCompendium/index.html?redirect¼/ datacompendium/; Published 2011. 3. Barton C, Miller B, Yaffe K. Improved evaluation and management of cognitive impairment: results of a comprehensive intervention in long-term care. J Am Med Dir Assoc. 2006;7:84e89. 4. Magaziner J, German P, Zimmerman SI, et al. The prevalence of dementia in a statewide sample of new nursing home admissions aged 65 and older: diagnosis by expert panel. Epidemiology of Dementia in Nursing Homes Research Group. Gerontologist. 2000;40(6):663e672. 5. Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing Home Survey: 2004 overview. National Center for Health Statistics. Vital Health Stat. 2009;13(167):1e155. 6. Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. J Am Med Assoc. 2005;293: 596e608. 7. Castle NG, Hanlon JT, Handler SM. Results of a longitudinal analysis of national data to examine relationships between organizational and market characteristics and changes in antipsychotic prescribing in nursing homes from 1996 through 2006. Am J Geriatr Pharmacother. 2009;7(3):143e150. 8. Briesacher BA, Tjia J, Field T, Peterson D, Gurwitz JH. Antipsychotic use among nursing home residents. J Am Med Assoc. 2013;309(5):440e442.
9. Briesacher BA, Limcangco R, Simoni-Wastila L, Doshi JA, Levens SR, Stuart B. The quality of antipsychotic drug prescribing in nursing homes. Arch Intern Med. 2005;165(11):1280e1285. 10. Rochon PA, Stukel TA, Bronskill SE, et al. Variation in nursing home antipsychotic prescribing rates. Arch Intern Med. 2007;167(7):676e683. 11. Centers for Medicare & Medicaid Services. Fact sheets: data show national partnership to improve dementia care exceeds goals to reduce unnecessary antipsychotic medication in nursing homes. Accessed 05.11.14, http://www.cms.gov/ Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/ 2014-09-19.html; Published September 19, 2014. 12. U.S Department of Health and Human Services. National quality strategy: working for quality: achieving better health and health care for all Americans. Accessed 29.12.14, http://www.ahrq.gov/workingforquality/; Published September 2014. 13. Zwijsen SA, Smalbrugge M, Eefsting JA, et al. Coming to grips with challenging behavior: a cluster randomized controlled trial on the effects of a multidisciplinary care program for challenging behaviors in dementia. J Am Med Dir Assoc. 2014;15(7):531. 14. Meeks TW, Jeste DV. Beyond the black box: what is the role for antipsychotics in dementia? Curr Psychiatr. 2008;7(6):50e65. 15. Centers for Medicare & Medicaid Services. Nursing Home data compendium 2013 edition. Accessed 08.12.13, http://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/CertificationandComplianc/downloads/nursing homedatacompendium_508.pdf; Published 2014. 16. Cowles Research Group. The Online Survey Certification and Reporting Date. Accessed 21.12.12, http://www.longtermcareinfo.com/about_oscar.html; Published 2011. 17. U.S. Government Printing Office. Electronic Code of Federal Regulations. Accessed 05.11.14, http://www.ecfr.gov/cgi-bin/text-idx?rgn¼div5&node¼ 42:5.0.1.1.2#se42.5.483_175; Updated November 3, 2014. 18. Huybrechts KF, Rothman KJ, Brookhart MA, et al. Variation in antipsychotic treatment choice across US nursing homes. J Clin Psychopharmacol. 2012;32(1): 11e17. 19. Levinson DR. Medicare atypical antipsychotic drug claims for elderly nursing home residents (OEI-07-08-00150). Office of the Inspector General, U.S. Department of Health and Human Services. Accessed 26.03.14, http://oig.hhs. gov/oei/reports/oei-07-08-00150.pdf; Published May, 2011. 20. Maglione M, Maher AR, Hu J, et al. Off-label use of atypical antipsychotics: an update (AHRQ Pub. No 11-EHC087-3). Accessed 26.03.14, http:// effectivehealthcare.ahrq.gov/ehc/index.cfm/search-for-guides-reviews-andreports/?pageAction¼displayProduct&productID¼1193; Published July, 2012. 21. Zhong KX, Tariot PN, Mintzer J, Minkwitz MC, Devine NA. Quetiapine to treat agitation in dementia: a randomized, double-blind, placebo-controlled study. Curr Alzheimer Res. 2007;4(1):81e93. 22. Centers for Medicare & Medicaid Services. State operations manual: Appendix PP: guidance to surveyors for long term care facilities (Rev. 70, 01-07-11). From, http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ som107ap_pp_guidelines_ltcf.pdf; Published 2011. Accessed 26.03.14. 23. Lindsey PL. Psychotropic medication use among older adults: what all nurses need to know. J Gerontol Nurs. 2009;35(9):28e38. 24. Weiser ML. Antipsychotics: restraints for the elderly? Am J Nurs. 2008;108(12):11. 25. Department of Health & Human Services, Centers for Medicare & Medicaid Services. CMS Manual System; 12/15/2006. Publication 100e07 State Operations Provider Certification. Transmittal 22. 26. Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995;153:1423e1431. 27. Smith M, Schultz SK, Seydel LL, et al. Improving antipsychotic agent use in nursing homes. J Gerontol Nurs. 2013;39(5):24e35. 28. Cimino NM, Lockman K, Grant M, McPherson ML. Knowledge, skills, and attitudes in caring for older adults with advanced illness among staff members of long-term care and assisted living facilities: an educational needs assessment. Am J Hosp Palliat Care; 2014, December 3:1e8. Epub ahead of print. 29. Baruch Y, Holtom BC. Survey response rate levels and trends in organizational research. Hum Relat. 2008;61(8):1139e1160.
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Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
Caring for people with dementia and challenging behaviors in nursing homes: A needs assessment geriatric nursing Jeanette M. Daly, RN, PhD a, *, Camden P. Bay, MS b, Barcey T. Levy, PhD, MD a, b, Ryan M. Carnahan, MS, PharmD b a b
Department of Family Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, USA Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, IA, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 November 2014 Received in revised form 29 December 2014 Accepted 5 January 2015 Available online 9 February 2015
An estimated 50% of nursing home residents have a dementia diagnosis. The purpose of this research was to conduct a needs assessment of directors of nursing (DON) in Iowa nursing homes in relation to caring for patients with Behavioral and Psychological Symptoms of Dementia. DON responses were linked to Online Survey Certification and Reporting/Certification and Survey Provider Enhanced Reporting (OSCAR/CASPER) data to examine how facility characteristics may be associated with use of and confidence in non-drug management strategies. From 431 questionnaires mailed to DONs, 160 (37%) were returned. Regression analysis showed that those who were more confident in managing challenging behavior were more likely to have satisfaction with current training on managing challenging behaviors and had a psychiatrist available to visit the facility. Facilities with a larger proportion of patients with challenging behaviors being treated with non-drug approaches instead of antipsychotics had DONs who were more likely to be confident in non-drug management strategies and have knowledge about the FDA antipsychotic medications risks. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Nursing home Director of nursing Dementia Challenging behaviors Antipsychotic medication
Currently, there are more than 15,000 Medicare and Medicaidcertified nursing homes in the United States1 with almost 3.3 million patients receiving care in those nursing homes.2 An estimated 50% of nursing home residents have a diagnosis of dementia3,4 with 13% having dementia or Alzheimer’s disease as their primary diagnosis.5 Neuropsychiatric disturbances occur in 60e98% of people with dementia, frequently triggering nursing home placement and antipsychotic treatment.6 Antipsychotics have been a mainstay of pharmacologic management. In 2006, 25.9% of nursing home residents in the United States received antipsychotics,7 compared to 16.4% just 10 years earlier. Recent estimates place the prevalence of nursing home antipsychotic use around 22%.8 Evidence suggests that antipsychotic use is often suboptimal, based on lack of appropriate indications, inappropriate dosing,9,10 and high variability in usage rates across facilities.10 This is of particular concern since antipsychotics are associated with serious side effects in people with dementia, including an increased risk of mortality
Funding: ARHQ R18 HS19355-01. * Corresponding author. 01290-F PFP, 200 Hawkins Drive, Iowa City, IA 52242, USA. Tel.: þ1 319 384 8995. E-mail address: [email protected] (J.M. Daly). 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2015.01.001
which was the reason for a black box warning required by the Food and Drug Administration. In 2014 the Centers for Medicare and Medicaid Services (CMS) launched the National Partnership to Improve Dementia Care initiative to enhance dementia care quality and address antipsychotic overuse, with a goal of reducing antipsychotic use in nursing homes by 30% at the end of 2016.11 Regulatory requirements have facilitated a marked improvement in decreasing the use of antipsychotic medications in nursing homes from 24% in the fourth quarter of 2011 to 20% in the first quarter of 2014.11 The current focus of the initiative is to not only reduce antipsychotics but also to encourage person-centered care and non-drug management of behavioral symptoms of dementia in order to reduce unnecessary antipsychotic use.12 Challenging behaviors for persons with dementia are common and multi-faceted being attributable to the environment, chronic conditions, health, or medications. More than 80% of nursing home residents with dementia exhibit one or more forms of challenging behaviors.13 Examples of challenging behaviors include agitation, anger, depression, disrobing, eating abnormalities, hoarding, inappropriate sexual behavior, irritability, paranoia, physical and verbal aggression, repetition, swearing, and withdrawal. There are situations in which antipsychotic use in dementia patients is considered appropriate by most clinicians as well as CMS, particularly when a patient’s behaviors are dangerous to
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themselves or others.14 Initial therapy for patients with dementia who have challenging behaviors is environmental modifications and non-pharmacologic approaches. However, if that is unsuccessful and antipsychotic use is warranted, an appropriate indication for use of the medication needs to be documented. Once antipsychotic medication is started ongoing monitoring to evaluate its effectiveness and observation for adverse effects is necessary. If the medication is ongoing, the lowest effective dose should be established and maintained. In 2013, the percentage of nursing home residents taking antipsychotic medication ranged from 12.3% in Hawaii to 33.1% in Louisiana with a mean of 24.2% in the U.S. 15 In Iowa the percentage of nursing home residents taking antipsychotic medication was 21.2% in 2012.15 The purpose of this research study was to conduct a needs assessment of directors of nursing (DON) in Iowa nursing homes in relation to caring for patients with dementia and those with challenging behaviors. That is a needs assessment to establish knowledge deficits in which to appropriately care for people with Behavioral and Psychological Symptoms of Dementia (BPSD) and then to best determine how they would like to receive additional training. This needs assessment would help to inform the development of educational materials and tools to help guide care for people with BPSD. In addition, the DON responses were linked to the Online Survey Certification and Reporting/Certification and Survey Provider Enhanced Reporting (“OSCAR/CASPER”) survey and inspection data to provider responses to examine how information on facility operations, patient census and regulatory compliance may be associated with use of and confidence in non-drug management strategies for behavioral symptoms of dementia. Comparison of both resident and facility data allows us to look at the variation and influence of these factors. In particular, we utilized regression modeling to aid in assessing the relationship between the proportion of dementia patients with challenging behavior treated using non-drug approaches and nurse’s knowledge, confidence, and education, family involvement, medical director education, availability of a psychiatrist or nurse practitioner with a dementia/ psychiatric specialty, facility operations, and patient census (see Table 1 for the entire list OSCAR/CASPER Date). Additionally, we wanted to look at nurse’s confidence in managing challenging patient behaviors associated with dementia and non-drug approaches. Methods After institutional review board approval, a mailed survey was sent to Iowa nursing homes. The Medicare nursing home compare website (medicare.gov/NursingHomeCompare) listed 443 nursing homes in Iowa. Of the 443, 12 were hospitals and eliminated from the list because the cover letter read director of nursing and would go to the hospital director and not the nursing home director, leaving 431 nursing homes. All nursing home DONs were invited to participate and questionnaires were mailed in January 2011. DONs were asked to complete the questionnaire while skipping any questions they did not want to answer and mail it back. If no response was given by a DON within three weeks, a second questionnaire was mailed. Following the two mailings, no further mailings or contacts were made. Instrument A 22-item questionnaire (see Appendix 1) entitled, “Needs Assessment: Caring for People with Dementia and Challenging Behaviors” developed by the research team of clinicians, researchers, and education specialists, was used to assess the needs of DONs in regard to caring for individuals with BPSD. To ensure
183
content validity, the questionnaire was critique by current or former nursing home employees that were on the research team. Questions included information pertaining to the treatment of dementia patients and the education of nursing home staff and family members about dementia. To better understand current dementia management approaches, DONs were asked about which antipsychotics were most often prescribed (a list of commonly used antipsychotics was provided), satisfaction with current training on managing dementia behaviors, if the nursing staff provides influence on the selection of the antipsychotic medication prescribed, their awareness of the FDA warning on antipsychotics in dementia, and their usage as well as confidence in non-drug treatment approaches for managing BPSD. To gather information related to the education of nursing home staff and family members of dementia patients, DONs were asked how they obtain information about dementia treatment, what dementia topics interest them the most, preferred methods of delivery (such as, CD-ROM, e-mail, handbook, mail, online resources, or pocket guides, poster) for dementia treatment information and what method would be best for communicating about the treatment of dementia symptoms with family members. Information about the medical director and availability of a psychiatrist or dementia specialist nurse consultant to consult or make a visit to the nursing home was collected. DON demographic information was collected and included age, gender, race, ethnicity, total years in practice, and total years employed at the current nursing home. OSCAR/CASPER data OSCAR is an administrative database of the Centers for Medicare and Medicaid Services (CMS). In July 2012, OSCAR data was replaced by the CASPER system. CASPER is a part of a large relational database operating within CMS Automated Survey Processing Environment (ASPEN). Every nursing home in the United States that is certified to provide services under either Medicare or Medicaid is listed in the survey data. The number of variables in a data file depends on the survey process and extensive data is collected for nursing homes. Data are available for download, but new survey data overwrites the previous data. Archived longitudinal data for this study were purchased from Cowles Research Group so the data was current with the survey.16 OSCAR/CASPER data were linked to each nursing home’s DON responding to the questionnaire through the nursing home’s respective National Provider Identifier (NPI). Thirty-two CMS OSCAR/CASPER variable descriptions were retrieved from their respective forms which included: 1) Long Term Care Facility Application for Medicare and Medicaid, 2) Resident Census and Conditions of Residents, 3) Statement of Deficiencies and Plan of Correction (see Table 1). The research team reviewed the forms and determined which variables to include in the data analysis. Data analysis Using the returned questionnaires, basic descriptive statistics for questions of interest were calculated. For any statistics derived from the questionnaires and reported as proportions, missing responses have been removed from the denominator for calculation; any missing data exceeding 10% for a question has been noted in the results. The analysis explored predictors for two of the questions asked on the questionnaire: 1) the proportion of dementia patients who had challenging behavior treated with non-drug approaches instead of medications (questionnaire takers were given five choices: “less than 1/4,” “less than 1/2 but more than 1/4,” “about 1/2,” “more than 1/2 but less than 3/4,” and “more than 3/4”), 2) the
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Table 1 Potential predictors for models. Source
Variablea
Needs Assessment Survey
-
-
-
-
-
Censusb
-
-
Census e Staffing
b
-
Census e Residents
b
-
-
-
a b
Proportion of dementia patients with challenging behavior treated using non-drug approaches (only in confidence model) Confidence in managing challenging dementia patient behaviors with non-drug approaches (only in proportion of dementia patients model) How often family members are involved in decision to use medication for challenging behaviors in dementia patients Awareness of FDA warnings on antipsychotic risks for patients with dementia Medical director specialty/additional training in geriatrics (dichotomous) Board-certified psychiatrist available by phone for help with medication management (dichotomous) Board-certified psychiatrist available through visits for help with medication management (dichotomous) Nurse or nurse practitioner specializing in dementia/psychiatrics available by phone (dichotomous) Nurse or nurse practitioner specializing in dementia/psychiatrics available through visits (dichotomous) Highest nursing education (continuous and categorical) Medical director years in practice Medical director years employed at facility Consulting nurses are used for information or clinical tools regarding challenging behaviors in patients with dementia (dichotomous) Consulting pharmacists are used for information or clinical tools regarding challenging behaviors in patients with dementia (dichotomous) Consulting drug company representatives are used for information or clinical tools regarding challenging behaviors in patients with dementia (dichotomous) Satisfaction with training of yourself and staff regarding management of challenging behaviors in people with dementia Provider category code (skilled nursing facility (dually certified)/skilled nursing facility (distinct part)/skilled nursing facility/ nursing facility) (categorical) Special care unit with beds for Alzheimer’s disease available (dichotomous) Nurse aide training and competency evaluation program (dichotomous) Medical director FTE Other physicians FTE Physician extenders FTE RN director of nurses FTE Nurses with administrative duties FTE Registered Nurse FTE and HPRD (hours per resident per day) Licensed practical/licensed vocational nurses (LPN/LVN) FTE and HPRD Certified nurse aides FTE and HPRD Nurse aides in training FTE and HPRD Registered Nurses þ LPN/LVN þ certified/in training nurse aides FTE and HPRD Medication aides/technicians FTE Therapeutic recreation specialists FTE Social workers FTE Other social service staff FTE Mental health services FTE Proportion of residents with . - documented psychiatric diagnosis (excludes dementias and depression) - dementia or Alzheimer’s disease - behavioral health care needs - behavioral health care needs and an individualized health care plan Proportion of residents receiving . - psychoactive medication - antipsychotic medication - antianxiety medication - antidepressant medication - hypnotic medication Proportion of residents’ dependent or requiring assistance for . - bathing - dressing - transferring - toilet use - eating
Variables were treated as continuous unless otherwise noted in parentheses. Variables from OSCAR/CASPER.
confidence in managing patients with dementia who had challenging behavior with non-drug approaches (question responses were on a 5-point Likert-like scale from “not at all confident” to “totally confident”). These were referred to as the “Proportion of Dementia Patients” model and the “Confidence” model respectively. Separate models were used for the two response questions. Responses to both questions were treated as categorical and collapsed down to three categories in order to simplify interpretation, suggesting that ordinal logistic regression should be utilized. The Proportion of Dementia Patients outcome was collapsed into three levels: 1) Less than 1/2 (n ¼ 39), 2) Approximately 1/2 (n ¼ 31), and 3) More than 1/2 (n ¼ 83). The Confidence outcome
was collapsed into three levels: 1) Not confident (n ¼ 52), 2) Medium confidence (n ¼ 74), and 3) Confident (n ¼ 32). Univariable analysis was performed with predictors of interest from the questionnaire and OSCAR/CASPER data for each response. Predictors with p-values 0.10 were selected for further analysis in a multivariable model (see Table 2). If there was evidence that the proportional odds assumption of the ordinal logistic regression models was not met (score test), multinomial logistic regression was utilized. Multinomial logistic regression requires a different interpretation for odds ratios than ordinal, as it does not assume proportional odds, but still provided relevant information for the investigation.
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Table 2 Candidate predictors selected through univariable analysis for proportion of dementia patients and confidence outcomes. Variablea Outcome: proportion of patients with dementia treated with non-drug approaches How often family members are involved in decision to use medication for challenging behaviors in dementia patients Confidence in managing challenging dementia patient behavior with non-drug approaches Awareness of FDA warnings on antipsychotic risks in dementia Satisfaction with training of yourself and staff regarding management of challenging behaviors in people with dementia Outcome: confidence in managing challenging behaviors of patients with dementia patient with non-drug approaches How often family members are involved in decision to use medication for challenging behaviors in dementia patients Awareness of FDA warnings on antipsychotic risks in dementia Visits from board-certified psychiatrist (dichotomous) Consulting pharmacists are used for information or clinical tools regarding challenging behaviors in patients with dementia (dichotomous) Satisfaction with current training for managing challenging behaviors in dementia patients Medical director years employed at facility Special care unit with beds for Alzheimer’s disease available (dichotomous) a
Odds ratios
90% CI
p-value
1.44 3.29 1.65 1.40
1.13e1.83 2.25e4.80 1.31e2.08 1.07e1.83
0.01 <0.0001 <0.001 0.04
1.44 1.77 2.16 2.12
1.13e1.84 1.40e2.22 1.30e3.57 1.27e3.54
0.01 <0.0001 0.01 0.02
2.61 1.03 2.45
1.95e3.50 1.00e1.06 1.38e4.34
<0.0001 0.09 0.01
All variables were entered continuously, unless otherwise noted.
Through univariable selection of predictors of interest for the Confidence outcome, seven candidate predictors were found for introduction into the full Confidence model. These candidate predictors can be found in Table 2 along with measures of effect. The proportion of dementia patients who had challenging behaviors treated with non-drug approaches was also significantly associated with confidence in non-drug management strategies. However, this was not included as a predictor in the model because it seemed likely that this was an outcome affected by confidence rather than a cause of confidence. It is also possible that a bidirectional relationship exists in which use of non-drug management strategies increases confidence and confidence impacts use of non-drug management strategies, but it was felt excluding this from the model predicting confidence would be most appropriate. For the Confidence outcome, the univariable analysis revealed many potential predictors (Table 2), limiting the interpretation of their independent contributions and risking over fitting, so forward selection was utilized with a reduction in AIC (Akaike Information Criterion) of greater than 1.0 being considered a cutoff for entrance into the full model. Before selection, all predictors were assessed for multi-collinearity using variance inflation factor (VIF), and at each step in the selection process, the model was checked for the proportional odds assumption. For the Proportion of Dementia Patients outcome, forward selection was also utilized to construct a full model. In order to account for all predictors of interest in the two models, OSCAR/CASPER data was linked to each nursing home that responded. Most of the predictors were proportions of the total number of patients in a nursing home, so controlling for size was accomplished. DON letters and questionnaires were mailed on January 3, 2011, and were completed within six weeks, so OSCAR/ CASPER assessments closest in time to this date were chosen for the linkage. The certification date of each nursing home was chosen as the date of assessment as it was found to be at most 43 days away from the start of assessment and 30 days away from the end of an assessment, and it was consistently reported in all OSCAR/CASPER assessment databases used. For all facilities, the difference between certification date and questionnaire mailing was less than nine months. Comparing those DONs who responded from DONs who did not respond, nursing homes that did not have a DON respond were more likely to be for-profit (60% vs. 52%). For size, the nursing homes that did not respond tended to be a little smaller (median of 49 vs. 52 patients). The median was used for both comparisons as the distributions were fairly skewed. All hypothesis testing was performed at a 0.05 significance level and two-tailed unless otherwise noted. Data were analyzed using SAS software, version 9.3 for Windows (SAS Institute, Cary NC). R, version 2.13.0, was used for the boxplot.
Results Of the 431 questionnaires mailed, 160 (37%) were returned. The mean age of the DONs was 45 years. Of the 160 DONs, 154 (99%) were female, 151 (98%) were Caucasian. The DONs had a mean of 20 years in nursing practice and had been employed at their current nursing home a mean of 10 years (see Table 3). The antipsychotics most frequently reported as being used for patients with dementia or delirium across nursing homes were risperidone, quetiapine, and olanzapine. These were also most frequently reported as the most commonly used antipsychotics within individual facilities (see Table 4). Of the DONs, 114 (72%) were not satisfied or neutral with their training on managing challenging behaviors in people with dementia with a mean score of 2.9 (SD 1.0) on a 5-point Likert scale. Ninety-four (63%) of the DONs said it would be helpful for them or their staff to receive training on how to use tools to assess cognition, behavioral symptoms, and movement disorders related to antipsychotics while 56 (37%) were comfortable with available tools. One hundred and seven (68%) DONs reported that nursing staff had little to moderate input into the antipsychotic medication
Table 3 Demographic and work characteristics of directors of nursing. Variable
DONs
Age in years (n ¼ 153) Range Years in practice (n ¼ 156) Range Years employed current nursing home (n ¼ 156) Range Gender (n ¼ 156) Female Male Race (n ¼ 154) American Indian Asian Black Native Hawaiian White Ethnicity (n ¼ 104) Hispanic a Nursing education (n ¼ 156) Associate’s degree Bachelor’s degree Diploma MS PhD
45.4 (9.7) 23e66 20.4 (9.9) 2e44 10.2 (9.4) 0e40 154 (98.7) 2 (1.3) 3 (1.9) 0 0 0 151 (98.0) 0 97 41 14 6 1
(62.2) (26.3) (9.0) (3.9) (0.6)
Values are presented as mean (standard deviation) in the case of continuous variables and frequency (percentage) in the case of categorical variables. a Some subjects fall into multiple categories.
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Table 4 Antipsychotic medications used and predominantly used in the nursing home for persons with dementia or delirium (n ¼ 160). Medication
Risperidone (Risperdal) Quetiapine (Seroquel) Olanzapine (Zyprexa) Haloperidol (Haldol) Aripiprazole (Abilify) Ziprasidone (Geodon) Clozapine (Clozaril) Thioridazine (Mellaril) Fluphenazine (Prolixin, Permitil) Paliperidone (Invega) Trifluoperazine (Stelazine) Chlorpromazine (Thorazine) Thiothixene (Navane) Perphenazine (Trilafon) Asenapine (Saphris) Iloperidone (Fanapt) Other
Used in the NH n (%)
Predominantly used in the NH n (%)
154 146 132 109 88 37 19 7 7 6 6 6 4 2 1 0 5
118 112 75 30 25 5 0 0 0 1 1 0 0 0 0 0 0
(96.3) (91.3) (82.5) (68.1) (55.0) (23.1) (11.9) (4.4) (4.4) (3.8) (3.8) (3.8) (2.5) (1.3) (0.6) (0.0) (3.1)
(73.8) (70.0) (46.9) (18.8) (15.6) (3.1) (0.0) (0.0) (0.0) (0.6) (0.6) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0)
prescribed, with a mean score of 2.7 (SD 1.3) on a 5-point scale from “not at all” to “very much.” A Pearson correlation coefficient between the influence of nursing staff on medication selection and satisfaction with training was found to be 0.25 (p-value < 0.01), suggesting a modest, positive linear association. Sources of information or clinical tools to help DONs or their staff address challenging behaviors were the consulting pharmacist by 96 (60%) respondents, facility in-services by 86 (54%), drug book by 63 (40%), consulting nurse by 62 (39%), and Internet resource by 49 (31%). Respondents wanted to learn more about managing difficult behaviors without medications, caring for difficult patients, and differentiating between dementia and delirium (see Table 5). They preferred the following methods of obtaining new information or clinical tools to help with challenging behaviors with persons who have dementia: facility in-services, pocket guides, e-mail, and an online resource. Table 6 provides DONs preferred and most likely to use tools to address challenging behaviors. One hundred and fourteen (72%) of the DONs reported often or always involving patient family members in decisions to use medications for challenging behaviors for persons with dementia, with a mean 5-point Likert scale score of 4.1 (SD 1.1). The DONs preferred the following information to help communicate with families about medications and non-drug approaches for challenging behaviors: one-page handout, easier-to-read materials, brochures, and booklets. Medical director specialties were reported as 115 (73%) family medicine, 31 (20%) certified in geriatrics, and 16 (10%) internal
Table 5 Information would like to learn more about to care for persons with dementia (n ¼ 159). Information
n (%)
Managing difficult behaviors without drugs Caring for difficult Patients Differentiating between dementia and delirium Tools for family members Types of dementia Measuring pain Medications Staff consistency Dementia in hospice/when to stop medications Other
139 120 88 76 70 70 65 55 55 5
(87.4) (75.5) (55.4) (47.8) (44.0) (44.0) (40.9) (34.6) (34.6) (3.1)
Table 6 DONs preferred and most likely to use tools to address challenging behaviors (n ¼ 159). Source
Preferred n (%)
Most likely to use n (%)
Facility in-service Pocket guides E-mail On-line resource Mail Handbook CD-ROM Short on-line videos Consulting nurse Informational poster Consulting pharmacist Application for other PDA device Screensavers Application for iPhone Facebook Other
126 88 84 82 80 64 53 50 45 45 43 4 2 1 1 4
53 36 34 37 22 31 26 17 13 13 12 1 0 1 0 2
(79.3) (55.4) (52.8) (51.6) (50.3) (40.3) (33.3) (31.5) (28.3) (28.3) (27.0) (2.5) (1.23) (0.6) (0.6) (2.5)
(33.3) (22.6) (21.4) (23.3) (13.8) (19.5) (16.4) (10.7) (8.2) (8.2) (7.6) (0.6) (0.0) (0.6) (0.0) (1.3)
medicine. Fifty (32%) reported that a board-certified psychiatrist was available by telephone for help with medication management. Seventy-three (46%) reported the psychiatrist would make a visit to the nursing home. Eighteen (11%) reported there was a nurse practitioner with a dementia/psychiatric specialization for consultation by telephone and 58 respondents (37%) reported they would make a visit to the nursing home. After forward selection with an AIC cutoff of 1.0, availability of a board-certified psychiatrist for making visits and satisfaction with current training in regard to managing patients with dementia were significant and independent predictors for the Confidence model (Table 7). The awareness of FDA warnings for antipsychotic drugs was also selected, but ultimately removed from the model as it did not have a strong linear relationship with the log odds as seen through highly decreased AIC upon inclusion of polynomial terms. It was also suspected that awareness of warnings would not be a direct cause of confidence in non-drug approaches, but was only associated because of a higher awareness of issues relating to care of dementia behaviors. A Spearman correlation coefficient of 0.31, (p < 0.0001) was found, providing evidence of the presence of an underlying monotonic, increasing relationship. Univariable selection of predictors of interest for the Proportion of Dementia Patients full model revealed four candidate predictors (Table 2). After forward selection, awareness of FDA warnings for antipsychotic drugs and confidence in treating dementia patient with non-drug approaches remained in the model (Table 7). Discussion The majority of DON respondents were middle-aged, female, experienced registered nurses with a work commitment to longterm care nursing by their longevity in the field. Less than a third of the DONs were satisfied with training on managing patients with challenging behaviors and over half said it would be helpful to receive additional training. They preferred to have this additional training mainly through facility in-services. Nursing homes routinely provide in-service education as federal requirements [Code of Federal Regulations, 483.75(e) Subsection 8]. Federal requirements require that the in-service education must be sufficiently intensive to ensure continuing competence of nursing assistants and be at least 12 hours a year.17 The in-services must address areas of staff weakness as determined by performance reviews and any special needs of current residents as determined by facility staff. The curriculum content for staff development is not specified in Federal requirements but there is the caveat that some
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Table 7 Final ordinal logistic regression models. Response
n
Variable
Odds ratio
95% confidence interval
Proportion of dementia patients treated with non-drug approaches
152
2.95
1.87e4.65
Confidence in managing challenging patient behavior with non-drug approaches
156
Confidence in managing challenging patient behavior with non-drug approaches Awareness of FDA warnings on antipsychotic risks in dementia Visits from board-certified psychiatrist Satisfaction with current training for managing challenging behaviors in dementia patients
1.42 2.12 2.58
1.05e1.92 1.14e3.97 1.81e3.66
of the content must deal with cognitive impairment. Since inservice education is part of the nursing home routine, it is an ideal setting for education on antipsychotic medications and management of difficult patient behaviors. Atypical antipsychotics were the predominant antipsychotics for patients with dementia or delirium which is similar to another study of the 65,618 nursing home patients prescribed antipsychotics, 91% were prescribed atypical antipsychotics.18 In this study and the Huybrechts et al,18 study, risperidone, quetiapine, and olanzapine were prescribed most frequently. This is very similar to results from other evaluations of national prescribing trends.8,19 While the use of risperidone and olanzapine are understandable given the evidence supporting limited efficacy in dementia, the frequent use of quetiapine is somewhat perplexing. Five randomized controlled trials have found overall that quetiapine is no better than placebo for management of agitation and psychosis in people with Alzheimer’s or vascular dementia.20 Only one secondary analysis of one trial found that 200 mg/day quetiapine was more effective than placebo for dementia-associated agitation,21 but this dose exceeds the CMS allowable dose for chronic use of quetiapine in nursing home residents with dementia.22 Other flexible dose trials allowed similar doses and showed no beneficial effect of quetiapine.20 One potential explanation for use of quetiapine is that it is a highly sedating antipsychotic,20 so sedation may be confused with efficacy. Less than a third of the DON respondents reported input influencing the selection of the antipsychotic medication that is prescribed. It is important for nurses, physicians, and consulting pharmacists to work together in monitoring the use of antipsychotic medications. Nurses should monitor for over sedation, orthostatic hypotension, unsteadiness, and acute extrapyramidal side effects when administering both conventional and atypical antipsychotic medications and be aware of the black box warnings for all antipsychotic medications.23,24 Each nursing home must employ or obtain the services of a licensed pharmacist.25 The pharmacist must provide consultation on all aspects of the provision of pharmacy services in the nursing home. Part of the consulting pharmacist’s role is to collaborate with nursing home DONs and staff who are responsible for medication administration. Usually the consulting pharmacist visits the nursing home monthly and staff is aware and prepare for the visit. It seems obvious from the responses that about two-thirds of the DONs value the consulting pharmacist’s knowledge and seek information from the pharmacist. The second sought resource, facility inservices, were valued to obtain information on challenging patient behaviors. Responses for information resources indicate that nurses are busy and rely on easy-to-read information that is readily available and quick to access. Confidence as a nurse comes from experience and exposure to as many different patient scenarios and clinical situations as possible. DON respondents had a mean of 20 years practicing nursing and 10 years practicing nursing in the nursing home, yet only one-fifth of them were confident in managing challenging patient behaviors with non-drug approaches. Those who were confident had greater satisfaction with current training on
managing challenging behaviors in people with dementia and were more likely to have access to a psychiatrist who would visit the facility. Greater confidence in non-drug approaches and awareness of the FDA warning on antipsychotics and mortality in dementia were associated with more frequent use non-drug management approaches instead of antipsychotics. Confidence building seems to be a mechanism to improve management of challenging patient behaviors. Suggestions for nurses to improve confidence would be focused education, a mentor such as a psychiatrist or advanced geriatric nurse practitioner, asking questions when unsure of behavior management, and to practice implementing non-drug approaches for managing challenging behaviors. The traditional lecture approach for education regarding the management of problem behaviors is weak in producing changes in practice.26 At the University of Iowa, the Iowa Geriatric Education Center website (https://www.healthcare.uiowa.edu/igec/iaadapt/) provides a training module and toolkit to help clinicians, providers, and consumers better understand how to manage problem behaviors and psychosis in people with dementia using evidencebased approaches. This includes brief lectures, written content, quick reference guides for clinicians and providers, and information for families or patients on the risks and benefits of antipsychotics for people with dementia. Content of the material was based on feedback from providers and nurses in long-term care settings, such as that obtained through this survey. Continuing education credit is provided for prescribers, nurses, and pharmacists.27 About half of the DONs in this study preferred to use online resources and pocket guides. Laminated pocket guides with information on managing dementia behaviors can be ordered through the Iowa Geriatric Education Center website, and pdfs are freely available. Another dissemination mechanism to go along with the pocket guide is the case-based mini-lecture that provides digital presentations presenting a case study that illustrates principles described in the pocket guides.27 Another study identifying through a needs assessment, the learning needs and preferences of nursing home staff providing care for patients with life-limiting illnesses found that the participants preferred to receive training online and at their convenience.28 At the time of the survey, the newer forms of social media, Facebook, and applications for the iPhone were not preferred or not more than likely to be used by the respondents to garner information regarding tools to address challenging behaviors. However, a mobile device application with information from the pocket guides was created and is available through the website. This study has several limitations. Although the response rate of 37% was consistent with prior reports of survey responses29 the results may not be representative of all DONs in Iowa or those in other states. A strength of the study was to use OSCAR/CASPER data, as it is the most extensive data for nursing homes that is available. Also, the nursing home survey process is rigorous whose data provides a rich source of information. There were, however, nursing home characteristics that may have influenced outcomes which we did not consider in this analysis. Univariable testing was used to narrow potential predictors. The large number of tests may have resulted in false positive hypothesis results, and the omission of
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variables based on univariable results may have resulted in exclusion of predictors that would have been significant after adjustment for other important predictors. Similarly, the forward selection procedure utilized to reduce the number of variables is limited in its ability to identify the best subset of all potential predictors. It is notable that among all potential predictors, very few were actually selected for the final models. The focus of this research was on DONs who are not the frontline staff providing direct care to patients in the nursing home. Future research should consider the perceptions and opinions of staff providing direct care, such as nursing assistants, medical assistants, and therapists. In conclusion, the typical DON who was more confident in managing patients with challenging behaviors was more likely to have the availability of a board-certified psychiatrist to make visits to the nursing home and was more likely to be satisfied in their training for managing these behaviors. Confidence in non-drug management strategies and awareness of the FDA warning on antipsychotics in dementia were associated with greater use of non-drug management strategies instead of antipsychotics for management of BPSD. These results suggest that education on managing challenging behaviors and psychiatrist availability may be helpful in promoting confidence and use of non-drug management strategies for management BPSD. The distribution of antipsychotics prescribed also suggests room for improvement, since the best available evidence suggests that quetiapine is not particularly effective for management of dementia symptoms.
References 1. Center for Medicare & Medicaid Services. What is nursing home compare?. Accessed 05.11.14, http://www.medicare.gov/nursinghomecompare/About/ What-Is-NHC.html; Published 2014. 2. Centers for Medicare & Medicaid Services. Nursing home data compendium 2010. Accessed 21.12.12, http://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/DataCompendium/index.html?redirect¼/ datacompendium/; Published 2011. 3. Barton C, Miller B, Yaffe K. Improved evaluation and management of cognitive impairment: results of a comprehensive intervention in long-term care. J Am Med Dir Assoc. 2006;7:84e89. 4. Magaziner J, German P, Zimmerman SI, et al. The prevalence of dementia in a statewide sample of new nursing home admissions aged 65 and older: diagnosis by expert panel. Epidemiology of Dementia in Nursing Homes Research Group. Gerontologist. 2000;40(6):663e672. 5. Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing Home Survey: 2004 overview. National Center for Health Statistics. Vital Health Stat. 2009;13(167):1e155. 6. Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. J Am Med Assoc. 2005;293: 596e608. 7. Castle NG, Hanlon JT, Handler SM. Results of a longitudinal analysis of national data to examine relationships between organizational and market characteristics and changes in antipsychotic prescribing in nursing homes from 1996 through 2006. Am J Geriatr Pharmacother. 2009;7(3):143e150. 8. Briesacher BA, Tjia J, Field T, Peterson D, Gurwitz JH. Antipsychotic use among nursing home residents. J Am Med Assoc. 2013;309(5):440e442.
9. Briesacher BA, Limcangco R, Simoni-Wastila L, Doshi JA, Levens SR, Stuart B. The quality of antipsychotic drug prescribing in nursing homes. Arch Intern Med. 2005;165(11):1280e1285. 10. Rochon PA, Stukel TA, Bronskill SE, et al. Variation in nursing home antipsychotic prescribing rates. Arch Intern Med. 2007;167(7):676e683. 11. Centers for Medicare & Medicaid Services. Fact sheets: data show national partnership to improve dementia care exceeds goals to reduce unnecessary antipsychotic medication in nursing homes. Accessed 05.11.14, http://www.cms.gov/ Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/ 2014-09-19.html; Published September 19, 2014. 12. U.S Department of Health and Human Services. National quality strategy: working for quality: achieving better health and health care for all Americans. Accessed 29.12.14, http://www.ahrq.gov/workingforquality/; Published September 2014. 13. Zwijsen SA, Smalbrugge M, Eefsting JA, et al. Coming to grips with challenging behavior: a cluster randomized controlled trial on the effects of a multidisciplinary care program for challenging behaviors in dementia. J Am Med Dir Assoc. 2014;15(7):531. 14. Meeks TW, Jeste DV. Beyond the black box: what is the role for antipsychotics in dementia? Curr Psychiatr. 2008;7(6):50e65. 15. Centers for Medicare & Medicaid Services. Nursing Home data compendium 2013 edition. Accessed 08.12.13, http://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/CertificationandComplianc/downloads/nursing homedatacompendium_508.pdf; Published 2014. 16. Cowles Research Group. The Online Survey Certification and Reporting Date. Accessed 21.12.12, http://www.longtermcareinfo.com/about_oscar.html; Published 2011. 17. U.S. Government Printing Office. Electronic Code of Federal Regulations. Accessed 05.11.14, http://www.ecfr.gov/cgi-bin/text-idx?rgn¼div5&node¼ 42:5.0.1.1.2#se42.5.483_175; Updated November 3, 2014. 18. Huybrechts KF, Rothman KJ, Brookhart MA, et al. Variation in antipsychotic treatment choice across US nursing homes. J Clin Psychopharmacol. 2012;32(1): 11e17. 19. Levinson DR. Medicare atypical antipsychotic drug claims for elderly nursing home residents (OEI-07-08-00150). Office of the Inspector General, U.S. Department of Health and Human Services. Accessed 26.03.14, http://oig.hhs. gov/oei/reports/oei-07-08-00150.pdf; Published May, 2011. 20. Maglione M, Maher AR, Hu J, et al. Off-label use of atypical antipsychotics: an update (AHRQ Pub. No 11-EHC087-3). Accessed 26.03.14, http:// effectivehealthcare.ahrq.gov/ehc/index.cfm/search-for-guides-reviews-andreports/?pageAction¼displayProduct&productID¼1193; Published July, 2012. 21. Zhong KX, Tariot PN, Mintzer J, Minkwitz MC, Devine NA. Quetiapine to treat agitation in dementia: a randomized, double-blind, placebo-controlled study. Curr Alzheimer Res. 2007;4(1):81e93. 22. Centers for Medicare & Medicaid Services. State operations manual: Appendix PP: guidance to surveyors for long term care facilities (Rev. 70, 01-07-11). From, http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ som107ap_pp_guidelines_ltcf.pdf; Published 2011. Accessed 26.03.14. 23. Lindsey PL. Psychotropic medication use among older adults: what all nurses need to know. J Gerontol Nurs. 2009;35(9):28e38. 24. Weiser ML. Antipsychotics: restraints for the elderly? Am J Nurs. 2008;108(12):11. 25. Department of Health & Human Services, Centers for Medicare & Medicaid Services. CMS Manual System; 12/15/2006. Publication 100e07 State Operations Provider Certification. Transmittal 22. 26. Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995;153:1423e1431. 27. Smith M, Schultz SK, Seydel LL, et al. Improving antipsychotic agent use in nursing homes. J Gerontol Nurs. 2013;39(5):24e35. 28. Cimino NM, Lockman K, Grant M, McPherson ML. Knowledge, skills, and attitudes in caring for older adults with advanced illness among staff members of long-term care and assisted living facilities: an educational needs assessment. Am J Hosp Palliat Care; 2014, December 3:1e8. Epub ahead of print. 29. Baruch Y, Holtom BC. Survey response rate levels and trends in organizational research. Hum Relat. 2008;61(8):1139e1160.
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