- Email: [email protected]
An Innovative Approach to Managing Behavioral and Psychological Dementia
An Innovative Approach to Managing Behavioral and Psychological Dementia Elizabeth M. Long, DNP, GNP-BC ABSTRACT
The older adult population in long-term care is experiencing significant growth, which includes an increased number of minority admissions. An estimated 48% of long-term care patients are admitted with a diagnosis of dementia. Patient-centered, culturally appropriate care is critical in the management of dementia and treatment of associated behavior and psychological symptoms of dementia (BPSD). The use of personalized music playlists has shown promise in the interdisciplinary treatment of BPSD. Regulatory agencies are closely monitoring the management of BPSD. Accurate diagnosis and treatment of BPSD is an increasingly important skill for the provider. Keywords: BPSD, culturally appropriate, dementia, individualized music, interdisciplinary, older adult, regulatory Ó 2017 Elsevier Inc. All rights reserved.
DEMENTIA AND THE OLDER ADULT
T
he older adult population has demonstrated significant growth over the last 2 decades. Minority populations have increased from 18% of the total population in 2004 to 22% in 2014. Projections predict minority populations will increase to 28% of the total population by 2030.1 The United States Centers for Disease Control (CDC) reported that, in 2014, there were 1.4 million residents in long-term care facilities (LTCFs) in the US.2 Research indicates numbers of racial and ethnic minority patients in long-term care are increasing even faster than the minority population overall.3 Alzheimer’s disease and other forms of dementias are common diagnoses among patients in LTCFs. In the last quarter of 2016, in LTCFs, the Minimum Data Set (MDS) revealed a diagnosis of dementia at a prevalence of 42.87% in Medicareand Medicaid-certified facilities.4 The MDS is a federally mandated standardized process of assessing the clinical status of patients in Medicare- and Medicaid-certified LTCFs across the US and provides a listing of specific diagnoses among patients.
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BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA
Dementia has a significant impact on patients, families, and caregivers, and can affect quality of life. Patients with dementia may present with behavioral disturbances, which can impact the provision of care and place them at risk for injury. These behaviors have been termed as the behavioral and psychological symptoms of dementia (BPSD). Common to patients in long-term care with dementia, these behaviors can negatively affect quality of life for the patient and the ability of the staff to provide care. Symptoms may include agitation, aggression, psychosis, and other inappropriate behaviors.5,6 Negative and inappropriate vocalizations and wandering are other behaviors that can put the patient with dementia at risk. Based on the MDS reports for the last quarter of 2016, at least 18.8% of patients in long-term care with dementia have behaviors that interfere with daily activities. These behaviors showed a prevalence of 22.5%. Behaviors that placed other residents at risk for physical injury were reported at 12.49% and behaviors placing the resident themselves at risk for physical injury at 12.44%.4
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TREATMENT AND MANAGEMENT OF BPSD
The treatment and management of BPSD is multifold. Common practices include determining the underlying cause of the behavior, communication tools such as redirection, providing person-centered care, and the use of antipsychotic agents.4,7,8 Potential underlying causes of unprovoked behavior include: infection; pain; medication effects or toxicity; fear; abuse; boredom; hunger; and/or thirst. Communication tools may include redirection or change in approach to the resident. Redirection is used as a first-line intervention to reduce or eliminate wandering or negative vocalizations.9 Studies have emphasized the importance of and improved outcomes with person-centered care for patients diagnosed with dementia in the long-term care setting. This system emphasizes that, despite cognitive impairment, patients can still maintain their identity. Recognizing, understanding, and acknowledging the feelings of a person with dementia through care actions is central to person-centered care. Identifying things that have meaning to the patient are essential in this approach. Studies have shown that person-centered care offers an evidencebased approach in which caregivers can incorporate patient preferences, feelings, culture, and life history into patient interactions.9,10 Additional studies are warranted regarding interventions that support the benefits of developing culturally sensitive, personcentered dementia care. With increases in the overall and minority older adult population overall and minority long-term care admissions, appropriate person-centered, culturally based care becomes important in those with dementia.8,11,12 Antipsychotic medication use in dementia is not supported in the evidence-based literature and is not considered best practice. The Beers Criteria is an evidence-based list developed to help providers improve medication safety while prescribing for older adults. This list incorporates pharmacologic properties and the physiologic changes that occur with aging, which can render certain medications inappropriate in the older adult. Antipsychotics are listed as a potentially inappropriate medication choice in older adults, with strong evidence to support the potential for adverse outcomes.13 476
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The prescribing of antipsychotics is not approved by the US Food and Drug Administration (FDA) in patients with dementia due to numerous side effects and increased mortality. A black box warning was issued in 2005 by the FDA related to increased mortality risk. Studies revealed the mortality rate in patients taking an antipsychotic was 4.5%, compared with 2.6% in the placebo group.14-17 Best practices include management of BPSD with nonpharmacologic interventions, such as communication, redirection, finding underlying causes of behavior, and provision of person-centered care. Within the management tools of communication and person-centered care, the roles associated with cultural background become important in promoting quality of life for the increasingly diversified population of long-term care patients.11,12 ECONOMIC IMPACT
The economic impact for treating dementia and BPSD is growing and expected to continue to increase. By 2050, the projected expenditures for Alzheimer’s and other dementia care will reach $1.1 trillion.19 In 2011, Medicare Part D spending on antipsychotic drugs totaled $7.6 billion, which was the second highest class of drugs, accounting for 8.4% of Part D spending.18 Individual atypical antipsychotics average in price from $100 to $600 per month.20 TREATMENT INNOVATION FOR BPSD
Evidence points to the benefits of music interventions in improving outcomes in agitation and other symptoms of BPSD. Even in advanced Alzheimer’s disease (AD), some musical memories may be maintained. Cuddy and colleagues21 proposed that the close links to emotion evoked by music allows for access to lifetime events. Music is thought to promote a physiologic response that can evoke autobiographical memories.22-27 Music is diverse, encompassing a variety of cultural preferences and can be an effective component of person-centered care. Developing a personalized music list, which has meaning to the individual patient, may tap into these autobiographical memories. Invoking positive memories through personalized music is increasingly demonstrating positive patient outcomes, including Volume 13, Issue 7, July/August 2017
increased communication and decreased agitation.20-23 These positive outcomes can improve the quality of life for the patient and decrease caregiver burden. Recent studies have explored the potential benefits of music on adverse events, such as falls and wandering. The benefits of using personalized music in care has been recommended by the Music and MemorySM organization. This nonprofit group has a goal for personalized music playlists as a standard of care in all LTCFs and has brought to light benefits of the program. The documentary, Alive Inside: A Story of Music and Memory, and a winner of the Audience Award at the 2014 Sundance Festival, highlighted the benefits of personalized music playlists and the work of the Music and MemorySM organization.28 The documentary highlights the applicability across cultures of personalized music and has demonstrated the positive outcomes and applicability with personalized music across cultures. In 2014, Texas ranked the highest among the states for antipsychotic prescribing in LTCFs. Following initiatives started in Wisconsin, Texas has taken a proactive stance to educate providers, empower facilities, and provide alternate nonpharmacologic treatment options. Initially, grants were provided by the Texas Department of Aging and Disability to 32 pilot facilities to implement a music and memory intervention. The grants included facility certification in Music and MemorySM, 15 iPod shufflesÒ and head phones, and $75 worth of iTunesÒ music to download to the shuffles. The early results were so promising that the grants were extended to 200 additional facilities with plans to extend these grants to at least 100 additional facilities in the future. Since taking this proactive stance, Texas now ranks 42nd nationally for antipsychotic prescriptions in LTCFs. The overall prevalence of antipsychotic use had decreased to a prevalence of 18.5% in June 2016.29 STATE AND NATIONAL POLICY IMPLICATIONS
State and federal agencies continue to closely monitor the use of antipsychotics and measures to provide patient-centered care in the long-term care setting. In 2016, the Centers for Medicare & Medicaid Services (CMS) finalized policy that will: improve the safety www.npjournal.org
and care of LTCF residents; develop quality strategy initiatives that envision person-centered health care; provide incentives for the right outcomes; be sustainable; emphasize coordinated care and shared decision-making; and rely on transparency of quality and cost information. Within these CMS strategies are foundational principles that include culturally and linguistically appropriate care. Table 1 lists the 6 quality strategy goals in this initiative30 and potential benefits with the use of personalized music playlists in the management of residents with dementia and BPSD. NEW FEDERAL REGULATION IMPLICATIONS
LTCFs are required to meet regulations set forth by the Department of Health and Human Services. These regulations are detailed in the Code of Federal Regulations (CFR) Title 42, Public Health. Federal regulations are applicable to the use of individualized music playlists within specific sections of the CFR. Section (x)483.75 requires facilities to develop, implement, and maintain a comprehensive and effective Quality Assurance and Performance Improvement program that is data-driven. It should have 3 foci: (1) systems of care; (2) outcomes of care; and (3) quality of life. In addition, x483.25 states that residents must be assured treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the patient’s choices. Music lists based on patient preference and history can help to accomplish an individualized, comprehensive plan that may improve outcomes of care and patient quality of life. Specific requirements for comprehensive personcentered care planning are detailed in x483.21. This section has specific indications for the interdisciplinary team. Long-term care facilities are required to develop and implement an interdisciplinary care plan, which includes instructions to provide effective and person-centered care. The regulation also now requires the team to add a nurse’s aide and a member of food and nutrition services to the interdisciplinary team.31 The pharmacist as an interdisciplinary team member and, as new requirement in x483.45, is required to review the patient medication list during the monthly medication review and identify The Journal for Nurse Practitioners - JNP
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Table 1. US Centers for Medicare & Medicaid Services Quality Strategy Goals and Potential Use of Personalized Music Goals
Use of Personalized Music
Make care safer by reducing harm caused in the delivery of care
Evidence suggests a correlation between personalized music playlists and a decrease in the use of antipsychotics Studies suggest a potential decrease in falls and wandering
Strengthen person and family engagement as partners in their care
Culturally appropriate patient-centered care with family involvement in development and sharing of music playlist Studies suggest memory recall and potential for increased communication with family and staff
Promote effective communication and coordination of care
Studies suggest communication and verbalization with implementation of individualized music playlists Personalized music playlists can be linguistically appropriate across cultures and languages Potential widespread applicability across disciplines and health care settings
Promote effective prevention and treatment of chronic disease
Evidence correlates use of personalized music playlists and decreased behavior and psychological symptoms of dementia Studies suggest potential decreases in depression and anxiety with the use of personalized music
Work with communities to promote best practice of healthy living
Best practice in long-term care Potential applications to other patient settings
Make care affordable
Personalized music playlists are a fiscally responsible best practice Potential cost savings with the prevention of falls, and decreased need for antipsychotics, depression, anxiety
Data taken from the Federal Register.30
medications that can affect brain processing and behavior. The pharmacist is also tasked with assisting to implement strategies to reduce or eliminate all psychotropic drugs to safeguard the patient’s health. Facilities and health care providers must ensure that antipsychotics are only used to treat specific conditions diagnosed and documented in the clinical record. The CMS requires facilities to attempt nonpharmacologic interventions before using antipsychotic medications. In the event a patient requires an antipsychotic medication, the provider must, unless clinically contraindicated, attempt to gradually decrease the dose and utilize behavioral interventions. Table 2 lists some, but not all, examples of noncompliance with this requirement for patients in LTCFs.32 Some of the approved adult indications for atypical and typical antipsychotics include: bipolar disorder; schizophrenia; schizoaffective disorder; delusional disorder; acute psychotic episodes; adjunct in major depressive disorder; atypical psychosis; 478
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Tourette’s disorder; Huntington’s disease; and shortterm treatment of hiccups, nausea, and vomiting.33 The use of antipsychotics in patients with dementia can result in adverse patient outcomes as well as deficiencies cited for the facility during inspections and surveys. Table 2. Examples of Noncompliance Related to Antipsychotic Prescribing in LTCFs Failure to attempt gradual dose reduction in the absence of identified and documented clinical contraindications Prolonged or indefinite antipsychotic use without attempting gradual dose reductions Failure to implement behavioral interventions to enable attempts to reduce or discontinue an antipsychotic medication Failure to discontinue an antipsychotic, prescribed for acute delirium, once delirium symptoms have subsided Data taken from the Department of Health and Human Services.32
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INTERDISCIPLINARY TEAM APPROACH
As the delivery of care in LTCFs has become more complex and with the increased diversity among residents, the importance of a diverse health care team becomes evident from both a cultural and discipline point of view. Interventions that promote efficient and well-coordinated delivery of health care services are key to successful patient and facility outcomes. The use of personalized music playlists in patients with dementia can be a strategy to improve outcomes for patients with BPSD and appropriate for
the interdisciplinary team as well as for meeting federal regulations. Table 3 outlines specifics from CFR Title 42, Public Health x483.2126 and the potential interdisciplinary team members who can utilize personalized music lists with patients to help meet regulatory requirements and improve patient outcomes. This regulation also details the requirement for culturally competent care. Individualized music can be a culturally appropriate intervention to meet the needs of an increasingly diverse population in long-term care.
Table 3. Code of Federal Regulations Title 42 x483.21 and Interdisciplinary Team Members Comprehensive Person-centered Care Planning
Interdisciplinary Team Members
Baseline care plans: A baseline care plan for each resident must be established within 48 hours of admission to a long-term care facility (LTCF). This plan must include instructions needed to provide effective person centered care. Initial goals, physician orders, dietary orders, therapy services, and social services must be incorporated into the baseline care plan
Comprehensive care plan: A comprehensive care plan must be developed by the LTCF team within 7 days of admission to the facility. This comprehensive plan must be prepared by an interdisciplinary team
Required team members: Patient and family Health care provider Registered nurse Nurse’s aide Nutrition services Patient Patient family Potential additional team members: Therapy services-physical, occupational, speech Social worker Activities director Pharmacist
Quarterly Review Assessments: The LTCF team must perform quarterly review assessment. These should be reviewed and revised by the interdisciplinary team after each assessment. The baseline care plan, comprehensive care plan and quarterly review assessment must be culturally competent
Patient and family Health care provider Registered nurse Licensed vocational nurse Dietician Nutrition services Physical therapy Occupational therapy Social worker
Patient and family Health care provider Registered nurse Licensed vocational nurse Nurse’s aide Dietician Nutrition services Physical therapy Occupational therapy Speech therapy Social worker Activities director Pharmacist
Data taken from the Federal Register.31
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Development of comprehensive, person-centered care plans with individualized music playlists can be suggested or implemented by members of the interdisciplinary team, including family members. Potential implications for nursing, dieticians, nutrition services, and speech language pathologist involvement include improving patient communication and food intake with the use of personalized music. Physical and occupational therapy can potentially integrate personalized music during skilled sessions and be used as a potential strategy to decrease falls. Nurses, nurse’s aides, activity directors, and social workers can play key roles in the implementation of this strategy across the disciplines. Decreasing the use of medications, such as antipsychotics, is part of an appropriate care plan intervention for the entire team, including the pharmacist.31 The potential management options for BPSD incorporating the interdisciplinary team are promising and merit further study. CONCLUSIONS
Nurse practitioners are in a key position within the interdisciplinary team to promote culturally appropriate, person-centered management of BPSD. The use of personalized music in the management of BPSD as an evidence-based practice has positively impacted patient outcomes in long-term care. Personalized music playlists can be used as a first-line, nonpharmacologic treatment with an aim to reduce the need for antipsychotic medications. This fiscally responsible initiative has the potential for widespread applicability across a variety of health care settings and disciplines in meeting the diverse needs of patients. References 1. US Department of Health and Human Services. Administration on aging: profile of older Americans 2015. 2016. https://aoa.acl.gov/Aging_Statistics/ Profile/2015/docs/2015-Profile.pdf/. Accessed March 1, 2017. 2. US Centers for Disease Control and Prevention. Nursing home stats. 2016. https:// www.cdc.gov/nchs/fastats/nursing-home-care.htm/. Accessed March 1, 2017. 3. Feng A, Fennell M, Tyler D, Clark M, Mor V. The care span: growth of racial and ethnic minorities in the US nursing homes driven by demographics and possible disparities in option. Health Affairs. 2011;30(7):1358-1365. http:// dx.doi.org/10.1377/htlhaff.2011.0126. 4. US Centers for Medicare & Medicaid Services. MDS 3.0 frequency report. 2017. https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer -Data-and-Systems/Minimum-Data-Set-3-0-Public-Reports/Minimum-Data -Set-3-0-frequency-report.html/. Accessed March 1, 2017. 5. Alzheimer’s Association. Managing behavioral and psychological symptoms of dementia (BPSD). 2013. http://www.alz.org/documents_custom/hcp_MD_ BPSD.pdf/. Accessed March 1, 2017.
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6. Cerejeira J, Lagarto L, Mukaetova-Ladinska EB. Behavioral and psychological symptoms of dementia. Front Neurol. 2012;3:73. http://doi.org/10.3389/fneur. 2012.00073/. Accessed March 1, 2017. 7. Chenoweth L, King M, Jeon Y, et al. Caring for Aged Dementia Care Resident Study (CADRES) of person-centered care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial. Lancet Neurol. 2009;8(4):317-325. 8. Stein-Parbury J, Chenoweth L, Jeon YH, Brodaty H, Haas M, Norman R. Implementing person-centered care in residential dementia care. Clin Gerontol. 2012;35(5):404-424. http://dx.doi.org/10.1080/07317115.2012. 702654. 9. Yusupov A, Galvin JE. Vocalization in dementia: a case report and review of the literature. Case Rep Neurol. 2014;6(1):126-133. http://dx.doi.org/10.1159/ 000362159. 10. Testad I, Mekki TE, Førland O. Modeling and evaluating evidence-based continuing education program in nursing home dementia care (MEDCED)— training of care home staff to reduce use of restraint in care home residents with dementia. A cluster randomized controlled trial. Int J Geriatr Psychiatry. 2016;31(1):24-32. 11. Savundranayagam M, Sibaliia J, Scotchmer E. Resident reactions to personcentered communication by long term care staff. Am J Alzheimers Dis Dement. 2016;31(6):530-537. http://dx.doi.org/10.1177/1533331751562291. 12. Nápoles AM, Chadiha L, Eversley R, Moreno-John G. Developing culturally sensitive dementia caregiver interventions: are we there yet? Am J Alzheimers Dis Dement. 2010;25(5):389-406. http://dx.doi.org/10.1177/ 1533317510370957. 13. American Geriatrics Society. Updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-2246. http://dx.doi.org/10.2222/jgs.13702. 14. Rice J, Humphreys C. Off-label use of antipsychotic drugs in patients with dementia. J Nurse Pract. 2014;10(3):200-204. 15. US Food and Drug Administration. Atypical antipsychotic drugs. 2013. https:// google2.fda.gov/search?as_sitesearch¼https://www.fda.gov/Safety/Med Watch/SafetyInformation&q¼safetyþwatchþ2013þantipsychotics&client¼ FDAgov&proxystylesheet¼FDAgov&output¼xml_no_dtd&site¼FDA gov&requiredfields¼-archive:Yes&sort¼date:D: L:d1&filter¼1&ie¼UTF -8&ulang¼en&&access¼p&entqr¼1&entqrm¼0&wc¼200&wc_mc¼1&oe ¼UTF-8&ud¼1/. Accessed March 1, 2017. 16. Agency for Healthcare Research and Quality. Comparative effectiveness review, number 39. First and second-generation antipsychotics for children and adults. 2012. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0040940/ pdf/PubMedHealth_PMH0040940.pdf/. Accessed March 13, 2017. 17. Schneider L, Dagerman K, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebocontrolled trials. JAMA. 2005;294:1934-1943. 18. Centers for Medicare and Medicaid Services. Partnership to improve dementia care exceeds goal to reduce use of antipsychotic medications in nursing homes: CMS announces new goal. 2014. https://www.cms.gov/ Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases -items/2014-09-19.html/. Accessed March 13, 2017. 19. Alzheimer’s Association. 2017 Alzheimer’s facts and figures. 2017. http:// www.alz.org/facts/. Accessed April 19, 2017. 20. Antipsychotics, 2nd generation. Epocrates Plus (version 17.1). 2017. https:// epocrates.com/. Accessed March 13, 2017. 21. Cuddy L, Sikka R, Vanstone A. Preservation of musical memory and engagement in healthy aging and Alzheimer’s disease. Ann NY Acad Sci. 2015;1337:223-231. 22. Janata P. The neural architecture of music-evoked autobiographical memories. Cerebr Cortex. 2009;19:2579-2594. http://dx.doi.org/10.1093/ cercor/bhp008. 23. Blackburn R, Burns T. Music therapy for service users with dementia: a critical review of the literature. J Psychiatric Mental Health Nurs. 2014;21:879-888. http://dx.doi.org/10.111/jpm.12165. 24. Gerdner L. Use of individualized music by trained staff and family: translating research into practice. J Gerontol Nurs. 2005;31(6):22-30. 25. Long E. Effect of a personalized music playlist on a patient with dementia and evening agitation. Ann Long Term Care. 2016;24(11):31-33. 26. Ridder H, Stige B, Qvale L, Gold C. Individual music therapy for agitation in dementia: an exploratory randomized controlled trial. Aging Mental Health. 2013;17(6):667-768. 27. Matthews S. Dementia and the power of music therapy. Bioethics. 2015;29(8):573-579. 28. Music and Memory. Our mission and vision. 2016. https://musicandmemory .org/about/mission-and-vision/. Accessed March 13, 2017. 29. Texas Health and Human Services. 2016. Quality monitoring program: music and memory. 2016. https://hhs.texas.gov/about-hhs/communications-events/ news/2016/11/quality-monitoring-program-monthly-bulletin-november-2016/. Accessed April 16, 2017.
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30. Centers for Medicare and Medicaid Services. Federal Register. CMS quality strategy. 2016. https://www.cms.gov/Medicare/Quality-Initiatives-Patient -Assessment-Instruments/QualityInitiativesGenInfo/Downloads/CMS-Quality -Strategy.pdf/. Accessed March 13, 2017. 31. Medicare and Medicaid programs; reform of requirements for long-term care facilities. The Daily Journal of the United States Government. Federal Register. 2016. https://www.federalregister.gov/documents/2016/10/04/2016 -23503/medicare-and-medicaid-programs-reform-of-requirements-for-long -term-care-facilities/. Accessed April 29, 2017. 32. US Department of Health and Human Services. 2016. Center for Clinical Standards and Quality/Survey and Certification Group. Ref S&C 16-15-NH. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/ SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-15.pdf/. Accessed March 1, 2017. 33. Centers for Medicare and Medicaid Services. Atypical antipsychotic use in adults. 2013. https://www.cms.gov/medicare-medicaid-coordination/ fraud-prevention/medicaid-integrity-education/pharmacy-education-
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materials/downloads/atyp-antipsych-adult-factsheet.pdf/. Accessed April 19, 2017.
Elizabeth M. Long, DNP, GNP-BC, is an assistant professor at Lamar University in Beaumont, TX. She can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/17/$ see front matter © 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2017.05.003
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The older adult population in long-term care is experiencing significant growth, which includes an increased number of minority admissions. An estimated 48% of long-term care patients are admitted with a diagnosis of dementia. Patient-centered, culturally appropriate care is critical in the management of dementia and treatment of associated behavior and psychological symptoms of dementia (BPSD). The use of personalized music playlists has shown promise in the interdisciplinary treatment of BPSD. Regulatory agencies are closely monitoring the management of BPSD. Accurate diagnosis and treatment of BPSD is an increasingly important skill for the provider. Keywords: BPSD, culturally appropriate, dementia, individualized music, interdisciplinary, older adult, regulatory Ó 2017 Elsevier Inc. All rights reserved.
DEMENTIA AND THE OLDER ADULT
T
he older adult population has demonstrated significant growth over the last 2 decades. Minority populations have increased from 18% of the total population in 2004 to 22% in 2014. Projections predict minority populations will increase to 28% of the total population by 2030.1 The United States Centers for Disease Control (CDC) reported that, in 2014, there were 1.4 million residents in long-term care facilities (LTCFs) in the US.2 Research indicates numbers of racial and ethnic minority patients in long-term care are increasing even faster than the minority population overall.3 Alzheimer’s disease and other forms of dementias are common diagnoses among patients in LTCFs. In the last quarter of 2016, in LTCFs, the Minimum Data Set (MDS) revealed a diagnosis of dementia at a prevalence of 42.87% in Medicareand Medicaid-certified facilities.4 The MDS is a federally mandated standardized process of assessing the clinical status of patients in Medicare- and Medicaid-certified LTCFs across the US and provides a listing of specific diagnoses among patients.
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BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA
Dementia has a significant impact on patients, families, and caregivers, and can affect quality of life. Patients with dementia may present with behavioral disturbances, which can impact the provision of care and place them at risk for injury. These behaviors have been termed as the behavioral and psychological symptoms of dementia (BPSD). Common to patients in long-term care with dementia, these behaviors can negatively affect quality of life for the patient and the ability of the staff to provide care. Symptoms may include agitation, aggression, psychosis, and other inappropriate behaviors.5,6 Negative and inappropriate vocalizations and wandering are other behaviors that can put the patient with dementia at risk. Based on the MDS reports for the last quarter of 2016, at least 18.8% of patients in long-term care with dementia have behaviors that interfere with daily activities. These behaviors showed a prevalence of 22.5%. Behaviors that placed other residents at risk for physical injury were reported at 12.49% and behaviors placing the resident themselves at risk for physical injury at 12.44%.4
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TREATMENT AND MANAGEMENT OF BPSD
The treatment and management of BPSD is multifold. Common practices include determining the underlying cause of the behavior, communication tools such as redirection, providing person-centered care, and the use of antipsychotic agents.4,7,8 Potential underlying causes of unprovoked behavior include: infection; pain; medication effects or toxicity; fear; abuse; boredom; hunger; and/or thirst. Communication tools may include redirection or change in approach to the resident. Redirection is used as a first-line intervention to reduce or eliminate wandering or negative vocalizations.9 Studies have emphasized the importance of and improved outcomes with person-centered care for patients diagnosed with dementia in the long-term care setting. This system emphasizes that, despite cognitive impairment, patients can still maintain their identity. Recognizing, understanding, and acknowledging the feelings of a person with dementia through care actions is central to person-centered care. Identifying things that have meaning to the patient are essential in this approach. Studies have shown that person-centered care offers an evidencebased approach in which caregivers can incorporate patient preferences, feelings, culture, and life history into patient interactions.9,10 Additional studies are warranted regarding interventions that support the benefits of developing culturally sensitive, personcentered dementia care. With increases in the overall and minority older adult population overall and minority long-term care admissions, appropriate person-centered, culturally based care becomes important in those with dementia.8,11,12 Antipsychotic medication use in dementia is not supported in the evidence-based literature and is not considered best practice. The Beers Criteria is an evidence-based list developed to help providers improve medication safety while prescribing for older adults. This list incorporates pharmacologic properties and the physiologic changes that occur with aging, which can render certain medications inappropriate in the older adult. Antipsychotics are listed as a potentially inappropriate medication choice in older adults, with strong evidence to support the potential for adverse outcomes.13 476
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The prescribing of antipsychotics is not approved by the US Food and Drug Administration (FDA) in patients with dementia due to numerous side effects and increased mortality. A black box warning was issued in 2005 by the FDA related to increased mortality risk. Studies revealed the mortality rate in patients taking an antipsychotic was 4.5%, compared with 2.6% in the placebo group.14-17 Best practices include management of BPSD with nonpharmacologic interventions, such as communication, redirection, finding underlying causes of behavior, and provision of person-centered care. Within the management tools of communication and person-centered care, the roles associated with cultural background become important in promoting quality of life for the increasingly diversified population of long-term care patients.11,12 ECONOMIC IMPACT
The economic impact for treating dementia and BPSD is growing and expected to continue to increase. By 2050, the projected expenditures for Alzheimer’s and other dementia care will reach $1.1 trillion.19 In 2011, Medicare Part D spending on antipsychotic drugs totaled $7.6 billion, which was the second highest class of drugs, accounting for 8.4% of Part D spending.18 Individual atypical antipsychotics average in price from $100 to $600 per month.20 TREATMENT INNOVATION FOR BPSD
Evidence points to the benefits of music interventions in improving outcomes in agitation and other symptoms of BPSD. Even in advanced Alzheimer’s disease (AD), some musical memories may be maintained. Cuddy and colleagues21 proposed that the close links to emotion evoked by music allows for access to lifetime events. Music is thought to promote a physiologic response that can evoke autobiographical memories.22-27 Music is diverse, encompassing a variety of cultural preferences and can be an effective component of person-centered care. Developing a personalized music list, which has meaning to the individual patient, may tap into these autobiographical memories. Invoking positive memories through personalized music is increasingly demonstrating positive patient outcomes, including Volume 13, Issue 7, July/August 2017
increased communication and decreased agitation.20-23 These positive outcomes can improve the quality of life for the patient and decrease caregiver burden. Recent studies have explored the potential benefits of music on adverse events, such as falls and wandering. The benefits of using personalized music in care has been recommended by the Music and MemorySM organization. This nonprofit group has a goal for personalized music playlists as a standard of care in all LTCFs and has brought to light benefits of the program. The documentary, Alive Inside: A Story of Music and Memory, and a winner of the Audience Award at the 2014 Sundance Festival, highlighted the benefits of personalized music playlists and the work of the Music and MemorySM organization.28 The documentary highlights the applicability across cultures of personalized music and has demonstrated the positive outcomes and applicability with personalized music across cultures. In 2014, Texas ranked the highest among the states for antipsychotic prescribing in LTCFs. Following initiatives started in Wisconsin, Texas has taken a proactive stance to educate providers, empower facilities, and provide alternate nonpharmacologic treatment options. Initially, grants were provided by the Texas Department of Aging and Disability to 32 pilot facilities to implement a music and memory intervention. The grants included facility certification in Music and MemorySM, 15 iPod shufflesÒ and head phones, and $75 worth of iTunesÒ music to download to the shuffles. The early results were so promising that the grants were extended to 200 additional facilities with plans to extend these grants to at least 100 additional facilities in the future. Since taking this proactive stance, Texas now ranks 42nd nationally for antipsychotic prescriptions in LTCFs. The overall prevalence of antipsychotic use had decreased to a prevalence of 18.5% in June 2016.29 STATE AND NATIONAL POLICY IMPLICATIONS
State and federal agencies continue to closely monitor the use of antipsychotics and measures to provide patient-centered care in the long-term care setting. In 2016, the Centers for Medicare & Medicaid Services (CMS) finalized policy that will: improve the safety www.npjournal.org
and care of LTCF residents; develop quality strategy initiatives that envision person-centered health care; provide incentives for the right outcomes; be sustainable; emphasize coordinated care and shared decision-making; and rely on transparency of quality and cost information. Within these CMS strategies are foundational principles that include culturally and linguistically appropriate care. Table 1 lists the 6 quality strategy goals in this initiative30 and potential benefits with the use of personalized music playlists in the management of residents with dementia and BPSD. NEW FEDERAL REGULATION IMPLICATIONS
LTCFs are required to meet regulations set forth by the Department of Health and Human Services. These regulations are detailed in the Code of Federal Regulations (CFR) Title 42, Public Health. Federal regulations are applicable to the use of individualized music playlists within specific sections of the CFR. Section (x)483.75 requires facilities to develop, implement, and maintain a comprehensive and effective Quality Assurance and Performance Improvement program that is data-driven. It should have 3 foci: (1) systems of care; (2) outcomes of care; and (3) quality of life. In addition, x483.25 states that residents must be assured treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the patient’s choices. Music lists based on patient preference and history can help to accomplish an individualized, comprehensive plan that may improve outcomes of care and patient quality of life. Specific requirements for comprehensive personcentered care planning are detailed in x483.21. This section has specific indications for the interdisciplinary team. Long-term care facilities are required to develop and implement an interdisciplinary care plan, which includes instructions to provide effective and person-centered care. The regulation also now requires the team to add a nurse’s aide and a member of food and nutrition services to the interdisciplinary team.31 The pharmacist as an interdisciplinary team member and, as new requirement in x483.45, is required to review the patient medication list during the monthly medication review and identify The Journal for Nurse Practitioners - JNP
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Table 1. US Centers for Medicare & Medicaid Services Quality Strategy Goals and Potential Use of Personalized Music Goals
Use of Personalized Music
Make care safer by reducing harm caused in the delivery of care
Evidence suggests a correlation between personalized music playlists and a decrease in the use of antipsychotics Studies suggest a potential decrease in falls and wandering
Strengthen person and family engagement as partners in their care
Culturally appropriate patient-centered care with family involvement in development and sharing of music playlist Studies suggest memory recall and potential for increased communication with family and staff
Promote effective communication and coordination of care
Studies suggest communication and verbalization with implementation of individualized music playlists Personalized music playlists can be linguistically appropriate across cultures and languages Potential widespread applicability across disciplines and health care settings
Promote effective prevention and treatment of chronic disease
Evidence correlates use of personalized music playlists and decreased behavior and psychological symptoms of dementia Studies suggest potential decreases in depression and anxiety with the use of personalized music
Work with communities to promote best practice of healthy living
Best practice in long-term care Potential applications to other patient settings
Make care affordable
Personalized music playlists are a fiscally responsible best practice Potential cost savings with the prevention of falls, and decreased need for antipsychotics, depression, anxiety
Data taken from the Federal Register.30
medications that can affect brain processing and behavior. The pharmacist is also tasked with assisting to implement strategies to reduce or eliminate all psychotropic drugs to safeguard the patient’s health. Facilities and health care providers must ensure that antipsychotics are only used to treat specific conditions diagnosed and documented in the clinical record. The CMS requires facilities to attempt nonpharmacologic interventions before using antipsychotic medications. In the event a patient requires an antipsychotic medication, the provider must, unless clinically contraindicated, attempt to gradually decrease the dose and utilize behavioral interventions. Table 2 lists some, but not all, examples of noncompliance with this requirement for patients in LTCFs.32 Some of the approved adult indications for atypical and typical antipsychotics include: bipolar disorder; schizophrenia; schizoaffective disorder; delusional disorder; acute psychotic episodes; adjunct in major depressive disorder; atypical psychosis; 478
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Tourette’s disorder; Huntington’s disease; and shortterm treatment of hiccups, nausea, and vomiting.33 The use of antipsychotics in patients with dementia can result in adverse patient outcomes as well as deficiencies cited for the facility during inspections and surveys. Table 2. Examples of Noncompliance Related to Antipsychotic Prescribing in LTCFs Failure to attempt gradual dose reduction in the absence of identified and documented clinical contraindications Prolonged or indefinite antipsychotic use without attempting gradual dose reductions Failure to implement behavioral interventions to enable attempts to reduce or discontinue an antipsychotic medication Failure to discontinue an antipsychotic, prescribed for acute delirium, once delirium symptoms have subsided Data taken from the Department of Health and Human Services.32
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INTERDISCIPLINARY TEAM APPROACH
As the delivery of care in LTCFs has become more complex and with the increased diversity among residents, the importance of a diverse health care team becomes evident from both a cultural and discipline point of view. Interventions that promote efficient and well-coordinated delivery of health care services are key to successful patient and facility outcomes. The use of personalized music playlists in patients with dementia can be a strategy to improve outcomes for patients with BPSD and appropriate for
the interdisciplinary team as well as for meeting federal regulations. Table 3 outlines specifics from CFR Title 42, Public Health x483.2126 and the potential interdisciplinary team members who can utilize personalized music lists with patients to help meet regulatory requirements and improve patient outcomes. This regulation also details the requirement for culturally competent care. Individualized music can be a culturally appropriate intervention to meet the needs of an increasingly diverse population in long-term care.
Table 3. Code of Federal Regulations Title 42 x483.21 and Interdisciplinary Team Members Comprehensive Person-centered Care Planning
Interdisciplinary Team Members
Baseline care plans: A baseline care plan for each resident must be established within 48 hours of admission to a long-term care facility (LTCF). This plan must include instructions needed to provide effective person centered care. Initial goals, physician orders, dietary orders, therapy services, and social services must be incorporated into the baseline care plan
Comprehensive care plan: A comprehensive care plan must be developed by the LTCF team within 7 days of admission to the facility. This comprehensive plan must be prepared by an interdisciplinary team
Required team members: Patient and family Health care provider Registered nurse Nurse’s aide Nutrition services Patient Patient family Potential additional team members: Therapy services-physical, occupational, speech Social worker Activities director Pharmacist
Quarterly Review Assessments: The LTCF team must perform quarterly review assessment. These should be reviewed and revised by the interdisciplinary team after each assessment. The baseline care plan, comprehensive care plan and quarterly review assessment must be culturally competent
Patient and family Health care provider Registered nurse Licensed vocational nurse Dietician Nutrition services Physical therapy Occupational therapy Social worker
Patient and family Health care provider Registered nurse Licensed vocational nurse Nurse’s aide Dietician Nutrition services Physical therapy Occupational therapy Speech therapy Social worker Activities director Pharmacist
Data taken from the Federal Register.31
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Development of comprehensive, person-centered care plans with individualized music playlists can be suggested or implemented by members of the interdisciplinary team, including family members. Potential implications for nursing, dieticians, nutrition services, and speech language pathologist involvement include improving patient communication and food intake with the use of personalized music. Physical and occupational therapy can potentially integrate personalized music during skilled sessions and be used as a potential strategy to decrease falls. Nurses, nurse’s aides, activity directors, and social workers can play key roles in the implementation of this strategy across the disciplines. Decreasing the use of medications, such as antipsychotics, is part of an appropriate care plan intervention for the entire team, including the pharmacist.31 The potential management options for BPSD incorporating the interdisciplinary team are promising and merit further study. CONCLUSIONS
Nurse practitioners are in a key position within the interdisciplinary team to promote culturally appropriate, person-centered management of BPSD. The use of personalized music in the management of BPSD as an evidence-based practice has positively impacted patient outcomes in long-term care. Personalized music playlists can be used as a first-line, nonpharmacologic treatment with an aim to reduce the need for antipsychotic medications. This fiscally responsible initiative has the potential for widespread applicability across a variety of health care settings and disciplines in meeting the diverse needs of patients. References 1. US Department of Health and Human Services. Administration on aging: profile of older Americans 2015. 2016. https://aoa.acl.gov/Aging_Statistics/ Profile/2015/docs/2015-Profile.pdf/. Accessed March 1, 2017. 2. US Centers for Disease Control and Prevention. Nursing home stats. 2016. https:// www.cdc.gov/nchs/fastats/nursing-home-care.htm/. Accessed March 1, 2017. 3. Feng A, Fennell M, Tyler D, Clark M, Mor V. The care span: growth of racial and ethnic minorities in the US nursing homes driven by demographics and possible disparities in option. Health Affairs. 2011;30(7):1358-1365. http:// dx.doi.org/10.1377/htlhaff.2011.0126. 4. US Centers for Medicare & Medicaid Services. MDS 3.0 frequency report. 2017. https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer -Data-and-Systems/Minimum-Data-Set-3-0-Public-Reports/Minimum-Data -Set-3-0-frequency-report.html/. Accessed March 1, 2017. 5. Alzheimer’s Association. Managing behavioral and psychological symptoms of dementia (BPSD). 2013. http://www.alz.org/documents_custom/hcp_MD_ BPSD.pdf/. Accessed March 1, 2017.
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6. Cerejeira J, Lagarto L, Mukaetova-Ladinska EB. Behavioral and psychological symptoms of dementia. Front Neurol. 2012;3:73. http://doi.org/10.3389/fneur. 2012.00073/. Accessed March 1, 2017. 7. Chenoweth L, King M, Jeon Y, et al. Caring for Aged Dementia Care Resident Study (CADRES) of person-centered care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial. Lancet Neurol. 2009;8(4):317-325. 8. Stein-Parbury J, Chenoweth L, Jeon YH, Brodaty H, Haas M, Norman R. Implementing person-centered care in residential dementia care. Clin Gerontol. 2012;35(5):404-424. http://dx.doi.org/10.1080/07317115.2012. 702654. 9. Yusupov A, Galvin JE. Vocalization in dementia: a case report and review of the literature. Case Rep Neurol. 2014;6(1):126-133. http://dx.doi.org/10.1159/ 000362159. 10. Testad I, Mekki TE, Førland O. Modeling and evaluating evidence-based continuing education program in nursing home dementia care (MEDCED)— training of care home staff to reduce use of restraint in care home residents with dementia. A cluster randomized controlled trial. Int J Geriatr Psychiatry. 2016;31(1):24-32. 11. Savundranayagam M, Sibaliia J, Scotchmer E. Resident reactions to personcentered communication by long term care staff. Am J Alzheimers Dis Dement. 2016;31(6):530-537. http://dx.doi.org/10.1177/1533331751562291. 12. Nápoles AM, Chadiha L, Eversley R, Moreno-John G. Developing culturally sensitive dementia caregiver interventions: are we there yet? Am J Alzheimers Dis Dement. 2010;25(5):389-406. http://dx.doi.org/10.1177/ 1533317510370957. 13. American Geriatrics Society. Updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-2246. http://dx.doi.org/10.2222/jgs.13702. 14. Rice J, Humphreys C. Off-label use of antipsychotic drugs in patients with dementia. J Nurse Pract. 2014;10(3):200-204. 15. US Food and Drug Administration. Atypical antipsychotic drugs. 2013. https:// google2.fda.gov/search?as_sitesearch¼https://www.fda.gov/Safety/Med Watch/SafetyInformation&q¼safetyþwatchþ2013þantipsychotics&client¼ FDAgov&proxystylesheet¼FDAgov&output¼xml_no_dtd&site¼FDA gov&requiredfields¼-archive:Yes&sort¼date:D: L:d1&filter¼1&ie¼UTF -8&ulang¼en&&access¼p&entqr¼1&entqrm¼0&wc¼200&wc_mc¼1&oe ¼UTF-8&ud¼1/. Accessed March 1, 2017. 16. Agency for Healthcare Research and Quality. Comparative effectiveness review, number 39. First and second-generation antipsychotics for children and adults. 2012. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0040940/ pdf/PubMedHealth_PMH0040940.pdf/. Accessed March 13, 2017. 17. Schneider L, Dagerman K, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebocontrolled trials. JAMA. 2005;294:1934-1943. 18. Centers for Medicare and Medicaid Services. Partnership to improve dementia care exceeds goal to reduce use of antipsychotic medications in nursing homes: CMS announces new goal. 2014. https://www.cms.gov/ Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases -items/2014-09-19.html/. Accessed March 13, 2017. 19. Alzheimer’s Association. 2017 Alzheimer’s facts and figures. 2017. http:// www.alz.org/facts/. Accessed April 19, 2017. 20. Antipsychotics, 2nd generation. Epocrates Plus (version 17.1). 2017. https:// epocrates.com/. Accessed March 13, 2017. 21. Cuddy L, Sikka R, Vanstone A. Preservation of musical memory and engagement in healthy aging and Alzheimer’s disease. Ann NY Acad Sci. 2015;1337:223-231. 22. Janata P. The neural architecture of music-evoked autobiographical memories. Cerebr Cortex. 2009;19:2579-2594. http://dx.doi.org/10.1093/ cercor/bhp008. 23. Blackburn R, Burns T. Music therapy for service users with dementia: a critical review of the literature. J Psychiatric Mental Health Nurs. 2014;21:879-888. http://dx.doi.org/10.111/jpm.12165. 24. Gerdner L. Use of individualized music by trained staff and family: translating research into practice. J Gerontol Nurs. 2005;31(6):22-30. 25. Long E. Effect of a personalized music playlist on a patient with dementia and evening agitation. Ann Long Term Care. 2016;24(11):31-33. 26. Ridder H, Stige B, Qvale L, Gold C. Individual music therapy for agitation in dementia: an exploratory randomized controlled trial. Aging Mental Health. 2013;17(6):667-768. 27. Matthews S. Dementia and the power of music therapy. Bioethics. 2015;29(8):573-579. 28. Music and Memory. Our mission and vision. 2016. https://musicandmemory .org/about/mission-and-vision/. Accessed March 13, 2017. 29. Texas Health and Human Services. 2016. Quality monitoring program: music and memory. 2016. https://hhs.texas.gov/about-hhs/communications-events/ news/2016/11/quality-monitoring-program-monthly-bulletin-november-2016/. Accessed April 16, 2017.
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30. Centers for Medicare and Medicaid Services. Federal Register. CMS quality strategy. 2016. https://www.cms.gov/Medicare/Quality-Initiatives-Patient -Assessment-Instruments/QualityInitiativesGenInfo/Downloads/CMS-Quality -Strategy.pdf/. Accessed March 13, 2017. 31. Medicare and Medicaid programs; reform of requirements for long-term care facilities. The Daily Journal of the United States Government. Federal Register. 2016. https://www.federalregister.gov/documents/2016/10/04/2016 -23503/medicare-and-medicaid-programs-reform-of-requirements-for-long -term-care-facilities/. Accessed April 29, 2017. 32. US Department of Health and Human Services. 2016. Center for Clinical Standards and Quality/Survey and Certification Group. Ref S&C 16-15-NH. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/ SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-15.pdf/. Accessed March 1, 2017. 33. Centers for Medicare and Medicaid Services. Atypical antipsychotic use in adults. 2013. https://www.cms.gov/medicare-medicaid-coordination/ fraud-prevention/medicaid-integrity-education/pharmacy-education-
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materials/downloads/atyp-antipsych-adult-factsheet.pdf/. Accessed April 19, 2017.
Elizabeth M. Long, DNP, GNP-BC, is an assistant professor at Lamar University in Beaumont, TX. She can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/17/$ see front matter © 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2017.05.003
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