• The Evidence Integration Triangle for Management of Behavioral Psychological Symptoms of Dementia

      Anderson, Courtney E.; Yarbrough, Karen (2020-05)
      Problem and Purpose Behavioral Psychological Symptoms of Dementia (BPSD) are described as symptoms of apathy, agitation, inappropriate vocalization, aggression, wandering, and resistance to care. Incorrectly managing BPSD can lead to the improper administration of psychotropic medications, which can negatively impact the health and quality of life for residents with dementia. The purpose of this quality improvement project was to implement the Evidence Integration Triangle for Management of Behavioral Psychological Symptoms of Dementia (EIT-4-BPSD) in a nursing home. The Evidence Integration Triangle is a four-step implementation framework that includes participatory implementation processes, provision of practical, evidence-based interventions, and pragmatic measures of progress towards goals. Methods The EIT-4-BPSD was implemented over a ten-week period. The four steps included: Step 1: Assessment of the environment and policies; Step 2: Education of staff; Step 3: Establishing person-centered care plans; and Step 4: Mentoring and motivating staff. Outcomes were evaluated pre and post-implementation. Resident outcomes were obtained from the Minimum Data Set National Database and included: use of psychotropic medications and falls. Staff outcomes included knowledge of person-centered behavioral approaches for BPSD based on a 10-item multiple-choice test. Facility outcomes included evaluation of a random sample of five de-identified care plans to evaluate for evidence of incorporation of person-centered approaches to managing BPSD. Results Patient outcomes revealed a 12.5% decrease in the administration of psychotropic medications and a 5.6% decrease in falls. Nurse’s post-test knowledge of person-centered management of BPSD increased from 63.5% to 70% post-implementation. Evidence of established personcentered care plans increased from 40% at baseline to 90% post-implementation. Conclusion The EIT-4-BPSD intervention was practical to implement and provided the staff with information and resources to help integrate person-centered behavioral approaches into care plans and routine clinical care. Ongoing work by the nurse champion is needed to continue to maintain the focus on the use of person-centered behavioral approaches.
    • Implementation of Cognitive Stimulation Therapy in Long Term Care

      Regan, Claire E.; Yarbrough, Karen (2020-05)
      Problem and Purpose: Individuals with dementia are often treated with psychotropic medications despite harmful side effects. Cognitive Stimulation Therapy (CST) has been shown to improve cognitive functioning and quality of life (QOL) in individuals with dementia and reduce adverse behaviors. The aim of this quality improvement (QI) project was to implement a CST program in a long term care facility for residents with dementia to decrease the number of adverse behaviors, reduce the use of psychotropic medications and improve cognition and quality of life. Methods: This quality improvement project was implemented in a 200 bed long term care facility in Baltimore City. Nine residents were selected to participate in a sevenweek CST program. A DNP student performed the CST sessions twice a week for 45 minutes. Content was based on activities outlined in the CST program manual, with a different theme for each session that incorporated cognitive stimulation, reality orientation, reminiscence therapy, and validation therapy. Outcome measures included the St. Louis University Mental Status (SLUMS) Exam and the Quality of Life in Alzheimer’s Disease (QOL-AD) Scale. Assessments were completed pre- and post-implementation. Psychotropic medication use and the frequency of adverse behaviors were monitored through chart audits performed bi-weekly. Results: Eight residents completed the full seven-week CST program. All participants attended at least half of the sessions. There was an overall average increase in SLUMS scores of 19% with a mean pre-implementation score of 16.75 and mean post implementation score of 20. QOL scores improved an overall average of 12% for six of the eight participants, and an average decrease of 20% for two participants. Deficiencies existed which prohibited the ability to accurately evaluate behavioral charting completed by the staff. There was no change in the use of psychotropic medications for residents enrolled in CST. An important secondary outcome was the observation of increased sustained socialization of residents when not participating in CST. Conclusion: CST improves cognitive functioning and may be correlated with the improving QOL of some residents. Additional research is needed to further investigate the effect CST has on increasing or sustaining socialization for long term care residents.
    • Screening for Depression in a Rural Primary Care Setting

      Wallander, Jacquelyn C.; Yarbrough, Karen (2020-05)
      Problem and Purpose: The United States Preventative Services Taskforce recommends depression screening in the general adult population. Patients with untreated depression have higher morbidity rates in many diagnosis groups. Detecting and managing depression allows patients to better self-manage chronic diseases and contributes to an overall sense of improved well-being. In a private primary care setting a practice gap existed in which patients were not routinely screened for depression. The purpose of this quality improvement (QI) project was to implement a screening process for adults in a primary care practice to detect depression symptoms and offer treatment if indicated. Methods: The primary aim of this QI project was to implement a depression screening process for adults in a primary care practice using the Patient Health Questionnaire-9 (PHQ-9), a validated depression screening instrument. Primary outcomes measured: provider compliance in obtaining depression screenings and calculating the percentage of patients identified with depression. Eligible patients were aged 18-64 being seen for an annual exam with two Nurse Practitioners (NP). The NPs were provided PHQ-9 education and weekly reminders to complete the screening. During each patient annual exam, the patient was provided a copy of the PHQ-9. The NP reviewed results and treated when indicated. Charts were audited weekly for: provider compliance and depression classification. Results: Depression screening compliance was 67%, (n=30/45) and 30% of patients screened (n=9/30) were diagnosed with depression. All depressed patients were offered treatment. 20% were new depression diagnoses (n=6/30) and 10% had a history of depression (n=3/30). 13% (n=4/30) of patients were provided referrals to psychotherapy and 7% (n=2/30) were started on a medication for depression. The majority of the positive depression screenings (67%, n=6/9) were detected as mild. Conclusion: Depression screening using the PHQ-9 instrument is an effective way to detect depression. This will reduce the untreated depression rates in the practice and connect patients to proper treatment. Once depression is managed, patients are able to better self-manage chronic diseases. Implementation of the PHQ-9 into the provider workflow will increase depression screening compliance. As a result of this project, the primary care practice built the PHQ-9 instrument into the electronic health record to facilitate provider compliance.