Welcome back. My name is Marianne Smith and I’m an Assistant Professor in the University of Iowa College of Nursing. In this part of the training program we’re going to talk about the important role of non-drug interventions. As the Algorithm for Treating Behavioral and Psychological Symptoms of Dementia indicates, non-drug interventions are used to address problems that persist after antecedents and triggers have been adequately treated. The term “non-drug” is broad, and encompasses caregiver approaches and routines, environmental adaptations, and specific psychosocial interventions that have been evaluated for use in dementia care. Let’s return to the story of Mrs. Klein. As we reviewed earlier, Mrs. Klein was admitted to the memory care unit of the Pine River Nursing Facility when home care demands became overwhelming to her husband. Baseline behaviors soon after admission included wandering, elopement attempts, distractibility at mealtimes, resistance to personal cares, and language deficits that interfered with communicating her wants and needs. Within the first month of admission, additional problems emerged, including failure to recognize her husband during his daily visits, suspiciousness about her husband’s whereabouts, nighttime wakefulness, increased restlessness and pacing, daytime napping, and distractibility and refusal to eat that resulted in an 8 pound weight loss. These new behaviors were reviewed individually to identify possible antecedents and/or triggers using a collaboration approach that involved communication among Mr. Klein, the facility staff, and the primary care provider. Her care team determined that she was suffering symptoms of delirium, with contributing factors of medication toxicity, infection, and dehydration. These were addressed using a combination of medication and non-drug interventions. Nearly all new behaviors resolved without use of antipsychotic medication. Problem behaviors that persisted after delirium resolved were focused on Mrs. Klein’s husband. Although she again recognized him and enjoyed his visits, her questions and comments about his whereabouts and activities increased. Instead of asking for her husband, she now demanded to know where he was. The gist of her worries had a jealous tone, and in fragmented sentences, suggested Mr. Klein may be with another woman. Repetitive comments and questions directed at other residents and staff alternated with softer muttering and nonverbal behaviors that indicated a combination of worry, fear, frustration, and anger. Her earlier wandering and searching behavior now focused on finding her husband and “that woman.” Secondary problems included resistance to enjoyable activities, and in turn, greater isolation and time to worry. Although her individualized nutrition plan was in place, food refusal and associated weight loss re-emerged. The memory unit staff focused their problem-solving on antecedents and triggers, as outlined in the algorithm. They looked to see whether there were triggers in all 4 areas – physical, psychological, environmental, and psychiatric. Physical causes were reviewed again, but revealed nothing new. Mrs. Klein’s dependency on her husband was well known. She preferred his company and care, and consistently resisted group activities with other residents. They observed that Mrs. Klein’s searching and repetitive questions tended to escalate late in the day, and were particularly problematic in the evening hours. The reassuring effects of her husband’s mid-day visits tended to wear off by the evening. Although her appetite was not good throughout the day, the evening meal was particularly challenging. She rarely sat to eat, and refused offers of “finger foods” to consume while she wandered. Common responses to encouragement included “it doesn’t taste good” or “right.” Psychotic disorder, not otherwise specified, was considered as a possible cause of Mrs. Klein’s recent jealous and suspicious behavior. Depression was also considered given her change in appetite, and excessive worry about her husband. Depression assessment included the MDS Staff Assessment of Mood items. Staff who provided daily cares noted that appetite disturbance and irritability were nearly every day. However, other symptoms were minimal or not present, resulting in a score of 9 out of 30 that suggested minimal depression. Given Mrs. Klein’s confusion, the social worker suggested using the Cornell Scale for Depression in Dementia to double-check their findings. As before, staff who worked with Mrs. Klein on a regular basis and knew her well were asked to rate the 19 items. In keeping with her MDS Mood score, the CSDD score of 8 of 38 indicated mild depression. Staff concluded that depression should be monitored, and that interventions aimed at behavioral activation may be helpful, but that medication wasn’t indicated at this time. Problem-solving continued by examining factors that would influence the selection of non-drug interventions that might distract, engage, and comfort Mrs. Klein. The main antecedents, time of day, inactivity, and longing for her husband’s presence, were discussed with Mr. Klein. Additional social history gathered from Mr. Klein helped staff develop person-centered approaches to Mrs. Klein. Of note, Mr. Klein believed his wife’s preoccupation stemmed from long-standing jealousy about a Korean girl he befriended when he was in the service. He emphasized the girl was only a friend, but his wife never quite understood or accepted that. He also stressed that his wife was “never crazy” until now. Mr. Klein also indicated that his wife’s long-standing activity preferences were for things she did alone, with her children, or as a couple – not with larger groups. He noted her main hobbies were cooking, sewing, and needlework, and that she also enjoyed music and dancing. In fact, they met at a dance sponsored by their church. The algorithm for treating behavioral symptoms provides a reminder of interventions to promote comfort and function based on adjusting caregiver approaches and the environment. The team worked in cooperation with Mr. Klein to develop care approaches and interventions aimed at helping Mrs. Klein be more comfortable and engaged. Part of the plan involved adjusting approaches to Mrs. Klein. Staff agreed that NOT disagreeing or challenging misbeliefs was critically important. Instead, they would attempt to reassure, comfort, and distract her using interventions that were tailored to her lifelong history. Changes in the environment included asking Mr. Klein to visit later in the day and share the evening meal with her. The goal was to see if the positive effects of his visit might offset negative behaviors later in the day, and if other activities might be substituted earlier. With the help of family, her room was decorated with pictures and favorite belongings that facilitated staff interactions about her family and lifelong history. These items also provided an important means to redirect her to happier times in her life when she was distressed. The algorithm for treating behavioral symptoms provides a reminder to personalize the approach by selecting interventions for specific problems in combination with caregiver approaches and changing the environment. Additional interventions chosen by the staff drew on Mrs. Klein’s lifelong history and interests. Her favorite music was played in her room to stimulate and soothe her. Simple Pleasures sewing cards were offered in lieu of needlework. A memory book about her early years, marriage, and children was developed by her daughter to use in 1 to 1 interactions with staff, and pictures of her needlework were put in a another memory book with the help of a volunteer. A video of her husband talking with her (simulated presence) was developed and played by the activity staff when she asked “where he was.” Telephone calls from children and grandchildren were “scheduled” with their cooperation as a pleasant activity. Dancing was offered in evening when her husband visited. Validation approaches (not arguing with misbeliefs) were emphasized, along with attempts to gently redirect her to happy memories using pictures and objects as cues. As the plan was implemented, the care plan coordinator and evening charge nurse both observed that some staff were not using the identified approaches in daily care. Further discussion revealed that some nursing assistants were not familiar with the recommended approaches, and a few others believed that NOT correcting Mrs. Klein’s misbeliefs was the same as “lying” and thus wrong. A staff training program was scheduled to review the underlying principles of the interventions being used. Stronger team approaches were developed to help staff who were inexperienced, or resistant. A “buddy” system was implemented so that desired interventions could be role modeled by more experienced staff. During the meeting, staff were asked to share their success and failure stories so all team members could benefit from what worked, and what didn’t work. The care plan included a number of specific outcomes that were documented at set intervals to help guide care plan revisions and the need for additional interventions. The social worker repeated the Cornell depression scale at weekly intervals to monitor overall changes in irritability, anxiety, and activity involvement. In addition, an individualized behavioral log targeting the frequency, intensity, duration, and quality of suspiciousness and abrasive interactions was developed and completed by nursing personnel each shift to track patterns of behavioral disturbance and possible delusions. Frequency and severity of food refusal, and her reasons for it, were also monitored and documented. In tandem, activity staff developed a simple coding system that was used by all staff to monitor Mrs. Klein’s responses to individual, one-to-one and small group activities, such as music, sewing cards, phone calls, and conversations. Physical indicators included weekly weights, daily episodes of incontinence, and number of water and juice bottles consumed. The change in approaches, routines, and environment – along with the addition of soothing and reassuring activities – reduced Mrs. Klein’s worried, demanding, and irritable behaviors. Threatening behaviors toward staff and other residents resolved as a set routine of pleasant activities was implemented. Although she still didn’t participate in the facility’s large group activities, she responded well to the individualized, 1 to 1, and small group approaches. In contrast, her food intake continued to decline. In spite of various adjustments to her personalized nutrition plan, her weight decreased 10 pounds over 2 months. Comments about food “not tasting right or good” extended to all meals, not just supper. Although Mrs. Klein’s appetite problems and weight loss had been attributed to depression, comments to her husband over dinner raised questions about psychosis. Mr. Klein reported that his wife told him to not eat, that the food was poisoned. In spite of his assurance that the food was good, and tasty, she shook her head and refused to eat. The next part of our series discusses strategies for involving the family or patient in the decision of whether or not to use an antipsychotic. This is known as shared decision making. Thanks for listening.