Across Canada, residents in long term care who have dementia are often prescribed antipsychotics to manage the symptoms associated with the illness. In fact, Quebec has the highest rate of antipsychotic prescription among people aged 65 and older with between 40 and 60 percent of residents in certain long term care facilities prescribed antipsychotics.
But now that is changing.
The Optimizing Practices Use, Care Services -Antipsychotics (OPUS-AP) is a province-wide initiative in Quebec that aims to change that by improving the quality and experience of care in long term care centres (CHSLDs) for people with dementia, their loved ones and staff and reduce the inappropriate use of antipsychotics.
Residents of the participating unit at the Camille Lefebvre Long Term Care Pavilion, which is part of the Lachine Hospital, have unique and complex needs. In some of their units, patients have complex psychiatric illnesses, as well as dementia. This makes adjusting and prescribing medications more challenging.
This didn’t stop staff from feeling excited and committed to the project. It just meant they had to thinking differently and take a creative approach to implementing the program.
“We believed we needed this project,” said Amelia Joucdar, Clinical Nurse Specialist, Nurse Clinician at Lachine Hospital and the project lead. “We were happy to see that it was well structured with lots of support. We are a small hospital, but we are part of a big university centre —McGill University Health Centre (MUHC).”
Because of their unique challenges, the team reached out to the MUCH pharmacy department to seek out the support and professional guidance of a geriatric pharmacist. They also partnered with a physician from the Douglas Mental Health Institute in Montreal, which is part of their health network. When they are unsure of a resident’s diagnosis or concerned that there may be an underlying undiagnosed psychiatric illness, they can send the resident to the Douglas for evaluation. This helps ensure residents receive a clear diagnosis and an appropriate medication can be prescribed.
“Once we got started, we built our team and identified champions on the floor,” said Joucdar. “We went very slowly, one resident at a time. We wanted to be sure we had input from frontline staff and we didn’t want staff to feel overwhelmed.”
The good news is that the unit already had a very strong culture of safety and improvement. They were accustomed to PDSA cycles (Plan, Do, Study, Act) which allowed them to document and test the changes, as well as regular huddles – brief, weekly discussions that focus on the action plan for the week, and help the team review how things are going and flag any concerns. Both are important tools in the team’s toolbox to help them manage the change associated with the project.
Using a person-centred approach to care, staff engage residents and their family in developing alternative approaches to care that consider the resident’s preferences and that ensure the resident feels safe and comfortable. This can include offering therapies and recreational activities that are meaningful and enjoyable.
For the team at Lachine Hospital, this was an opportunity to get creative and think outside the box.
“The evening can be a time when residents experience challenging behaviours related to dementia,” adds Joucdar. “And we don’t have a lot of staff in the evening. So we started looking at group activities that don’t require a lot of supervision and that would interest as many people as possible.”
They started a colouring club. They offered puzzles, and modelling clay. There are also several ladies on the unit who enjoy looking their best. For them, they purchased nail polish and together they could give themselves manicures. For the group who liked to sing? They printed out song sheets with large characters.
“We invested in little things like that. You don’t have a lot of staff to constantly redirect them. During the day they are calm, because they are occupied. Now we have quite a bit happening in the evening. And these were all ideas from the frontline team. I was just really impressed – they took on the project and they made it their own.”
Joucdar says that because staff could see positive results, they became even more involved and committed to the success of the approach.
“It was nice for them, because the more we would de-prescribe, the more they [the staff] would we see their [resident’s] personalities emerge. The more they can interact with residents.”
The change has not been without challenges. For example, Joucdar said that the first phase of the project really demonstrated the gaps in staff’s knowledge about dementia and these medications. For Phase 2, they know that staff need intensive training before work gets underway.
“In Phase 1, even though staff were learning along the way as part of our PDSA cycles, we realized that they didn’t have the knowledge they needed to put in place the right kind of interventions. We realized if team members had been trained from the beginning it would have been a lot easier. In Phase 2, we’ll provide more upfront training.”
The team is enthusiastic about Phase 2 and ready to get started. Joucdar is clear, not only is it important for the team to have the tools and knowledge they need for the program to be successful, but the facilities administration has been a significant driver of the change.
“To have the head of pharmacy say, ‘Yes, I will lend you a pharmacist’. To have the head of the hospital say, ‘I will meet with you regularly to make sure things are going great’. To have our institution recognize this as a priority and give us the means to do it as well has made a difference.”
Last Updated: February 2019