Presentation - Dr. Duncan Robertson

“Challenging Behaviours”,
or is it Behaviours that Challenge us?
How AHS Seniors’ Health SCN will collaborate in addressing
this challenge.
Presentation by
Duncan Robertson
Senior Medical Director
Seniors’ Health SCN
Challenging Behaviours Meeting
Corbett Hall. University of Alberta
• Strategic Clinical Networks (SCN) in AHS
• Seniors’ Health “Platforms” 3-5 years
• Initial Projects for 2013-14
• Questions
Challenging behaviour – defined
"culturally abnormal behaviour of such intensity,
frequency or duration that the physical safety of the
person or others is placed in serious jeopardy, or
behaviour which is likely to seriously limit or deny
access to the use of ordinary community facilities"
and may be exhibited by people with developmental
disabilities, dementia, psychosis and by children.
- Emerson E 2001 ISBN 9780521794442
Behaviours that challenge us in the context of
dementing illnesses
Angry (aggressive) behaviour
Excessive walking (wandering behaviour)
Repetitive behaviours
Vocally disruptive behaviours
Disinhibited behaviours
What are Strategic Clinical Networks (SCNs) ?
• Collaborative clinical teams (with a strategic mandate)
• Led by clinicians and driven by clinical needs
• Comprised of:
• Front-line Clinicians
• Zone and Other Clinical Operations / Clinical Support
Service Leaders
• Researchers
• Content Experts
• Public / Patients
• Alberta Health & other external partners
Six SCNs Launched in 2012
Obesity, Diabetes and Nutrition
Bone and Joint Health
Cardiovascular Health and Stroke
Addiction and Mental Health
Cancer Care
Seniors’ Health
Ogden Nash (1902-1971)
Crossing the Border
“Senescence begins
And middle age ends
The day your descendents
Outnumber your friends.”
• Today, 1 in 9 Albertans is over 65 years of age
• In 25 years, 1 in 5 Albertans will be a senior
• 47% of Alberta seniors have a health condition that
limits their everyday activities
• Alberta seniors visit emergency departments at twice
the rate of non-seniors
• Alberta seniors are admitted to an inpatient unit at 5
times the rate of non-seniors.
• Dementia and delirium are major contributors to LOS,
ALC days and admissions to LTC
What is the Provincial Mandate of SCNs?
• To:
– Improve population health
– Ensure continuous quality improvement
– Incorporate research that impacts patients
– Focus on patient outcomes
– Design more accessible care
– Develop & implement appropriate clinical practices
– Make patient safety a priority
– Ensure value for money
Alberta Seniors Population Growth 2005-2020
• Today: Seniors make
up 10.6% of Alberta’s
• Seniors make up
14.6% of the
Non-sustainable healthcare cost increases in
34.2 M
Canada 1975 to 2010
• Expenditure increases = 3.5 fold
• Population increases = 1.5 fold
Seniors Health SCN Platform 1
Aging Brain Care:
Aging Brain Care Pathway incorporates:
• Healthy Brain Aging
• Prevention, diagnosis, treatment, and
management of co-morbidity
• Advance care planning and issues for
individuals and caregivers
• EOL care
Seniors Health SCN Platform 2
Healthy Aging and Seniors Care:
• Health Promotion and Prevention
• Development of a Care Pathway to guide
citizens, families and caregivers, practitioners
and others on the patient journey of the frail
elder across the care continuum.
Initial Project: Elder Friendly Care 1/2
What is the problem?
• One-third of frail seniors develop new
functional disabilities in hospitals as a result
of delirium, immobility, falls, prolonged
catheter use and infections.
• Result is longer LOS, discharges to higher
level of care, loss of independence and
reduced well-being.
Initial Project: Elder Friendly Care 2/2
What is the solution?
• Multiple interventions to prevent unintended
outcomes of hospitalization
• Start in hospital sector and move to other
parts of continuum
Elder Friendly Care Strategies
Delirium Prevention, Detection & Management
Preventing Functional Decline (through mobility)
Continence Management (reduced use of catheters)
Nutrition & Hydration
Comfort Rounds (being evaluated in Calgary Zone)
– Scheduled nursing rounds at least q2h to improve
inpatient care safety and quality
– Includes communication, toileting, positioning,
nutrition, hydration, & pain management
Why Elder Friendly Care?
• AHS/AH Priority - HQCA Ministerial Directive to reduce
ALC days and occupancy in hospitals; Destination Home
• Builds on successful delirium screening component of
Bone & Joint Hip Fracture Pathway
• Builds on Zone priorities:
- Calgary Zone: Elder Friendly Care Project in hospitals
already underway; Destination Home in Home Care
- Central Zone: priority on improving elder care in Red Deer
Regional Hospital
- Edmonton Zone: alignment with Care Transformation Project
in acute care hospitals
Elder Friendly Care - Appropriate Use of Catheters
What is the problem?
• Unnecessary use of catheters leads to high
infection rates, antimicrobial resistance,
immobility, delirium, falls, longer LOS and
poor patient experience
• Risk is highest for seniors in emergency and
inpatient units, especially those with dementia
Elder Friendly Care - Appropriate Use of Catheters
What is the solution?
• Guidelines for insertion of catheters (“7
reasons only”)
• Nurse-led protocol for removal, checked daily
• Reminder system
Philippus Theophrastus Aureolus Bombastus
von Hohenheim (1493-1591 alias Paracelsus )
Alle Ding' sind Gift und
nichts ohn' Gift; allein
die Dosis macht, dass
ein Ding kein Gift ist.
“all things are poison
and nothing is without
poison, only the dose
permits something not
to be poisonous."
Initial Project :Appropriate Use of Antipsychotics
What is the problem?
• Over 1 in 4 residents in Long-Term Care (LTC) facilities in Alberta
receive antipsychotics for management of behaviours
associated with dementia
• Evidence exists for harm when used
inappropriately and for long periods of time – including loss of
mobility, loss of cognition, stroke, falls, death
Prevalence of Antipsychotic Drug Use in Absence of Psychotic and Related
Conditions (%) - April 2011 - March 2012
Edmonton Central
Rest of
North Zone
South Zone Alberta
US Initiatives on Antipsychotic Use in Care
Facilities 1/2
1987 OBRA Act (Implemented 1990)
Appropriate Diagnosis
Target Symptoms
24-Hour Dose Guidance
Concurrent Behavioral treatment
Attempt to Reduce d/c in 6 Months
US Initiatives on Antipsychotic Use in Care
Facilities 2/2
• 2007 Iteration of OBRA
– If used, must document 2 attempts at GDR* at least 1
month apart in 1 year
– If used over 1 year must document:
• Worsening of Sx when D/C
• MD opinion why no further D/C attempt
• 2005 FDA “Black Box Warning”
* Gradual dose reduction
Appropriate Use of Antipsychotics
In Collaboration with A&MH SCN
What is the solution?
- Use antipsychotics only when required according to
- Identify non-pharmacological approaches for
challenging behaviours
- Educate on behaviour management practices
- Engage families, government and advocacy groups
Why Appropriate Use of Antipsychotics?
• Alberta Health Continuing Care Health Service Standards
• Accreditation Canada Standards
• American Geriatric Society’s Updated Criteria (2012) for
Potentially Inappropriate Medication Use in the Older
• AHS Seniors Health Medication Management Initiative and
Cognitive Impairment Strategy
• Public, government and media concerns
• Zone Priorities: All Zones Participating

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