Skilled Nursing
Articles
Nonpharmacologic Management of Behavioral Issues
December 16, 2024Creating and sustaining such a culture that prioritizes nonpharmacologic interventions can be challenging, especially when access to resources is limited, turnover makes it difficult to keep staff trained consistently, and the proliferation of misconceptions and lack of communication all contribute to psychotropic prescribing and use.
Jeffrey Herr, PharmD, manager of clinical operations at PharMerica further noted, “Nurses have to spend so much of their time complying with regulations. They have less time for direct patient care and often feel stressed out and frustrated. Strategizing and implementing nonpharmacologic interventions take time, and this is in short supply in most facilities.”
However, there are some steps facilities can take to boost a focus on nonpharmacologic strategies for behavioral issues:
1. Tailor nonpharmacologic interventions so they are as quick and easy as possible.
Herr stated, “Consider some simple interventions such as changing ambient lightening, utilizing white noise, or reducing caffeine intake for someone with sleep problems. Train staff to assess and identify what might be causing a behavior and what easy-to-implement interventions might be effective.”
2. Involve family and caregivers in care planning.
Family members, caregivers, and others who know the resident may be able to offer insights into what triggers or traumas they have, what their life and habits were before admission, and what kinds of things might agitate them (e.g., they have a fear of spiders) or calm them down (e.g., they love dogs or flowers).
3. Focus on what is best for the resident.
“When I talk with nurses dealing with situations, I remind them that this is our focus,” said Herr. This means, he noted, not just putting or keeping a resident on psychotropics because the family likes that mom is calm or it makes them easier to care for. Instead, he said, “We have to focus on medical justification and risk versus benefit; then we have to document this in the progress notes.”
To simplify this, Herr suggested creating an SBAR/EMR assessment for staff to complete before a psychotropic is started. This will help document that there is a valid indication for the drug, that nonpharmacologic interventions were tried, and that behavior and side effect monitoring processes are in place. Regularly scheduled psychotropic/behavior meetings also can be effective. However, prescriber engagement is necessary for these to be successful.
4. Remember it’s about trial and error.
There is no panacea for addressing behavioral issues. Instead, Herr suggested, “We have to make choices based on the information we have and balancing the risks and benefits. We have to be willing to try things and see what happens. If they don’t work, we regroup and try something else.” It also is important to realize, he said, that if trying a feasible solution once doesn’t work, it’s worth trying it again another day or another time before discarding it.
5. Communication is key.
All stakeholders must have up-to-date, accurate information, and they need to be able to share thoughts, suggestions, and recommendations. For instance, the prescriber and the consultant pharmacist must be able to communicate to improve gradual dose reduction (GDR) success, which includes one-on-one communication. Team members and families should be schooled on the risks and benefits of psychotropics and when it might be appropriate to use these medications as well as when they aren’t indicated or appropriate.
6. Implement a strong psychotropic stewardship program.
An effective, detailed, and clearly defined stewardship program can help ensure that when psychotropics are used, they have the appropriate diagnosis/indications, outcomes are being monitored, adverse events and side effects are identified and addressed promptly, and opportunities to lower dosages or discontinue the medications are ongoing efforts.
“Stewardship doesn’t mean ‘cookie-cutter’ care,” Herr stressed. In fact, he said, “Stewardship reminds us to take one patient at a time.”