SIGN Vol 20, Issue 4 July/August 2013

President's Message: A Clear Picture Ahead Matters

I recently had an opportunity to learn that replacing the wiper blades on my car certainly makes it easier to see the road ahead.  I’m sure some of you can relate.  You switch on the windshield wipers only to find that they don’t seem to be clearing the water like they used to, the road is a blur and your heart is racing because you truly can’t see where you are going.
Advances in science, rapidly shifting regulations and reimbursement and changing expectations of gerontological nurses in all settings are appearing at every turn.  Having a clear view ahead adds to peace of mind.  NGNA members can take advantage of many resources to keep a clear view of the road ahead.  
Our growing e-Learning Library now includes options for the NGNA/Hartford Institute for Geriatric Nursing monthly webinars.  These are a great way to get discounted continuing education credits and hear from national experts on evidence-based practice in gerontological nursing.   If you miss the live, interactive webinar programs, no worries.  The programs are archived for on-demand access. There are also no cost e-Learning courses on our website.  Our journal, Geriatric Nursing continues to be packed with quality evidence to guide nursing practice. 
And of course, our 2013 Annual Convention is quickly approaching, October 3-5, 2013 at the Hilton Clearwater Beach in Florida.  This year’s theme A Clear Vision of Care for the Older Adult is guiding an exciting and dynamic program to equip nurse educators, researchers, administrators and clinicians with the latest knowledge to be more effective in our roles. 
It takes time to fill up the passion meter and stay on top of the latest best practices in gerontological nursing care.    I encourage you to give your view of gerontological nursing a tune-up.  Take advantage of opportunities to access resources and network with your peers at NGNA!  
Warm regards,

 Convention Planning Committee Update

Submitted by Colleen Steinhauser MSN, RN-BC, Convention Planning Committee
As an educator teaching a stand alone Gerontological Nursing course, I start each course by asking how many students want to work in Labor and Delivery (a few raise their hands), then I ask how many students want to work in Pediatrics (a few more raise their hands). Finally, I ask how many students want to be gerontological nurses. I might get one or two in a class of 45 students.  I then inform them that everyone who did not raise their hands earlier will be a gerontological nurse in some way.
I have been excited to see that NGNA has included options during our Annual Conventions to help draw our younger nurses to become active and interested in Gerontological Nursing.  We will host our Student Networking Session on Saturday afternoon to give students an opportunity to meet mentors in our profession.  Students can ask questions to learn more about our specific population as well as gerontologic nursing certification. 
Another draw for students to become involved is with our Student Poster Presentations.  Each year we invite students to present their work as undergraduate and graduate students in the area of Gerontological Nursing.  Our current deadline for Student Poster Presentations is August 30, 2013.  More information can be found by clicking here.
This year we will hear from Mary Lou Brunell who will be giving a presentation titled, "Will There Be a Nurse Workforce to Care for the Older Adult?"  Older adults often present with multiple co-morbid conditions, and the Institute of Medicine’s 2010 Future of Nursing Report hallenges us to have a qualified and adequate nurse workforce to meet our patients’ health needs.  I look forward to hear what she has to say.
Please take a look at the Conference Brochure to see all of the educational offerings the convention planning committee has arranged.  We have offerings to match whatever your area of specialty: acute care, long term care, and education.  The brochure can be viewed by clicking here and online registration is now open.  On behalf of the convention planning committee, we look forward to seeing you there.

Coming to the NGNA Annual Convention in October - Don’t miss this important and timely presentation!
By Ruth Tappen, EdD, RN, FAAN

INTERACT ™ (Interventions to Reduce Acute Care Transfers) is a quality improvement program designed for long-term care facilities. It is unique in its focus on improving care within the facility while helping to reduce costly transfers to acute care. First developed in Georgia, then tested in New York, Massachusetts and Florida, it is now being implemented nationwide.

At the 2013 NGNA Annual Convention in Clearwater, Florida, a top member of the INTERACT team, Dr. Ruth Tappen will explain the components of INTERACT, the three primary strategies employed to reduce unnecessary rehospitalizations, and detail key strategies for successful implementation. She will also describe current INTERACT initiatives and provide us with some of the evidence gathered to date that reflect its effectiveness.

Interested in learning more? We’ll be looking for you at the beach in Clearwater!

Antipsychotic Use in Nursing Homes: Problem and Alternatives

Submitted by Kerry Jordan MSN, ACNS-BC, CNL
Edited by Che Reed MSN, CNL

The prevalence of dementia among individuals living in the United States aged 71 and older is currently estimated to be 13.9 percent (Plassman, Langa, Fisher, Herringa, Weir, Ofstedal et al., 2007).  This percentage is expected to increase exponentially as the population of those 85 years and older doubles in coming decades (U.S. Census Bureau, 2010). Consequently, measures protecting this vulnerable population are needed to ensure appropriate care.
One area of concern is the prolific use of antipsychotics in the treatment of neuropsychiatric symptoms associated with dementia in nursing home patients. Antipsychotics are often administered to people with dementia without specific FDA approval and rates of antipsychotic use in nursing homes have increased since 1999 (Lester et al., 2011). Individuals with dementia receiving these medications may experience disastrous effects. The purpose of this article is to examine current use of antipsychotics in nursing home patients with dementia and describe potential alternative symptom management strategies.
The occurrence of neuropsychiatric symptoms presents a challenge in the care of dementia patients. Behaviors categorized as neuropsychiatric symptoms include agitation, delusions, hallucinations, and sleep impairment occurring singly or in clusters (Cerijeira, Lagarto, Mukaetova-Ludenska, 2012). These behaviors are prevalent in people with dementia. Constantine and colleagues (2002) studied 682 community dwelling individuals with either mild cognitive impairment or dementia and found that 44 to 75 percent of those studied exhibited one or more neuropsychiatric symptoms per month. In another study the frequency of neuropsychiatric symptoms in nursing home patients was found to be 80 percent (Testad, Asland & Arsland, 2007).  These findings are of particular concern as the presence of neuropsychiatric symptoms often results in serious complications including decreased quality of life, increased rates of institutionalization and increased mortality (Okura et al., 2010). Consequently, healthcare professionals often manage these symptoms in dementia patients through the use of antipsychotic medications.
Unfortunately antipsychotic medications can have serious side effects. There are two primary classes of antipsychotic medications, typical and atypical. Atypical antipsychotics have replaced many older, typical antipsychotics, because atypical antipsychotics have fewer side effects. One exception to this change in practice includes haloperidol (Haldol®), a typical antipsychotic used on an “as needed” basis in many dementia patient care settings. Although atypical antipsychotics have a decreased risk of acute extrapyramidal symptoms (i.e. abnormal, uncontrollable and/or difficult movements) and tardive dyskinesia compared to typical antipsychotics, these medications can cause sedation, postural hypotension and falls (Jeste, Blazer, Casey, Meeks, Salzman, Scheider et. al. 2008). More serious complications of atypical antipsychotic medication use include increased mortality and risk for cerebrovascular adverse events (Jeste et al., 2008). Schneider and colleagues (2005) found the absolute mortality risk for nursing home residents with dementia to be two percent higher for residents treated for eight to twelve weeks with an antipsychotic medication compared to those treated with a placebo. Because of the risk for increased mortality, antipsychotics received black box warning labels for treatment of neuropsychiatric symptoms in people with dementia (FDA, 2005; FDA, 2008).
Not only can antipsychotics be dangerous for people with dementia, their efficacy in decreasing neuropsychiatric symptoms is questionable. Jeste and colleagues (2008) evaluated the evidence from several systematic reviews and randomized controlled trials examining the efficacy of antipsychotics and concluded that antipsychotics used for psychosis and/or agitation showed mixed results. Although the reviews demonstrated modest efficacy, several of the individual trials yielded negative results in terms of symptom reduction. 
Despite the potential for serious problems associated with antipsychotic use and their questionable efficacy, rates of antipsychotic medication use in nursing homes remain high, with some studies indicating that one in four residents receive antipsychotic medication (Bakerjian, 2011). A recent national initiative seeks to curb excessive use of antipsychotics in institutions and replace current neuropsychological symptom management methods with non-pharmacological therapies. The Partnership to Improve Dementia Care, a Center for Medicare and Medicaid Services (CMS) sponsored initiative aims to reduce the use of antipsychotic medications in nursing home residents by 15 percent (CMS, 2012). Steps stemming from this initiative include 1) enhancing training for nursing home workers and federal and state surveyors, emphasizing person-centered care and behavioral health; 2) increasing transparency by posting each nursing home’s rate of antipsychotic medication use on the Nursing Home Compare website; and 3) emphasizing alternatives to antipsychotic medication for nursing home residents, including consistent staff assignments, increased exercise, individualized activities and managing pain (CMS, 2012). Various state coalitions are actively working toward developing policies and strategies related to this initiative. Policy ideas emanating from these coalitions are varied but often include strengthening enforcement of dementia care best practices.
As a result of the increased interest from researchers and experts on this issue, further evidence is available for individual practitioners seeking alternatives to using antipsychotic medications to treat neuropsychiatric symptoms in dementia patients. Jeste and colleagues (2008) identify three potential alternatives including; no treatment in mild to moderate cases of psychosis and agitation, use of other psychotropic medications (e.g. antidepressants, sedatives) and psychosocial interventions. Psychosis or mild agitation may not be harmful to the patient or others in the environment. As such, not treating the psychosis or agitation may be the preferred option when weighed against the detrimental effects of antipsychotics. Skilled caregiver assessment determining the level and extent of danger associated with delusions, hallucinations, and/or agitation is imperative. A second option is treatment with other psychotropic medications such as antidepressants, short acting benzodiazepines, antiseizure medications, or cholinesterase inhibitors. However, Jeste and colleagues (2008), concluded after a systematic review of 17 studies that the evidence was weak regarding efficacy of these medications and, like antipsychotics, the FDA has not approved use of these medications for neuropsychiatric symptoms of dementia. The risk to benefit ratio of off label pharmacological management should be evaluated on a case-by-case basis. The third potential alternative to antipsychotic medication use includes psychosocial and psychotherapeutic interventions. These interventions include activities such as sensory stimulation therapy, behavioral management techniques, music therapy, and caregiver education. Several evidence based protocols recommend the use of these therapies as first line management of neuropsychiatric symptoms in dementia patients (Alzheimer’s Association, 2006, Dettmore et al., 2009, Hartford Institute, 2008). In addition to these management suggestions, Jeste and colleagues (2008) convey the need for more research validating the efficacy of such therapies.    
Administering antipsychotics to control neuropsychiatric symptoms associated with dementia may prove detrimental to patients. Caregivers should work to employ alternatives to antipsychotic use when appropriate.
Click here to access the list of references for this article.

Reducing Inappropriate Use of Antipsychotics in Community Dwelling Older Adults with Dementia: A Nursing Perspective

Submitted by Wanda Spurlock, DNS, RN-BC, CNE, FNGNA

Once considered a rare disorder, over 5 million Americans are now living with Alzheimer’s disease (AD), the most common type of chronic, irreversible dementia occurring in older adults.  The most rapid growing population in the United States is comprised of older adults, those age 65 years and older.  Although dementia is not synonymous with aging, the greatest risk factor for developing AD is advancing age.  Unfortunately, if current demographic population trends continue and a cure is not discovered, there will be approximately 16 million persons with AD and other dementias by the middle of this century, in the United States alone.
Contrary to popular belief, the majority of older adults with AD and other dementias reside in the community and are cared for by family members, significant others, and friends.  According to the Alzheimer’s Association (2013), in 2012, Americans provided more than 17.5 billion hours of unpaid care to persons with AD and other dementias.  Nurses interface with older adults with AD and other dementias across the entire illness trajectory and across diverse health care settings, especially community-based sites.  These community-based sites include acute care, primary healthcare settings and other ambulatory care clinics, and the home setting.  In 2008, an estimated 23 percent of Medicare beneficiaries age 65 and older with AD and other dementias received at least one home health visit during the year, compared with only 10% of Medicare beneficiaries without this diagnosis (Alzheimer’s Association, 2013).  
In addition to cognitive deterioration, the vast majority of persons with AD and other dementias will experience some form of behavioral symptoms during the course of the disease trajectory.  These behavioral and psychological symptoms of dementia (BPSD) can range from anxiety, restlessness, and apathy, to screaming, sundowning, wandering, agitation, and psychotic symptoms, i.e. paranoia, hallucinations, and delusions.  Regardless of the care setting, nurses play a critical role in assessment, medication monitoring, (especially for adverse side effects), caregiver teaching regarding the day-to-day care and management of symptoms (including communication strategies and behavioral approaches), counseling, referrals, and provision of a safe environment with appropriate levels of stimulation, to name a few. 
Although approved by the Federal Drug Administration (FDA) to treat psychotic symptoms that occur with schizophrenia and bipolar disorder, antipsychotic drugs are being inappropriately prescribed to treat behavioral disturbances that occur in older adults with dementia.   Generally, antipsychotic drugs are classified into two groups; typical antipsychotics and atypical antipsychotics.  When comparing the side effect profile of the two classes of antipsychotic drugs, typical antipsychotics are generally associated with a higher risk for extrapyramidal and movement effects (i.e. akathisia, parkinsonism, tardive dyskinesia) and anticholinergic side effects.  Although the newer atypical antipsychotics are associated with a lower risk for these adverse effects, this class of drugs is associated with a higher risk for weight gain, hyperglycemia, and hyperlipidemia (Adams, Holland & Urban, 2014 & Lindsey, 2009).  Examples of other side effects from antipsychotic drugs include orthostatic hypotension and sedation that can result in falls and excess disability.
A public advisory was issued in 2005 by the FDA regarding the use of atypical antipsychotics in the treatment of behavioral disturbances in older adults with dementia,  thereby requiring manufactures of these drugs to include information about the risk of increased mortality in a boxed warning and in the warnings section of the drug’s prescribing information.  In 2008, the FDA also extended the black box warning to typical antipsychotic medications, warning that both classes of drugs are associated with an increased risk of death related to cerebrovascular adverse events, including stroke, when used in the treatment of dementia related psychosis in the elderly.  Furthermore, neither class of drugs, typical antipsychotics such as chlorpromazine (Thorazine), and haloperiodol (Haldol), or atypical antipsychotics such as aripiprazole (Abilify), olanzapine (Zyprexa), and quetiapine (Seroquel) are FDA approved for the treatment of BPSD in older adults.  Use of these drugs in the treatment of patients with symptoms of dementia is referred to as “off label” use and is left to the discretion of the prescribing health care provider.  However, due to the serious adverse effects associated with antipsychotic drugs in older adults with BPSD, they should only be used when all other options have been exhausted or when there is a severe distress or an imminent danger or threat of self-injury or injury to others.  Therefore, non-pharmacological approaches including communication techniques, behavioral management interventions and environmental modifications, are recommended as the front-line approach to the management of cognitive and behavioral symptoms of dementia. 
Perhaps one of the most significant developments in dementia care in the last decade is person-centered care (PCC). This approach promotes purpose and meaning in the life of the person with dementia and should be the cornerstone of dementia care, across all treatment settings, including community-based care.  Plainly stated, nursing care revolves around, and adapts to the changing needs of the “person.” Therefore, PCC is critical to the success of non-pharmacological interventions and requires knowledge of the individual’s personal history, life-long personality, patterns, and preferences (including likes and dislikes).
Because behavioral symptoms are often multifactorial, the key is to identify the root cause of the symptoms, keeping in mind that “all behavior is meaningful.”  Regardless of the progression of the dementia or the treatment setting, nurses should always assess for underlying medical illnesses or conditions (i.e. urinary tract infection, fecal impaction, pain, or fatigue), or environmental triggers (i.e. noise, bright lights, or dim lights resulting in shadowing effect), to name a few.  Likewise, as advocates for older adults with dementia, nurses should never attribute a sudden worsening in the person’s behavioral symptoms to a “normal progression” of the dementia.  To the contrary, a sudden onset of behavioral symptoms or an abrupt increase in severity of symptoms should warrant a thorough assessment to rule out any potential underlying physiological or psychological causes, psychiatric disorders, environmental or pharmacological triggers.  Medication review is another important area of assessment, in light of the risk for polypharmacy with older adults and the increased potential for occurrence of adverse drug effects. 
On May 12, 2012, the Centers for Medicare and Medicaid (CMS) announced a national partnership to improve dementia care in nursing homes with the goal of decreasing the inappropriate use of antipsychotic drugs in nursing home residents.  Gerontological nurses play a critical role in reducing the inappropriate use of these drugs in older adults across all treatment settings, especially within the community, where the majority of older adults with dementia reside. 
Adams, M., Holland, N., Urban, C. (2014). Pharmacology for nurses: A pathophysiological approach. (4th ed). Upper Saddle River: New Jersey.  Pearson Education.

Lindsey, P. (2009). Psychotropic medication use among older adults. Journal of Gerontological Nursing, 35 (9), 28-38.

Alzheimer’s Association.  (2013). 2013 Alzheimer’s disease facts and figures. Retrieved June 11, 2013, from

NGNA Donor Recognition

The NGNA Board of Directors and staff members wish to thank the following individuals for their recent donations.
Fellows Fund
Marcia Shad, RN-BC, FNGNA
Darlene Shoemaker, MS, RN, C, FNGNA
Dia Campbell-Detrixhe, PhD, RN, FNGNA, CNE
Sharon Wexler, PhD, RN, BC, FNGNA
Karen Armacost, MS, RN-BC, FNGNA
Sarah Jean Fisher, BA, RN-BC, MSN, FNGNA
Linda J. Hassler, RN, MS, GCNS-BC, FNGNA
Nanci McLeskey, MCG, MDiv, RN-BC, FNGNA
Scholarship Fund
Marcia Shad, RN-BC, FNGNA
Mission Advancement Fund
Sarah Burger, MPH, RN, C
Ann Mayo, DNSc, RN
Karen Armacost, MS, RN-BC, FNGNA

NGNA Members in the News

Congratulations, Janice Crist!
Janice D. Crist, PhD, RN, FNGNA, FAAN was the Western Institute of Nursing Research 2013 Winner of the WIN-Hartford Regional Nursing Research Award for an Experienced Researcher.