BACKGROUND: Disruptive behavior in people with dementia is indicative of unmet care needs. Disruptive behaviors may include repetitive questioning, impaired sleep, wandering, inappropriate behaviors, agitation, and aggression. Most people with dementia display one or more these disruptive behaviors throughout progression of their illness. Managing disruptive behavior is complex, stressful, and costly (Kales, Gitlin, & Lyketsos, 2015). Veterans with dementia are at high risk for injury, behavioral or psychiatric problems, poor quality of life, and high service utilization (Karel et al., 2017). The Veterans Health Administration (VHA) Deputy Undersecretary for Health Policy and Planning estimates the prevalence of patients with dementia to exceed 335,425 in 2023 (VHA, 2013). Development of the “Prevention and Management of Agitation and Aggression in Veterans with Dementia” (PMAAVD) program began in December 2020 in response to patient safety events involving hospitalized Veterans with dementia. The purpose of PMAAVD is to improve behavioral outcomes for Veterans with dementia by proactively addressing their care needs.
OBJECTIVES: PMAAVD aims to reduce the number of disruptive behavior events in a southeastern United States Veteran Affairs (VA) healthcare system on four non-traditional dementia care units by 20% by the end of 2023.
METHODS: PMAAVD utilizes five strategies: 1) standardized care processes for dementia recognition and personalized care, 2) dementia friendly rooms and diversional activity carts, 3) weekly interprofessional behavioral care huddles, 4) system wide dementia care assessment and virtual reality staff and trainee education, and 5) volunteer sitter program and patient engagement tool. The interdisciplinary workgroup consists of more than 50 members across chaplain services, geriatric trainees, nursing (nurses, nursing assistants, educators, managers), nutrition, occupational therapy, physical therapy, providers (nurse practitioners, psychiatrists, psychologists), recreational therapy, social work, and speech therapy.
RESULTS/OUTCOMES/IMPROVEMENTS: The primary patient outcome was number of disruptive behavior events, as reported by staff to the disruptive behavior reporting system, among patients with dementia on four acute care units. The pilot unit had a 17% reduction in disruptive behavior events over a one-year period. Quantitative and qualitative data were collected on huddle attendance and content. Adoption outcomes showed that our goal of having two or more dementia consultants attending each huddle was achieved. Fidelity outcomes showed that 97% of staff and consultants reported that patients’ behavioral concerns were identified and discussed as intended during huddles.
SIGNIFICANCE/IMPLICATIONS/RELEVANCE: Disruptive behavior in dementia is a complex problem that requires multifaceted complex solutions. The PMAAVD program is an innovative model of care that facilitates prevention and management of disruptive behavior in acute care units that do not typically provide care to patients with dementia. Huddles provide an opportunity to proactively address concerns and give real-time feedback. The workgroup faced challenges including staff turnover, dedicated time for huddle facilitators, and obtaining accurate and available data on patients with a diagnosis of dementia. With a commitment to sustainable solutions, we piloted an electronic note template for identifying patients with dementia, which contains inclusion and exclusion criteria for huddles and aids staff in describing patient behavior and choosing patient-centered, evidence-based interventions. Overall, findings are promising for use of a multicomponent program to reduce disruptive behavior in hospitalized patients with dementia.
