The Society of Clinical Geropsychology (SCG) – Section 2 of the Society of Clinical Psychology (SCP) – has recently become involved in supporting the National Partnership to Improve Dementia Care in Nursing Homes, along with several other geropsychology organizations. The “National Partnership” is an initiative (starting in 2012) of the Centers for Medicare and Medicaid Services (CMS) to improve dementia care through individualized care approaches, with the goal of reducing the use of unnecessary antipsychotic medications to address behavioral expressions in dementia (see https://www.nhqualitycampaign.org/dementiaCare.aspx).
A variety of challenging behaviors are commonly associated with dementia, such as verbally or physically aggressive behaviors, repetitive vocalizations, wandering, disengagement, and depression. Such behaviors are often expressions of unmet needs or responses to particular interpersonal or environmental triggers that may inadvertently be reinforced by caregivers’ responses to the behaviors. Despite the growing evidence base for behavioral approaches to managing behavioral expressions in dementia, the mainstay for treatment has been the use of antipsychotic and other psychotropic medications. Unfortunately, there is limited efficacy for the use of these medications for managing challenging behaviors in dementia, along with an increased risk of death. As a consequence of this risk profile, the FDA issued Black Box warnings for the use of antipsychotic medications in individuals with dementia, in 2005 (atypical antipsychotics) and 2008 (conventional antipsychotics).
Until recently, psychologists have not played a major role in supporting the National Partnership. However, they psychologists can play a critical role in helping nursing home leaders and teams develop and implement non-pharmacological interventions to help reduce distress and discomfort among their residents with dementia. In fact, geropsychologist Dr. Kimberly Van Haitsma co-led with Ann Kolanowski, RN, an expert panel that developed an on-line nursing home toolkit: Promoting Positive Behavioral Health: A Nonpharmacological Toolkit for Senior Living Communities (see www.nursinghometoolkit.com). That effort was supported by the Commonwealth Fund and the Hartford Foundation.
This toolkit divides resources into five major categories, all of which psychologists are well-equipped to help nursing home staff address: (1) system integration: supporting system-wide implementation of new models of care; (2) education and leadership; (3) assessment; (4) clinical decision making; and (5) non-pharmacological approaches. Psychologists who work in nursing home settings have abundant opportunities to help their teams in one or more of these domains (see the organization Psychologists in Long Term Care, at http://www.pltcweb.org). However, CMS and many nursing home administrators may not be fully aware of the services that psychologists can provide.
Several geropsychologists – Drs. Kelly Carney, Jane Fisher, Andrew Heck, Michele Karel, Mary Lewis, Victor Molinari, Jennifer Moye, Margaret Norris, and Kimberly Van Haitsma – have joined a working group to collaborate with CMS on strategies to get the word out to (1) the nursing home industry about how psychologists can contribute to the National Partnership and (2) psychologists who may be interested to learn more and help with this initiative. In this vein, this working group is developing a description of Professional Psychology that will serve as a template for descriptions of all the professions working in long-term care; in part, there is a basic need for interprofessional education about the knowledge and skills that the various professions can bring to this partnership (e.g., recreation therapists, social workers, occupational therapists, chaplains, etc).
Likewise, we want to spread the news about the role of psychologists in developing the evidence base for non-pharmacological interventions in long-term care settings, and their role in disseminating these interventions. I will share an example of one national implementation effort with which I am involved. The Veterans Health Administration (VHA) of the Department of Veterans Affairs provides skilled nursing long-term, rehabilitation, and palliative care in its 130+ Community Living Centers nationwide. Dr. Brad Karlin, President-Elect of SCP, oversaw an initiative to integrate psychologists into all of the VHA CLCs and to train these mental health providers to help their teams develop the knowledge and skills to care for Veterans with dementia-related challenging behaviors. In collaboration with Dr. Linda Teri, VHA adapted her STAR (Staff Training in Assisted Living Residences) intervention for application in VHA CLCs. A pilot implementation initiative and subsequent development and dissemination of this training program has demonstrated decreases in the frequency and severity of target behaviors, as well as decreases in symptoms of depression, anxiety, and agitation, and increased self-reported team member confidence in their ability to manage these behaviors effectively.
If you are interested to learn more or to support the efforts of the National Partnership to Improve Dementia Care in Nursing Homes, please see the websites and references included here, and contact Dr. Kelly Carney (firstname.lastname@example.org) or Dr. Margaret Norris (email@example.com) for more information.
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Curyto, K. J., Trevino, K. M., Ogland-Hand, S., & Lichtenberg, P. (2012). Evidence-based treatments for behavioral disturbances in long-term care. In F. Scogin, A. Shah (Eds.) , Making evidence-based psychological treatments work with older adults (pp. 167-223). Washington, DC, US: American Psychological Association. doi:10.1037/13753-006
Gitlin, L. N., Kales, H. C., & Lyketsos, C. G. (2012). Nonpharmacologic management of behavioral symptoms in dementia. Journal of the American Medical Association, 308, 2020-2029. doi:10.1001/jama.2012.36918
Kolanowski, A., Van Haitsma, K., Resnick, B., & Boltz, M. (In press). A toolkit for behavioral health. Journal of the American Medical Directors Association.
Karlin, B. E., Visnic, S., Shealy McGee, J., & Teri, L. (2014). Results from the multisite implementation of STAR-VA: A multicomponent psychosocial intervention for managing challenging dementia-related behaviors of veterans. Psychological Services, 11, 200-208. doi:10.1037/a0033683
Seitz, D. P., Brisbin, S., Herrmann, N., Rapoport, M. J., Wilson, K., Gill, S. S., Rines, J., Le Clair, K., & Conn, D. (2012).Efficacy and feasibility of nonpharmacological interventions for neuropsychiatric symptoms of dementia in long term care: a systematic review. Journal of the American Medical Directors Associaition. 13, 503-506. doi: 10.1016/j.jamda.2011.12.059
Seitz, D. P., Gill, S. S., Herrmann, N., Brisbin, S., Rapoport, M. J., Rines, J., & … Conn, D. K. (2013). Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: A systematic review. International Psychogeriatrics, 25, 185-203. doi:10.1017/S1041610212001627
Teri, L., Huda, P., Gibbons, L., Young, H., & van Leynseele, J. (2005). STAR: A Dementia-Specific Training Program for Staff in Assisted Living Residences. The Gerontologist, 45, 686-693. doi:10.1093/geront/45.5.686