1. Care Forum Wales welcomes the opportunity to respond to this call for information. We are a membership organisation for Health and Social Care Providers in Wales representing over 450 independent providers (both private and third sector), the majority of whom own care homes.
2. We promote excellence in practice in health and social care and have a number of expert leads in key areas, including dementia care. Steve Ford, our dementia lead, recently appeared on BBC’s television programme, Eye on Wales, endorsing calls for the use of anti-psychotic medicines to be carefully monitored and reduced wherever possible, to enhance the quality of life of people living with dementia and to avoid unnecessary and harmful side effects, such as increased likelihood of falls.
3. Some of the first generation medicines have potentially serious side effects and have been largely discredited for use for people living with dementia. Some studies have shown increased mortality rates, incidence of stroke and cardio-toxicity. We believe that anti-psychotic medication should only be given as a last resort and, if it is appropriate, there should be a robust system of review every 3 months.
4. We are in the process of writing to our members to remind them of our campaign to be “A Champions” (Assessment of Challenging and Management Problems Initiating Options for New Solutions) and to re-issue guidance that we first issued in 2011.
5. We recognise that the responsibility for prescribing antipsychotic medicines rests with the GP and hospital psychiatrists or clinicians. However, it is often prescribed in response to the care team seeking to manage behaviours that challenge. We would rather urge care practitioners to seek individualised, creative and innovative interventions. The first step is to recognise and understand the triggers that cause this behaviour. The A Champions document includes a concise and practical checklist to help care practitioners to identify behaviours and likely triggers; to rate the level of incident and to find interventions that work for the individual. A copy of the document is attached at the bottom of this response.
6. We have worked previously with the University of South Wales in devising a dementia certificate for nurses to create better understanding of these issues. We are currently in discussion about adapting the training materials to a format that can be shared and used by all care practitioners.
7. We would encourage providers and GPs to work together to review medication with a view to reduction and eventual elimination over a suitable time period, not forgetting the contribution that community pharmacists can make.
Melanie Minty
Policy Advisor
Assessment of Challenging and Management Problems Initiating Options for New Solutions
Responsible care providers are committed to finding sensitive creative and individualized appropriate care interventions to safely manage behaviour that challenges, exhibited by service users with dementia, and thereby avoiding administration of antipsychotic medications as far as is practicable and safe to do so.
The elimination of or successful management of catalysts and identification of common denominators will inform care intervention strategies and promote problem resolution. Please tick the appropriate boxes, as relevant and complete the document which is designed to take no more than 5 minutes.
This document is suitable for use in all care delivery settings and can be completed by careworkers, carers, nurses or others providing care in hospitals, clinics, day centres, care homes, domiciliary care or care at home by family members or others.
Name of Service User.……………………………………………………………….
Date of birth………………………………………………………………………….
Type of care setting ………………………………………………………………….
Address ………………………………………………………………………………
Date of Admission/Residency.……………………………………………………… Diagnosis…………………………………………………………………………….. G.P…………………………………………………………………………………….
Other relevant agencies……………………………………………………………..
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TYPES OF BEHAVIOUR THAT CHALLENGES
PHYSICAL AGGRESSION Please tick as appropriate.
Punch ( ) Slap ( ) Kick ( ) Bite ( ) Head butt ( ) Squeeze ( ) Pinch ( ) Push ( ) Spitting ( ) Throwing objects ( ) Describe object thrown……………………………….. Blocking others movements ( ) Throwing liquids ( ) Stamping ( ) Using items as weapons e.g. walking stick ( ) Describe…………………………………………………..
Other ………………………………………………………………………………………
Comments ………………………………………………………………………………….
Screaming ( ) Shouting ( ) Repetitive statements ( ) Demanding ( ) Loud behaviour ( ) Unreasonable requests ( ) Threatening ( ) Intimidating ( ) Swearing ( ) Clapping ( ) Other……………………………………………………………………………………….
Comments …………………………………………………………………………………
Hitting oneself ( ) Scratching oneself ( ) Pinching oneself ( ) Using an object to hurt or injure oneself ( ) Describe……………………………………………………………… Threatening to hurt oneself ( ) Verbalizing suicidal thoughts ( )
Placing oneself on floor ( ) Deliberately rolling oneself out of bed ( ) Attempting to eat/drink non food objects ( ) Describe……………………………………………………. Other……………………………………………………………………………………….. Comments………………………………………………………………………………….
Unwelcome sexual comments ( ) Inappropriate kissing ( ) Inappropriate touching ( ) Fondling ( ) Penetrating actions ( ) Describe ..…………………………………………...
……………………………………………………………………………………………… Exposing oneself ( ) Use of sexual swear words ( )
Masturbation in room other than bedroom ( ) Identify ……………………..……..............
……………………………………………………………………………………………… Inappropriate flirting ( ) Describe ……………………………………................................ Other………………………………………………………………………………………..
Comments ………………………………………………………………………………….
Damage to electrical appliances ( ) Homes fixtures and fittings ( ) Walls/wallpaper ( ) Throwing objects ( ) Please describe ……………………………………………………... Throwing food ( ) Trashing rooms ( ) Identify which ………… ………………………... Shredding/Ripping items…………………………………………………………………...
Other ………………………………………………………………………………………
Comments ………………………………………………………………………………….
Urinating in inappropriate places ( ) Describe location …………………………………... Defecating in inappropriate places ( ) Describe location ………………………………..... Manually handling/smearing/throwing faeces ( ) Other ( ) Describe……………………..
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Comments………………………………………………………………………………….
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Any further relevant information.
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(Please record as appropriate in the following sections)
P = Possible I = Identified/Confirmed ……………………………………….
Dehydration ( ) Constipation ( ) Diarrhoea ( )
Infection (e.g. U.T.I) ( )Describe ………..………………………………………………...
Pressure ulcers/wounds/tissue viability problems ( ) (describe)…………………………...
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Medication side effects () describe ………………………………………………………. Sight/Hearing/Sensory problems ( ) describe ……………………………………………..
Dental pain/oral problems ( ) describe …………………………………………………….
Sleep disturbance ( ) describe ……………………………………………………………..
Seizure activity ( ) describe ………………………………………………………………..
Specific Medical Condition ( ) describe .………………………………………………….
Polypharmacy ( ) describe ……………………………………….......................................
Immobility ( ) describe …………………………….. ……………………………………..
Other Medical Issues ( ) describe……………………………………………………………………..........................
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Pain ( ) Discomfort ( ) Sore bottom (sitting/lying for long periods of time ( ) Hunger ( ) Thirst ( ) Too hot ( ) Too cold ( ) Wanting to go to the toilet ( ) Incontinence ( ) Feeling of being interfered with ( )
Other ………………………………………………………………………………………
Comments …………………………….…………………………………………………..
Agitation ( ) Irritability ( ) Anxiety ( ) Anger ( ) Depression ( ) Tearful ( ) Accusatory ( ) Hallucinations ( ) Delusions ( ) Hyperactive ( ) Intolerant of others ( ) Boredom/isolation ( ) Sleepy ( ) Not wishing to be disturbed ( ) Pacing ( )
Sundowning ( ) Disinhibition ( ) Suspicious/paranoid feelings ( ) Communication difficulties ( )
Other ……………………………………………………………………………………….
Comments ………………………………………………………………………………….
Crowded room ( ) Too noisy ( ) TV/Radio blaring away ( ) Wanting to leave ( ) Incompatibility of adjacent people ( ) Unpleasant odours ( )
Lack of therapeutic environment ( ) Deprivation of liberty ( )
Describe ……………………………………………………………………………………
Other ………………………………………………………………………………………
Comments ………………………………………………………………………………….
Inappropriate approach by staff ( ) Medical/nursing procedures by staff ( ) Administration of medication by staff ( )
No/insufficient explanation of care intervention procedures by staff ( ) Inadequate numbers of staff to provide the necessary care ( ) Poor staff skills ( ) Staff ignoring requests/questions ( ) Change of carer ( )
Other ……………………………………………………………………………………….
Comments ……………………………………………………………………………….....
Disturbed by behavior of other service users ( )
Describe ……………….………………………………………………………………….
Aggression from another service user ( )
Repetitive behavior from another service user ( )
Unwanted personal contact/intrusive behavior from another service user ( )
Other ………………………………………………………………………………………
Comments …………………………………………………………………………………
Unwanted visitor ( ) Inappropriate behaviour from visitor ( )
Challenging behaviour to a visitor ( ) Challenging behaviour after a visitor leaves ( ) Challenging behaviour following an outing with a visitor ( )
(Please specify). .…………………………………………………………………………. Other………………………………………………………………………………………..
Comments ………………………………………………………………………………….
Other catalysts/triggers/reasons Comment upon domain/specifics:-
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No identifiable catalysts/triggers/common denominators ( ) Issues/actions that are indefinable/unassessable/difficult to categorize ( )
Comments …………………………………………………………………………………
Time of challenging behaviour …………………………………………………………..
Date of challenging behaviour …………………………………………………………...
Day of challenging behaviour (e.g. Monday) ……………………………………………..
Location of challenging behaviour ………………………………………………………
INCIDENT RATING 0 = NO HARM; 5 = MODERATE HARM/RISK OF HARM 10 = VERY HIGH RISK OF HARM OR ACTUAL HARM/POTENTIALLY LIFE THREATENING
PLEASE RATE INCIDENT 0 – 10……………………………………………………… Other……………………………………………………………………………………….
Comments …………………………………………………………………………………
Escort service user away from location ( )
Please identify to which area of the home………………………………………………….
One to one care/reassurance ( ) Comment………………………………………………...
Activity sessions ( ) Comment …………………………………………………………….
Reality orientation ( ) Comment ……………………………………………………….….
Validation therapy ( ) Comment …………………………………………………………..
Snoezelen room ( ) Comment ……………………………………………………………..
Escorted outing ( ) Comment …………………………………………………………....... Contact/interaction with specific staff member ( ) Identify ………………………………. Contact/interaction with family member/visitor/advocate ( ) Identify …………………… Contact/interaction with service user ( ) Identify ………………………………………… Contact/interaction with visiting professional ( ) Identify ……………………................... Contact/interaction with visiting chaplain/clergy ( ) Identify …………………………….. Contact/Interaction with Other ( ) Identify ………………………………………………..
Distraction ( ) Comments ……………………………………………………………….....
Use of comfort object ( ) Comments ………………………………………………………
Use of isolation with discreet observations ( ) Comments ……………………………......
Use of drink substances ( ) e.g. glass of wine/cup of tea, Comments
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Assess fluid intake ( ) describe tool used ………………………………………………….
Use of food Substances ( ) Comments …………………………......................................... Ventilation of feelings ( ) Expressions of anger ( ) Active listening ( )
Personal contact, e.g. holding hands ( )
Firm verbal directives ( ) *Identify in care plan
Address Medical Issues ( ) Describe ………………………………………………………
Medication ( ) Type ………………… Antipsychotic Yes/No PRN Yes/No
Name and dose…………………………………………………………………………….
Method of administration………………………………………………………………….
Comments …………………………………………………………………………………
Restraint ( ) Was this the only feasible option? ( )
Type of Restraint ………………………………. For How Long………………………… Comments …………………………………………………………………………………. Recorded in Restraint register ( )
Who is the person(s) that was harmed/placed at risk of harm ………………………...
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Designation of individual …………………………………………………………………
Was the harm avoidable? Comments …………………………………………………...
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Relevant/Likely Themes/common denominations relating to undesirable behaviour/incidents……………………………………………………………………….
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……………………………………………………………………………………………… What have we learned to become better equipped to deal with future incidents or avoid them…………………………………………………………………………………
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Please describe any changes in service users presentation relating to behaviour without/since non administration of anti psychotic medication given for incident resolution…………………………………………………………………………………...
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Time period involved……………………………………………………………………….
Discussed with/ please identify …………………………………………………………….
……………………………………………………………………………………………… Has the Care home received recognition of good practice in dealing with behaviour that challenges. Yes ( ) No ( )
By whom………………………….…Designation…………………………………………
Copy Sent To: Service user ( )
Service users family/advocate ( )
G.P ( )
Social services ( ) BCUHB ( ) CSSIW ( )
Police ( ) File ( )
Other ( ) Please specify ...…………………………………………………. Name of Person completing document ………………………………………………......... Designation ………………………………………………………………………………... Signed …………………………………………………………………………………….. Dated ………………………………………………………………………………………
© 2011 Stephen Ford
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‘A CHAMPIONS’ document conceived by Stephen Ford MA, RGN, RMN.Dip.Ger. Dementia Care Policy Coordinator
Care Forum Wales December 2011. © 2011 Stephen Ford