COMPASSIONATE CARE IN RESIDENTIAL AGED CARE FACILITIES IN A COVID 19 - PowerPoint PPT Presentation

26 th May 2020 COMPASSIONATE CARE IN RESIDENTIAL AGED CARE FACILITIES IN A COVID 19 WORLD S U S AN KU RRLE G E R I A T R I C I A N H O R N S B Y K U - R I N G - G A I A N D E U R O B O D A L L A H E A L T H S E R V I C E S C U R R A N P R O F E S S O R I N H E A L T H C A R E O F O L D E R P E O P L E , F A C U L T Y O F M E D I C I N E , U N I V E R S I T Y O F S Y D N E Y S U S A N . K U R R L E @ S Y D N E Y. E D U . A U

ROYAL COMMISSION INTO AGED CARE QUALITY AND SAFETY 2

ROYAL COMMISSION INTERIM REPORT 2019 “A Shocking Tale of Neglect”: ‘Dreadful’ food, nutrition and hydration • Inadequate wound care • Poor continence care • High use of physical restraints • Overprescribing of psychotropic medications • Low availability of palliative care • Aged care is built around funding mechanisms, process • and procedures….not care needs The antithesis of compassionate care 3 3

COMPASSIONATE CARE ‘noticing, feeling, and responding to suffering’ • ‘intelligent kindness’ • care based on empathy, respect and dignity • pity and concern for the misfortunes of others • compassion underpins caring: • understanding what is important to the other person • understanding what the other person is going through • acting to alleviate suffering in a selfless way • Florence Nightingale: “Gentleness, kindness, courtesy, compassion” • 4 4

COMPASSIONATE CARE IN A COVID WORLD Lack of compassionate care towards RACFs: • acute hospitals planning to decline admissions from RACFs • acute hospitals providing ‘hospital in the home’ to residents with Covid 19 to • prevent ‘unnecessary admissions’ when residents may have benefitted from hospital care Lack of compassionate care within RACFs • RACFs refusing access to family members of dying residents • RACFs not prioritising residents’ emotional needs above general • organisational safety and not allowing close family members to visit despite government guidelines Tale of 2 mothers • 5 5

COMPASSIONATE CARE IN A COVID WORLD Communication and connection • The importance of physical presence • 6 6

COMPASSIONATE CARE IN A COVID WORLD Communication and connection • The importance of celebration and remembering • 7 7

COMPASSIONATE CARE IN A COVID WORLD Animal Assisted Therapy • There is no evidence that domestic dogs (or chicks or alpacas) spread COVID19 • 8 8

COMPASSIONATE CARE IN A COVID WORLD Getting some fresh air • 9 9

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INTERGENERATIONAL PRACTICE IN AUSTRALIA Programs bring people from different generations together to participate in • purposeful activities that are beneficial to all involved Aim is to reconnect generations that may have lost touch • Research has shown that for older people, the programs have had a positive • impact on their health and well-being; the programs have sparked enjoyment and improved mood, and have given them a sense of purpose, all of which may contribute to delaying the cognitive decline. For children, there has been an increase in confidence and communication skills • Can implement in many different models: • Colocated child care/pre-schools and aged care • Visiting models • Playgroups visiting aged care facilities • Baby groups visiting aged care facilities • Day care – children and adults together • 11 11

COMPASSIONATE CARE IN A PRE-COVID WORLD Concept of Intergenerational Care • The ABC documentary series ‘Old People’s Home for 4 Year Olds ’ was an example • of an intergenerational program which aimed to improve well being, physical activity, and socialisation amongst older people living isolated lives in residential care, and to improve confidence, and communication and speech skills in pre- school children 12 12

COMPASSIONATE CARE IN A PRE-COVID WORLD During the series we witnessed the effect of the intergenerational program on • participants old and young Increased mood and feelings of pleasure, and physical activity in older participants • Increased confidence to interact with older people, and improved language skills, • and awareness of older people in the pre-schoolers The benefits of cooperation when doing things together such as painting or cooking • or counting 13 13

COMPASSIONATE CARE IN A PRE-COVID WORLD Effect on physical frailty: A pre-post interventional study of frail and pre-frail older people living in a • retirement village in supported accommodation N = 11, mean age 87.3 years (range 78-95) • Primary outcome: walking speed, HGS, tandem stance • Intervention over 7 weeks: interaction with 10 4 year olds • Clinically and statistically significant improvement in all primary outcome measures • 14 14 ABC 2019

AWARD WINNING COMPASSIONATE CARE 15 15

COMPASSIONATE CARE IN A POST-COVID WORLD Intergenerational care through playgroups meeting in aged care • facilities Need adequate space and tables and chairs • (Physical distancing may be difficult) • Need coordinator at aged care facility • Benefits to all participants – children, parents, older residents • See: agelessplay.com.au • 16 16

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COMPASSIONATE CARE IN A COVID WORLD Management of Behaviours and Psychological Symptoms of Dementia (BPSD) Aged Care Royal Commission noted that this was a major area of concern, with physical restraint and high doses of psychotropic medication being widely used 18

COMPASSIONATE CARE IN A COVID WORLD BPSD occurs in around 95% of people with dementia – agitation, aggression, wandering, hallucinations, delusions, apathy, elation, disinhibition, sleep changes Compassionate care underpins management of these distressing symptoms: ‘noticing, feeling, and responding to suffering’ • ‘intelligent kindness’ • care based on empathy, respect and dignity • Understanding what sits behind the behaviours, and what are the causes • Knowing the person and their background is key to appropriate management • 19 19

COMPASSIONATE CARE IN A COVID WORLD An approach to management of behaviours: 1. look at acute medical factors – delirium, UTI, RTI, drugs, hypoxia, constipation, pain 2. look at chronic medical factors – pain and discomfort, heat, cold (most people get grumpy when they are in pain) 3. ask what is happening in the brain – the worse the dementia, the more severe the behaviours eg frontotemporal dementia often results in apathy or disinhibition 4. ask what is the person trying to tell you with the behaviours – resistive behaviour with personal care may be due to embarrassment, misinterpretation of staff intentions, self defence 5. look at environment – noisy, boring, hard to navigate, confusing 20 20

COMPASSIONATE CARE IN A COVID WORLD Environmental interventions: 1. Provide a predictable routine 2. Separate noisy and disruptive persons for quieter persons 3. Provide a safe environment - use security doors, etc 4. Use a night light 5. Provide orienting stimuli 6. Provide bright enough daytime lighting 21 21

COMPASSIONATE CARE IN A COVID WORLD Behaviour interventions: 1. Reduce isolation, talk to patient to distract from frustration 2. Identify specific precipitants 3. Experiment with targeted changes to schedule and environment 4. Provide reassurance 5. Allow patient to wander if secure environment 6. Encourage pleasant experiences 22 22

COMPASSIONATE CARE IN A COVID WORLD Recommended therapy alternatives for BPSD: a) Only after a reasonable trial without medication b) Consider a trial of analgesia in a stepped approach if pain is an issue c) Consider using SSRI (e.g. citalopram 10-20mg) first for 6-8 weeks d) Risperidone is the only oral antipsychotic approved for use in BPSD (in Australia) – aggression and psychotic symptoms 0.5-1.5 mg/day e) Use should be restricted to 3 month trial (as per PBS) and then reviewed and possibly discontinued Always gain consent from the resident, or the substitute decision maker 23

COMPASSIONATE CARE IN A COVID WORLD Understanding the person and treating the cause: • Treatments focused on understanding the cause of BPSD seem as effective as those relying on drugs and are associated with reduction in psychotropic usage • Person-centred care strategies are more effective than usual care in reducing agitation • Always consider undiagnosed pain as a cause of agitation or aggression DBMAS 18 1800 699 799 24 24

COMPASSIONATE CARE IN A COVID WORLD MR GREEN 82 year old man, moderately severe mixed dementia, resident in aged care facility • for 3 years Minimal language, not recognising family, required assistance with all ADLs, • unable to mobilise independently Would often call out ‘help me’ when he was thirsty or uncomfortable and needed • repositioning, staff usually able to respond to his needs Began calling out constantly every few minutes and was given extra analgesia as • staff thought he was in pain from arthritis Calling out continued for several days, developed diarrhoea, not eating or • drinking much, not responding to attention from family or staff Rectal examination indicating faecal impaction with overflow diarrhoea • Analgesics ceased, aperients and fluids started, good response to Fleet enemas • 25

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