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CAMH Stories Centre for Addiction
and Mental Health

CAMH dementia agitation and aggression pathway offers streamlined service to patients

“Alzheimer’s dementia and related neurodegenerative diseases are inflicting a national crisis.”

Dr. Tarek Rajji is CAMH’s Chief of Geriatric Psychiatry and the Medical Head of CAMH’s Geriatric Outpatient Clinics and Services. He and his staff see the impact of Alzheimer’s dementia and neurodegenerative diseases in his work every day. In Ontario alone, more than 200,000 people live with dementia. About 75 per cent will manifest agitation or aggression at one stage of their illness. Agitation and aggression occur for a variety of reasons, including hallucinations and delusions, a change in the brain that affects judgement and self-control and side effects of medication.

“Aggression and agitation are highly prevalent among patients with Alzheimer’s dementia. They impose a tremendous burden on the individuals living with Alzheimer’s dementia, their families, caregivers and the health care systems beyond the cognitive impairment per se,” says Dr. Rajji. “They are the leading cause for hospitalizing patients with Alzheimer’s dementia and transferring them into long-term care facilities.”

A new path

In the summer of 2013, CAMH introduced a new way to treat patients with agitation and aggression associated with Alzheimer’s dementia. It’s called the Dementia Integrated Care Pathway (ICP). ICPs are systems where clinicians from multiple disciplines follow a set of best practices, using evidence-informed interventions, to achieve the best outcome possible for an individual patient. These include medications as well as non-pharmacological options.

“Antipsychotics are often used to treat agitation and aggression associated with Alzheimer’s dementia. However, antipsychotics are associated with significant negative outcomes such as increased mortality, cerebrovascular accidents, infections and falls,” says Dr. Rajji. “These detrimental outcomes are particularly high if these medications are not used appropriately, in combination with other medications or longer than what is needed. Also, these medications are often used before or without the use of non-pharmacological interventions that could prevent, delay or minimize the use of antipsychotics.”

So his team created the ICP to address those issues. “This approach ensures that all potential factors that are contributing to the agitation and aggression are uncovered, and that unnecessary and ineffective treatments are not used.”

Non-pharmacological interventions include things like music interventions, which are helpful when used in combination with an optimal level of medication. Christopher Uranis is an Advanced Practice Nurse with the Professional Practice Office at CAMH. He’s also a team member with the Dementia Integrated Care Pathway (ICP).

“I’ll never forget Client One,” says Christopher. Client One was the first patient the team saw. In the case of Client One, they discovered she responded well to music, but only specific genres of Italian music. A clinician discovered Client One responded well to music, and that treatment continued along with other forms of care. It was so effective it was also recommended to be continued after her discharge from CAMH. Luckily, the Alzheimer’s Society had a music and memory program.

“There was a seamless transition. The pathway encourages family and client education. You build an interprofessional care plan, and you initiate these interventions,” said Christopher. “We figured we could make our own playlist here but we didn’t have the ability to give the person her own equipment. However, this program already existed, and we were able to get the playlist done up for them based on the clients’ linguistic and memory preferences.”

Dementia ICP team
(L to R) Some of the staff who work with patients from the dementia pathway: Registered Nurse Regina Beecham, Advanced Practice Nurse Christopher Uranis, Registered Nurse Sylvia Brazas, Social Worker Holly Ito and Registered Nurse Younten Tsomo

Innovations in treatment

The teamwork necessitated by the pathway has even lead to innovations. As part of the pathway, the team gathers data as to what kind of diagnoses their patients had; and it turned out a number of patients were diagnosed as having frontotemporal lobe dementia (FTD), something the dementia ICP medication algorithm wasn’t designed for. So the team created a whole new branch to the  pathway -- which works within the existing dementia ICP -- to treat these patients.

“We didn’t anticipate it was needed but it wasn’t a surprise either. Our pathways are not set in stone, they are continuous improvement exercises, so even now if we feel some of the processes need to be updated to accommodate the population or changing environment, we’ll go ahead and update that,” said Shivali Kapila, one of the project managers with ICP who supported the team in creating the FTD branch. For example, the team has had a client exit the pathway after benefiting from a decrease in the medication they were taking.

The dementia ICP is designed not only to provide treatment in a timely manner, but also to help improve a client’s quality of life. “If the person doesn’t have symptoms, they can participate in recreation activities and they can have the opportunity to be in a group setting or return to their loved ones in the community,” said Christopher. “We’ve had a small percentage go back to their home environment and the others have gone to other living arrangements.”

Dr. Philip Gerretsen is a psychiatrist in the Geriatric Acute Care Unit who works with dementia ICP patients. “It’s a scary condition, creates a lot of disruption for patients and families. The pathway now starts to provide [structure] that families can expect...in terms of the treatment, which can provide a lot of reassurance and a sense of security when things feel so uncertain. I think it also benefits physicians and allied health professional staff in general because it gives them guidance in how to approach the problem in a systematic way.”

Gold standard care

“It’s brought our level of practice to the gold standard,” said Christopher. “It allows every admission into the pathway the equal level of care and service and there’s no ‘one person gets less’ and ‘one person gets more’. There’s an equality.”

And now CAMH’s pathway is being presented nationally and internationally at conferences and other academic settings.

“We have received multiple requests for this pathway. We were approached by North Bay Regional Hospital as they are very interested in implementing this pathway in their inpatient setting. We are starting a collaborative project with them in February,” said Saima Awan, Senior Manager of CAMH’s Integrated Care Pathways Program.

She says London Health Sciences Centre and some long-term care facilities are also interested. “Our long-term goal is for the expansion of this model to include health care providers in non-academic inpatient settings and in long-term care facilities where most of the patients with acute dementia and behavioural symptoms reside.”

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