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A cultural change
The Awakenings Program began in 2009 with Eva Lanigan, a nurse at Sunrise Home in Two Harbors, and Dr. Tracy Tomac, a neuropsychiatrist. Lanigan is now retired. Tomac works for Regions Hospital in St. Paul and as a consultant for Ecumen.
About 40 percent of dementia patients go through psychotic episodes, and most get agitated at times. Some may warrant the use of antipsychotics, Tomac said, but some may not. The question, she said, is whether the psychosis causes suffering for the patient. She said one woman had visual delusions that made her see the world as if it were through a window into a Cecil B. DeMille movie, but it did not cause her any distress, so it didn’t require medication.
In cases where medicine is required, she said, the goal is to find the lowest effective dose.
“We don’t want to say medications are bad. We want to talk about appropriate use,” Tomac said.
Oftentimes, behavioral problems can be accommodated with creative adaptations. Tomac described the case of a male patient who wandered around the facility. Staff learned that he’d been an outdoorsman and liked to move about. So they set up a walking perimeter around the nursing home and marked a path with visual cues. That safely fulfilled his needs, Tomac said. Allowing for normal movement is important in the management of dementia and may actually lead to less wandering, Tomac said.
“Many times it’s what we [caretakers] are doing that is causing the behavior,” said Shelley Matthes, who oversees clinical quality at Ecumen. “That’s what we had to drill into the staff. What are the antecedents?”
That approach required a cultural change within the nursing homes, Matthes said. “Part of the problem is, we are a medicine culture. We want a pill to fix everything.”
Reyes recalled another client who came to Ecumen from a hospital “with a nice little cocktail of medication.” The woman had initially gone to the hospital with a urinary tract infection. Such infections can cause people to become confused, Reyes said. She was given Haldol. She had trouble sleeping, so they gave her Ambien. Those drugs may have been appropriate during her stay at an acute care hospital, she said. But her confusion persisted at the nursing home.
Reyes said they gradually weaned her from the medications and after several months, she walked out of the memory care unit and returned home.
“I’d never seen that before,” she said. “It was a classic case of delirium, which can have many causes. In her case, it was the medication.”
Dr. Alvin Holm, medical director of Alzheimer’s and memory loss care at Bethesda Hospital, said agitated behavior is a form of communication for dementia patients who can no longer connect with people appropriately because of their disorder.
“We would like to treat behavioral disturbances like we treat strep throat,” Holm said. “But it doesn’t work that way.”
“Drug therapy is no substitute for environmental supports,” Holm said. “If drug therapy was the answer we wouldn’t need places like Ecumen. All patients would be at home on drugs.”
Dan Browning • 612-673-4493