Reducing Agitation Through
Non-Pharmacological Therapies
Govind Bharwani, Ph.D.
Director of Nursing Ergonomics and Alzheimer’s Care
Nursing Institute of West Central Ohio
Wright State University, Dayton, OH
Speaker Disclosure
Dr. Bharwani occasionally provides strategic consulting
services for long-term care facilities in Ohio through his
position in the Nursing Institute of West Central Ohio
Acknowledgement
The authors gratefully acknowledge the support
of the AMDA Foundation and Pfizer for an
unrestricted Quality Improvement Award.
Application of Behavior-Based
Ergonomics Therapies (BBET)
to Improve Quality of Life of
Alzheimer’s/Dementia Residents
BBET Program Description

BBET = Behavior-Based Ergonomics Therapies to manage behaviors and
promote engagement

Individualized therapeutic activities (as a complement to group activities) to get
ahead of resident stress caused by boredom or disengagement

Music therapy (M1 to M30)

Video therapy (D1 to D30)

Stimulating therapy (S1 to S30)

Memory Prop therapy (provided by the family)

90+ tools available in the BBET Resource Center

Staff can provide an intervention within a few minutes

The customized action plan allows staff to initiate a therapy and move to other
tasks (1:1 care not required)

A memory care training strategy (including an internal certification and
continuing education) is implemented with the program
Benefits of BBET Program

Families can enjoy interacting with their loved ones using these items during their
visits. Families can also review a BBET engagement report in care conferences.

Risk of residents falls is greatly reduced.

Challenging behaviors are managed proactively (or redirected as needed),
reducing the need for medication.

Residents sleep better due to being engaged longer with activities they enjoy at
the times they are most ready.

In addition to the engagement during the therapy, the residents are also more
calm and alert after the therapy. This can help with personal care (inc. bathing),
meals, group activities, family visits, shift changes, and any other triggers of
stress/behaviors.

The staff takes pride in their certification & expertise. They are more cohesive
and confident as a care team.

Direct care staff have less stress and are able to spend more quality time with
residents. This helps to attract and retain the right staff for this type of
specialized care.
Retrospective Research Study
(IRB Approval obtained July 2011)
Research Time Period

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Pre-implementation period = Aug 2009 –Jan 2010
Implementation period = Feb 2010
Post-Implementation period = Mar 2010 – Aug 2010
Research Site



18-bed Alzheimer’s secured unit
Target cohort = 9 residents
Total hall population = 48 residents
Sources for Data Analysis

Optimus EMR

ADT dates
Progress notes
Incident reports
eMAR
 PRN usage
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Routine medication orders
STAT orders
Mood & Behavior charting
ADL flowcharts
Pharmacy data
Paper charts
BBET tracking sheets
MDS 2.0 reports
Study Results for Target Cohort
Metric
Preimplementation
Postimplementation
Change
Resident Falls
19
12
-37%
MDS Mood counts
76
23
-69%
MDS Behavior counts
163
58
-63%
Number of behavioral
episodes
40
15
-61%
PRN (Ativan) usage*
7
3
-57%
*Excludes:
1) PRN used during the 1st week on the unit
2) PRN used for special medical conditions, i.e. stroke, hospice, etc . . .
Study Results for Hall Population
Metric
Preimplementation
Postimplementation
Change
Resident Falls
40
27
-33%
MDS Mood counts
131
42
-68%
MDS Behavior counts
279
94
-66%
Number of behavioral
episodes
96
60
-38%
PRN (Ativan) usage*
19
10
-47%
*Excludes:
1) PRN used during the 1st week on the unit
2) PRN used for special medical conditions, i.e. stroke, hospice, etc . . .
Comments by Care Team

“Before I used to have many problems with giving bath to residents. Now I
use BBET program to calm them before giving them a bath” – STNA

“One resident loves the music therapy & begins to start dancing” – STNA

“We use BBET a lot before dinner time while they wait for food” – STNA

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“There has been a reduction in medication because there is much more
focus to use BBET program to calm the residents” – Unit Manager
“The BBET program has a calming effect on the residents, and they react to
their environment in a more positive way” – Unit Nurse
“I think that BBET program is excellent. This program has created some
consistency in approach to handle behavior problems” – Medical Director
“As staff got to use the BBET program, we stopped getting emergency phone
calls” – Geriatric Nurse Practitioner
“I feel that the anti-psychotic meds have been reduced because the staff is
using BBET program” – Geriatric Nurse Practitioner
Conclusions from the Research Study

The results of our research study shows that there is
strong evidence that the non-pharmacological BBET
program can reduce agitation and improve the quality of
life of Alzheimer’s residents.

The BBET program can improve quality of life by reducing
falls, behavior and mood counts, number of behavioral
episodes & PRN medications.

There is also evidence to support that BBET program can
reduce routine behavioral medications. However, a further
controlled study must be conducted to conclusively
validate this claim.

The effectiveness of BBET program during the late stage
of Alzheimer’s disease and/or hospice is inconclusive.