Expert panel on Agitation and Aggression in Dementia
Quality Standards and Clinical Handbook
AGHPS Summit
November 13, 2015
Health Quality Ontario

Population and topic in scope
• Individuals with agitation and aggression in the context of
Dementia being cared for in the following settings: Emergency
Department, Inpatient Hospital, LTCF
• Transitions between these 3 environments
Population and topics out of scope
• Individuals with agitation and aggression in Dementia in the
Community (non-LTCF)
• Individuals with Dementia where agitation and aggression is not an area of clinical concern
• Clinical issues related to the care of individuals with Dementia that are not specific to agitation and aggression www.HQOntario.ca
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For each prioritized key area:
Summary of relevant recommendations and guidance statements
CE will identify recommendations or statements from relevant guidelines (such as NICE or NICE-accredited guidelines, guidelines used in current practice, or those otherwise identified through scoping exercise) that support potential quality statement development.
Evidence review
Establishment of consensus
If limited or no evidence exists for a key area, the CE will ideally conduct an evidence review using the most appropriate review method.
If there is no evidence, the panel may wish to:
• Use expert consensus
• Note prioritized key area for future consideration www.HQOntario.ca
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Identification and Inclusion of Clinical Guidelines
• Identify relevant guidelines covering the population(s) and setting(s) of interest, with guidance from the medical librarians and input from the advisory panel
• Use the AGREE II instrument to select 4 –5 highest quality clinical guidelines, including at least 1 contextually relevant (Canadian) guideline
A ppraisal of G uidelines for Re search & E valuation II
1) Scope and Purpose
2) Stakeholder Involvement
3) Rigour of Development
4) Clarity of Presentation
5) Applicability
6) Editorial Independence www.HQOntario.ca
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• 5 –10 quality statements will be drafted, based on either recommendations from relevant guidelines or an evidence review
• Quality statements are not verbatim restatements of the relevant recommendations from source guideline(s)
• One quality statement may map to recommendations from one or more guidelines, and/or may be derived by rewording one or more recommendations into a single statement www.HQOntario.ca
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Dr.
Ilan
Dr. Tarek
Dr.
Krista
Ms. Vincci
Fischler
Rajji
Lanctot
Tang
Ms. Saima
Dr. Amer
Dr. Dallas
Awan
Burhan
Seitz
Dr.
Evelyn
Ms. Carrie
Williams
Acton
Ms. Ashley Miller
Ms. Denise Malhotra
Ms. Natasha Ward
Dr.
Richard Shulman
Ms. Lori
Dr.
Jenny
Dr. Barry
Whelan
Ingram
Goldlist
Ms. Sandi
Mr.
Ken
Robinson
Wong
Ms. Margaret Weiser
Titl e
HQO's Expert Advisory Panel on Dementia with
First
Name
Last Name
Agitation or Aggression
Affiliation Specialization
OSCMHS
CAMH
Geriatric Psychiatrist
Geriatric Psychiatrist
Sunnybrook Health Sciences Centre
Ontario Shores Centre for Mental Health Sciences
CAMH
– clinical pathway support
PhD Pharmacologist
Deputy CFO & Director of
IT & Decision Support
Manager, Integrated Care
Pathways Program
Geriatric Psychiatrist Western University (London)
Queen's University Providence Care
Sunnybrook Health Sciences Centre
Muskoka Landing LTC - Huntsville
Geriatric Psychiatrist
Head, Division of Long
Term Care
Administrator
Administrator Regina Gardens Long Term Care Center
Erie St. Clair Community Care Access Centre (CCAC) Decision Support Analyst
Thunder Bay Regional Health Science Center Nursing
Trillium Health Partners Geriatric Psychiatrist
St. Michael's Hospital
Kawartha Regional Memory Clinic
Mount Sinai Hospital (MSH)
Occupational Therapist
Geriatrician
Geriatrician
Accalaim Health Alzheimer Services
Full-Time Caregiver
Private Practice
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Social Worker
Patient Advocate
Psychologist

1.
Assessment and monitoring
2.
Nonpharmacological interventions
3.
Pharmacological interventions
4.
Physical restraint minimization
5.
Provider education and training
6.
Caregiver education and training
7.
Access to specialty care
8.
Physical care environment
9.
Consent and decision-making capacity
10.
Transition of care www.HQOntario.ca
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• People with dementia receive a comprehensive evaluation with the use of appropriate validated tools or instruments , which includes early identification of individual risk for behavioural challenges.
• People with dementia and agitation or aggression receive behavioural interventions that are tailored to their specific needs and symptoms, as specified in their care plan. Evidence-based behavioural interventions include:
– Aromatherapy,
– Multisensory therapy,
– Therapeutic music and dance therapy,
– Pet-assisted therapy
– Massage therapy www.HQOntario.ca
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• Medication review for dosing reduction and discontinuation is performed on a regular basis (at least every 3 months) for people with dementia who receive pharmacological agents for agitation or aggression
• Physical restraints are only used in people with dementia and agitation or aggression when behavioural and/or pharmacological measures have been unsuccessful, and individuals continue to pose an imminent risk of harm to themselves or others
• People with dementia and agitation or aggression receive care from providers with structured specialized training in dementia and its behavioural symptoms, which are consistent with the provider’s roles and responsibilities.
www.HQOntario.ca
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• Carers of people with dementia and agitation or aggression are informed of advocacy and support groups and services and how to access them.
• People with dementia and agitation or aggression receive access to mental health and behavioural support services from a multidisciplinary team, which provides specialized care in dementia with behavioural and psychological symptoms
• People with dementia and agitation should be assessed and treated in a physical care environment that is supportive and therapeutic.
• People with dementia and agitation and/or carers are actively engaged in the transition preparation process, and receive an up-to-date proactive care plan that is agreed upon by all providers and considers the changing needs of the person with dementia.
www.HQOntario.ca
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– Step 1: Guideline selection
– Step 2: Development of Algorithm
– Step 3: Gap Analysis
– Step 4: Create supporting governance structure
– Step 5: Selection of adherence and outcome measures
– Step 6: Create Project Charter
– Step 7: Utilize informatics – eg. electronic templates, automated decision support
– Step 8: Realignment of Therapeutic Services
– Step 9: Monitor Adherence and Promote Quality
Improvement
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– Electronic ABC tracking tool
– Implement Evidence-based non-pharmacologic interventions:
» Pet therapy, Aromatherapy, Massage Therapy,
Formalized exercise program (already had multisensory stimulation, music therapy, reminiscence, etc.)
– New training program for all clinical staff – with a focus on person-centred care
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– New assessment tools to be completed by interprofessional staff at prescribed times
• PAIN-AD, Cornell, CAM, Prompted voiding trial assessment, environmental assessment, NPI-NH and others
– New interprofessional care plan
– New social work psychosocial assessment with a focus on caregiver assessment and support and relationship with
Long-term care
– New physician assessment tools to standardize family meetings and follow-up of treatment response
– Incorporate CAMH medication algorithm
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
 Improved quality of care
 Enhanced patient outcomes
 Reduced health care costs

Assessment &
Medications
Discontinuation
Non-
Pharmacological
Cognitive
Enhancers
(AChEI,
Memantine)
Pharmacological
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Zaraa, 2003

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• Consent
• Caregiver education and support
• Enhance communication with the patient
• Ensure safe environment
• Increase or decrease stimulation in the environment
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Allied Health
Professional
Please check discipline:
Occupational
Therapist
Recreation
Therapist
Social Worker
Primary Nurse
NON-PHARMACOLOGICAL INTERVENTIONS IDENTIFIED
INITIALLY AS MOST APPROPRIATE*
Social Contact
Pet therapy
Sensory
Enhancement/
Relaxation
Purposeful Activity Physical Activity
Exercise group
One-to-one visit Hand massage
Helping tasks /
Volunteer role
Indoor/outdoor walks
Other:___________
____
Individualized Music Inclusion in group programs of
Individualized art identified interest
Sensory modulation Access to outdoors
Individual exercise program
Name:
Sign:
Other:___________
____
Other:___________
____
Other:____________
___
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Date:

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Risperidone
Aripiprazole
Carbamazepine
Quetiepine
Citalopram
Gabapentin
Prazosin
ECT
For partial responders:
1.
Extend the trial
2.
Increase the dose
3.
Augment with another agent that showed also partial response
PRNs:
1.
Trazodone
2.
Lorazepam
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Combined Total
Patients
Enrolled
(Alzheimer’s and
Frontotemporal
Dementia)
Combined Total
Patients
Completed
ICP’s
(Alzheimer’s and
Frontotemporal
Dementia)
Alzheimer’s/Mixed Vascular
Completed Step One of
Medication
Algorithm
Step Two of
Medication
Algorithm
Exited
(no meds)
Currently being treated
Frontotemporal
Dementia
Completed
21 19 18 13 4 1 1 1
Combined Total
Patients (Alzheimer’s and Frontotemporal
Dementia)
Patients Enrolled and
Tolerating
Three or More
Non-
Pharmacological
Interventions (any selected combination from algorithm)
Patients Enrolled and
Tolerating
Two or Less
Non-Pharmacological
Interventions (any selected combination from algorithm)
Did Not Respond,
Tolerate or Accept any Non-
Pharmacological
Interventions
21 15 1 5
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