Improving behavioral and psychological symptoms and cognitive status of particip

Running Head: IMPROVING SYMPTOMS OF DEMENTIA WITH TIP 1 Improving Behavioral and Psychological Symptoms and Cognitive Status of Participants with Dementia through the Use of Toy Interactive Pets Bryanna Streit Florida Atlantic University Fall 2019 Faculty Team Member: Dr. Lisa Wiese Community Team Member: Dr. María Ordóñez Proposed Title of Project: Improving Behavioral and Psychological Symptoms and Cognitive Status of Participants with Dementia through the Use of Toy Interactive Pets Clinical question (PICOT format): In adults aged 50 and older with Alzheimer’s disease or related dementias in an adult day center (P), how does the use of affordable toy interactive pets (TIP) (I) impact participants’ behavioral and psychological symptoms and cognitive status as indicated by specific observational measures (O) over 12 visits (T)? Site of project: South Florida Adult Day Center IMPROVING SYMPTOMS OF DEMENTIA WITH TIP 2 Abstract Background: In the US, one in three older adults die with Alzheimer’s or related dementia (Gaugler et al. Currently, there is no cure for the rapidly growing burden, but there are pharmacological treatments to manage the symptoms, which lead to numerous side effects (Kales et al.

Method: We tested the effectiveness of a non-pharmacological toy interactive pet (TIP) in improving mood/behavior and cognition among twelve persons with mild-severe dementia attending an adult day center (ADC) over 12 visits. Mood/behavioral symptoms were assessed using the Alzheimer’s Disease and Related Dementias Mood Scale (AD-RD), Observed Emotion Rating Scale (OERS), and the Cornell Scale for Depression in Dementia (CSDD). Cognition was assessed via Mini Mental State Examination (MMSE). Paired-sample t-tests, Pearson’s correlation, repeated measures t-test, and a post-intervention qualitative inquiry were used to examine the significance of TIP.

Results: All mood scores improved over time, with two showing significance: OERS (M = 73.67%) scored higher on the MMSE post-test than the pre-test: M =10. Participants stroked and spoke often to their pets. Several family members reported participants sleeping with their pet following the program’s conclusion. Conclusion: TIP proved to be a safe alternative method to improving mood/behavior in persons with dementia attending an ADC.

MMSE scores also improved, although confounding factors such as inter-rater reliability and a potential endorphin affect may have impacted scores. IMPROVING SYMPTOMS OF DEMENTIA WITH TIP 3 Improving Behavioral and Psychological Symptoms and Cognitive Status of Participants with Dementia through the Use of Toy Interactive Pets Dementia is a syndrome that affects over 50 million people worldwide, with a new case emerging every three seconds (Alzheimer’s Disease International, 2018). Alzheimer’s disease (AD) is expected to nearly triple by 2050. In the US, one in three older adults die with Alzheimer’s or a related dementia (ADRD); more than from breast cancer and prostate cancer combined (Gaugler, James, Johnson, Marin, & Weuve, 2019).

In Florida alone, the rate of AD is expected to increase by 33. Currently, there is no cure for the rapidly growing burden of ADRD. There are only treatments to manage the symptoms. Those who have dementia often experience behavioral and psychological symptoms (BPSD), which includes agitation, aggression, depression, anxiety, psychosis, and disinhibition (Kales, Gitlin, & Lyketsos, 2015).

These symptoms usually lead to pharmacological treatment with antipsychotics, antidepressants, and benzodiazepines. These and other medications lead to early placement into nursing homes, excess morbidity, mortality, and hospital admissions due to the numerous side effects including hypotension, extrapyramidal symptoms, dizziness, and weight gain (Kales, Gitlin, & Lyketsos, 2015). There are evidence- based approaches of using live as well as robotic pet therapy for individuals with dementia that showed a decrease in their negative behaviors and an increase in positive behaviors in institutionalized settings. However, the use of robotic pet therapy, particularly in Adult Day Centers (ADCs), has not been widely tested.

Project Purpose, Goals, and Objectives The purpose of this quality improvement project was to evaluate a method for reducing troublesome behavioral and psychological symptoms of dementia (BPSD) and improving IMPROVING SYMPTOMS OF DEMENTIA WITH TIP 4 cognitive status of individuals with dementia attending an ADC. This project piloted a change in current practice: the use of affordable robotic toy interactive pets (TIP) that could be of use in community settings for improving mood and cognition among persons with ADRD. An added benefit is that this project supports the use of a non-pharmacological approach in reducing psychological symptoms such as sadness, anger, anxiety, and the risk of depression. To attain this goal, specific, measurable, achievable, relevant, and time-bound (SMART) objectives were used to measure the outcomes for this project.

The percentage criteria were based on findings reported by previous animal assisted therapy programs demonstrating that a majority of participants experienced improvement in patient stress levels. The objectives of the project that were implemented at a South Florida Adult Day Center beginning June 18th, 2019 were: Objective 1: 100% of participants will receive a “Joy for All” companion pet and use it two times a week, over 12 visits for a duration of 30 minutes each, in a group setting. Objective 2: 80% of participants will demonstrate a one-point increase in Mini Mental State Exam (MMSE) following the TIP intervention as indicated by pre and post-test MMSE scores (Menna, Santaniello, Gerardi, Di Maggio, & Milan, 2016). Objective 3: 80% of participants will demonstrate an increased positive mood/behavior following the TIP intervention as indicated by a 60% increase in scores on the Alzheimer's Disease and Related Disorders Mood Scale (Tappen & Williams, 2008) and Observed Emotion Rating Scale (Chen et al., 2016; Lee, Algase, & McConnell, 2013).

Objective 4: 80% of participants will demonstrate decreased depression risk following the TIP intervention as measured by a 60% decrease on the Cornell Scale for Depression in Dementia (Friedmann et al. IMPROVING SYMPTOMS OF DEMENTIA WITH TIP 5 The intended impact was an improvement of BPSD and cognitive status for participants with dementia who received the TIP intervention. Specifically, the goal was to increase positive emotion, decrease the risk of depression, and improve cognitive status. The role of the DNP in addressing the problem is aligned with the American Association of College of Nursing’s (2006), Essential of Organizational and Systems Leadership for Quality Improvement and Systems Thinking (American Association of College of Nursing, 2006).

As a future DNP addressing the BPSD and cognitive status, I provided a therapeutic solution using toy pets that was cost effective without added risks to ADC attendees. Team Development Bryanna Streit, Doctor of Nursing Practice (DNP) student at Christine E. Lynn College of Nursing, Florida Atlantic University (FAU) led this quality improvement project. The student completed her master’s degree in nursing (MSN) at FAU in May 2019 and became a board- certified adult gerontological nurse practitioner during the project development.

Additionally, the student has experience working with the adult and geriatric population in an internal medicine and pulmonologist outpatient office. The faculty team member for the project is Lisa Kirk Wiese, PhD, RN, PHNA-BC, Assistant Professor of Christine E. Lynn College of Nursing. Wiese has served as a thesis chair twice for neuroscience students studying AD in the community setting, and recently as the community chair for a DNP project focused on community-dwelling older adults at risk for dementia.

She just completed a two-year project funded by the Florida Department of Health, Ed and Ethel Moore Alzheimer’s Disease Foundation, in which she collaborated with Dr. Ordóñez and Dr. Hain from the ADC. Wiese volunteers at the ADC four hours monthly.

The community chair member is María Ordóñez, DNP, APRN, GNP-BC, PMHNP-BC, FAANP, FAAN, director of the ADC, FAU Memory Disorder Clinic Coordinator, IMPROVING SYMPTOMS OF DEMENTIA WITH TIP 6 Florida Alzheimer’s Disease Initiative, and Associate Professor. In addition to these multi- faceted roles, Dr. Ordóñez has vast experience in managing care for persons with ADRD as a primary care practitioner. Additionally, three BSN-DNP students from the Christine E.

Lynn College of Nursing volunteered to assist during TIP intervention. Literature Review and Synthesis Pet therapy has been proven to be a cost effective, therapeutic intervention for improving mood and behavior in the older adult population. An early live animal assisted therapy evidence- based program and its follow-up study were proven successful in a day center program (Kanamori et al., 2001a; Kanamori et al., 2001b) as well as a more recent study (Liang et al. However, more articles researched pet therapy in long-term care facilities (Moyle et al., 2017; Sicurella, 2016), assisted living facilities (Friedmann, et al., 2015), and nursing homes (Jøranson, Pederson, Rokstad, & Ihlebæk, 2015).

These programs demonstrated patient and family perceptions of improved quality of life and self-care management by aiding in controlling symptoms of dementia. Current Treatment of ADRD in Institutionalized Settings Behavioral and psychological symptoms of ADRD are seen in most individuals who have dementia. Apathy, depression, and anxiety are the most common symptoms (Kales, Gitlin, & Lyketsos, 2015). These symptoms impact the care given to the individuals as well as their family members.

In a meta-analysis, Kales and colleagues studied systematic reviews, Cochrane reviews, and randomized controlled trials of pharmacological treatments of behavioral and psychological symptoms of individuals who have dementia (2015). They noted that the medication used to treat BPSD is off label since the Food and Drug administration has not approved their use in the U. It is unclear if the benefits outweigh the risks of the adverse effects IMPROVING SYMPTOMS OF DEMENTIA WITH TIP 7 (AE) associated with these medications. AE of antipsychotics (typical and atypical) include anticholinergic effects, postural hypotension, prolonged QT, extrapyramidal symptoms, weight gain, diabetes, and increased risk of cerebrovascular events.

Kales’ team (2015) also found that several studies showed increased mortality. Tricyclic antidepressants showed limited benefit with AE similar to antipsychotics, while selective serotonin reuptake inhibitor (SSRI) antidepressants showed a reduction in agitation. However, side effects included nausea, vomiting, headaches, tremor, gastrointestinal bleeding, and QT prolongation. In other studies reviewed, they found a positive impact with the use of cholinesterase inhibitors, but there was often an increase in Parkinsonian symptoms such as tremors.

These investigators also advised against benzodiazepines for management of BPSD except in acute crisis, due to AE of sedation, dizziness, worsened cognition, respiratory depression, dependency, and falls (Kales, Gitlin, & Lyketsos, 2015). With this adult population, the use of these medications often provides more harm than benefit. This population endures physiological changes starting at the age of 40, with a decrease in kidney function leading to less excretion of the medication, thus, longer half-life and enhanced response from the medication (Kennedy-Malone, Martin-Plank, & Duffy, 2019). The AE of these medications are more prominent in this older adult population.

The risk of syncope, sedation, dehydration, and hypotension is increased, which can lead to falls and broken hips or subdural hematomas resulting in worse outcomes. Kales, Gitlin, & Lyketsos (2015) summarized the current evidence, suggesting that non-pharmacologic strategies demonstrate a greater effect than most drug treatments. The use of TIP is a non-pharmacologic treatment that offers a safe intervention to improve the behavioral and psychological effects seen in individuals with ADRD. IMPROVING SYMPTOMS OF DEMENTIA WITH TIP 8 Long-term care facilities.

A cluster-randomized controlled trial was conducted in 28 long-term care facilities (LTC) in Australia with aims to compare the effects of Paro (a robotic seal), a plush toy, and usual care has on emotional and behavioral symptoms of individuals who have dementia in LTC facilities (Moyle et al. There were three groups: 1) a group with 137 participants from 9 facilities receiving usual care, 2) a group with 138 participants from 9 facilities receiving Paro intervention, and 3) a group with 140 participants from 10 facilities receiving a nonrobotic plush toy (Moyle et al. Both intervention groups using Paro, or the plush toy met 3 days a week, 15-minute sessions, for 10 weeks (Moyle et al. Although the groups using the Paro and plush toys expressed more anger which was contributed to various reasons such as interruption of current activity or removal of Paro, there was a statistically significant (p = .01) reduction in agitation using Paro, reduction in neutral effect with Paro intervention (p = .02) and improvement in pleasure (p = .