Our Take

Using behavioral interventions in memory care

Learn how behavioral interventions can reduce hospitalizations and mitigate challenging behavior in memory care.


Behavioral interventions in memory care are designed to better address the complicated behavioral challenges that result from memory loss. Although this is not a new solution, stakeholders have historically been hesitant to implement behavioral interventions due to a lack of specialists in this field. They have instead focused on the easier alternative of pharmacological solutions like anti-psychotics. However, stakeholders should use a behavior-first approach to avoid negative outcomes and prevent escalating patients to higher levels of care.


What are behavioral interventions in memory care?

Behavioral interventions in memory care focus on helping caregivers understand how dementia affects brain function, so that they can adjust how they interact with people with dementia. The goal is to understand and modify the underlying trigger for the behavior, rather than trying to control the behavior itself.

Examples of behavioral challenges:

  • aggression and anger
  • anxiety and agitation
  • depression
  • hallucinations
  • confusion
  • suspicions and delusions
  • wandering
  • sleep issues and sundowning
  • repetition

Examples of behavioral interventions:

  • speaking with either a professional therapist or a caregiver trained in behavioral health issues for memory care patients
  • using familiar touch, sound, sight, taste, and smell to soothe anxiety or confusion
  • using creative solutions to prevent common issues like incontinence or exit seeking
  • electro convulsion therapy for treatment of depression

The conventional wisdom

Many stakeholders agree that one of the most challenging aspects of memory care is dealing with the behavioral changes that come with memory loss. However, there is less agreement on how to best deal with these changes.

Behavioral challenges associated to memory loss are expected but challenging to manage. A normal consequence of dementia is the deterioration of the brain over time and subsequent changes to behavior. Patients eventually lose their ability to respond to their environment, converse with others, maintain socially expected norms of behavior, and control their movements. Although expected, these changes manifest in unique and often challenging ways that can cause problems in care centers—especially for understaffed care centers.

There is no easy, one-size-fits-all approach to managing behavior. Historically, providers have been slow to adopt behavioral interventions for patients with dementia due to the lack of, and cost, of behavioral health clinicians. Behavioral interventions for non-specialists can also be difficult to implement effectively without proper training. It often takes more time, and can cost more upfront, to identify the behavioral interventions needed for each patient than to use a pharmacologic interventions like anti-psychotics. When individuals’ behaviors are not properly managed, however, they typically end up in higher, more expensive levels of care.


Our take

1. Behavioral interventions prevent escalation to higher levels of care

To address the challenging behaviors related to memory loss, stakeholders should work to incorporate behavioral health into the broader care team as early as possible. When care centers and caregivers do not have adequate resources to support behavioral health concerns in dementia patients, they often find hospitalization the only option. This is particularly true in the later stages of the disease’s progression. People with dementia experience more than three times the hospitalization rate of older adults without cognitive impairment. However, once escalated to the hospital patients’ symptoms often worsen due to the confusion and the added stress of the new surroundings. Delirium develops in more than 50% of hospitalized patients with dementia. Not only does delirium increase morbidity and mortality, but it also creates additional costs to the health care system.

2. Behavioral interventions should precede pharmacological interventions

Most memory care patients who are in the later stages of the disease are already taking numerous prescriptions, and the additional medications used to treat difficult behaviors can easily lead to adverse drug effects and hospitalization. Additionally, a behavior-first approach prevents escalating patients to higher levels of care: studies show that when patients with memory loss go to the hospital, they often deteriorate more quickly, become more confused, and die quicker than those who are not placed under this additional mental stress.


Three ways to implement behavioralsolutions in memory care

There are three ways the healthcare industry can implement behavioral interventions for challenging behavior related to memory loss:

Geriatric psychiatrists (GPs) focus on prevention, evaluation, diagnosis, and treatment of mental and emotional disorders in the elderly. Using GPs in the inpatient setting allows for earlier detection of patients who may be struggling before they’ve escalated to a point where they need more severe interventions. Additionally, GPs who work within the multidisciplinary medical team and collaborate with nurses and social workers can better inform care decisions. The care team can help collect all relevant and necessary information before the actual physical assessment—leading to improved care management and clinical decision making.

One of the major challenges of hiring GPs is that they are expensive and there are simply not enough of them to meet the behavioral health needs of all memory care patients in this country. However, providers can use telehealth visits to connect patients with GPs, which helps cut travel costs and creates more time for the GP to work top of license. One of the benefits of using virtual care for behavioral intervention is that (typically) both the patient and the caregiver are present during the visit. This promotes better information collection without having to visit the patient and caregiver in-person. Beyond that, using virtual visits can also be used for behavioral observation. GPs can better track both the progression and duration of behavioral challenges, as well as how quickly things change while helping to make better care decisions for the patient.


Case profile

SSM Health
Home Health Care Services company

SSM Health is a leader in behavioral health services, offering nearly 300 inpatient beds across Missouri, 269 inpatient beds in Oklahoma, 24 inpatient beds in Illinois and 20 inpatient beds in Wisconsin. In 2016, they opened their first inpatient geriatric behavioral health units in Mid-Missouri and Illinois, where they provide one-on-one consultations with geriatric psychiatrists, treatment, therapy, and medication education and follow-up with patients. The addition of these units brought new employment opportunities for each community, including social workers, case managers, psychiatrists, recreational therapists and nursing staff.

Geriatric psychiatrists are not the only healthcare professional who can implement behavioral interventions. Nursing home staff, particularly nurse practitioners (NPs), can be trained on behavioral best practices to help clinicians focus on treating the most complex patients. This also enables providers to scale their dementia care services more easily. Staff can be trained to:

  • describe psychiatric symptoms
  • conduct cognitive assessments
  • regularly assess possible underlying medical causes of psychiatric symptoms
  • integrate medical and psychiatric treatment plans including pharmacologic and non-pharmacologic approaches

Case profile

Optum House Calls
Annual in-home clinical assessment for members of participating health plans

Optum’s House Calls and I-SNP programs focus on training staff to handle behavioral assessments. UHG members who enroll in an I-SNP have a care provider assigned to them—typically an NP who will come every few days to keep track of any cognitive or behavioral changes. The NPs can check for changes in the patient and make medicine changes more frequently, reducing potential deterioration and escalation to the hospital.

Hospitals, particularly emergency departments, are often busy and chaotic environments. This can create stress and anxiety for older adults experiencing memory loss. Front line staff can use a series of screening questions for delirium, past surgeries or admissions, and medications before they decide if the patient is high-risk and should go to a psychiatric unit or receive other specialized, behavioral care within the ED. Ultimately, this helps providers better understand what is going on with the patient so they can decide the best course of action for a patient and catch issues that might arise before they happen. Appropriate screening for behavioral health can ultimately reduce length-of-stay in the hospital.


Ways to create a dementia-friendly ED environment

  • assign trained staff or volunteers to engage and orient unaccompanied patients
  • create comfortable room temperature and proper lighting
  • minimize noise
  • avoid use of cardiac monitoring, IVs, and urinary catheters unless necessary
  • offer food and fluids frequently unless contraindicated
  • offer frequent toileting. Avoid nighttime diuretics and IV fluids if possible c
  • display eye-level signage and orienting cues
  • make sure the patient has access to their glasses and/or hearing aids
  • assist patients in mobility (up in chair, ambulate) as able
  • provide a preferred activity and distraction aids

Case profile

Lifespan
Not-for-profit health system

Lifespan uses multidisciplinary teams headed by a psychiatrist to provide inpatient and emergency department consultations. The team includes psychiatrists, neuropsychologists, psychiatric nurse clinicians, nurse specialists, psychiatric social workers, and psychiatric residents. They work collaboratively to evaluate and care for patients whose psychiatric problems affect their medical conditions or whose medical illness generates psychiatric (neuropsychiatric) symptoms or conditions. They evaluate for pain management, dementia, decision-making ability, and the need for subsequent care. Their care team works closely with patients' physicians, social workers, and nursing staff to ensure that the mental health needs of both patients and their families are met.


Parting thoughts

Although regulatory changes to incentivize and pay providers to implement more behavioral interventions for memory care patients, there are important reasons to implement them despite the up-front time and cost. Below are the headwinds and tailwinds for behavioral interventions:

Tailwinds

  • Prevention of delirium and deterioration from the stress of hospital stay is a clinical and financial priority because it exacerbates health complications.
  • Minimizes the use of pharmaceutical interventions which could lead to adverse drug effects and hospitalization.
  • Helps prevent evictions from nursing homes. Although illegal, this can happen if facilities are ill-equipped to care for dementia patients.

Headwinds

  • The cost per hour of a geriatric psychiatrists is expensive (upfront cost is high).
  • There are not enough clinically-trained behavioral health workers to meet one-on-one with all the memory care patients who need them.
  • There are regulatory barriers to implementing some behavioral health techniques, especially around restraining patients.
  • Behavioral interventions require a lot of creativity and knowledge to determine what is best for each patient—there isn’t a one size fits all approach.

For additional support, please visit advisory.com/seniors.


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MORE ON CARING FOR SENIORS

Explore the collection of resources that our team has developed to help you understand how the industry is currently caring for older adults (ages 65+), why change is essential, and how industry stakeholders can collaborate to build a better care model for seniors.

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AFTER YOU READ THIS
  • You'll understand how behavioral interventions work in memory care.
  • You'll learn how to implement behavioral interventions in memory care. 
  • You'll discover strategies for reducing hospitalizations in memory care.
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