Caring For The Dementia Patient Evidence Based Practice- Lisa Krier
The population of elderly people in society is continually increasin
Introduction
This assignment will reflect on and critically study an incident from a clinical setting whilst using a model of reflection. This will allow me to analyse and make sense of the incident and draw conclusions relating to personal learning outcomes. The incident will be described and analysed, followed by the process of reflection using Driscoll’s Reflective Model (2000) as it facilitates critical thinking and in-depth reflection which will help me to accumulate learning objectives for the future. To comply with the Nursing and Midwifery Council (NMC) (2015) Code of Conduct, confidentiality will be maintained therefore the individual will be known throughout as Ben.
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Reflection is defined as a process of explaining and expressing from our own experiences and helps to develop and improve our skills and knowledge towards becoming professional practitioners (Jasper, 2003). I have chosen to use the Driscoll’s Reflective Model (2000) as a guidance as it is straightforward and encourages a clear description of the situation which will allow me to look at the experience and identify how it made me feel, asking what was good and bad, and what I can learn (Sellman and Snelling 2010). Wolverson (2000) includes this as an important process for all nurses wishing to improve their practice.
What?
Ben was born prematurely following an emergency caesarean section, whereby he received prolonged resuscitation and suffered severe hypoxic-ischaemic encephalopathy (HIE). According to Boxwell (2010), infants with severe encephalopathy have a 75% risk of dying with coma persisting, or progressing to brain death by 72 hours of life. There was a realisation that continuing treatment may be causing Ben harm in that it was unlikely to restore his health or relieve suffering. Boxwell (2010) further states that survivors of HIE carry an almost certain risk of poor neurological outcome. It is these times when consideration must be given to withholding and/or withdrawing treatment, subsequently re-orientating treatment to compassionate care. I was informed by my mentor that there would be a multi-disciplinary team (MDT) meeting to discuss and justify the decision to withdraw treatment.
I was invited into the MDT meeting by my mentor to both witness and actively participate in the discussion if I felt confident enough. The MDT consisted of two paediatricians, a paediatric registrar, the neonatal sister, and myself, a paediatric student nurse. The Royal College of Paediatrics and Child Health (RCPCH) (2004) suggest that all members of the health care team need to feel part of the decision-making process in that their views should be listened to. At the time, I was hesitant to contribute due to my knowledge, understanding and experience surrounding the clinical and ethical matter. However, I was reassured that greater openness between disciplines will facilitate better understanding of individual roles and enhance the sense of responsibility (RCPCH, 2004).
We considered what was legally permitted and required, but also at what was ethically appropriate. In considering quality of life (QOL)Â determinations, it was important to refer back to the ethical foundation involved with surrogate decision making, which is the standard of best interest. Some professionals argued that Ben had no prior QOL on which to base a judgment. The Children Act (1989) provides an overall statutory framework for the provision of children’s welfare and services but makes no specific provision concerning withholding or withdrawing treatment (RCPCH, 2004). It does however state that the welfare of the child is paramount which is further supported by The United Nations Convention on the Rights of the Child (1989). Article 3 under this legislation states that actions affecting children must have their ‘best interests’ as a primary consideration (RCPCH, 2004).
The NMC (2015) framework governs the maintenance of standards of practice and professional conduct in the interests of patients, acting as a guide to ethical practice within nursing. The principle of non-maleficence is one of the hallmark principles of ethics in health care which prohibits healthcare professionals from doing any action that will result harm to the patient. Also paramount, is the goal to restore health and relieve suffering, promoting good or beneficence. In the principle of beneficence, nurses are obliged to protect, prevent harm and maintain the best interest for patients (Beauchamp & Childress, 2001). Those involved needed to be conï¬dent in their ability to understand the ethical dilemmas they faced, and had to ensure they were aware of the underlying ethical principles to support their contribution to the discussion.
The decision to withdraw life sustaining treatment should be made with the parents on the basis of knowledge and trust, but ultimately, the clinical team carries the responsibility for decision making, as an expression of their moral and legal duties as health care professionals. It is not uncommon for parents to feel indecisiveness, shame or guilt about the decision to palliate their neonate, particularly when the outcome of the neonate’s condition is uncertain (Reid et al, 2011). However, the final decision to withdraw intensive care was made with the consent from both parents, and this was clearly recorded in his clinical notes, together with a written account of the process and factors leading to the decision.
So What?
Parents impending the loss of their infant experience a complex emotional reaction to their situation, typically one of anticipatory grief, shock and confusion (Gardner and Dickey, 2011). They may also experience feelings of profound loss, related not only to the imminent loss of their child but also to a loss of their expectations, aspirations and role as parents (Gardner and Dickey, 2011). Parents are fundamental in the decision-making processes around neonatal palliation and as it is they who will be the most significantly affected by these decisions (Branchett and Stretton, 2012), neonatal EOL care places a particular focus on caring for parents. Developing a flexible, transparent and family-centred care plan is essential, and so that their preferences are met, parents should take a key role in this process (Williamson et al, 2008). Spence (2011) recommends that a holistic approach is taken to clarify the family’s wishes, desires and needs in order to effectively advocate for infants.
Whilst most parents wish to be involved in decisions and planning around EOL care for their baby, some may find this responsibility overwhelming (Williams et al, 2008). Despite this, we exposed the parents to a range of options which they synthesised in order to make the best decisions for their family. However, it was important for the neonatal nurse and I to realise that highly emotive situations can often cause significant deficits in parents’ ability to comprehend and process such information (Williams et al, 2008). As competent nurses, it is our responsibility to provide nursing care that advocates for our patients’ rights in life and death, showing respect and dignity towards them and the family. We advocated for Ben by protecting his rights, being attentive to his needs, ensuring comfort and protection, and by participating in the ethical discussion to ensure a collaborative perspective of ethical negotiation (Spence, 2011).
The National Association of Neonatal Nurses (2015) suggests that palliative care should include comfort measures, such as kangaroo care, an ongoing assessment of pain using an appropriate pain assessment tool and written care plans to manage discomfort, pain and other distressing symptoms such as seizures using the least invasive effective route of administration. As the parent’s wished to be present at time of death, the neonatal nurse prepared the family for what they would observe as life-sustaining treatment was discontinued. This included informing them of gasping and other noises, colour changes, and stating that Ben may continue to breathe and have a heart rate for minutes or hours. This is an fundamental aspect of palliative care, and provides the family with the opportunity to ask questions. However, a study conducted by Ahern (2013) stated that nurses often express anxieties surrounding how to support parental grief and how to prepare them for the imminent death of their infant. Parental preferences were also assessed, including whom they wish present, whether they want to hold the infant, and whether they wished to participate in any rituals or memory-making activities.
Although my mentor took the lead role in planning the infant’s EOL care, my contribution focused on memory-making activities. Although this is often nurse initiated, making memories is increasingly recognised as an aid in parental coping and grieving (Schott, Henley and Kohner, 2007). However, McGuinness, Coughlan and Power (2014) reported that rather than physical keepsakes, parents and families instead appreciated other actions and gestures that demonstrated respect for their needs, including having time alone with the infant and being encouraged and supported to provide care to their baby. I asked the parents if they would like photos to be taken, and although parent’s declined photography, I offered to take some to keep in the medical records in case they decided they would like them at a later date which they appreciated (Mancini et al, 2014). Despite this, the parents were acceptant of the offer to keep items that were related to Ben’s care, including his wristband, blankets and hat.
Throughout planning Ben’s EOL care, the effectiveness of the therapeutic relationship in meeting the family’s needs was achieved by showing empathy, and by doing so I obtained the individuals trust, and respect. Carl Rogers (1961) has influenced the shift from a task- to a person-centred and holistic view of nursing care, with the adoption of Rogers’ ‘core conditions’ (Bach and Grant, 2005). Rogers identified unconditional positive regard, genuineness and empathy as necessary conditions for helping someone change effectively through a good therapeutic relationship. This was achieved through both proficient nursing knowledge and utilising interpersonal communication skills. According to Jones (2007), there is little research in nursing literature that discusses interpersonal skills, particularly in nursing education. There is also a critique that nursing education is often removed from the realities that students experience during their clinical practice (Bach and Grant, 2005). I felt confident and assured that my interpersonal skills would bring positivity throughout a very difficult time, helping them through the grieving process. I acknowledged that both parent’s appreciated my forward-thinking and empathy towards the current situation. Being empathetic during this situation required my ability to be understanding not only of the parent’s beliefs, values and ideas but also the significance that their situation had for them and their associated feelings (Greenberg, 2007).
Egan (2010) identiï¬es certain non-verbal skills summarised in the acronym SOLER that can help the nurse to create the therapeutic space. I did this by sitting facing the family squarely, at a slight angle; adopting an open posture; leaning slightly forward; maintaining good eye contact, without staring and presenting a relaxed open posture. To enhance the communication through these skills, I used active-listening skills to ensure a successful interaction through techniques that facilitated the discussion. I did this by using sounds of encouragement, demonstrating that I was listening and assimilating the information provided by the parents. This was also done by summarising, paraphrasing and reflecting on the feelings and statements. Effective use of reflective skills can facilitate exploration, build trust, and communicate acceptance and understanding to the individual (Balzer-Riley, 2004). Geldard and Geldard (2005) state that it is often the paralinguistic elements of speech rather than what is actually said that betray true feelings and emotions.
Now What?
As EOL approached, Ben was extubated on the neonatal unit and transferred to the bereavement suite whereby my mentor continued to provide one-to-one care. I was not present throughout the final palliative care phase as I wanted to respect the family’s privacy. At this point, I held emotions of helplessness, sadness and anxiety, therefore I took some time to reflect on what had happened. It is important that nurses recognise and confront their own feelings toward death so that they can assist patients and families in EOL issues (Dickinson, 2007).
Nurses often experience sadness and grief when dealing with the deaths of patients, and without any support, can suffer distress (Hanna and Romana, 2007). Debriefing is a beneficial intervention designed to help nurses to explore and process their experiences. Irving and Long (2001) suggest that debriefing demonstrates a significant reduction in stress and greater use of coping strategies through discussion in a reminiscent fashion to let their feelings out. Through reflection, I have come to the realisation and understanding that patient death is an integral part of nursing practice in palliative care settings. I have recognised that support from all members of the MDT have positive implications for nursing students coping with stressors associated with patient death.
Furthermore, the experience helped me learn the importance of both verbal and non-verbal communication. As an aspiring nurse, I have to continuously improve my communication skills because I shall be interacting with more varied patients in the future. I have also been able to utilise my knowledge of ethical principles in relation to withdrawing treatment, thereby integrating theory into practice.
Conclusion
To conclude, the care that patients receive has the direct potential to improve through reflective practice. Becoming a reflective practitioner will help me to focus upon knowledge, skill and behaviours that I will need to develop for effective clinical practice. Reflection helps to make sense of complicated and difficult situations, a medium to learn from experiences and therefore improve performance and patient care.
Reference List
Ahern, K. (2013) What neonatal intensive care nurses need to know about neonatal palliative care. Advanced Journal of Neonatal Care. 13(2), pp. 108-14
Bach, S. and Grant, A. (2005) Communication and Interpersonal Skills for Nurses. Exeter: Learning Matters
Balzer-Riley, J. (2004) Communication in Nursing. Mosby, MO: Mosby/Elsevier.
Boxwell, G. (2010) Neonatal Intensive Care Nursing. 2nd Edition. New York: Routledge
Branchett, K. and Stretton, J. (2012), ‘Neonatal palliative and end of life care: What parents want from professionals’, Journal of Neonatal Nursing. 18(2), pp. 40-44.
Dickenson, G. E. (2007). End of life and palliative care issues in medical and nursing schools. Death Studies, 31, pp. 713-726.
Driscoll, J. (2000) Practising Clinical Supervision. London: Balliere Tindall
Egan, G. (2010) The Skilled Helper: A problem management and opportunity development approah to helping.9th edition. Pacific Grove, CA: Brooks/Cole.
Geldard, D. and Geldard, K. (2005) Practical Counselling Skills: An Integrative Approach. Basingstoke: Palgrave Macmillan
Greenberg, L.S. (2002) Emotion-focused therapy: Coaching clients to work through feelings Washington, D.C: American Psychological Association
Hanna, D.R. and Romana, M. (2007). Debriefing after a crisis. Nursing Management. 8, pp. 39-47.
Irving, P. and Long, A. (2001). Critical incident stress debriefing following traumatic life experiences. Journal of Psychiatric and Mental Health Nursing. 8, pp. 307-314.
Jasper M (2003). Beginning reflective practice. Cheltenham: Nelson Thornes
Mancini, A., Uthaya, S., Beardsley, C., Wood, D. and Modi, N (2014) Practical guidance for the management of palliative care on neonatal unit. London: Royal College of Paediatrics and Child Health
McGuniess, D., Coughlan, B. and Power, S. (2014) Empty arms: supporting bereaved mothers during the immediate postnatal period. British Journal of Midwifery. 22(4), pp. 146-52.
National Association of Neonatal Nurses (2015) Palliative and End-of-life Care for Newborn’s and Infants. Chicago: National Association of Neonatal Nurses
Nursing and Midwifery Council (NMC) (2015). The Code: professional standards of practice and behaviour for nurses and midwives. London: NMC
Reid, S., Bredemeyer, S., van den Berg, C., Cresp, T., Martin, T., Miara, N., Coombs, S., Heaton, M., Pussell, K., and Wooderson, S. (2011) ‘Palliative care in the neonatal nursery’. Neonatal, Paediatric & Child Health Nursing. 14(2), pp. 2-8
Royal College of Paediatrics and Child Health (2004) Withholding or Withdrawing Life Sustaining Treatment in Children: A Framework for Practice. London: Royal College of Paediatrics and Child Health
Schott, J., Henley, A. and Kohner, N. (2007) Pregnancy loss and the death of a baby: guidelines for professionals. 3rd Edition. London: SANDS
Sellman, D. and Snelling, P.C. (2010) Becoming a nurse: A textbook for professional practice. Harlow: Pearson Education
Spence, K. (2011) Ethical advocacy based on caring: A model for neonatal and paediatric nurses. Journal of Paediatrics and Child Health. 47, pp. 642-645
Williams, C., Munson, D., Zupancic, J. and Kirpalani, H. (2008) ‘Supporting bereaved parents: Practical steps in providing compassionate perinatal and neonatal end-of-life care’. Seminars in Fetal and Neonatal Medicine. 13(5), pp. 335-340.
Wolverson, M. (2000). ‘On reflection’. Professional Practice. 3(2), pp. 31-34
g, which places demands on the health care system. Drugs are extensively used in the elderly, and when the patients have dementia, this raises their level of vulnerability (Jedenius, Johnell, Fastbom, Stromqvist, Winbald & Andreasen, 2011). The administration of psychotropic drugs to dementia patients experiencing out of character responses has become increasingly controversial. Many of these drugs come with black-box warnings from the FDA, have not been approved for use in patients with dementia and are not recommended for the elderly. Many of these drugs have shown to be harmful in the elderly, decreasing quality of life and even leading to death, and have adverse effects (Azermai, Elseviers, Petrovic, Van Bortel, & Vander Stichele, 2011). Nurses have two options when dementia patients experience out of character responses, 1) administer a psychotropic medication to calm the resident, or 2) use a therapeutic approach to calm the patient without the potential of adverse side effects that medications pose (Logsdon, McCurry, & Teri, 2007).
Change Model Overview
The John Hopkins Nursing Evidence-Based Practice Process consists of defining the practice question, gathering, appraising, and synthesizing the available evidence, and then translating the plan into the clinical setting. Nurses with various levels of education have been able to use this process successfully with mentors assisting and the support of their organizations. Nursing professionals find this process beneficial in understanding the elements of nursing intervention and implementing the evidence found into their practice setting (Dearholt & Dang, 2012)
Practice Question
Step 1: Identify an EBP question
The population involved in this evidence-based practice question is dementia patients who experience out of character responses. The intervention being utilized is the use of therapeutic approaches to calm the dementia patient, compared with the use of psychotropic drugs to calm the dementia patient suffering an out of character response. The desired outcome is to see a decrease in the number and severity of out of character reactions in the patients, along with fewer adverse side effects that psychotropic medications may have (Jeste et al., 2008).
Step 2: Scope of practice question
The population of elderly in the United States is steadily increasing and many of these elderly will require the services of a long-term care facility sometime in their life (Harris-Kojetson, Sengupta, Park-Lee, & Valverde, 2013). It is estimated that 69% of residents in long-term care facilities were taking at least one psychotropic medication (Galik & Resnick, 2013). Out of character reactions are common in patients with dementia, but there is no FDA approved drugs to deal with these responses in the dementia patient. The unlabeled use of psychotropic medications is commonly used, even though many of these drugs come with black-box warnings from the FDA. These drugs can cause postural hypotension, sedation, falls, and even mortality, especially with the use of atypical antipsychotics (Jeste et al., 2008). The cost of fall related injuries are estimated to be between $16 and $19 billion annually for nonfatal injuries and around $170 million for deaths resulting from falls, adding additional demands on an already stressed health care system (Currie, 2008).
Steps 3, 4, and 5: Team
The team members involved in this pilot project consist of the Memory Support Coordinator, the Life Enrichment Coordinator, the night shift nursing supervisor, the day shift nursing supervisor, two Certified Nursing Assistants from the day shift and one Certified Nursing Assistance from the night shift. All of the selected participants have direct patient contact and work in the Memory Support Unit with all of the patients having a diagnosis of dementia. The Memory Support Coordinator will be the project’s bridge to the facility’s administration. The chosen team members will be trained in therapeutic approaches to maintain a calming environment and to utilize when any of the patients experiences an out of character response.
Evidence
Steps 6 and 7: Internal and external search for evidence
The quantitative research that was obtained for this projected consisted of three peer-reviewed research articles and one systematic review. One of the peer-reviewed research articles that was utilized for this project was of high evidence, with the other two peer-reviewed research articles containing good evidence. The systematic review that was used consisted of several randomized controlled trials. All of the articles used for this project did make recommendations based upon the evidence cited in the research.
Steps 8 and 9: Summarize the evidence
One of the peer-reviewed research articles that was obtained was of high strength and evidence. It consisted of a randomized study, a large sample size, a control group, and detailed the physical outcomes of dementia patients receiving psychotropic medications. The study recommends that careful consideration of the adverse effects of psychotropic medication used in the elderly along with further longitudinal studies is necessary to fully explore the impact these medications have on the elderly (Galik & Resnick, 2013). The other two peer-reviewed research articles that were obtained were of good evidence and strength. One of the articles consisted of a systematic review of randomized clinical trials and discussed behavioral treatments that were successful in treating behavioral disturbances in dementia patients (Logsdon, McCurry, & Teri, 2007). The third peer-reviewed research articles utilized for this project was a randomized study to discuss the prevalence of psychotropic medications used in nursing homes in relation to patient’s behaviors. The article consisted of a randomized study with a large sample size, but the study did not have a control group. Several recommendations were cited, including the withdrawal of psychotropic therapy in the elderly population (Azermai, Elseviers, Petrovic, Van Bortel, & Stichele, 2011). The final research that was used for this project was a systematic review of randomized, controlled trials that had adequate sample sizes and control groups. This article discusses the two approaches used in treating dementia patients with behavior disturbances, pharmacological and behavioral. The articles discuss what is known and what is not known in regards to the two approaches and make several clinical and research recommendations (Jeste et al., 2008).
Step 10: Recommendations for change
All of the articles used in this project discussed the adverse effects of psychotropic medication use in this population and the fact that these medications are not effective in treating behavior disturbances in the dementia patient. When psychotropic medications are used to treat out of character responses in the elderly, they are being prescribed off-label as the FDA has not approved any of these medications for treating behavioral disturbances in the dementia patient. Also, many psychotropic medications come with black-box warnings from the FDA and have been proven to have many adverse effects, especially in the elderly population (Jeste et al., 2008). Two of the articles discuss the success of the use of therapeutic approaches in calming the dementia patient experiencing an out of character response. What makes the use of therapeutic approaches exciting is that there are no adverse physical effects associated with them and the quality of life is not diminished, and may possibly be enhanced, in the dementia patient (Logsdon, McCurry, & Teri, 2007).
Translation
Steps 11, 12, and 13: Action plan
This pilot study will take place in the Memory Support Unit, which is home to approximately 36 residents, all of whom have a diagnosis of dementia. The eight faculty members that will be participating in this study will all attend a three-day training seminar on how to recognize the early signs of residents who are becoming anxious, and implementing therapeutic approaches for these patients to calm them rapidly and efficiently without the use of medication. After the training seminar, the staff will meet on a biweekly basis and carefully review each resident’s life story to become familiar with their history and likes or dislikes to design therapeutic approaches that are appropriate for the individual patient, as well as thoroughly examine the behavioral monitoring sheets of each resident who experiences out of character responses. The primary emphasis for the team will be to maintain a calm, quiet environment to prevent the onset of out of character responses, and decrease the number and severity of these behavioral disturbances. This project will be evaluated during each biweekly meeting, to see if the therapeutic approaches being used are effective for the individual residents by reviewing their behavioral monitoring sheets. Any changes to the resident’s individual care plan will take place during these meetings. The pilot study will be evaluated after the first six months to review the effects of any dosage reductions in psychotropic medications for individual residents and the efficacy of any therapeutic approaches utilized to manage their out of character responses. The Memory Support Coordinator will report the results to the administration of the facility and will discuss the findings at the weekly department head meetings.
Steps 14 and 15: Evaluating outcomes
It is the objective of this pilot study to see dosage reductions in any psychotropic medications being used, and eliminated altogether if possible, and to see the number and severity of out of character responses decreased without the use of psychotropic medication. Residents in the Memory Support Unit who receive psychotropic medications have their records reviewed by the pharmacist on a quarterly basis and recommendations for dosage reductions of these medications are then forwarded to the physician. Residents in the Memory Support Unit have detailed behavioral sheets where any behavioral disturbances are noted, how many times these disturbances occur per shift, any therapeutic interventions utilized before the administration of a prn medication, the efficacy of the intervention utilized, and any side effects noted from the administration of psychotropic medications. The behavioral sheets will be monitored on a weekly basis by the Memory Support Coordinator to see if there have been changes in any of the categories previously mentioned. Therapeutic approaches that have proven to be effective for individual residents will be added to their care plans. The individual results for each resident will be discussed at the biweekly meetings attended by the pilot study staff and the Memory Support Coordinator will forward this information on to the administration of the facility.
Steps 16, 17, and 18: Implementation
As there are dementia residents in every part of the facility, they also have behavioral monitoring sheets where the same information is recorded as those patients residing in the Memory Support Unit. After the initial pilot study staff have been trained and are utilizing therapeutic responses with all of the individuals in the Memory Support Unit, the entire staff in the Unit will be trained and coached by the pilot study staff. After the training has been completed in the Memory Support Unit, staff in the other areas of the facility will be trained and coached by the Memory Support Unit staff and will begin implementing the appropriate therapeutic approaches for their individual patients. The implementation of gradual dose reductions of psychotropic medications, unless clinically contraindicated, is mandated by CMS guidelines, as well as individualized approaches to person-centered care (CMS, 2013). This ensures that the implementations set forth in this pilot study will become permanent. The behavioral sheets for every resident with a diagnosis of dementia and/or receive psychotropic medications will continue to be monitored and discussed at the risk meetings that are attended by all department supervisors on a weekly basis. The results of this study will be entered into a database for forwarded to the home office, to be shared with all of the facilities in the organization.
Conclusion
The administration of psychotropic medications to elderly patients, especially those suffering from dementia, has been increasingly controversial. Currently there are no medications approved by the FDA for use in dementia patients suffering from behavioral disturbances, and if these drugs are being utilized, they are being prescribed for off-label use (Jeste et al., 2008). Psychotropic medications have shown to have negative effects on the physical function of elderly patients (Galik & Resnick, 2013), even leading to mortality (Azermai, Elseviers, Petrovic, Van Bortel, & Vander Stichele, 2011). Guidelines from the CMS mandate that gradual dose reductions be attempted for all psychotropic medications, unless clinically contraindicated, and individualized approaches to person-centered care are utilized (CMS, 2013). After thoroughly examining the evidence from the research articles, the pilot study staff will be trained in the use of therapeutic approaches to deal with resident experiencing out of character responses. As the pilot staff becomes comfortable with implementing these approaches, the staff in the rest of the facility will be trained. The behavioral sheets for each resident will be monitored, and the therapeutic approaches that have proven to be effective for each resident will be added to their individual care plan. The behavioral sheets will be reviewed each week at the risk meetings attended by all department supervisors, and any appropriate changes will be made to the resident’s individualized care plans. The goal of this pilot study is to decrease the dangerous effects of psychotropic drug use in the elderly (Azermai, Elseviers, Petrovic, Van Bortel, & Vander Stichele, 2011), as well as improve their quality of life with the use of therapeutic approaches specifically tailored to their individual needs and wants (Logsdon, McCurry, & Teri, 2007).
References
Azermai, M., Elseviers, M., Petrovic, M., Van Bortel, L., & Vander Stichele, R., (2011). Geriatric drug utilization of psychotropics in Belgian nursing homes. Human Psychopharmacology, 26, 12-20.
Center for Medical & Medicaid Services. (2013). Center for clinical standards and quality survey & certification group. Retrieved from http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CB4QFjAA&url=http%3A%2F%2Fwww.cms.gov%2FMedicare%2FProvider-Enrollment-and-Certification%2FSurveyCertificationGenInfo%2FDownloads%2FSurvey-and-Cert-Letter-13-35.pdf&ei=6g1xVO4V6YmxBMW8gdgE&usg=AFQjCNH-POJP2PwdaIXyFpIGmzHN-vDrKw
Currie, L. (2008). Fall and injury prevention. In R. Hughes (Ed.). Patient safety and quality: An evidence-based handbook for nurses. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK26531
Dearholt S. L., & Dang, D. (2012). John Hopkins nursing evidence-based practice: Model and guidelines (2nd ed.). Indianapolis, IN: sigma Theta Tau International.
Galik, E., & Resnick B. (2013). Psychotropic medication use and association with physical and psychosocial outcomes in nursing home residents. Journal of Psychiatric and Mental Health Nursing, 20, 244-252.
Harris-Kojetson, L., Sengupta, M., Park-Lee, E., & Valverde, R. (2013). Long-term care services in the United States: 2013 overview. Hyattsville, MD: National Center for Health Statistics.
Jedenius, E., Johnell, K., Fastbom, J., Stromqvist, J., Winbald, B, & Andreasen, N. (2011). Dementia management programme in a community setting and the use of psychotropic drugs in the elderly population. Scandinavian Journal of Primary Health Care, 29, 181-186.
Jeste, D. V., Blazer, D., Casey, D., Meeks, T., Salzman, C., Schneider, L., … Yaffe, K. (2008). ACNP white paper: Update on use of antipsychotic drugs in elderly persons with dementia. Neuropsychopharmacology, 33, 957-970.
Logsdon, R. G., McCurry, S. M., & Teri, L. (2007). Evidence-based psychological treatments for disruptive behaviors in individuals with dementia. Psychology and Aging, 22(1), 28-36.
