Transcript 2-Ervin IFA presentation Kaye Ervin 29 5 1300.ppsx

Reducing the use of antipsychotics in
rural residential dementia care through
family participation.
Ervin K1 ,Finlayson SE1,2,, Cross, M1
1School
of Rural Health, The University of Melbourne, Shepparton, Vic
2Benalla & District Memorial Hospital, Vic
Benalla and
District Memorial
Hospital
BACKGROUND
• In Australia 60-80% of all residents in aged care facilities have a
dementing illness, with this figure predicted to increase.
• A literature review undertaken by O’Connor and Ames identified that
management of behavioural problems tailored to the individual’s
background and preferences seemed especially beneficial. The
literature review also found that interventions were more useful if
they were tailored to the individual’s symptoms [1] .
• Family participation is essential to tailor management for residents
with dementia, to inform carers of past preferences where people
with dementia are unable to communicate needs. Previous research
[2,3] identified that working with families, and collaboration with the
person were essential aspects of care for people with dementia.
1.
2.
3.
O'Connor, D.&Ames, D., Behavioural and psychological symptoms of dementia: A literature review of psychosocial
treatments and the indentification of further research topics regarding treatment effectiveness and implementation.
Dementia Collaborative Research Centre - Assessment and better care outcomes., 2008(Australian Government).
Ericson, I. What constitutes good care for people with dementia? British Journal of Nursing, 2001. 10(11): p. 71014.
Kitwood, T., Dementia reconsidered: the person comes first. Open University Press, Buckingham., 1997.
Intervention 1:
Intensive staff
education program with
family and
Consumer
participation
Intervention 2:
Intensive staff
education program
without family and
Consumer
participation
Intervention group
1: Cobram District
Health
Intervention group
2: Numurkah
District Health
Service
Control group:
Benalla & District
Memorial Hospital
Measurement pre intervention:
 Antipsychotic drug use
 Nursing Home Problem
Behaviour Scale
 Opinions about Family and
Work Scale
Measurement post intervention:
 Antipsychotic drug use
 Nursing Home Problem Behaviour Scale
 Opinions about Family and Work Scale
 Qualitative interviews with staff and families
from site 1
Figure 1: Controlled before and after (CBA) study design: Description and examples. Cochrane Consumers and Communication review
group resources 2010.( http://www.latrobe.edu.au/chcp/hkn/resources.html).
METHODOLOGY
• Staff from the intervention sites invited to
participate in the education sessions via
email and poster displays
• Management of 3 facilities identified
residents with a diagnosis of dementia and
mailed out consent forms to the
responsible person.
• Measurement tools implemented prior to
the intervention
MEASUREMENT TOOLS
•
Nursing Home Problem Behaviour Scale [1,2]
•
Opinions about Family and Work [3]
•
Antipsychotic Drug Usage Evaluation (DUE) kit
[4]
1.
Ray, W., Taylor, J., Lichtenstein, M., & Meador, K., The nursing home behaviour problem scale. Journal of
Gerontology, 1992. 47(1): p. 9-16.
Crotty, M., Whitehead, C., Lange, K.et al, Using the nursing home behaviour problem scale in an Australian
residential care setting. Australasian Journal on Ageing, 2004. 23(3): p. 150-155.
Farhall, J.F., Webster, B., Hocking, B., Leggatt, M, Reiss, C. & Young, J. , Training to enhance partnerships
between mental health professionals and family caregivers: A comparative study. Psychiatric Services, 1998.
49(11).
(2007) Drug use evaluation: Antipsychotic use in the management or dementia in aged care homes. National
Prescribing Service. www.nps.org.au
2.
3.
4.
INTERVENTION
• 12 staff from site 1 and 13 staff from site 2 (25%
of available staff – voluntary) were introduced to
an online learning tool; TIME for dementia.
Website developed by a collaboration of experts
in dementia care and consists of 10 core
modules. Following each module staff answer a
series of questions to test their knowledge.
• Website supplemented with literature from the
National Prescribing Service related to the role
of antipsychotics in managing behavioural
symptoms of dementia.
INTERVENTION
• Staff at site 1 also undertook an additional day of
education in life story telling delivered by the Hume
memoir writers service. Based on the barriers and
enablers of narrative medicine.
• Staff encouraged to use the ‘Discovery Tool’ a proforma
developed by the Aged Care Standards and
Accreditation Agency. Staff then presented the residents
life history information in a user friendly format (posters,
quilts, booklets). Example next slides.
• Staff, residents and families at site 1 invited to participate
in a face to face interview to explore the impact of the
intervention and staff/family relationships.
Jean lived in Sydney where she worked as a hairdresser. She met & married Leigh in 1944.
They honeymooned in the Blue Mountains. Ask Jean about the “bed bugs”!
Jean loved riding
bareback during her
childhood in Parkes.
Jean also loved to
help her father
deliver the milk in a
horse & cart.
Jean was an excellent cook; creating
many exotic & traditional dishes. Jean
continues to make the family traditional
Christmas pudding.
Jean loved the home that
Leigh built in Sledmere
Avenue where she enjoyed
gardening and raising their
family.
Jean was very creative & made
most of the family’s clothes. Ask
Jean about the “Pickled people”
she made & sold at Paddy’s Market
in Sydney.
Examples of life stories..
RESULTS
• 47 residents diagnosed with dementia
across the 3 sites, with 30 prescribed
antipsychotic drugs (64%).
• At site 1, 85% of residents with dementia
were prescribed antipsychotics
• At site 2, 50% of residents with dementia
were prescribed antipsychotics
• At the control site, 61% of residents with
dementia were prescribed antipsychotics.
Brodaty’s seven-tiered model of management of
behavioural and psychological symptoms of
dementia (BPSD)
•
RESULTS pre and post
intervention
Percentage of residents with dementia prescribed antipsychotic
drugs
Pre intervention
Post intervention
100%
80%
60%
85%
n =11
40%
69%
n =9
50%
n =8
20%
62.5%
61% n =10
n =11
38%
n =5
0%
Site 1
Site 2
Control site
The greatest reduction in the use of antipsychotics was 16% at site 1 where
families were invited to participate. There was a slight increase at the control site.
RESULTS
• Pre intervention only 37% of
antipsychotics prescribed complied with
therapeutic guidelines (the lowest dose
possible for balancing efficacy and side
effects). Post intervention this increased to
67% overall.
• The greatest increase in compliance was
again at site 1, where families participated.
RESULTS pre and post for
compliance with therapeutic
guidelines
Compliance with therapeutic prescribing guidelines
100%
80%
n=7
n=7
60%
n=3
n=6
40%
n=6
n=5
20%
0%
Site 1
Site 2
Control site
Pre intervention
Post intervention
RESULTS – Review of practices
against best practice criteria
• Evidence of excluding other possible causes
of behaviour such as pain, constipation,
infection…
• Evidence of response to antipsychotic drugs
• Evidence of adverse effects (drowsiness, dry
mouth)
• Documented review of therapy and
attempted withdrawal of antipsychotic drugs
RESULTS- review of best practice
Site 1 review of best practice in antipsychotic use
Control site review of best practice in antipsychotic use
Withdraw al attempted
Withdraw al attempted
Review of therapy
Review of therapy
site 1 post
Evidence of adverse effects
site 1 pre
Control site post
Evidence of adverse effects
Control site pre
Evidence of response to drug
Evidence of response to drug
Reversible causes excluded
Reversible causes excluded
0
20
40
60
80 100
0
Percentage (n = 11 pre / n = 9 post)
20
40
60
80 100
Percentage ( n= 11 pre / n = 10 post)
Site 2 also recorded positive changes, but again Site 1
where families participated showed the greatest
change, while the control site remained stable
RESULTS – Falls rate
Reported falls rate for residents prescribed antipsychotic drugs
100%
80%
60%
91%
n = 10
75%
n=6
55%
n=5
80%
n=8
60%
n=3
64%
n=7
Pre intervention
Post intervention
40%
20%
0%
Site 1
Site 2
Control Site
This is the recorded falls rates for those prescribed
antipsychotics, not the falls rate overall for each facility
RESULTS - Benzodiazepines
• Residents prescribed antipsychotics are
also frequently prescribed
benzodiazepines (common sedatives).
• While benzodiazepine prescription rates
increased overall post intervention, there
was not a corresponding increase at site
1, where the use of benzodiazepines also
decreased.
Benzodiazepines
Benzodiazepine prescription pre and post intervention for
residents prescribed antipsychotics
n=7
Control Site
n=6
Post intervention
n=3
Site 2
n=2
Pre intervention
n=2
n=3
Site 1
0%
20%
40%
60%
80%
100%
FINDINGS
• Education of staff reduces antipsychotic
prescribing rates
• This is further enhanced when families are
invited to participate in care
• Family participation ensures that care is tailored
to the individuals needs and is more personcentred
• Staff are more easily able to identify and
attribute meaning to the behaviour and thereby
manage it without the use of antipsychotics
FINDINGS
• There is world wide concern at the
increased risk of adverse effects of
antipsychotics in aged populations (Chen,
2010; Levinson, 2011). More than 75% of
the residents in this study were greater
than 75 years of age.
Chen, Y., Briesacher, B., Field, T., Tjia, J., Lau, D., Gurwitz, J. (2010).
Unexplained variation across US nursing homes in antipsychotic
prescribing rates. Archives of Internal Medicine, 170(1), 89-95.
Levinson, D. (2011). Cause for alarm: Antipsychotic drugs for nursing
home patients., Citizens Commission on Human Rights International
(Vol. May).
FINDINGS
• Increasingly, antipsychotics are being used as a first line
treatment (Byrne, 2011). This study appears to support
this practice. Pre intervention there was little evidence
that staff had excluded other causes of behaviour,
documented response or adverse effects. This increased
markedly post intervention.
• Staff in this study identified barriers to reviewing and
withdrawing antipsychotics, a factor identified in other
studies (Szymczynska, 2011).
Byrne, G. (2011). Address antipsychotic use in aged care. Australian Nursing Journal,
19(1), pg 6.
Szymczynska, P., Innes, A. . (2011). Evaluation of a dementia training workshop for
health and social care staff in rural Scotland. Rural and Remote Health, 11.
FINDINGS
• Use of antipsychotics has been strongly linked to the risk
of falls (Riefkohl, 2003), especially when doses
exceeded the recommended therapeutic guidelines (Ito,
2005; National Prescribing Service, 2007; Nishtala,
2008). This study clearly demonstrated and supported
these findings from other studies.
Ito, H., & Higuchi, T.,. (2005). Polypharmacy and excessive dosing: Psychiatrists'
perceptions of antipsychotic drug prescription. British Journal of Psychiatry,
187(Sept), 234-237.
National Prescribing Service. (2007). Drug use evaluation: Antipsychotic use in the
management or dementia in aged care homes, National Prescribing Service.
www.nps.org.au.
Nishtala, P., McLachlan, A., Bell, J. Chen, T. (2008). Psychotropic prescribing in longterm care facilities: Impact of medication reviews and educational interventions
American Journal of Psychiatry, 16(8), 621.
Riefkohl, E., Bieber, H., Burlingame, M., Lowenthal, D. (2003). Medications and Falls in
the Elderly:A Review of the Evidence and Practical Considerations. PT journal,
28(11), 724-733.
LIMITATIONS
• Small sample size of the study meant numbers
did not reach statistical significance. However
because the results align so closely with other
findings there is theoretical generalizability.
• Awareness raising at the control site – may have
been greater differences
• Staff participation was voluntary, so only small
numbers at each site and no senior staff
members which may have increased barriers of
translating training into practice
ACKNOWLEDGEMENTS
• All participating organisations (Cobram
District Health, Numurkah District Health
Service, Benalla and District Memorial
Health Service)
• Participation Advisory Committee
• Department of Health Statewide Quality
Branch