A few years ago I took up my first nursing post in a dementia care unit in Northern Ireland. The unit I worked in was very progressive and care was underpinned with up-to-date practices. Some examples included; specialist signage displayed around the unit that facilitated people with dementia in navigation to bathrooms, dining rooms and the TV lounge (http://findsignage.co.uk/) and reminisce boxes that included items that were meaningful for resident’s thus promoting opportunity for engagement with care-staff. The operationalization of this person-centred approach was advocated by the likes of Tom Kitwood (1997) and Dawn Brooker (2007) in a bid to enhance the lives of people with dementia.
There were many other examples of best practice being translated into the dementia care unit but the one I was most heavily involved in, and subsequently led, was the desire to reduce the number of psychotropic medications that our residents were prescribed. The over-prescription of psychotropic medication has long been identified as a problem in the dementia care literature. Traditionally psychotropic medications were a means to address manifestations of distress which included behaviours like wandering, repetitive questioning, anxiety and other behaviours that challenged. Indeed in a Department of Health review carried out in 2009, it was found that of the 180,000 prescriptions of psychotropic medications for people with dementia, approximately 140,000 (almost 80%) were deemed to be inappropriate. Importantly, psychotropic medications have a number of debilitating side-effects: excessive sedation, dizziness and unsteadiness, which can lead to increased falls and injuries, increased tremors, body restlessness, reduced well-being, social withdrawal and accelerated cognitive decline.
Armed with this evidence, I approached the unit manager about reducing psychotropic medications for some of our residents with dementia. I was given the support of the unit manager to approach the GPs of each of our thirty residents; importantly twenty-seven (90%) of our residents were prescribed psychotropic medications. As a junior nurse I perceived advocating for my residents as a challenge: my limited clinical experience had taught me that some people resist change (even in spite of best practice!) To my relief, all GPs of the patients agreed to reduce doses of psychotropic medications initially with a view to total discontinuation if appropriate.
Naturally, there were some challenges in the unit. Initially some healthcare assistants (and nursing professionals) were dubious about the reduction in any form of medications. The fear for this was based on the notion that all people prescribed with these medications needed them and without them this would lead to greater distress among those living with dementia. Open 2-way communication amongst all grades of care staff was important. While administration of medications was undertaken by the nursing team, the care-assistant team was on the front-line and so often were the first to notice subtle differences in the behaviour of people living with dementia for which they cared. Following brief educational sessions (lasting only about 10 minutes) and the availability of a few pieces of literature which supported the reduction of psychotropic medications, all members of the care team embraced the change because every member of the team recognised they had a role to play: it was a team effort because the whole raison d’etre of the initiative was – to enhance the wellbeing of people living with dementia.
Assessment of wellbeing was carried out in a number of ways which included validated tools (Ready and Ott, 2003), like ‘Dementia Care Mapping’ and ‘Cornell-Brown Scale for Quality of Life in Dementia’, as well as non-empirical measures, like daily care plan notes recorded by both nursing and care staff. The review of these multi-measures was carried out daily and served to ensure the safety of people living with dementia first and foremost. This was important because, while most people prescribed psychotropic medications didn’t require them, some people actually did. As there was no robust way to assess this prior to reduction and discontinuation of medications; all grades of care staff were on-hand to monitor and observe change in behaviour.
For the majority of residents under my care their levels of engagement increased, as well as their levels of wellbeing. Interestingly, there were also a number of residents who showed no change post-reduction of medications (even after 6 months). These two groups of people eventually saw their prescriptions of psychotropic medications (like Olanzapine and Risperidone) withdrawn. It should be noted that for all these residents, the next-of-kin was also part of the reduction/withdrawal process.
Importantly, only four people (15% of the unit), living with dementia were re-prescribed their psychotropic medications which led to around an 80% reduction in the unit after 6 months. This corresponded with the DOH (2009) guidelines in that 85% of our psychotropic medication prescriptions were deemed to be inappropriate. Importantly the assessment of wellbeing and review of psychotropic medication prescriptions is variable in a unit. The initiative was not a one off occurrence and continues as a cyclic process in practice. On a personal note, this translation of evidence into practice was a big factor for me in deciding to undertake a PhD at the School of Nursing at Queen’s University in Belfast.
Join the #EBNJC chat this Wednesday 14th May 2014 8-9pm GMT to discuss the challenges of dementia and building dementia friendly communities.
Brooker, D. (2007) Person-centred dementia care: making services better. Jessica Kingsley Publishers: London.
Department of Health (2009) The use of antipsychotic medication for people with dementia: time for action. Department of Health. London.
Kitwood, T. (1997) Dementia Reconsidered: The Person Comes First. Open University Press: Buckingham.
Ready, R. and Ott, B. (2003) ‘Quality of life measures for dementia’, Health and Quality of Life Outcomes, 1, (11), pp. 1-9. [http://www.hqlo.com/content/1/1/11]
RN MSc BSc
Doctoral Student at Queen’s University Belfast
Regional Dementia Care Advisor for Northern Ireland/Wales at Four Seasons Healthcare