Ervin K 1, Finlayson SE 1,2,, Cross, M 1 1 School of Rural Health, The University of Melbourne, Shepparton, Vic 2 Benalla & District Memorial Hospital, Vic Reducing the use of antipsychotics in rural residential dementia care through family participation. 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.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). 2.Ericson, I. What constitutes good care for people with dementia? British Journal of Nursing, (11): p Kitwood, T., Dementia reconsidered: the person comes first. Open University Press, Buckingham., 1997.

Intervention group 1: Cobram District Health Intervention group 2: Numurkah District Health Service Control group: Benalla & District Memorial Hospital Intervention 1: Intensive staff education program with family and Consumer participation Intervention 2: Intensive staff education program without family and Consumer participation 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.( ).

METHODOLOGY Staff from the intervention sites invited to participate in the education sessions via 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, (1): p 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, (3): p 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, (11). 4.(2007) Drug use evaluation: Antipsychotic use in the management or dementia in aged care homes. National Prescribing Service.

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 They honeymooned in the Blue Mountains. Ask Jean about the “bed bugs”! 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. 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.

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 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

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 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 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

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 person- centred 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), 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), National Prescribing Service. (2007). Drug use evaluation: Antipsychotic use in the management or dementia in aged care homes, National Prescribing Service. Nishtala, P., McLachlan, A., Bell, J. Chen, T. (2008). Psychotropic prescribing in long- term 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),

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