The known
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Higher prevalence of psychotropic medicines dispensing to resident with dementia living in rural nursing homes.
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Non-pharmacological intervention has the potential to reduce the use of psychotropic medicines prescription 3-months pre- and post-intervention.
Background
Methods
Study design and settings
Participants
Intervention: staff training and person-centered music
Data collection
Statistical analysis
Results
Characteristics of the participants
Antipsychotics | Antidepressants | Benzodiazepines |
---|---|---|
Risperidone (0.25 mg OD and BD, 0.5 mg OD and BD, 1 mg OD) Olanzapine (2.5 mg OD, 5–10 mg TDS, 5 mg OD) Quetiapine (12.5 mg BD and TDS, 25 mg OD, BD and TDS, 50 mg OD, 75 mg OD, 100 mg OD) | SSRIs Escitalopram (5 mg OD, 10 mg OD) Sertraline (100 mg OD) Tricyclic antidepressants: Amitriptyline (50 mg OD) Serotonin and noradrenaline reuptake inhibitors: Venlafaxine (150 mg OD) Other antidepressants: Mirtazapine (15 mg OD, 30 mg OD | Oxazepam (5 mg BD, 7.5 mg OD, BD and TDS, 15 mg TDS) Temazepam (10 mg OD) Clonazepam (0.5 mg OD) Diazepam (2.5 mg OD) |
Characteristics | N (%) |
---|---|
Gender | |
Male | 9 (29.0) |
Female | 21 (68.0) |
Age in years, median (IQR) | 83 (78–89) |
Average duration of stay in aged care centers (years), median (IQR) | 2 (1–4) |
Polypharmacy | 27 (87.1) |
Number of medications used, median (IQR) | 8 (5–11) |
Born in Australia | 19 (61.3) |
Born oversea | 7 (23.0) |
Highest level of qualification | |
No formal education | 11 (35.5) |
Primary schooling | 7 (22.6) |
Secondary Schooling | 10 (32.3) |
University Graduate | 1 (3.2) |
Comorbidities | |
Hypertension | 19 (61.3) |
hyperlipidemia | 13 (42.0) |
Osteoarthritis | 12 (39.0) |
Diabetes | 10 (32.3) |
GORD | 10 (32.3) |
Eye disease | 9 (29.0) |
Alzheimer’s disease | 6 (19.4) |
Thyroid disease | 6 (19.4) |
Osteoporosis | 6 (19.4) |
Asthma | 5 (16.1) |
CRF | 5 (16.1) |
COPD | 5 (16.1) |
Atrial fibrillation | 4 (13.0) |
Psychotropic medications use among the participants
Use of Medications (%) | Pre-intervention (n = 31) | Post intervention (n = 31) | P-value |
---|---|---|---|
At least any psychotropics | 24 (77.4) | 17 (55.0) | 0.106 |
Antipsychotics | 12 (39.0) | 6 (19.4) | 0.161 |
Risperidone | 5 (16.1) | 4 (13.0) | 1.0 |
Olanzapine | 4 (13.0) | 1 (3.2) | 0.354 |
Quetiapine | 4 (13.0) | 4 (13.0) | 1.0 |
Antidepressants | 13 (42.0) | 11 (35.5) | 0.795 |
Mirtazapine | 3 (8.0) | 3 (8.0) | 1.0 |
Escitalopram | 6 (19.4) | 5 (16.1) | 1.0 |
Benzodiazepines | 12 (39.0) | 6 (19.4) | 0.161 |
Oxazepam | 6 (19.4) | 3 (8.0) | 0.473 |
Temazepam | 3 (8.0) | 3 (8.0) | 1.0 |
Anti-dementia medications | 8 (26.0) | 8 (26.0) | 1.0 |
Memantine | 2 (6.5) | 2 (6.5) | 1.0 |
Donepezil | 6 (19.4) | 6 (19.4) | 1.0 |
Combination of antipsychotics and antidepressants | 6 (19.4) | 4 (13.0) | 0.731 |
Combination of antipsychotics and benzodiazepines | 5 (16.1) | 1 (3.2) | 0.195 |
Combination of antipsychotics and anti-dementia | 5 (16.1) | 4 (13.0) | 1.0 |
Combination of antipsychotics and donepezil | 3 (8.0) | 3 (8.0) | 1.0 |
Combination of antipsychotics and memantine | 2 (6.5) | 2 (6.5) | 1.0 |
Medication class | < 3 months | 3–6 months | > 6 months |
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Antipsychotics (n = 17) | 7 (41.17) | 3 (17.64) | 7 (41.17) |
Antidepressants (n = 14) | 3 (21.42) | 5 (35.71) | 6 (42.85) |
Benzodiazepines (n = 12) | 5 (41.66) | 2 (16.66) | 5 (41.66) |
Anti-dementia (n = 9) | 2 (22.22) | 3 (33.33) | 4 (44.44) |
Major themes from in-depth interviews with aged care staff
Less behavioral and psychiatric symptoms due to medication weaning or dose tapering
Yeah, I would need to look at that, yeah. We don’t use a lot of antipsychotic medication anyway. Um, we have a little bit – a little bit regular for you know, some residents to manage their mental health illnesses. But we don’t use a lot of PRM antipsychotic, and I do – I do measure that regularly from time to time just to measure where we’re at with antipsychotic medication … . [ Staff 1]Yeah, there’s lots of medication weaning, doctors are reducing the dose of medication. So, that’s really happening, good for these people, yeah, is working on that a lot … . [Staff 2]Well, medications constantly change. Um, there have been a couple that we’ve been able to take off of things like risperidone and oxazepam which is good. Um, so that’s always a plus when we can do that … because their behaviors aren’t there anymore, they are not needing … it, so, ah, but it’s, yeah, that’s a few of them. Like I said, other than that, their medications change, but, um … . only with that risperidone and oxaz, I’ve seen a reduction in that … but … but nothing … . [Staff 3]Um, well, we do medications, um, I don’t really have a lot of things to say about medications because, um, that’s – as a for now that’s out of my scope. But yeah, ah, at times I have … In general, yeah, I would say it – it – it effects, you know, them and their behaviors as well. Um, even with regards to like falls and stuff because, you know, some medications make them really drowsy. So, it’s yeah, like some of them I could see like – because they really that sleepier and shaky. So, um, yeah, or some of them, I guess it’s just due to medications as well that doesn’t suit, yeah, you know, them, and they became more agitated. So that’s just … … . [Staff 4]
Other strategy to reduce medication use
I — I’m not a nurse. I do help with medication, so I don’t see all the medications. Um, again, I think some of our extreme cases, we try to use other strategies before the medication. Some people — it — unfortunately, it seems as if every strategy you use, enact, it doesn’t work on everybody. So - - - medication may be the last resort. Um, but it’s those extreme cases that we can’t always cut through from what I’ve seen. Those are the ones that we use medication with, and I don’t know for sure, but I don’t think it’s changed the amount as such. Um, and again, I don’t know, but - Uh, I can’t give you an accurate answer because I’m not here - - - like, I’m not with the nurse all the time - - - I mean I would expect less medication used because of a lower, uh, lower stressors and lower reactive behaviors. But again, I know, through my experience with the people that are more extreme cases, they still get worked up. They still get worked up. They still, um, at times, need medication. Some of them more moderate or lower end of the dementia, I would think that we could probably stick with more of the strategies that aren’t medication based. I mean I — I don’t know for sure but that’s just, from my, uh, my experience, yeah, I would — I would like to think that would be less. But I don’t really know. I can’t give you an exact number. … … [Staff 5]Um, we've actually reduced, I think, two people are now off Risperidone all together, that we’ve just recently stopped that we were tapering it down and we’ve just, recently they’ve ceased it. We still do have a couple that need it, because they're still in that stage, but we haven’t worked with them quite as intensively just yet … . Yep. Um, there aren’t too many that have sleeping tablets overnight anymore, we used to get people, and they would automatically just give them a sleeping tablet if they were up. Now they give them a drink and Weet-Bix and they don’t need the sleeping tablet, which is really good. Because then you haven’t got people in the morning who are drugged out and sleepy and hung over and falling … ... [Staff 6]… um, obviously we have – we have I guess given less pain relief, given less behavior management medication like Oxazepam and all that. So there has been some because I keep an eye on progress notes while in care. So, I have seen that there was a lot before, but it has decreased. We used to give medications a lot to some people, and now obviously introducing a rest period and the music therapy combined, I think it had an impact on the way they behaved. As I said, Oxazepam we used to give for the behavior management. … . [Staff 7]
Environmental or noise control
I don’t know whether there has been any. I would love to have seen medications have gone down through the floor, because of the quiet, very quiet environment. I would love to have seen that. I don’t know whether there has been … . I don’t know whether there has been any. I would love to have seen medications have gone down through the floor, because of the quiet, very quiet environment. I would love to have seen that. I don’t know whether there has been. Because I’ve come – I’ve just been back and watched, and I’ve been seeing ice-creams being handed out to people. So, I don’t know, but I would love to know whether the medications had dropped during that period. And then it may be worthwhile … ... [Staff 8]