Addressing the use of psychoactive medication for people living with dementia through non-pharmacological techniques

Background:

A female resident in a care home was struggling to accept twice daily personal care, with a baseline average of two sessions of personal care accepted per week. Desensitising the resident to the bathroom where personal care took place had limited effect. The service tried consistent staff, which had some effect, but gender of care staff had no effect. However, staff identified that height of care staff was a trigger factor for this person.

Change implemented:

Staff of similar height to reduce anxiety

Outcomes:

• improved personal care - around 10-12 personal care sessions per week
• a successful reduction (over 50%) of antipsychotic (quetiapine) medication
• resident has also gained 2.25kg, has a Malnutrition Universal Screening Tool (MUST) score of 0 and healthy body mass index (BMI), with staff reporting she now sits and enjoys her meal in the dining room, something she would not do before
• reduced staff time dealing with the administrative and challenging effects of the behaviours

Number of personal care sessions per week

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Background:

One staff member identified a resident watching care staff leave through the glass front door as a key trigger for the resident’s stress and distress behaviour.

Change implemented:

a frosted covering was applied to the door

Outcomes:

• less stress and distress for the resident
• 60% reduction in use of when required anxiolytics
• weight gain of 1.4kg and now has a MUST score of 0 and healthy BMI
• care staff noted less time dealing with effects of behaviours that challenge, including filling in ABC (Antecedent, Behaviour, Consequence) charts and seeking input from external healthcare professionals.

Frosted glass door covering reducing stress and distress

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Background:

A resident nearing end of life was prescribed and received regular, and when required, psychoactive medicines.

Change implemented:

To make her feel safe and reduce her stress, care staff adapted her room to provide a familiar space resembling her own living room, including familiar pictures, throws and cushions. They also purchased a reed diffuser to provide the comforting smell of her husband’s aftershave.

Outcomes:

• the resident was more settled, and her psychoactive medicines were discontinued
• a relative of the resident said: “Mum passed away peacefully, not on any sedative medication. She was able to hold a conversation with us and share memories. I will never be able to thank the staff enough for never giving up and giving my mum a nice death.”
• seeing the outcomes for this resident, staff created a cosy lounge area with a kitchen area and free access to outside space. This allowed a space away from the main lounge that residents could go to if they wanted somewhere quieter
• a reduction across the unit of when required psychoactive medication by 89%

Changes to room and unit environment reducing use of PRN psychoactive medicines

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Background:

Background: The resident initially presented with symptoms that suggested end-of-life. Dementia Care Team determined to ‘find the why’ of the behaviours of distress which increased during sunset, with possible hallucinations caused by shadows in their room. The resident also felt threatened by people following them or sitting outside their room. 

Change implemented:

• as believed to be at end-of-life regular antipsychotic doses reduced and stopped
• a blind was fitted to the person’s room to reduce shadows and therefore hallucinations
• a door alarm linked to the nurse call system was implemented so that the person could have private time in their room
• an activity plan tailored to the resident’s interest (gardening) started

Outcomes:

• environmental measures resulted in a reduction in stress and distress incidents
• sedating psychoactive medicines were withdrawn and the resident re-engaged with the environment. However stress and distress increased to a level that the resident was served notice to leave the home
• psychoactive medicines were re-started but at a lower dose to allow resident to remain in the home
• the resident now runs a gardening club in the care home, are now mobilising and independent with personal care and eating

“Finding the Why” of stress and distress behaviours

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Background:

A resident was admitted to a care home with an expectation from social work that the placement would fail due to her ‘behaviours of concern’, with long-term hospital care the next stage. The staff recognised there was no activity provided for the resident in order to provide a meaningful day. 

Change implemented:

They found things she liked to do and included these in tailored activity plans, along with opportunities for independent activity through ‘life stations’. A life station is an area designed to evoke familiarity and comfort for residents with dementia. These stations reflect aspects of their past life, such as hobbies, careers, or routines. This included her supporting staff with folding towels and matching socks, organising the dressing table life station and supporting the wellbeing staff to set up activity trolleys, dining tables and organise cupboards throughout the day.

Outcomes:

• a complete reduction in stress and distress incidents
• no use of when required anxiolytic use in the last four months of the project, and a 25% reduction in the regular risperidone dose
• the placement in the home was a success
• the staff approach of “It’s never too late, you must always seek the why” gave this resident the opportunity to live their dementia journey in a homely environment.

Background:

One home worked closely with their GP to agree a process for re-starting (post COVID) three monthly reviews of psychoactive medicines. Eleven residents were prescribed psychoactive medications at the start of the project.

Change implemented:

GP reviews and staff training (from the dementia care team) with regular reviews

Outcomes:

• Eight now had a psychoactive medication review by the end of project:
  • five have an active reduction plan in place
  • two have had risperidone discontinued
  • one had lorazepam discontinued
• an overall reduction in the level of when required psychoactive medicines used
• Note: The increase in use of psychoactive medication later in the project was driven primarily by staff who were less familiar with residents, using medicines as a first line option for management of stress and distress
• therefore, further change implemented when using staff who were unfamiliar with residents, the home’s approach to medication use was shared at the daily flash meetings

When required psychoactive medication use

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Background:

A home recognised that current reviews by prescribers were ineffective because staff did not have the relevant information to hand when clinical discussions took place. 

Change implemented:

Staff develop a form containing the necessary information pre-review, such as how often when required medicines are used, the number of distress incidents, resident presentation etc, to make reviews meaningful. The form was developed using a quality improvement approach of rapid change cycles, with different staff members inputting at each cycle. 

Outcomes:

• by the end of the project the home were on version four of the form
• five residents have had a review with reduction plan in place, and two residents have had psychoactive medication discontinued.
• feedback on the form was positive:
  • “As a new nurse this form gave me the confidence that I could have the discussion to reduce medication, prompted me to have all the information I needed ahead of time, ready to present and discuss with the prescribing practitioner”. (Staff Nurse)
  • “It encouraged the process and benefit is not using medication.” (Consultant Psychiatrist)
• A relative of one of the residents noted the benefits of reduced use of medicine. “My wife has had her risperidone and trazodone medication stopped since moving into the care home and staff working closely with her. I feel my wife has a better quality of life and she is now able to understand some of what is being said and is now managing to do things for herself that she couldn’t do before when at home.” 

Background:

A couple of homes wanted to tackle the issue of staff using when required psychoactive medication as a first approach rather than a last resort for behaviours that challenge. A psychological safe space was essential so staff could be honest about administration practices and ways to change this without fear of judgement. 

Change implemented:

The homes tested implementing ABC charts with peer review to show what steps were tried before administration of ‘when required’ psychoactive medication. Training and support were given to staff, so they knew what to document on the charts, how to review behaviours, “find the why” and implement strategies to support residents rather than use psychoactive medicines. The idea of the peer review was in case a second person could suggest anything that hadn’t been tried. This gave staff the confidence that when medication was felt necessary that they had explored all non-pharmacological interventions and could evidence as such. 

Outcomes:

• the results in both homes were a reduction in when required psychoactive medication use (Chart 16 and Chart 17).
• in the first home (Chart 16) the change idea was tested on one resident:
  • when required quetiapine being discontinued, along with a reduction in regular risperidone
  • reduction in falls and better quality of life during their last three months
• in the second home (Chart 17) there was a 65% reduction in ‘when required’ psychoactive medication administration. This included a period of disruption caused by opening up/merging of units in the home.

Reduction in resident when required quetiapine

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Reduction in whole unit when required psychoactive medication

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