The national dementia advisory service is ramping up its engagement with doctors in a bid to reduce the use of psychotropic medications among aged care residents.
The Dementia Behaviour Management Advisory Service (DBMAS) and the Severe Behaviour Response Teams (SBRT), which are operated nationally by Dementia Support Australia, provide personalised multidisciplinary support to people experiencing behavioural and psychological symptoms of dementia.
As previously reported, an analysis of SBRT cases for three months found the frequency and severity of severe behaviours were significantly reduced but only a slight decrease in psychotropic drug use (read more here).
Associate Professor Stephen Macfarlane, who is head of clinical services at DSA, said the next challenge for DSA was to reduce inappropriate use of medications.
“We had hoped that we would be able to demonstrate not only a massive decrease in behaviours but also a decrease in psychotropic drug prescription,” Associate Professor Macfarlane told Australian Ageing Agenda at the recent International Dementia Conference in Sydney.
“We make recommendations around reducing psychotropics but only in about 10 per cent of cases are those recommendations actually implemented in full by the GPs.”
DSA will address this challenge by ramping up its engagement with general practice to better inform them on what the services do and their outcomes, he said.
High prevalence of range of symptoms
Elsewhere at the conference, DSA researcher and analyst Dr Thomas Morris presented statistics for the 12 months to 1 May 2018 for both programs, which operate nationally with 170 staff out of offices in 29 different locations.
Over 12-month period, DBMAS saw 6,628 clients, 50 per cent of whom were female, while SBRT saw 624 clients, 40 per cent of whom were females, Dr Morris told delegates.
He said clients experienced “quite a high prevalence of a whole range of symptoms,” which were measured across 12 domains.
Similar to SBRT findings reported in 2016, agitation and aggression remain the most common referral behaviours among residents referred to both the DBMAS (82 per cent) and SBRT (97 per cent).
The next most common symptoms were irritability and lability, anxiety, night-time behaviour followed by apathy and indifference for DBMAS clients and irritability and lability, disinhibition, depression and dysphoria, and anxiety among SBRT clients.
Dr Morris said there was both a large reduction in the frequency and severity of all behaviours for clients across DBMAS and SBRT programs.
In the DBMAS, 67 per cent of aggressive behaviours were assessed as severe or moderate at intake, this is reduced to 13 per cent at discharge, he said.
Similar outcomes were achieved with SBRT clients.
“While 91 per cent of aggressive behaviours were considered severe or moderate at intake this reduced to only 29 per cent at discharge,” Dr Morris said.
Accurate identification of contributing factors
Dr Morris said DSA consultants have detected over 60 contributing factors to client behaviours as part of their aim to accurately identify as many contributing factors as they can for each client.
In DBMAS the most prevalent factors identified were pain (41 per cent), carer approach (33 per cent) memory impairment (31 per cent), over or under stimulation (26 percent) and loneliness or boredom (25 per cent).
The factors were similar for SBRT but the prevalence was higher with the most common being pain (58 per cent), carer approach (46 per cent), over or under stimulation (39 per cent), memory impairment (33 per cent), and loneliness or boredom (31 per cent).
“Accurate detection leads to improved quality of life and can also reduce the rates of incorrectly prescribed anti-psychotics and improve staff attention,” Dr Morris said.
Similar to pain, contributing factors that are difficult to identify are also most at risk of being undetected, he said.
The level of noise and light – either bright or dim – in a residential facility or person’s home are two difficult-to-detect contributing factors DSA consultants have identified, Dr Morris said.
“We know that light in residential facilities is often insufficient for people with dementia… We also know residential facilities can be very noisy places. Noise is not only irritating to people with dementia but also inhibits their ability to communicate and socialise with others.”
To help objectively measure these three areas, DSA has rolled out the PainChek app – the facial recognition and artificial intelligence tool to detect minute facial expressions of pain – to all consultants and provided light and noise metres at every DSA office in Australia.
Related coverage: Non-drug approaches lead to ‘massive decreases’ in BPSD
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After researching reducing psychotropic use in aged care homes for over a decade and successfully implementing a nationwide program to reduce psychotropic use in 150 Australian aged care homes I can tell you that exclusively targeting GPs will not impact use.
I have never met a GP that endorses the use of antipsychotics or benzodiazepines. Most tell me that they are pressured to prescribe these by time-strapped aged care staff, or relatives who are very alarmed at the distressed behaviours they see in their mum, aunt or dad. Initiatives aimed at GPs such as guideline mail outs, detailing, electronic reminders etc. don’t stop the pressure from staff or change the organisational culture that has used these medications as a quick fix for decades. Staff predominantly believe this medication is highly effective and improves quality of life. Challenge these beliefs first. Non-pharmacological strategies cost time and money. Psychotropic medication costs are borne by the resident, relatives and mostly subsidised heavily by the government.
There is so much literature out there on effective approaches to reduce use of psychotropic medication use in aged care. Cochrane reviews and JAMDA systematic reviews. Please read them – they all say the same thing. Target staff and organisational culture – not prescribers.
Fully agree with Dr. Westbury.
I am a geriatrician who see patients in aged care facilities.
Issues are:
inadequate staffing – time constraint
Staff without adequate training.
Environment – not designed to manage disturbed patients
Lack of meaningful diversional therapy, group or individual program
I am interested to know how many calls DBMAS receives from family members who are concerned about the prescription of antipsychotics for their mum, aunt or dad in residential aged care?
I currently work in an aged care behavioural unit that specialises in dementia, BPSD and chronic treatment resistant psychiatric disorders. Many of our residents are on multiple antipsychotic medications and require regular additional meds of a sedative nature to control or alleviate disturbing and dangerous behaviours. All staff are mental health trained nurses and our facility is purpose built to specifically meet the needs of our targeted clientele. We also have a full time Diversional Therapist. Our staff ratio is 1 nurse for 5 residents, however, most residents require at least 2 staff to attend to physical interventions. Even with the use of sedatives and antipsychotic meds, we are all ran off our feet trying to meet the individual needs of our residents. Resident aggression and resistive behaviours are commonplace. Just the thought of reducing meds instills concern amongst the nurses as it places us all at risk of injury. Finding a ‘sweet spot’ with the residents medications is a challenging pursuit in the area of mental health and dementia care.
Ah both Drs Westbury and Chua have hit the nail on the head. Effective lifestyle therapeutic activities support and assist people living with dementia. A robust activity schedule has been well documented in supporting and reducing behaviour. Then tell me why care homes do not invest in these staff? Why do most groups allocated one lifestyle professional to 80 people and expect great outcomes? In some cases one person to over 100. It isn’t rocket science to see the numbers don’t work. Lifestyle professionals have just as much reporting to undertake as nurses, plans, assessments, monthly reports, daily reports, review and update said plans and assessments every 3 months or sooner if behaviours and needs change. Research into new and approved approaches to therapeutic activities etc etc. Why do most groups give a 0 budget to its activities division. If you see a concentrated effort by this department to raise monies you can be certain the group does not believe in or support an Activities program. A Lifestyle professional studies 12 months and can go further to attain their university degree in 3 years. Compare that to the lack of training to become certified as a carer. ( that is another subject again regarding care staff to resident ratios & RTOs ) Most groups hire an activities professional to tick a box for Standard 3. Quality Agency for some reason also don’t understand what a vibrant activity program can bring to enhance the lives of our elderly. DBMAS and psychgeriatricians can harp on all they like about implementing a person centred approach to behaviours but until groups are serious in investing in appropriate staff then I am afraid reaching for drugs in some cases that would be unnecessary will continue.