Needless treatments: Psychotropics are rarely effective in ‘calming’ dementia patients

         Elderly individuals with dementia often experience several neuropsychiatric symptoms such as delusion, hallucinations, anxiety, irritability and agitation. Currently, the management of these symptoms is a combination of non- pharmacological and pharmacological interventions such as use of psychotropic drugs (PDs) (Janus et al., 2016). In people with dementia, the use of these medications is less appropriate because of the side effects such as parkinsonism, rapid cognitive decline, cerebral vascular accidents and increased risks of falls caused by drowsiness (Janus et al., 2017). Studies indicate that more than half of people in residential care homes and 80% of people with dementia are receiving psychotropic medication, this number depends on the facilities  (Cousins et al., 2017). There is evidence to suggest that in some cases these medications have been prescribed inappropriately (Nørgaard et al., 2017). Inappropriate use of PDs can be classified as chemical restraint.

       Spek et al., 2018, when assessing the barriers to reducing the use of restraints, be it chemical or physical among health care professionals included; fear of resident’s injury, staff and resource limitation, lack of education and policy/management issues. Other factors pointed out includes belief and expectations of staff, family and residents and inadequate review of practices and communication barriers. Amura Francesca Fog et al., 2017, found that medical reviews in nursing homes resulted in overall less drug use, most pronounced for psychotropic drugs and opioids. Lam et al., 2017, was an observational analysis of over 2000 older people in Hongkong, the study found that the use of chemical and physical restraint was highly prevalent over the eleven-year study. This was especially evident in the most physically and cognitively impaired residents.  The study emphasised the need for dementia trained health care staff. And provision of care that is characterised by individual needs, dignity, empathy and respect. 

     Thirdly, (Ferreira et al., 2020) in a study of the factors that contribute to an increase in the likelihood of resident experiencing neuropsychiatric symptoms highlighted the need to respond to residents needs in a timely manner. The study found that unmet needs are often underrecognized and untreated and could contribute to the increase in neuropsychiatric symptoms in the elderly.  For example, not being assisted with toileting, lack of sensory stimulation during the day, which in turn affected the sleep pattern and not having ways to manage sundowning behaviours (Cohen-Mansfield et al., 2015).  However, while this could be a contributing factor, the study fails to point out the fact that people with dementia normally suffer from memory loss and will forget that there needs where met. It then becomes unrealistic to expect staff to constantly attend to one resident’s needs at the expense of the others. 

        Other studies show that the decision to use psychotropics is normally considered in the aspects of striking a balance between the rights of the individual residents and the other residents in the ward. Health care staff are usually not bothered with the individual behaviours of the residents, but nurses feel they are obliged to take further steps to limit the behaviours for the safety of other residents. This is especially so in residents that are violent, physically aggressive and verbally disruptive.  Staff also must deal with numerous competing rights, the rights of the resident with extreme behaviours, the rights of other residents to live in peace and the nurses own professional responsibility. In cases of residents resisting care and being violent, the question then becomes, for  how long do staff respect the resident’s autonomy before they are accused of neglect (Evans et al., 2018).

       Finally, psychotropic drugs are commonly prescribed in residential care homes. This is despite extensive evidence of their limited efficacy in the management of behavioural and psychological symptoms of dementia (BPSD). Studies indicate that almost 40% of residents on psychotropic drugs to manage behaviours do not need to be on them (Brimelow et al., 2019). In 2019, amendments to the quality of care principles placed explicit obligations on nursing homes to minimise the use of chemical and physical restraints. The amendment principles require that nursing staff exhaust all other alternatives and strategies to ensure that restraints are used as last resort (Health, 2019). Over prescription of medication in nursing homes has always been an issue, one reason could be that, there is currently no clear and consistent framework to guide nursing staff on the use and management of psychotropics.   

Sources

Amura Francesca Fog, Gunnar Kvalvaag, Knut Engedal, & Jørund Straand. (2017). Drug-related problems and changes in drug utilization after medication reviews in nursing homes in Oslo, Norway. Scandinavian Journal of Primary Health Care, 35(4), 329–335. https://doi.org/10.1080/02813432.2017.1397246

Brimelow, R. E., Wollin, J. A., Byrne, G. J., & Dissanayaka, N. N. (2019). Prescribing of psychotropic drugs and indicators for use in residential aged care and residents with dementia. International Psychogeriatrics, 31(6), 837–847. https://doi.org/10.1017/S1041610218001229

Cohen-Mansfield, J., Dakheel-Ali, M., Marx, M. S., Thein, K., & Regier, N. G. (2015). Which unmet needs contribute to behavior problems in persons with advanced dementia? Psychiatry Research, 228(1), 59–64. https://doi.org/10.1016/j.psychres.2015.03.043

Cousins, J. M., Bereznicki, L. R., Cooling, N. B., & Peterson, G. M. (2017). Prescribing of psychotropic medication for nursing home residents with dementia: A general practitioner survey. Clinical Interventions in Aging, 12, 1573–1578. https://doi.org/10.2147/CIA.S146613

Juola, A.-L., Bjorkman, M. P., Pylkkanen, S., Finne-Soveri, H., Soini, H., Kautiainen, H., Simon Bell, J., & Pitkala, K. H. (2015). Nurse Education to Reduce Harmful Medication Use in Assisted Living Facilities: Effects of a Randomized Controlled Trial on Falls and Cognition. Drugs & Aging, 32(11), 947–955. https://doi.org/10.1007/s40266-015-0311-8

Lam, K., Kwan, J. S. K., Wai Kwan, C., Chong, A. M. L., Lai, C. K. Y., Lou, V. W. Q., Leung, A. Y. M., Liu, J. Y. W., Bai, X., & Chi, I. (2017). Factors Associated With the Trend of Physical and Chemical Restraint Use Among Long-Term Care Facility Residents in Hong Kong: Data From an 11-Year Observational Study. Journal of the American Medical Directors Association, 18(12), 1043–1048. https://doi.org/10.1016/j.jamda.2017.06.018 Langford, A. V., Chen, T. F., Roberts, C., & Schneider, C. R. (2019). Measuring the impact of system level strategies on psychotropic medicine use in aged care facilities: A scoping review.

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