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Best Practice in the use of Medication within Care Homes

Dr Salma Iqbal, Harriet Toop & Andy Swanson
Clinical Psychologist/ Assistant Psychologist/Senior Nurse
Submitted Date: 13/04/2012
Review Date: 06/12/2012
A service evaluation involving staff from Psychological Services and Elderly Mental Health.
The aim of this work was to quantify the prevalence rates of psychotropic medication usage and highlight behaviours deemed problematic and requiring input from Community Services.
Local Area
Ayrshire and Arran
Care Setting
Community care, Education and Training
Care Group
Later Life
Evidence Base for Practice
Recent publications identify the ongoing use of medication for the management of challenging behaviour among residents with dementia in care homes (Care Commission and Mental Welfare Commission, 2009). Antipsychotic medications have been found to have modest beneficial treatment effects for specific symptomatology over short term periods (6-12 weeks), however they are noted to cause negative side effects including cognitive and/or cerebrovascular harm (James et al., 2006).

Within NHS Ayrshire and Arran, consistent evidence was found for the role of Community Mental Health Teams for the Elderly (CMHT-E's) providing support via direct client contact or training provision to nursing and residential homes. The latter often being frequently repeated due to high staff turnover and absence rates. National documentation (Scottish Government, 2010; Department of Health, 2009; SIGN 86, 2006) state the importance of services exploring non-pharmacological means by which to manage challenging behaviour and committing to auditing the usage of psychotropic medication usage.

Informed by both national and local practice, the audit was developed to support future service innovation and ensure that Elderly Mental Health practice remains in line with Scottish Government recommendations.
Quality assurance/impact of practice
A total of thirty four referrals were recorded, with 56% of the sample being female. 74% were between the ages of 71-90 years old, similar to figures from national prevalence rates (Care Commission and Mental Welfare Commission, 2009). A variation in diagnostic presentations was noted, with dementia being most common (73% of sample; of those, 46% had vascular dementia). With regards to presenting difficulties, restlessness (32%) and physical aggression (19%) were the most common reasons for patient referral to the CMHT-E. 53% of patients were already known to the service; 50% of these re-referrals were requiring input for the same presenting difficulty, suggestive of symptom persistence. 59% of patients were currently prescribed a psychotropic medication, with Lorazepam of highest prevalence (30%). Longer term prescribing (over 3 months) was found in over half the sample, including benzodiazepines that are recommended for short term (2-4 weeks) use only (British National Formulary, 2011). The findings indicate that psychotropic medication usage remains prevalent and figures gathered in the local audit are consistent with other studies (James et al., 2006).

The Elderly Mental Health Service sought to improve management of individuals who are presenting with behaviours that cause distress to themselves and others. The recent establishment of an Elderly Mental Health Community Care Home Nursing Liaison Service is intended to increase access to specialist assessment and deliver training in the management of patients consistent with a biopsychosocial model (James, 2011). The liaison nurses will work closely with GPs and care homes to increase knowledge and understanding of non-pharmacological interventions for challenging behaviour. They will also ensure that regular reviews of pharmacological prescribing take place with the aim of reducing overall rates of psychotropic medication usage, consistent with Scottish Government recommendations.
Practice Summary
Within NHS Ayrshire and Arran, an audit was conducted in nursing and residential homes to identify the psychological presentations and psychotropic medication usage of residents that were considered to display behaviours that challenge. The aim of this work was to quantify the prevalence rates of psychotropic medication usage and highlight behaviours deemed problematic and requiring input from Community Services. The work has served to provide baseline data of referral rates and support the need for development of access to specialist services. This project has further supported the benefit of the introduction of a nurse led Community Care Home liaison service.
Practice Detail
The following objectives were identified and evaluated through the audit procedure:

1. Nature of referral – Identify common reasons for referral to Community Mental Health Teams for Elderly (CMHT-E)
2. Psychotropic Medication Usage – Document prevalence of psychotropic medication usage of referrals to CMHT-E’s from nursing and residential homes across NHS Ayrshire and Arran.

An audit steering group was established in October 2009 to oversee project objectives, issues of research and clinical governance, development of an audit proposal and ensure continued consultation with key stakeholders (CMHT-E nursing staff, Elderly Mental Health senior management and Psychological Services). Upon agreement of project procedure, the audit phase was active from October 2010-January 2011. During this period, details of all referrals received by CMHT-E’s from nursing/residential homes were recorded by staff on an electronic audit survey tool. Data collected included age, gender, diagnosis, locality, referrer, reasons for referral and psychotropic medication prescriptions detail. During the active audit phase, weekly reminders were sent to ensure adherence to the project. Access to audit procedure guidance sheets and contact with the principal contributor to deal with any troubleshooting queries was also made possible.

The audit project has served as a baseline of prevalence rates of psychotropic medication usage in clients referred from nursing and residential homes. This data will now be used to measure changes over time following the establishment of the Community Care Home Nursing Liaison Service. The practice established by the current audit will be sustained via re-evaluation on an annual basis by the nursing liaison service in conjunction with support from Psychological Services. It is intended that this will serve to monitor a reduction in the number of inappropriate anti-psychotic prescriptions in care and residential homes.
Response rates were slightly lower than might have been anticipated and also highlighted a geographical variation in referral location, e.g. one locality had no referrals recorded. The reason for this discrepancy remains unknown, whether there was an actual lack of referrals in this area at this time or non-entry of relevant information to the audit database.

Prevalence rate of psychotropic medications was gathered however reason for prescription of medication was not noted. Since the reason for prescription is unknown we cannot comment upon the appropriateness of the medication type or effectiveness for presenting problems of the individual referred.

Prevalence related data on psychotropic medication usage was quantified (medication type, length and referrer) however details regarding date of last review were not gathered in the current audit. It was found that 55% of medications recorded were prescribed over three months previously. Examination of medication type in comparison to national guidance (British National Formulary, 2011) highlighted that some medications were being used for longer than guidance would recommend. However, given the lack of detail regarding medication review, it was unable to be determined whether longer term prescribing was appropriate (due to symptom persistence), or not, in the case of the individual referred.
Additional Comments
For access to the audit tool developed, full report findings or further detail regarding the Elderly Mental Health Community Care Home Nursing Liaison Service please contact Dr Salma Iqbal (Clinical Psychologist and Principal Contributor) or Andy Swanson (Senior Nurse) via the ‘Contact’ link at the top of the page.

Reference List
Please see the ‘Additional Information’ tab to access those sources available as PDF documents. Additional references are listed below:

James IA, Wood-Mitchell A, Waterworth A. Treating challenging behaviour in dementia with psychotropic medication – help or hindrance? PSIGE Newsletter 2006; 94: 11-18.

James IA. Understanding Behaviour in Dementia that Challenges: A Guide to Assessment and Treatment. London: Jessica Kingsley Publishers; 2011.
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