In Australia, almost 1 in 10 people aged 65 years and over, and 3 in 10 people aged 85 years and over have dementia (Department of Health and Ageing, 2013). Over 320,000 Australians are living with dementia. Dementia is now the second leading cause of death in Australia with no existing cure. Moreover, deaths due to dementia have increased approximately 137% over the past ten years, with nearly 11,000 deaths recorded in 2013 (Australian Bureau of Statistics 2014).
Dementia is described as a ‘loss of self (Cohen & Eisdorfer, 1986) or a condition in which the environment becomes increasingly alien, similar to living in a bad dream causing a progressively set down stress threshold (Stolley, 1994). These unfamiliar terrains in turn may lead to aggressive behaviour such as insomnia, agitations development of depression and delirium. It also increases the risk for serious adverse effects, such as cardio metabolic dysfunction (Carson et al. 2006), cerebrovascular events, diabetes, thromboembolism, and sudden cardiac death (Ray et al. 2009).
Considering the behavioural and physical aspects of dementia, patient care requires a special set of professional attitudes and expertise, which involves a respectful, empathic, and compassionate approach to individuals who have serious disabling adverse risks and stigmatising conditions (Williams et al. 1995). The management of complex behaviour in elderly patients with dementia in aged care can have a major impact on quality of life for patients as well as the nursing staff, and results in poor outcomes and the likelihood for patients being institutionalised (Burns & Hope, 1997).
A review of the literature shows a general consensus that early assessment of predisposing factors of delirium and depression, can be managed with the provision of a basic understanding and the establishment of a supportive environment which could help to facilitate holistic care for all involved, the patient, the staff and the carer (Andersson 1993). In order to achieve such care, an evidence-based approach needs to be in place detailing the priority for management and nursing assessment of delirium, depression, aggression and other mental disorder associated with dementia.
This two-week project will evaluate the use of medical and nonmedical therapies for behavioral management of the elderly with dementia at the Blue Care aged care facility. The project aims to accommodate suggestions that are evidence-based for improved quality use of alternative therapy and antipsychotic medications in elderly living with dementia in the residential care facility. The clinical goal is to provide a supportive environment and care to reduce the impact of aggression and depression on patients with dementia while promoting the residents’ wellbeing and promoting the approach of person centered care.
The following tools to assess the behavioural problems will be used in the project: a) the Cohen-Mansfield Agitation Inventory (CMAI), which has been used to evaluate the outcomes of antipsychotic interventions (Camp et al 2002); b) the Kitwood Dementia Care Mapping (DCM) (Kitwood 1997); and c) Drug usage evaluation (DUE) to asses the prescription and administration of antipsychotic medications (Holloway and Green 2003). In addition, medication charts, progress notes and pharmacy reviews will be evaluated.
The research project focuses on the Blue Care aged care objective to understand and ameliorate the negative effects of over prescription and inappropriate use of medication to treat mental illness. The findings of this project will help inform policymaking and improve clinical practice in the Blue Care facility, with an effort to create awareness among staff, doctors, and pharmacists about the variation in antipsychotic prescribing rates, the frequency of prescribing, and the risk of serious medication side-effects, including metabolic syndrome, stroke, thromboembolism and death.
Literature Review At present, antipsychotic medications are frequently used in aged care facilities as strategies for managing behavioral symptoms and agitations (Banerjee 2009). A number of studies have shown that antipsychotic medications are effective in managing these behavioural aspects of dementia. For instance, a cost efficient study by the French public psychiatric sector found that the antipsychotic medications are safer with less cognitive symptoms, if the elderly residents are compliant with the medication regime (Liorca et al. 2005). The researchers also found that the efficacy of risperidone and olanzapine in elderly residents was effective in treating behavioral aggression (Liorca et al. 2005). A retrospective population-based cohort study that linked administrative health care databases in Canada (Suh & Shah 2005), concluded that olanzapine and risperidone use were not associated with any significant increased risk of stroke nor they had increased the risk of hospitalisation for those treated.
However, when compared with antipsychotic medication usage, the percentage of mortality rate in those who had not received antipsychotics was higher than that of those who had received antipsychotic medications. A randomized-control study over a period of one year, based on 273 patients, found no increase in mortality rate among patients receiving antipsychotic medication (Suh & Shah, 2005). Another large-scale 18 months study of elderly nursing home residents, based on 1130 patients and 3658 control subjects, found no increased risk of cerebrovascular events associated with antipsychotic use.
These findings suggest that a pre-existing cerebrovascular risk factor could exist but not in patients receiving risperidone or antipsychotic medication (Liperoti et al. 2005). Current literature also shows that there is a wide variability in the levels of evidence supporting the use of antipsychotic medication for the treatment of dementia and related agitation. Moreover, the usage of antipsychotics in aged care facilities have increased outside of the approved indications of administrative standards (Wastila et al. 009), and its potential benefits most probably outweigh their risks.
These types of medication may or may not be effective and well tolerated (including cognitively) in the treatment of behavioural and psychological symptoms of dementia (BPSD) in elderly patients (Wancata 2004). Neil and colleagues (2003) reported that generally, first-generation or ‘typical’ antipsychotics have been identified as non-beneficial for treating BPSD with the exception of haloperidol, which has been found to have statistically beneficial effects in treating both BPSD and delirium.
It has also being identified that Haloperidol is also associated with extrapyramidal side effects, including Parkinsonian-like symptoms, akathisia, and tardive dyskinesia and in rare cases, malignant neuroleptic syndrome, which could potentially be dangerous (Ballard et al. 2006). In addition, the use of typical antipsychotics in general has been also shown to greatly increase the potential of over sedation and the risk of falls (Ballard et al. 2006). In view of these adverse effects most countries, antipsychotics are only prescribed for residents with severe aggression and not for residents without aggression (Ballard et al. 009).
This finding also indicates suboptimal guideline adherence and inappropriate drug prescription practices. However at times during antipsychotic treatment, the prevalence of behavioral problems may even increase (Kleijer et al. 2009). In the United States due to the persistent high levels of concern about overuse of antipsychotics, a legislation (Omnibus Reconciliation Act 1987) has been introduced in an attempt to restrict prescribing antipsychotics to residents in nursing homes without the documented diagnosis of psychosis and as a result of the adverse effects and limited evidence supporting its efficacy (Shorr 1994).