Improving the Appropriateness of Antipsychotic Prescribing for Behavioral and Psychological Symptoms of Dementia (BPSD): A Pilot Study of the Psychotropic Use Monitoring (PUM) Program

Abstract

In nursing homes, antipsychotic prescribing decisions (APDs) for managing behavioral and psychological symptoms of dementia (BPSD) depend on the nursing staff’s feedback. Inappropriate APDs can result in the lack of timeliness, objectivity and important clinical information when nursing staff’s feedback on residents’ behavior and pharmacotherapy outcomes. Currently, there are no reported interventions for improving psychiatrists’ APDs through nursing staff’s monitoring and feedback processes. This one-group pre-and-post pilot study aimed to evaluate the feasibility and impact of implementing a newly-developed Psychotropic Use Monitoring (PUM) program for improving the appropriateness of APDs in a 50-bed dementia ward of a nursing home. The PUM intervention involved 16 pharmacist-trained nursing staff, who monitored and reported residents’ BPSD changes and psychotropic side effects for 24 weeks, while carrying out their routine care duties. A face-to-face interview was then administered to determine the nursing staff’s perceptions of PUM. Data of 51 residents were collected from hardcopy individual patient records to evaluate the changes in APDs and the number of resident falls before and after implementing PUM. The nursing staff reported increases in their knowledge, awareness, confidence, and actual frequency of monitoring for side effects, as well as their ability in differentiating and managing BPSD (p < 0.05). After PUM, there was a significant increase in the number of APDs due to side effect-related reasons (4 versus 16) (p < 0.031). Although not significant, the number of APDs with no documented reasons (5 versus 9) and the number of resident falls (7 versus 15) appeared to be lesser after PUM. This study demonstrated the nursing staff’s positive participation in PUM intervention, specifically in monitoring and feedback of side effects. Furthermore, a potential exists for PUM to encourage more judicious APDs, which may be useful in settings with heavy patient load, limited human resources and dependence on foreign nursing staff from differing cultural backgrounds.

Share and Cite:

Yap, K. , Kua, E. , Chan, S. and Lee, J. (2014) Improving the Appropriateness of Antipsychotic Prescribing for Behavioral and Psychological Symptoms of Dementia (BPSD): A Pilot Study of the Psychotropic Use Monitoring (PUM) Program. Open Journal of Psychiatry, 4, 153-162. doi: 10.4236/ojpsych.2014.42020.

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1] Steinberg, M., Shao, H., Zandi, P., Lyketsos, C.G., Welsh-Bohmer, K.A., Norton, M.C., et al. (2008) Point and 5-Year Period Prevalence of Neuropsychiatric Symptoms in Dementia: The Cache County Study. International Journal of Geriatric Psychiatry, 23, 170-177. http://dx.doi.org/10.1002/gps.1858
[2] Shah, A., Carey, I. M., Harris, T., DeWilde, S. and Cook, D.G. (2011) Antipsychotic Prescribing to Older People Living in Care Homes and the Community in England and Wales. International Journal of Geriatric Psychiatry, 26, 423-434. http://dx.doi.org/10.1002/gps.2557
[3] Schneider, L.S., Dagerman, K.S. and Insel, P. (2005) Risk of Death with Atypical Antipsychotic Drug Treatment for Dementia. Meta-Analysis of Randomized Placebo-Controlled Trials. JAMA, 294, 1934-1943. http://dx.doi.org/10.1001/jama.294.15.1934
[4] Schultz, S.K. (2008) Atypical Antipsychotic Medications in Alzheimer’s Disease: Effectiveness versus Expectations. American Journal of Psychiatry, 165, 787-789. http://dx.doi.org/10.1176/appi.ajp.2008. 08040517
[5] Declercq, T., Petrovic, M., Vander Stichele, R., De Sutter, A.I.M., van Driel, M.L. and Christiaens, T. (2013) Withdrawal versus Continuation of Chronic Antipsychotic Drugs for Behavioural and Psychological Symptoms in Older People with Dementia. Cochrane Database of Systematic Review, Article ID: CD0 07726.
[6] Crystal, S., Olfson, M., Huang, C., Pincus, H. and Gerhard, T. (2009) Broadened Use of Atypical Antipsychotics: Safety, Effectiveness, and Policy Challenges. Health Affairs, 28, w770-781.
http://dx.doi.org/10.1377/hlthaff.28.5.w770
[7] Leung, T. and Menon, S. (2011) Who Will Look after Our Elderly? April 29, 2012.
http://www.siiaonline.org/?q=programmes/commentary/who-will-look-after-our-elderly
[8] Tellis-Nayak, V. and Tellis-Nayak, M. (1989) Quality of Care and the Burden of Two Cultures: When the World of the Nurse’s Aide Enters the World of the Nursing Home. The Gerontologist, 29, 307-313.
http://dx.doi.org/10.1093/geront/29.3.307
[9] Lindquist, L.A., Jain, N., Tam, K., Martin, G.J. and Baker, D.W. (2009) Inadequate Health Literacy among Paid Caregivers of Seniors. Journal of General Internal Medicine, 26, 474-479.
http://dx.doi.org/10.1007/s11606-010-1596-2
[10] Barher, N.D., Alldred, D.P., Raynor, D.K., Dickinson, R., Garfield, S., Jessen, B., et al. (2009) Care homes’ Use of Medicines Study: Prevalence, Causes and Potential Harm of Medication Errors in Care Homes for Older People. Quality & Safety in Health Care, 18, 341-346. http://dx.doi.org/10.1136/qshc.2009.034231
[11] Khatutsky, G., Wiener, J.M. and Anderson, W.L. (2010) Immigrant and Non-Immigrant Certified Nursing Assistants in Nursing Homes: How Do They Differ? Journal of Aging & Social Policy, 22, 267-287.
http://dx.doi.org/10.1080/08959420.2010.485526
[12] Mamun, K., Goh-Tan, C.Y.E. and Ng, L.L. (2003) Prescribing Psychoactive Medications in Nursing Homes: Current Practice in Singapore. Singapore Medical Journal, 44, 625-629.
[13] Buetow, S.A., Sibbald, B., Cantrill, J.A. and Halliwell, S. (1997) Appropriateness in Health Care: Application to Prescribing. Social Science & Medicine, 45, 261-271. http://dx.doi.org/10.1016/S0277-9536(96)00342-5
[14] Castle, N.G. (2003) Providing Outcomes Information to Nursing Homes: Can It Improve Quality of Care? The Gerontologist, 43, 483-492. http://dx.doi.org/10.1093/geront/43.4.483
[15] Hagen, B.F., Armstrong-Esther, C., Quail, P., Williams, R.J., Norton, P., Le Navenec, C.-L., et al. (2005) Neuroleptic and Benzodiazepine Use in Long-Term Care in Urban and Rural Alberta: Characteristics and Results of an Education Intervention to Ensure Appropriate Use. International Psychogeriatrics, 17, 631-652. http://dx.doi.org/10.1017/S1041610205002188
[16] Kotynia-English, R., McGowan, H. and Almeida, O. (2005) A Randomized Trial of Early Psychiatric Intervention in Residential Care: Impact on Health Outcomes. International Psychogeriatrics, 17, 475-485. http://dx.doi.org/10.1017/S1041610205001572
[17] Fossey, J., Ballard, C., Juszczak, E., James, I., Alder, N., Jacoby, R., et al. (2006) Effect of Enhanced Psychosocial Care on Antipsychotic Use in Nursing Home Residents with Severe Dementia: Cluster Randomised Trial. British Medical Journal, 332, 756-761. http://dx.doi.org/10.1136/bmj.38782.575868.7C
[18] Putman, L. and Wang, J.T. (2007) The Closing Group: Therapeutic Recreation for Nursing Home Residents with Dementia and Accompanying Agitation and/or Anxiety. American Journal of Alzheimer’s Disease & Other Dementias, 22, 167-175. http://dx.doi.org/10.1177/1533317507300514
[19] Dahl, L.J., Wright, R.J., Xiao, A., Keeven, A. and Carr, D.B. (2008) Quality Improvement in Long Term Care: The Psychotropic Assessment Tool (PAT). Journal of the American Medical Directors Association, 9, 676-683. http://dx.doi.org/10.1016/j.jamda.2008.07.002
[20] Monette, J., Champoux, N., Monette, M., Fournier, L., Wolfson, C., Galbaud du Fort, G., Sourial, N., Le Cruguel, J.P. and Gore, B. (2008) Effect of an Interdisciplinary Educational Program on Antipsychotic Prescribing among Nursing Home Residents with Dementia. International Journal of Geriatric Psychiatry, 23, 574-579. http://dx.doi.org/10.1002/gps.1934
[21] Patterson, S.M., Hughes, C.M., Crealey, G., Cardwell, C. and Lapane, K.L. (2010) An Evaluation of an Adapted U.S. Model of Pharmaceutical Care to Improve Psychoactive Prescribing for Nursing Home Residents in Northern Ireland (Fleetwood Northern Ireland Study). Journal of the American Geriatrics Society, 58, 44-53. http://dx.doi.org/10.1111/j.1532-5415.2009.02617.x
[22] Westbury, J., Jackson, S., Gee, P. and Peterson, G. (2010) An Effective Approach to Decrease Antipsychotic and Benzodiazepine Use in Nursing Homes: The RedUSe Project. International Psychogeriatrics, 22, 26-36. http://dx.doi.org/10.1017/S1041610209991128
[23] Westbury, J., Tichelaar, L., Peterson, G., Gee, P. and Jackson, S. (2011) A 12-Month Follow-Up Study of “RedUSe”: A Trial Aimed at Reducing Antipsychotic and Benzodiazepine Use in Nursing Homes. International Psychogeriatrics, 23, 1260-1269. http://dx.doi.org/10.1017/S1041610211000421
[24] Leipzig, R.M., Cumming, R.G. and Tinetti, M.E. (1999) Drugs and Falls in Older People: A Systematic Review and Meta-Analysis: I. Psychotropic Drugs. Journal of the American Geriatrics Society, 47, 30-39.
[25] Sylliaas, H., Selbaek, G. and Bergland, A. (2012) Do Behavioral Disturbances Predict Falls among Nursing Home Residents? Aging Clinical and Experimental Research, 24, 251-256.
[26] Cummings, J.L. (1997) The Neuropsychiatric Inventory: Assessing Psychopathology in Dementia Patients. Neurology, 48, S10-S16. http://dx.doi.org/10.1212/WNL.48.5_Suppl_6.10S
[27] (2013) DRUGDEX® System (Micromedex 2.0). http://www.micromedexsolutions.com/home/dispatch
[28] Semla, T.P., Beizer, J.L. and Higbee, M.D. (2008) Geriatric Dosage Handbook. 14th Edition, Lexi-Comp, Inc., Hudson.
[29] Joint Formulary Committee of the British Medical Association and the Pharmaceutical Society of Great Britain (2011) British National Formulary (BNF 61). Pharmaceutical Press, London.
[30] Hertzog, M. (2008) Considerations in Determining Sample Size for Pilot Studies. Research in Nursing & Health, 31, 180-191. http://dx.doi.org/10.1002/nur.20247
[31] Kane, J.M., Aguglia, E., Altamura, A.C., Gutierrez, J.L.A., Brunello, N., Fleischhacker, W.W., et al. (1998) Guidelines for Depot Antipsychotic Treatment in Schizophrenia. European Neuropsychopharmacology, 8, 55-66. http://dx.doi.org/10.1016/S0924-977X(97)00045-X
[32] Woods, S.W. (2003) Chlorpromazine Equivalent Doses for the Newer Atypical Antipsychotics. Journal of Clinical Psychiatry, 64, 663-667. http://dx.doi.org/10.4088/JCP.v64n0607
[33] Stuart, A. (2002) The State of the World’s Pharmacy: A Portrait of the Pharmacy Profession. Journal of Interprofessional Care, 16, 391-404. http://dx.doi.org/10.1080/1356182021000008337
[34] Jordan, S., Tunnicliffe, C. and Sykes, A. (2002) Minimizing Side-Effects: The Clinical Impact of Nurse-Administered ‘Side-Effect’ Checklists. Journal of Advanced Nursing, 37, 155-165.
http://dx.doi.org/10.1046/j.1365-2648.2002.02064.x
[35] Feng, Z., Fennell, M.L., Typer, D.A., Clark, M. and Mor, V. (2011) Growth of Racial and Ethnic Minorities in US Nursing Homes Driven by Demographics and Possible Disparities in Options. Health Affairs, 30, 1358-1365. http://dx.doi.org/10.1377/hlthaff.2011.0126
[36] British Columbia Ministry of Health (2012) Best Practice Guideline for Accommodating and Managing Behavioural and Psychological Symptoms of Dementia in Residential Care. 31 October 2013.
http://www.health.gov.bc.ca/library/publications/year/2012/bpsd-guideline.pdf
[37] Lester, P., Kohen, I., Stefanacci, R.G. and Feuerman, M. (2011) Antipsychotic Drug Use since the FDA Black Box Warning: Survey of Nursing Home Policies. Journal of the American Medical Directors Association, 12, 573-577. http://dx.doi.org/10.1016/j.jamda.2010.04.005

Copyright © 2024 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.