Preventing Unnecessary Use of Antipsychotics in Dementia Care

Research has shown that antipsychotic medicines (which may cause significant side-effects) are too often used to manage behavioural and psychological symptoms of dementia (Alzheimer’s Australia 2014).

So, how can nurses use non-pharmacological interventions to prevent antipsychotic use for people with dementia?

Non-Pharmacological Treatment in Dementia Care

According to a systematic review by Richter et al. (2012), psychosocial interventions for aged care residents with dementia can prevent the use of antipsychotic medicine.

Often, behavioural and psychological symptoms of dementia such as agitation are treated in residential facilities with prescribed antipsychotic medicines. However, this can lead to frequent side effects including falls, sedation and cardiovascular issues (Richter et al. 2012). Additionally, antipsychotic medicines have been associated with increased risk of stroke, increased risk of mortality and confusion (Alzheimer’s Australia 2014).

A study in Sweden found that people with dementia who lived in specialised units were often inappropriately prescribed long-term antipsychotics (Gustaffson, Karlsson & Lovheim 2013). The participants of the study were most likely to be prescribed antipsychotic medicines if they were observed as being aggressive or passive, or if they had a mild cognitive impairment (Gustaffson et al. 2013).

Again, these findings reinforce the need to have medical officers and pharmacists regularly review medicines to ensure that clients are receiving appropriate treatments for their individual needs/changes for only the appropriate/necessary timeframe. This study emphasises that antipsychotic medications should be time-limited and Selbaek et al. (cited in Gustaffson et al. 2013) ‘demonstrated that most symptoms show an intermittent course which does not support long-term treatment with antipsychotics’. O’Connor et al. (cited in Gustaffson et al. 2013) suggest that sometimes symptoms are categorised as being current, but are actually intermittent.

Psychosocial or ‘non-pharmacological’ interventions may involve interpersonal interactions such as verbal discussions, health education and psychological approaches. A multi-strategy approach is recommended (Richter et al. 2012).

One approach could involve monthly interprofessional team meetings to discuss residents’ medicine use. Others may involve offering an information session for family members or carers, and completing quarterly medicine reviews for each resident. It could also be beneficial to include a strategy such as evidence-based training videos and/or consultations for workers who care for people with dementia (Richter et al. 2012).

Gustaffson et al. (2013) emphasise the need to investigate symptoms thoroughly to identify triggers for behaviours of concern. They also recommend that in addition to reviewing medicines, discontinuation is considered if the medicines have ‘potentially adverse effects on the central nervous system’.

Gustaffson et al. (2013) also suggest that environmental factors can support people with dementia more effectively if music, physical activity and recreation are included in care delivery.

Potential Triggers for Behavioural Changes

There are many triggers that may lead to behavioural changes, including:

• Fatigue;
• Sleep deprivation;
• Pain;
• Discomfort;
• Illness;
• Fear;
• Hallucinations;
• Poor lighting;
• Infection;
• Unfamiliar environment;
• Psychiatric illness;
• Dehydration
• Feeling hungry;
• Unfamiliar routines;
• Environmental temperature; and
• Medicine side effects.

(Better Health Channel 2014)

Potential Non-Pharmacological Interventions

• Reduce stress for the person;
• Have a consistent routine;
• Encourage regular exercise;
• Improve comfort;
• Use short, clear statements;
• Use a calm tone and calm body language (thereby if the words are not comprehended, the non-verbal communication may still be understood);
• Do not argue with the person;
• Do not scold the person; and
• Ensure the person's environment is comfortable (e.g. implement night lights, control environmental temperature, place familiar objects in the person's room).

(Dementia Australia 2017; Better Health Channel 2014)

Aggression-Specific Management Strategies

• Speak calmly;
• Reassure the person;
• Use a simple distraction (e.g. invite the person to come for a walk outside);
• Avoid ‘closing in’ on the person or restraining them; and
• Document and communicate behaviour management plans so that continuity of care can occur (e.g. use a behaviour chart to indicate triggers for specific behaviours and which strategies were and were not effective to alleviate the behavioural and psychological symptoms of dementia).

(Dementia Australia 2017)

References

• Better Health Channel 2014, Dementia - Behaviour Changes, Better Health Channel, viewed 13 January 2021, https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/dementia-behaviour-changes
• Dementia Australia 2014, A New Approach to Reducing the Use of Antipsychotic Medications in People With Dementia, Dementia Australia, viewed 12 January 2021, https://www.dementia.org.au/about-us/news-and-stories/news/new-approach-reducing-use-antipsychotic-medications-people-dementia
• Dementia Australia 2017, Behaviour Changes, Dementia Australia, viewed 13 January 2021, https://www.dementia.org.au/about-dementia-and-memory-loss/about-dementia/behaviour/behaviour-changes
• Gustafsson, M, Karlsson, S & Lövheim, H 2013, 'Inappropriate Long-term Use of Antipsychotic Drugs is Common Among People With Dementia Living in Specialized Care Units', BMC Pharmacology & Toxicology, vol. 14, no. 10, viewed 11 October 2017, http://doi.org/10.1186/2050-6511-14-10
• Richter, T, Meyer, G, Mohler, R & Kopke, S 2012, 'Psychosocial Interventions for Reducing Antipsychotic Medication in Care Home Residents', Cochrane Database of Systematic Reviews, iss. 12, viewed 20 September 2017, http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008634.pub2/full Doi: 10.1002/14651858.CD008634.pub2