How does the 'culture' within a nursing home influence the prescription of certain drugs?

Lead Investigator: Professor Carmel Hughes
Institution: Queen's University, Belfast
Grant type: PhD studentship
Duration: 3 years
Amount: £73,690

Scientific title: The impact of contextual factors on the prescribing of psychoactive drugs with older people: An analysis of treatment culture in nursing homes

What do we already know?

This project is going to look at how treatment culture may affect the prescribing of psychoactive medication - antipsychotics, hypnotics (sleeping tablets) and anxiolytics (tranquilizers) - in older people with dementia living in care homes (specifically nursing homes). These medications have been used with older people when they are not always required and have sometimes been described as 'chemical restraints' or the 'chemical cosh'. Alzheimer's Society estimates that 2 out of 3 people with dementia who are prescribed antipsychotic medication have this medication prescribed unnecessarily. Antipsychotics can cause complications such as an increased risk of stroke, and also lead to an increased risk of death if taken for more than 12 weeks at a time. Alzheimer's Society is campaigning for a reduction in the number of people with dementia who are prescribed these drugs, and call for more person-centred care as a way to manage the behavioural and psychological symptoms of dementia that may lead to such prescriptions.

We know that there are some things that may influence why someone may receive these medications. They may have a genuine medical reason for needing these medications. But other research has shown that the type of home a person is in (for-profit or not for profit), the number of nurses employed and the type of training a doctor has received can also affect whether someone in a nursing home receives one of these medications. However, even when all of these factors are taken into account, there is still great variation in the prescribing of these medications across nursing homes; in other words, there are homes with high levels of prescribing and homes with low levels of prescribing and we don't know why. This project is going to try and explore why this happens.

Treatment culture refers to the way things are done in relation to prescribing of medication, specifically psychoactive medication.  Nursing homes can be categorised as having a resident-centred culture, an ambiguous culture or a traditional culture.

A resident-centred culture is one in which each resident is treated as an individual, emphasis is placed on all nursing home staff and other health and social care professionals such as GPs, pharmacists and social workers working together, and trying to avoid the use of psychoactive medication as far as possible and not using physical restraints. A traditional culture is completely the opposite where the resident is not considered as an individual, people don't work together and there may be excessive use of medication and physical restraints. An ambiguous culture lies somewhere in between resident-centred and traditional cultures. Research has shown that homes that are categorised as being resident-centred have lower levels of prescribing of these psychoactive medications compared to other homes in the other culture categories.

What we don't know is why some homes have a resident-centred culture and others do not, so the researchers want to continue this work through a PhD studentship supported by the Alzheimer's Society. We want to try and understand what a resident-centred culture really 'looks like' and we want to try and understand what promotes and encourages a resident-centred culture. By understanding this, we may be in a better position to train staff and encourage the development of a resident-centred culture in nursing homes. We would hope that this will lead to strategies to reduce the use of psychoactive medication in residents, particularly those with dementia.

What does this project involve?

The project will take place in six nursing homes, two of which will have a resident-centred treatment culture, two traditional and two will have an ambiguous culture; the treatment culture of each home has already been identified from previous work conducted by the researchers.

The project will involve interviews with the staff in nursing homes, GPs who prescribe for residents in nursing homes and will explore the culture within the nursing homes in more depth. Observations of the culture within the nursing homes accompanied by additional in-depth interviews will be conducted in half of the nursing homes. All of the information will be analysed, and the results used to inform and educational resource, developed along with nurses, GPs and other people interested in the prescribing in nursing homes.

The idea behind the resource is to develop a set of materials that can help teams who work in and with nursing homes to assess the culture of the home, train staff in how to change parts of the culture (if needed) and improve how they make decisions about prescribing drugs such as major tranquilisers.

How will this benefit people with dementia?

There has been a lot of publicity about the overuse of antipsychotics, hypnotics (sleeping tablets) and anxiolytics (tranquilizers) in people with dementia, particularly those living in nursing homes. There have been a number of approaches to try and reduce the use of these medications, and some have been successful. However, we know that these medications continue to be used, and used when there is no medical reason. There has been a recent call from the Dementia Action Alliance to review the use of antipsychotics and Alzheimer's Society is firmly behind this campaign.

Understanding why there is high use of antipsychotics and similar medicines in some homes and low use in other homes is an important step in trying to reduce their use. Research has already shown that homes that are resident-centred in culture have lower rates of prescribing of psychoactive medication than homes with other categories of culture. If we can understand what helps to promote a resident-centred culture in nursing homes, we may be able to reduce the prescribing of these medications even further, particularly in people with dementia.