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The Journal of Quality Research in Dementia, Issue 4 (lay summary)

Training for staff can reduce use of sedatives in care homes

Jane Fossey

Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK Telephone +(0)1865 226 391; Email jane.fossey@psych.ox.ac.uk

Study shows that improving understanding of dementia is key to reducing the use of un‑licensed sedatives in care homes.

Behavioural symptoms, such as aggression and irritability, are very common in dementia. Those affected are often treated with major tranquillisers, even though there is little evidence that these drugs are helpful. In a study based in nursing homes, researchers have shown that a person-centred approach is a viable alternative to medication in treating behavioural problems.

People with dementia can sometimes behave in ways that might be considered challenging or disruptive. On average more than half of people with dementia develop some behavioural symptoms such as anxiety, restlessness or behaviour that can be seen as aggressive.

We know that around 40 per cent of people with dementia in care homes are prescribed powerful tranquillisers known as neuroleptics to help calm their mental or physical agitation. These drugs have not been proved to work well for people with dementia and so are not technically licensed to treat it. Neuroleptics can have many side effects including hampering balance and mobility and increasing confusion.

Testing an alternative

A research project was designed to test whether it is possible to safely manage the behavioural symptoms of people with severe dementia by improving the skills and practice of staff and in turn whether this new approach could reduce the number of people with dementia being treated with neuroleptics. The technical term for the style of trial chosen is a cluster randomised controlled trial. The research team chose to work with people with Alzheimer's disease who were resident in 12 different homes, four in Newcastle, four in Oxford and four in London. At least 25% of the residents in the homes had dementia and were taking neuroleptic drugs to treat their behavioural symptoms.

A psychiatrist from the research team and a senior member of each home's nursing staff reviewed the drug prescriptions of the residents in each home and made recommendations. It was advised that residents should not be given neuroleptic drugs for more than three months at a time and that prescriptions should also be stopped when the residents' behavioural problems had resolved. After this review half of the homes carried on with business as usual while the other half received support and training from a clinical psychologist for two days a week over ten months. The support varied from home to home, but it was all aimed at improving the staff's ability to deliver person centred care to residents who had dementia. All of the homes were at different starting points; for some it was about looking at how their daily routines affected the residents and families, for others it was about improving communication between staff and residents. Overall the support included skills training, behavioural management techniques and ongoing training and support for staff.

We rarely change our behaviour without a reason and this remains true for people with dementia. This is one of the central tenets of 'person-centred care' which was developed in the late 1980s and has come to be regarded as best practice for dementia care services.

Traditional dementia care focussed on managing the symptoms caused by physical changes in the brain. In contrast, person-centred care seeks to view the person with dementia as a whole. It requires consideration of how they are influenced by factors beyond the damage to their brain, including their personal history, and the social and physical environments in which they live. Person-centred care means care that meets the physical, mental and emotional needs of an individual.

When a person with dementia becomes agitated or depressed the challenge is to establish if there are any specific 'triggers' for this change in behaviour. Ideally everyone involved will have a rounded picture of the personality, life history, interests and skills of the person they are caring for. When a person-centred approach is taken it is easier to identify triggers of behavioural symptoms. For example someone who has always taken pride in their appearance may not react well to having their clothes chosen for them. Staff were encouraged to use different ways of finding out what the person's feelings were, which in turn improved how well that person was understood and looked after.

Each resident's daily dose of drugs was translated into a single comparable measure (chlorpromazine daily equivalent). A standard scale was used to measure individuals' reported levels of agitation and behavioural problems (The Cohen Mansfield agitation inventory). A system known as dementia care mapping was used to assist the development of person centred care.

Information on levels of individuals' health was recorded at the start of the research. After 12 months this assessment was repeated by a psychology research assistant who did not know which home had tried which technique and therefore did not bring a bias to the results.

Results

After 12 months 23% of residents in the six intervention homes were taking neuroleptics compared with 42.1% in the six control homes (an average reduction of 19.1%). Further scrutiny showed that when residents who could not be taken off neuroleptics were removed from the analysis the figures became 17.4% of residents in the intervention group were taking neuroleptics after 12 months compared to 38.7% in the control group (an average reduction of 21.3%).

The mean strength of the doses being taken was 107.1 in the control group and 102.1 in the intervention group (an average difference of 1.9). After discounting residents who could not be taken off neuroleptics this difference increased to 19.3.

The levels of other psychotropic drugs being taken by residents were roughly equivalent between the homes, thus indicating that the reduction in neuroleptics was not simply replaced with other psychotropic drugs.

There were no significant differences between the levels of agitation experienced by people in the intervention and control groups at 12 months. The same was true for acts of aggression. After 12 months the ratings for levels of well-being in both groups were similar.

Findings

This research shows that offering support with individualised psychological intervention as part of a programme promoting person-centred care and good practice provides a viable alternative to neuroleptics for treating the behavioural symptoms of people with dementia.

In both intervention and control homes, psychiatrists reviewed the prescriptions of the residents and recommended withdrawal of neuroleptics in accordance with best clinical practise, yet significantly fewer residents in the intervention homes remained taking these drugs. The percentage of residents who were still prescribed neuroleptics at the end of 12 months was less than half that in the control homes. Levels of agitation and episodes of aggressive behaviour did not increase in the homes that reduced the prescription of neuroleptics. The nursing homes that took part reflect a typical range of care provision for people with dementia in the UK: three were privately owned and managed, seven homes belonged to large groups of care home providers and two homes were NHS managed.

The training and support of care home staff reduced neuroleptic use in residents with dementia in nursing homes without worsening behavioural symptoms.