Care of nursing home residents with advanced dementia

Read about a research project we funded into the care of nursing home residents with advanced dementia - feasibility study.

Lead Investigator: Dr Carole Parsons
Institution: Queen's University Belfast
Grant type: Project
Amount: ÂŁ67,545
Start date: April 2011
Completion date: October 2012

What was the project, and what did the researchers do?

Assessing the appropriateness of drug prescriptions allows medical practitioners to be better informed about which drugs should and should not be prescribed for various forms of dementia. This in turn improves the care of people with dementia, particularly when studies have shown that inappropriate prescribing of drugs, specifically antipsychotics, may cause hundreds of deaths in people with dementia.  

In this study the researchers sent out three rounds of questionnaires by post to the nine doctors who are members of the Clinical Management Group of the Northern Ireland Clinical Research Network for Dementia to ask them to decide which medicines (of 97 medicines or medicines classes in total) are 'never appropriate', 'rarely appropriate', 'sometimes appropriate' or 'always appropriate' for use in nursing home residents with advanced dementia nearing the end of life. This study used a technique called the Delphi Consensus technique, where the questions are asked in series of rounds. After each round, responses are shared with all participants and the questions asked again. The aim is to achieve a consensus among the experts. 

At the end of the third round, the doctors had agreed on the classification of 87 (90%) of the 97 medications and medication classes included in the survey.

The researchers then looked at how easy or difficulty it is to collect information about older residents with severe dementia in nursing homes in Northern Ireland. In particular, they examined the numbers and types of medicines prescribed, medical procedures, illnesses or events such as going into hospital, and whether there was a statement giving directions for a resident’s future medical care, written by the resident before their illness was so severe that they were unable to make decisions for themselves, known as an advance directive. Three nursing homes agreed to participate in the study and 15 residents were recruited. During the study, which lasted nine months, four residents passed away and one was moved from the nursing home.

Data was collected in each of the nursing homes at the start of the study, three months, six months and nine months. For the four residents who died during data collection, data were collected within two weeks of the residents' death. 

For the medication data collected, the researchers looked at how many medicines in each category ('never appropriate', 'rarely appropriate', 'sometimes appropriate' or 'always appropriate') were prescribed for the residents in our study. 

What were the key results, and how will this help in the fight against dementia?

The researchers found that residents were prescribed on average 16 medicines at the start of the study, but the number of prescriptions decreased over the time of the study. Antipsychotic drugs were prescribed for six residents during the study period. Antibiotics were commonly prescribed in each of the three nursing homes, and were started to treat chest infections and pneumonia in the last seven days of life.

At baseline, 14 of the 15 participating residents were prescribed at least one 'never appropriate' medication and a significant proportion (up to one quarter) of medications prescribed were considered by the consensus panel to be 'never appropriate’. This proportion stayed fairly stable during the study period, as did the proportion of medicines considered to be 'always appropriate'.

There was a reduction in the proportion of 'never appropriate' medicines and an increase in the proportion of 'always appropriate' medicines in the last two weeks of life for the four residents who died during the study, suggesting a move away from medicines to cure towards prescribing to manage symptoms.

Four residents had one or more advance directives in place (most commonly a do-not-resuscitate [DNR] or do not hospitalise [DNH] order). The most commonly occurring events that impacted upon the health of the resident or their use of medicines were infections (e.g. urinary tract infections, chest infections) and skin problems such as infections or wounds.

What happened next? Future work and additional grants

Dr Laura McCann started an associate lecturing role at National College of Ireland in April 2013 and will continue working in a professional support capacity in the health care sector in Northern Ireland.

Dr Carole Parsons and Professor Carmel Hughes will continue their research in pharmacy practice and primary care.

How were people told about the results? Conferences and publications

McCann et al, 2012. Abstract submission and oral presentation.

22 June 2012: Research Seminar to colleagues in the Clinical and Practice Research Group, Queen's School of Pharmacy.

9 September 2012: Royal Pharmaceutical Society Annual Conference.  Session 2 Supporting patients with dementia and in palliative care.

This project was jointly funded by Alzheimer's Society and the Bupa foundation.

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