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Reducing Antipsychotics for People with Dementia in Care Homes
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Reducing Antipsychotics for People with Dementia in Care Homes

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Reducing Antipsychotics for People with Dementia in Care Homes: Evaluating a Pilot Intervention in Coventry & Warwickshire. …

Reducing Antipsychotics for People with Dementia in Care Homes: Evaluating a Pilot Intervention in Coventry & Warwickshire.

This file was featured in a presentation that was recorded on November 12, 2013, as part of CLeAR's monthly webinar series. It was delivered by:

Dr Karim Saad FRCPsych
Regional Clinical Lead for Dementia, NHS West Midlands
Consultant in old age psychiatry, Coventry & Warwickshire Partnership Trust

Watch a recording of this presentation: https://vimeo.com/79311561

CLeAR – a Call for Less Antipsychotics in Residential Care – aims to reduce the number of these seniors on antipsychotic medications by 50% across BC by December 31, 2014.

Learn more about CLeAR: www.CLearBC.ca

Published in: Health & Medicine, Sports

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  • 1. Reducing Antipsychotics for People with Dementia in Care Homes. Evaluating a Pilot Intervention in Coventry & Warwickshire. Dr Karim Saad FRCPsych Regional Clinical Lead for Dementia, NHS West Midlands Consultant in old age psychiatry, Coventry & Warwickshire Partnership Trust Dr Bartley Sheehan MRCPsych Associate Clinical Professor in old age psychiatry, Warwick University Honorary Consultant in old age psychiatry, Coventry & Warwickshire Partnership Trust Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 2. 800,000 people with dementia (PwD) in UK Greatest health concern for people over 55! 44% PwD receive a diagnosis 2/3 PwD live in the community while 1/3 live in a care home 400,000 Care Home residents 80% of people living in care homes have a form of dementia or severe cognitive impairment 20% prescriptions for (PwD) include an Antipsychotic (AP) drug (Fossey, 2006) 1000 AP prescriptions x 12 weeks = 10 Deaths + 18 CVAs + 58-94 Gait Disturbances (Banerjee, 2009) ↑ Mortality Risk persists at least 6 months after initial prescription (DART-AD, 2009) Quetiapine accelerates dementia decline in Care Homes residents (Ballard, 2006) Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 3. National & Regional Priority NHS Operating Framework Department of Health Funding for each region Reduce Prescribing to 1/3 by October 2011 W Mids Regional Strategy emphasises – quality dementia services – closer to home – focus on Prevention Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 4. Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 5. Aims Design an Intervention for PwD in Care Homes that: 1. ↓ AP Prescriptions 2. Provides a viable alternative for management of BPSD 3. Represents good value 4. Can be reproducible Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 6. The Intervention • 1.2 WTE Nurse: – 0.6 WTE band 6 – 0.6 WTE band 5 • • • • Duration: 3 months (2 months per Care Home) Supervision: Authors & Pharmacist Research Nurse sessions Components: A. Training Intervention B. Main Pilot Intervention Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 7. (A) Training Intervention • • • • • • • 2 sessions per Care Homes (1 week apart) Each Session: 45 – 60 min Target: all staff Delivered by band 6 nurse Session 1: identify behaviours due to dementia Session 2: identify +ve & -ve responses to behaviours Contents: written materials, discussion, verbal instruction, literature review • Video: simulated residents & carers (developed for OPERA, HTA-funded) Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 8. (A) Training Intervention • Session 1 – – – – – Introduction (3 min) What is dementia? (10 min) BPSD (10 min) Video, carer interacting with PWD with BPSD (5 – 7 min) Discussion, what behaviours are due to dementia (15 – 17 min) • Session 2 – – – – – Recap of session 1 (5 min) How do we respond to behaviours seen in dementia? (10 min) Introduction of ABC & person-centred approach (10 min) Video, carer interacting in a new way with PWD with BPSD (5 – 7 min) Discussion of responses to behaviours in dementia (13 – 15 min) • Feedback collected after each session Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 9. (B) Main Pilot Intervention • Case note review with care home managers identified PWD on AP • Guide to appropriate AP prescribing Proforma • Cases selected for AP Withdrawal • Withdrawal plans shared with GP & Care Home • Withdrawal supervised by consultant &/or Pharmacist • Withdrawal monitored by band 6 & 5 nurse • NPI-NH version at weeks 4 & 8 Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 10. Video
  • 11. Results
  • 12. The Care Homes Care Home Designation Location Number of residents A Residential care, Pinnacle Care Group, dementia Rugby 18 B Care Home, privately owned, dementia Rugby 26 C Residential care, Crosscrown Ltd., dementia, old age, learning difficulties Rugby 26 D Supported Housing, Extra care, over 55 Coventry 58 bungalows E Care Home with Nursing, privately owned, dementia, mental health, excl. learning disability, old age Coventry 64 F Care Home, Southern Cross, dementia Coventry 30 G Residential care, Anchor, dementia, old age Coventry 40 H Nursing Home, privately owned, old age, Rugby 40 Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 13. A total of 40 residents were taking antipsychotic (AP) medication, in 8 Care Homes 10 9 8 7 6 5 4 3 2 1 0 A B C D E F G H Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 14. 5 of 8 Care Homes withdrew residents from AP medication 10 9 8 7 6 5 Number taking a/p medication = 40 4 Number withdrawn from a/p medication = 16 3 2 1 0 A B C D E F G H Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 15. Prevalence of AP Prescribing: 40/302 residents (13%) 70 60 50 40 30 20 10 Number on a/p Number of residents 0 Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 16. Characteristics of 40 residents prescribed AP • Highest rates of AP prescribing in dementia specialist Care Homes • Lowest in Extra Care Housing Unit (no prescriptions) • Of these 40, 16 selected for Withdrawal • All 16 were PWD Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 17. N=16 Withdrawn off AP Residents taking a/p - 40 Residents withdrawn = 16 Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 18. AP Prescriptions N=16 people withdrawn from antipsychotics, the following had been prescribed (range of daily doses in mg/24hr in brackets) • • • • Quetiapine Risperidone Haloperidol Olanzapine 8 prescriptions 5 prescriptions 2 prescriptions 1 prescription (25-100) (0.5-1.5) (0.5) (10) In the 24 people not withdrawn the following had been prescribed • • • • • • • • Quetiapine Risperidone Haloperidol Promazine Chlorpromazine Flupenthixol Olanzapine Amisulpiride 10 prescriptions 8 prescriptions 1 prescription 1 prescription 1 prescription 1 prescription 1 prescription 1 prescription (12.5-100) (0.25-4.0) (1.5) (100) (50) (0.6) (5) (50) Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 19. Characteristics of those withdrawn n=16 Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 20. Reasons for Non-Withdrawal n=24 Schizophrenia, n = 4 Bi-polar, n = 4 Behavioural, n = 6 Information not provided by GP, n = 9 Not known, n = 1 Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 21. Domains and scoring for NPI – NH in residents withdrawn off AP Domain Frequency Severity 1234 Frequency + severity 123 Occupational disruptiveness 012345 A. Delusions B. Hallucinations C. Agitation/ Aggression D. Depression/ Dysphoria E. Anxiety F. Elation/ Euphoria G. Apathy/ indifference H. Disinhibition I. Irritability/ Lability J. Aberrant Motor Behaviour TOTAL SCORE Highest possible score = frequency + severity for each domain = 70 Lowest possible score = 0 Occupational disruptiveness – assessed by carer Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 22. NPI –NH Outcomes in residents withdrawn from AP Identifier Baseline score 4 week score 8 week score Outcome A1 4–0 missing missing A2 8-4 8–4 missing A3 49 – 19 missing missing A4 6–3 missing missing A5 17 – 5 21 – 10 12 – 06 restarted E1 25 – 7 22 – 9 28 – 15 restarted E2 0–0 0–0 0–0 E3 14 – 5 10 – 2 9–3 E4 2–0 0–0 0–0 F1 6–0 9–0 6–0 F2 2–0 11 – 5 4–2 F3 0–0 0–0 0–0 F4 12 – 5 12 – 4 9–2 F5 32 – 8 12 – 2 10 – 1 G1 0–0 0–0 0–0 H1 0-0 26 - 19 4-2 restarted restarted restarted Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 23. 5/16 residents were restarted on AP within 4 weeks All were restarted because of ↑ BPSD Residents withdrawn from a/p - 16 Residents restarted = 5 Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 24. 11/40 (27.5 %) successfully withdrawn for 4 weeks Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 25. Evaluation of staff training Training session were held in the 8 Care Homes that participated in the Pilot study. 6 Homes completed 2 sessions 2 Homes completed only 1 session Home A, no record of second session Home H, cancelled second session - infection control closure to all but essential staff Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 26. Numbers of staff attending training sessions (by years of experience as carer) Home Session one: Session two: Over 3 years experience Under 3 years experience Over 3 years experience Under 3 years experience A 4 1 B 5 3 4 7 C 2 1 1 1 D 5 6 4 5 E 3 1 2 1 F 4 1 4 1 G 4 0 4 0 H 5 2 Total: 32 15 19 15 Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 27. Evaluation of staff training Evaluation of training completed by participating staff (same questions used for both sessions): Question 1: the session was relevant to my job Question 2: I learned something new from this session Question 3: I am glad I attended this session Question 4: The session was just the right length Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 28. Evaluation of Session 1 Question Total responded Strongly agree Agree Don’t know Disagree Strongly disagree 1 47 42 3 0 0 2 2 46 35 9 1 0 1 3 46 38 7 0 0 1 4 47 34 8 3 1 1 Evaluation of Session 2 Question Total responded Strongly agree Agree Don’t know Disagree Strongly disagree 1 25 18 2 5 0 0 2 25 19 4 2 0 0 3 25 19 3 3 0 0 4 24 14 7 3 0 0 Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 29. Staff responded positively to the training, they found it relevant and useful and expressed enthusiasm for further teaching ‘education on medication was useful’ ‘gained more understanding of behaviours in dementia and would like more training in depth to support to give the right skills to help people with dementia’ ‘was very informative and descriptive with regards to dementia and medication associated with it’ ‘found it very informal- more of an insight to what my residents are feeling’ ‘was very interesting but also would like more training on medication; found it very informative and useful.’ ‘would like more training to have better understanding to enable me to help people with dementia’ ‘more training on dementia medication also more in depth training about mood swings in relation to dementia ‘ ‘more training with dealing with conflicts’ ‘very informative’ Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 30. Findings 1 AP all causes N=40 13% (National 20%) AP Dementia N=16 Successful Withdrawal N=11* AP Other N=24 Failed Withdrawal N=5 * Broadly in keeping with Banerjee, 2009 Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 31. Findings 2 • Care Home Staff Training Sessions were well attended & well received (high levels of confidence & staff satisfaction) • Main Pilot Intervention: – Secondary prevention (Withdrawal of AP) – Replaced with individualised supervised nonpharmacological interventions • Estimated £80,000 direct savings and £240,000 quality of life improvements per annum (Based on Burns & Chambers, 2011) Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 32. Findings 3 • Approximately 150 Care Homes in Coventry & Warwickshire • If 3 band 6 CPNs targeted this population FT for 1 year • They could provide 220x2x3 half day visits = 1320 visits/year, or 8 – 9 half day visits per Care Home • Enough to screen all residents, run 2 training sessions for care homes’ staff, monitor eligible residents at least twice, and offer some interventions Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 33. Findings 4 • Our model would successfully secure an extra 285 PWD off AP • In doing so: – prevent 2 – 3 extra deaths, 2 – 3 extra strokes, 15 – 25 gait disturbances per year – reducing new prescriptions – enhancing staff skills all round Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 34. Conclusion • • • • • • Safe Secondary Prevention Model Clinically & cost effective Specialist intervention Easily reproducible Improves experience & QoL for PWD Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 35. Recommendations • Suited for localities seeking to redesign the interface with Care Homes & Primary Care • Reducing inappropriate prescriptions of Psychotropic drugs? • Consider other configuration e.g. Band 3 healthcare support worker for follow-up role (2.5WTE band 6 & 0.5wte HCA) Karim Saad Webinar 12 Nov 2013 CLeAR initiative British Columbia Patient Safety and Quality Council
  • 36. Thank You! Twitter - @KarimS3D Blog - KarimS3D.com

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