Melissa Morley and Bronwen Wright report on Dementia Training Australia’s work to support two residential aged care facilities through a quality improvement process to tackle the issue of antipsychotic medication for people living with dementia
There is growing concern regarding potential overuse – and inappropriate use of – psychotropic medications, such as antipsychotics and other sedatives, in older people, especially those living with dementia who are at increased risk of injury and death when prescribed these.
Dementia Training Australia (DTA) offers a Medication Management Consultancy (MMC) service which is consultant-led and evidence-based. It aims to embed knowledge and processes to reduce and/or optimise the use of antipsychotic medication if prescribed for people living with dementia in a residential aged care facility who may be experiencing responsive behaviours.
In this article, we report on DTA’s recent involvement delivering an MMC service within two residential aged care facilities operated by Ananda Aged Care. They were the first MMCs to be completed in South Australia and resulted in considerable beneficial changes for both residents and staff.
Ananda Aged Care offers general and dementia-specific care within two aged care sites, Findon and Hope Valley, both in Adelaide. Both sites undertook the MMC during mid-2019 and successfully completed the service by June 2020. This longer than average MMC completion time (most are completed within six months) stemmed from Ananda Aged Care’s dedication to continue the MMC, even during the global COVID-19 pandemic.
About DTA’s consultancy
The MMC is a quality improvement service which offers organisations the following benefits:
Dementia Training Australia
Dementia Training Australia
Each DTA consultant is a highly experienced health professional, working in dementia care. They support staff through this change process, providing continuity throughout the course of the consultancy. DTA consultants guide staff through a process which involves care teams reviewing how their procedures and policies shape the way their team is currently managing antipsychotic medications. They support teams to develop evidence-based mechanisms that can ensure sustainability and align with best practice changes, for example through medication management policy and procedure improvements.
This is conducted at the beginning and end of the consultancy, and involves measuring staff knowledge about recommended use of antipsychotic medications for responsive behaviours, and the number of residents prescribed antipsychotic medications for responsive behaviours.
3. Provision of resources to support appropriate use of antipsychotic medications for responsive behaviours, which include:
- A 1-1.5 hour interactive online staff education training course: by completing this course, staff will have gained a greater awareness of the limited role antipsychotic medications have in supporting a person living with dementia, and enhanced their knowledge of alternative strategies to use instead of antipsychotics.
- Education delivered to staff on how to use the DTA resources, including how to implement evidence-based processes within a facility, through regular video conferencing with the DTA consultant.
- Other resources provided as a complimentary package mailed to the facility, including fact sheets for consumers about antipsychotic medication use for responsive behaviours from Dementia Australia, DTA antipsychotic review reminder stickers, reference cards and posters.
Over the past three years, 15 residential aged care facilities have completed an MMC with DTA. It is a popular national service, with another 17 MMCs currently in progress at different facilities around Australia. Key contributors to the success of the MMC service include regular support and facilitation offered by the DTA consultants, coupled with a collaborative relationship with the nominated Action Group at the facility. Ultimately, this presents a unique opportunity for an organisation to reduce the number of antipsychotic medications used to support people with responsive behaviours and/or ensure best practice recommendations are followed if prescribed.
The Action Group
A key contributor to achieving the MMC outcomes included the nomination by Ananda Aged Care of a diverse team, known as the Action Group, to work cohesively and meet regularly via video conference with their dedicated DTA consultant. The Action Group participants at both sites included a mix of clinical nurse specialists and managers, registered and enrolled nurses, medication-competent care workers and a development workplace manager. Each had their own experience, knowledge, unique skill set, role and responsibilities. The meetings formed a safe and comfortable, non-judgmental opportunity for participants to reflect on their practice and interactions with residents, and brainstorm site processes and procedure enhancements, assessing these from the perspective of different staff roles.
The MMC service aims to develop the Action Group into a confident and knowledgeable team regarding antipsychotic medication management with emphasis placed on aligning recommendations for best practice care. One of the strengths of the Action Group is that it provides other internal and external staff with a point of reference to guide, foster and contribute opportunities to raise awareness about alternative strategies in preference to antipsychotics, and help reduce and/or ensure best practice recommendations are followed, if these medicines are prescribed.
What did the Action Group do?
During the MMC, the Action Group trialled and adopted different strategies in order to develop their own antipsychotic management procedure. For example, DTA antipsychotic review reminder stickers were trialled in a dedicated paper-based documentation system. Staff at Hope Valley found this particularly useful as a simple way to communicate to the rest of the multidisciplinary team as to when prescriber reviews were planned, if actions were undertaken and what the outcome was. Meanwhile, staff at Findon added antipsychotic review alerts to an electronic system to improve monitoring of prescriber reviews within the Memory Support Unit (MSU).
Additionally, the Action Groups at both sites worked cohesively to ensure accurate documentation of antipsychotic usage, including recording behaviours and tracking trends over time, reviewing for effectiveness, monitoring for any side-effects, and managing titration plans. Communicating key information to prescribers in a concise, confident manner and continuing to practise Ananda Aged Care’s approach to providing holistic care also helped the teams to successfully titrate and cease antipsychotics as per recommended best practice.
New medication guidelines
The Pharmaceutical Society of Australia (PSA), the national peak body for pharmacists in Australia, produces standards and guidelines governing the professional practice of pharmacists in Australia. Two new guidelines from PSA will be of interest to those working with people with dementia, particularly those in residential aged care.
Guidelines for Quality Use of Medicines (QUM) services provides guidance to pharmacists on professional issues relating to the various activities undertaken within the scope of Quality Use of Medicines (QUM) services. QUM services are a key strategy to optimise medication management within residential aged care facilities (RACFs). They support RACFs to safely manage medicines and improve medicine management practices and procedures. QUM services involve three types of activities: education and training; clinical governance; and resident-level activities, which are implemented following the development of a QUM plan, as part of a cohesive quality improvement process.
Guidelines for Comprehensive Medication Management Reviews focuses on comprehensive medication management reviews which aim to identify, resolve and prevent medication-related problems and optimise medicines use in partnership with medical practitioners and patients, regardless of practice setting. The guideline sets out clear information about patients’ rights, confidentiality and consent; professional collaboration and communication; clinical and quality governance; and focuses in detail on the comprehensive medication management review cycle of care which can now involve up to two follow-up reviews of care.
PSA has also partnered with the Department of Health to publish a range of practice resources to support pharmacists conducting medication reviews via telehealth, given the widespread use of telehealth in the current COVID-19 pandemic. The resources include two-page fact sheets on the following topics: Use of visual and audio technology in telehealth medication review consultations; Assessment of safe storage and disposal of medicines during a telehealth medication review consultation; How to prepare for, and what to expect from a telehealth medication review consultation (consumer resource), and Use of digital resources to support the medication review consultation.
To access these resources go to: https://bit.ly/30LEDcs.
Two key measures relating to antipsychotic use at Ananda Aged Care included:
- staff knowledge regarding psychotropic medication measured using a validated tool in the form of an anonymous quiz (Brown et al 2016) followed by,
- the number of residents prescribed antipsychotic medications for responsive behaviours assessed by clinical audit.
Across both sites, 49 respondents completed the quiz. Upon completion of the MMC, the average number of correct responses improved by 23%.
As part of the Medication Management Consultancy, staff receive a comprehensive antipsychotic resources suite which includes an antipsychotic poster (pictured left), summarising suggested steps to support a person with new responsive behaviour, and quick reference cards (right)
Findon achieved an average 26% reduction in antipsychotic use following the MMC process. Specifically, cessations occurred for all ‘when required’ antipsychotic medications by the end of the consultancy. Furthermore, six residents within the MSU had their antipsychotic doses reduced by 50% to align with recommended best practice.
In comparison, Hope Valley increased their antipsychotic usage by an average 31% at the end of the consultancy. A contributing factor to increased usage was an influx of new residents to the facility who were already prescribed antipsychotic medication. However, while the overall usage increased, at least 12 residents had their antipsychotic medication reduced to minimum doses with further plans for cessation. Furthermore, the MMC service has provided staff with robust processes to support new residents and ensure further optimal medication management in relation to antipsychotic use.
Anecdotal reporting from staff provides additional insight into the various benefits offered during the MMC service including:
- More meaningful interactions and engagement from residents with staff.
- Significant reductions in incidences of drowsiness, improved night-time sleep quality, increased mobility, fewer falls, increased appetite and enjoyment from food when residents’ antipsychotic medication doses were reduced and/or ceased.
- Strengthening of existing non-pharmacological interventions, developing and documenting a comprehensive review process when an antipsychotic medication is prescribed, and monitoring for signs of ineffectiveness and adverse effects.
- Seeing value in developing a tailored and new antipsychotic procedure with a sustainability plan to ensure the processes continue to be implemented after the consultancy ends.
Lessons from the work
DTA knows that there is a greater acceptance for any changes to practice when all key stakeholders, including senior management, are involved in the MMC process. At Ananda Aged Care, the Action Group included staff in senior roles, which provided organisational support to drive and lead onsite quality improvement and practice change.
A major quality improvement outcome achieved for Ananda Care included the development of site-specific antipsychotic management procedures. These ensured a systematic process was in place that aligned to the evidence-based, best-practice recommendations and included collaborative development to represent the thoughts and ideas from a diverse range of participants within the Action Group. Learnings from Ananda Aged Care’s success has influenced DTA’s recommendations regarding selection of Action Group participants and will further shape future improvements in the way DTA supports organisations through sustainable change processes.
Supporting Ananda Aged Care throughout the MMC process has led to benefits for both staff and residents. The MMC process has demonstrated improved staff knowledge of antipsychotic use, as well as reduction in prescribed antipsychotics for residents. We congratulate the organisation on its ongoing dedication in delivering what matters most to people living with dementia and its success at making such a difference at these facilities.
Melissa Morley and Bronwen Wright are both Medication Management Consultants with DTA
Brown D, Westbury J (2016) Assessing Health Practitioner Knowledge of Appropriate Psychotropic Medication Use in Nursing Homes: Validation of the Older Age Psychotropic Quiz. Journal of Gerontological Nursing 42(9) 21-27.
Dementia Training Australia offers the Medication Management Consultancy Service alongside a range of other consultancies and educational services through Tailored Training Packages (TTPs), which are designed to bring about sustainable change within organisations to improve the wellbeing of people living with dementia and the staff who care for them. For more information about improving the use of antipsychotic medications used to support people living with dementia, visit the DTA website or phone (02) 4221 5555 to request a call-back from a DTA consultant.