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Vol 5 No 5 October/November 2016
Australian Journal of Dementia Care
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registered nurses (RNs) appointed in
each facility to drive the education,
awareness and implementation of non-
pharmacological behaviour management
strategies to support deprescribing.
Education
While we are still evaluating the project,
one issue has been consistently
highlighted by the champions: the need
for ongoing and consistent education
about dementia, dementia care and
person-centred care.
Many of the facilities involved in the trial
have, at the same time, also been
participating in capacity-building initiatives
focused on person-centred care which have
complemented the HALT project. However,
this education is still predominantly
targeted at RNs andmay not filter through
to care workers, management and allied
health professionals. Champions indicated
that particular attention needs to be paid to
ensuring education is provided to
AINs/care staff whomake up the majority
of workers providing hands-on care to
residents. This is evenmore important as
policy around the requirement for RNs
remains controversial.
Continuing training can be supported
at the organisational level, however there
is a real need to engage with tertiary
institutions offering formal aged care
qualifications and review the curriculum
to ensure they provide solid foundations
in dementia, BPSD and dementia care.
Management support
Champions have recognised the need to
embed the person-centred philosophy of
care into organisational policy and be
specific about what this means for
residents and staff alike. One champion
said that her facility nowmakes person-
centred care part of the mandatory training
undertaken by all staff on an annual basis.
While this is a positive step, she also said
this approach and the organisational
values underpinning it need to be
consistently reinforced by management
and supported at the organisational level
to ensure resources are available to meet
the changing environment.
Ultimately this needs to be reflected in
government policy and accreditation
standards which will encourage
organisations lacking direction in this
area to get on board.
Awareness and confidence
Overall, the feedback from champions
has been positive even if, at the outset,
they or other staff members were
concerned that taking residents off
antipsychotic medications would lead to
an increased burden on staff and
‘unmanageable’ residents.
The majority of champions have said
that participating in the HALT trial has
definitely created more awareness among
staff about antipsychotics and the
alternatives they can try first instead of
jumping straight on the phone and asking
a GP to prescribe these medications.
The majority of champions identified
pain management as one of the most
effective strategies for responding to
challenging behaviours. This feedback
from champions clearly confirms the
well-known fact that pain is
underdiagnosed and undertreated in
people with dementia.
The HALT Project has also empowered
staff to evaluate and question the need
for antipsychotic medications in newly
admitted residents. As one champion
said: “They [new residents] come to us
on a stack of medications, but being on
the project has just made us more aware
that we can speak up about it because we
know more about it and we can make a
more informed decision and say to the
doctors, ‘let them get settled and then see
if they really still need to be on that’.”
This increased awareness and
confidence to challenge the
appropriateness of antipsychotic use in
some residents is a positive outcome and
has the potential to have a powerful
impact on people with dementia.
A recent study has provided updated
data on the risk of mortality with
different antipsychotics compared to
non-use and with alternative
psychotropics (anti-depressants and
valproic acid), and the findings are
concerning (Maust
et al
2015).
Number Needed to Harm
The phrase ‘Number Needed to Harm’ is
used to describe how many people need
to be exposed to a risky treatment for one
person to be harmed. Previous
conservative findings suggested the
number needed to harm for haloperidol,
a typical antipsychotic, was 100
(Schneider
et al
2006).
However Maust and colleagues’
updated estimate is 26, with Risperidone,
an atypical and commonly used
antipsychotic, very closely following at
27. This means that on average, for every
27 people taking Risperidone, one person
will be negatively impacted by one of the
many associated risks.
This study also demonstrated that risk of
mortality correlates with dose: higher dose
equals higher risk of mortality. This means
that in the absence of a relevant mental
health condition, it is crucial to regularly
review the need for antipsychotic
medications for people with BPSD, as even
a dose reduction is a positive outcome if
cessation cannot be achieved.
Lack of consent
The HALT Project has brought many
systemic issues to light; one that is
particularly concerning is the number of
cases where medication is being
prescribed without consent. NSW law
requires that written informed consent is
obtained before prescribing drugs that
act on the nervous system, such as
antipsychotics. Consent is required from
either the individual or their ‘person
responsible’ if they lack capacity.
In our study sample, participants’
current course of antipsychotic
medication was commonly prescribed
outside these guidelines and, in the
majority of cases, without informed
consent, and continued without change
for lengthy periods until the HALT
intervention. Only one case out of 139
followed the proper consent procedures.
In another 21 cases we saw comments in
the residents’ files indicating verbal
consent, however whether this was truly
‘informed consent’ is questionable,
especially considering our conversations
with family members revealed their
general lack of knowledge of risks
associated with antipsychotic use.
Education is the key to tackling this
long-standing problem of over-
prescribing of antipsychotics in aged
care, and the qualitative feedback from
the HALT champions emphasises this
point. The critical need for education and
training doesn’t end with aged care staff.
It involves GPs, specialist clinicians and
allied health personnel.
Importantly, families, when faced with
the distress of a loved one experiencing
BPSD, also need to be involved in the
conversation and understand the
potential risks and benefits of
antipsychotic medications so they can
make an informed decision about their
loved one’s treatment and well-being.
Equally important, families should be
made aware of non-pharmacological
alternatives and the vital role they (the
family) can play in successfully
implementing person-centred strategies
for their loved one living with dementia.
Building on HALT success
The results of this project will be used to
encourage the development of a
nationally applicable and sustainable
approach to the care of people with BPSD
in long-term residential facilities. This
will require significant investment from
the government and the sector and will
not happen overnight. However, the
results of this project should empower
DCRC SPEC I AL I SSUE : THE B I G P I CTURE I N DEMENT I A RESEARCH