Making a Difference in Dementia. A Pilot Study. Prepared for the Medicine Management Integrated Care Collaborative

Transcription

1 Making a Difference in Dementia A Pilt Study Prepared fr the Medicine Management Integrated Care Cllabrative By Karen Jacbs-Grant PHARMAC and Jeremy Ly, CCDHB December P a g e

2 Table f Cntents Executive Summary Intrductin Methd Results Discussin Limitatins Cnclusins and Recmmendatins Acknwledgements References Appendix One Prject Grup Appendix Tw BPAC Audit Appendix Three Antipsychtic Planning Frm Appendix Fur Timeline f Activities Appendix Five Prject Benefits P a g e

3 Executive Summary The Making a Difference in Dementia pilt was a jint initiative by PHARMAC and Capital & Cast DHB s Medicatin Management Integrated Care Cllabrative (MM-ICC). The pilt cmmenced in Nvember 2015 and was designed t reinfrce best practice use f antipsychtics with elderly peple diagnsed with dementia in the Aged Residential Care (ARC) setting. The main bjectives f the prject were t: Understand current practice and attitudes f staff that intrduce and prescribe antipsychtics fr patients with symptms f dementia in ARC facilities. Evaluate the impact and respnse t the use f varius interventins (e.g. educatin and medicines guidelines. Tw Aged Residential Care (ARC) facilities, Sprtt Huse and Malvina Majr Retirement Village, agreed t take part in this prject. A clinical nurse manager and GP frm each facility, a representative frm their cntracted pharmacies, and CCDHB psychgeriatric service staff were invited t participate in wrking grup discussins. Pilt activities invlved a mix f patient audits cnducted by GPs, ARC staff educatin n managing patients with dementia and the rle f antipsychtics, and the implementatin f an antipsychtic planning frm t prmpt the regular review f treatment. PHARMAC cmmissined BPAC t evaluate the findings f the patient audits, and cmmissined Quigley and Watts Ltd t cnduct ARC staff interviews t determine whether the pilt had influenced their knwledge and behaviurs twards managing patients with dementia. The results f this pilt study indicated that sme f the current prescribing practices fr using antipsychtics in elderly peple are in accrdance with recmmendatins. Hwever, there was still rm fr imprvement with regard t hw antipsychtic therapy is regularly reviewed and cnsidered fr withdrawal. The pilt interventins were psitively received, with a reprted increase in staff emplying nnpharmaclgical strategies fr patients with symptms f dementia, and thinking twice befre using antipsychtics. Hwever, participants suggested there was a need fr further training t keep updated n changes in antipsychtic medicines and the use f nn-pharmaclgical strategies. While these findings were supprted by a reductin in antipsychtic prescribing acrss bth facilities this study cntained a number f limitatins. This included its small sample size, and the inability t cntrl fr external factrs such as internal ARC staff training. Furthermre, while the antipsychtic planning frm had received psitive feedback; it had nt been in place lng enugh t draw cnclusins n its benefits. In rder t validate the pilt s interventins and utcmes it is recmmended this prject be expanded t a larger range f ARC facilities. 3 P a g e

4 1. Intrductin Over the last few years there has been increasing cncern abut the grwing use f antipsychtics t manage the behaviur f elderly peple wh suffer frm dementia. Older peple represent a vulnerable ppulatin wh are particularly susceptible t the serius adverse effects assciated with antipsychtic medicines. Best practice prescribing f antipsychtics needs t be carefully mnitred t ensure the use f these medicines des nt cmprmise the care r wellbeing f residents in Aged Residential Care (ARC) facilities. Best practice guidelines are clear in that nn-pharmaclgical strategies shuld be a first line treatment f challenging behaviurs and symptms in dementia. Medicines such as antipsychtics if and when used as part f any interventin shuld be prescribed at the lwest effective dse, fr the shrtest pssible time, and nly fr the specific indicatins in which they have prven benefit. Review f the cntinuing benefit, and mnitring fr serius r intlerable adverse effects shuld take place regularly. In 2012 The Minister f Health agreed t PHARMAC cnducting a prgramme f wrk arund the use f antipsychtics in peple wh had been diagnsed with dementia. In late 2014 PHARMAC engaged the Medicines Management Integrated Care Cllabrative (MM-ICC) Grup (Appendix One) f Capital & Cast District Health Bard (CCDHB) t develp and implement the Making a Difference in Dementia pilt. The Making a Difference in Dementia pilt was designed t reinfrce best practice in the use f antipsychtics with elderly peple in the Aged Residential Care setting and t prmte the apprpriate use f antipsychtics in elderly patients diagnsed with dementia. The bjectives f the pilt were t: Understand current practice and attitudes f staff that intrduce and prescribe antipsychtics fr patients with symptms f dementia in ARC facilities. Evaluate the impact and respnse t the use f varius interventins (e.g. educatin and medicines guidelines. 1, 2 The pilt did nt seek t cmpare the tw aged residential care facilities. 2. Methd Tw ARC facilities in the Wellingtn regin (Sprtt Huse and Malvina Majr Retirement Village) were cntacted and agreed t take part in this pilt prject. Sprtt Huse, lcated in Karri, has a ttal f 95 beds (61 hspital, 34 rest hme) and has a specialised dementia unit, rest hme care and geriatric hspital services. Malvina Majr, based in Khandallah, prvides rest hme care as well as medical and geriatric hspital services, and has a ttal f 130 beds (80 hspital, 50 rest hme). 4 P a g e

5 A GP and Clinical Nurse Manager (CNM) frm each facility were invited t participate in pilt prject meetings. The pilt prject ran frm the 1st Nvember 2014 t 31 July During the curse f the pilt prject the fllwing activities were agreed upn and carried ut: The develpment f prmtinal material t raise awareness and prmte the purpse f the pilt t residents and their families, and ARC staff. Invitatin f pilt site staff t a PHARMAC Seminar abut managing peple with dementia, and the rle f antipsychtics and ther pharmaclgical and nn-pharmaclgical interventins. Educatin sessins t ARC staff led by PHO Pharmacy Facilitatrs abut the rle f pharmaclgical and nn-pharmaclgical interventins in patients with dementia. A pre and pst-pilt audit f antipsychtic prescribing with ARC patients cmpleted by their respective GPs (Appendix Tw). The bjective f these audits was t btain an understanding f hw antipsychtics were being prescribed and reviewed. The develpment f an antipsychtic planning and mnitring frm fr ARC staff t use t prmpt the regular review f the antipsychtic use with patients and the effect (Appendix Three). PRN (nn-regular) medicatin frms at bth rest hme sites were updated t enable, and prmpt, registered nurses t dcument the reasn why a PRN medicatin was administered. Fr the purpses f this reprt the pre-pilt perid refers t the time befre any interventins (educatin, antipsychtic frms) were implemented and pst-pilt being the time after. Analysis The effect f the pilt interventins were evaluated via the fllwing means: 1) Patient Audits Cnducted by GPs: T investigate whether data frm the pre and pst-pilt GP audits, regarding antipsychtic use and selectin, were cmpiled int a summary reprt by BPAC. 2) Qualitative Research Staff Interviews: PHARMAC cmmissined Quigley and Watts Ltd, a Wellingtn-based public health research cmpany, t prvide qualitative research supprt t the pilt. The aim was t identify any changes in the attitudes and behaviurs f participating health practitiners (clinical managers, nurses, residential caregivers and GPs) related t antipsychtic use after taking part in the pilt s training and supprt interventins. The breakdwn f participant rles acrss the tw ARC facilities is utlined in the fllwing table: Health Practitiner Grup Sprtt Huse Malvina Majr Ttal Residential caregivers Registered nurses Clinical manager/s GPs Ttal P a g e

6 3) Rest Hme Prescribing Data PHARMAC s Analyst team used dispensing data frm Pharmhuse t measure changes in antipsychtic prescribing at bth pilt sites. Dispensing data fr risperidne and quetiapine frm three different time perids were cllected: Perid 1: t (cntrl perid) Perid 2: t (pre-pilt) Perid 3: t (pst-pilt) These perids were analysed t help determine whether changes in antipsychtic prescribing were mre likely t be due t the prject s activities as ppsed t chance. These time perids enabled the cnstructin f three chrts fr analysis: 1) 3-Perid Chrt: a chrt f rest hme residents (RHRs) exists: in either rest hme within all the three perids; and n any f the key medicines within any f the three perids. 2) Cntrl Chrt: a chrt f RHRs exists: in either rest hme within bth Perid 1 and Perid 2; and n any f the key medicines within any f Perid 1 and Perid 2. 3) Experiment Chrt: a chrt f RHRs exists in either rest hme within bth Perid 2 and Perid 3; and n any f the key medicines within any f Perid 2 and Perid 3. Data cllected included the number f residents n any f the key medicines, the milligrams (mgs) dispensed per resident, and the ttal amunt f mgs dispensed verall. 3. Results Patient Audits Cnducted by GPs: Key findings frm the BPAC PHARMAC Pilt Reprt: Prescribing Antipsychtics t Older Peple included: Use f Antipsychtics Clinical reviews were cmpleted fr a ttal f 37 patients; 25 patients frm Sprtt Huse and 12 frm Malvina Majr Retirement Village. The majrity f antipsychtics prescribed fr the patients in the study were initiated by a general practitiner (31 ut f 37 patients). 27 ut f 37 patients were prescribed an antipsychtic t manage the behaviural and psychlgical symptms f dementia (BPSD). Target symptms were identified in 25 patients prir t prescribing an antipsychtic 6 P a g e

7 11 patients were prescribed an antipsychtic fr mild t mderate symptms and f this grup six respnded t the antipsychtic (55%) and three did nt (27%). Of the 23 patients prescribed an antipsychtic fr mderate t severe symptms, 19 respnded (83%) and tw did nt (9%). Nn-pharmaclgical treatments were nly trialled in 15 patients befre prescribing antipsychtics, and a differential diagnsis was nt cnsidered in seven patients. Antipsychtic use may nt have been discussed with up t 11 f the 37 patients r their families. Of the 37 patients, 29 had been prescribed an antipsychtic fr mre than six mnths. The n-ging need fr an antipsychtic was assessed in 26 patients, and withdrawal was nly attempted in the last three t six mnths in 16 patients. Ten patients had n evidence f mnitring r review fr adverse effects f antipsychtics. Selectin f Antipsychtic The majrity f patients were prescribed quetiapine (22), fllwed by risperidne (15), with a small number f patients prescribed halperidl r ziprasidne. Apprximately equivalent numbers f patients were prescribed quetiapine r risperidne fr BPSD. As risperidne is the nly antipsychtic indicated fr the management f sme patients with BPSD, it is the recmmended first-line chice. In thery, patients with BPSD shuld nly be prescribed quetiapine if they have been unable t tlerate risperidne r it has been ineffective. Only three f the 15 patients prescribed risperidne were prescribed mre than the recmmended 2mg daily, including ne patient prescribed mre than the maximum recmmended 4mg. Three patients were prescribed mre than ne antipsychtic medicine. This increases the risk f seizure and QT prlngatin. Of the 37 patients prescribed an antipsychtic, 18 were als taking anther sedating medicine, increasing the risk f adverse events. Of these 18 patients, ten were taking ne additinal sedating medicine, six were taking tw additinal medicines, and tw were taking three sedating medicines in additin t an antipsychtic. Please refer t the Prescribing Antipsychtics t Older Peple Reprt by BPAC at fr further detail. Qualitative Research - Staff Interviews: Key findings frm the Qualitative Research n Antipsychtic Use in Dementia Reprt included: Pre-pilt findings There was a strng and cnsistent view that antipsychtic medicines had a rle in managing behaviural and psychlgical symptms f dementia in sme 7 P a g e

8 circumstances. Regular mnitring and review were seen as vital, with a view t reducing r eliminating antipsychtic use as apprpriate. Antipsychtics were generally used as a last resrt after varius nnpharmaclgical (e.g. behaviural, diversinal r envirnmental) strategies had been trialled. There was a gd level f knwledge and awareness abut the use f nn-pharmaclgical alternatives participants cnsidered them rutine and used a wide range f strategies. Almst all participants reprted the current level f antipsychtic use at their facility was apprpriate; they did nt think these medicatins were being verused. A team apprach, including invlvement f family members, was used t make decisins abut antipsychtic use. There were mixed views n the feasibility f reducing antipsychtic use verall. Key factrs that helped t reduce the use f antipsychtics included: staff capacity and cmpetence (e.g. in using nn-pharmaclgical strategies t manage challenging behaviur); and gd supprt frm management, GP and family members. The main barriers t reducing antipsychtic use were the desire t keep the resident in their current residential facility/hme, and a lack f specialised dementia beds in the cmmunity. Psitive views were expressed abut psychgeriatric supprt and care crdinatin, particularly where this had been mre practive r regular than in the past, fr example a weekly clinic with a psychgeriatric nurse practitiner. Hwever, delays in accessing psychgeriatric services were als identified as a barrier at times. Pst-pilt findings Several changes t knwledge and behaviur were reprted after the pilt, including mre use f best-practice guidance n antipsychtics, greater awareness f antipsychtic effects, thinking twice abut prescribing antipsychtics, and increased applicatin f nn-pharmaclgical strategies. Managers reprted imprvements in hw staff members managed challenging behaviurs f residents. The extent t which these changes are attributable t the pilt culd nt be determined. This is because f the qualitative (nn-experimental) methd, uneven participatin in the pilt, and the presence f additinal training during the pilt perid. Participants suggested there was a need fr further training t keep updated n changes in antipsychtic medicines and the use f alternative strategies, particularly regular, interactive training. Please refer t the Qualitative research n Antipsychtic Use in Dementia Reprt by Quigley & Watts Ltd at fr further detail. 8 P a g e

9 3. Rest Hme Prescribing Data: Results f the prescribing data analysis is summarised in the table belw: Risperidne Quetiapine Perid N. Ttal mg dispensed est. mg per patient per day N. Ttal mg dispensed est. mg per patient per day (cntrl) t (pre-pilt baseline ) t (pst-pilt) t mg , mg mg , mg mg , mg Cmpared t the pre-pilt perid: The number f patients prescribed risperidne decreased frm 12 t 10. Fr risperidne, the estimated average daily dse per patient reduced frm 0.82mg t 0.71mg. The number f patients prescribed quetiapine reduced frm 17 t 15. Fr quetiapine, the estimated average daily dse per patient reduced frm 79.88mg t 74.53mg. While the 3-perid chrt shwed a further reductin in the number f patients prescribed risperidne (15 t 10), there was n change ver this perid fr quetiapine. There appeared t be n significant change in the average daily dse f either antipsychtic dispensed. The graphs belw als summarise this infrmatin. Hwever, the analysis has been perfrmed by using the pre-pilt perid as a benchmark against the cntrl and pst-pilt perids. 9 P a g e

10 Cmpared t the 2014 baseline, ttal dispensed dse f quetiapine was 17.67% lwer in the 2015 three-mnth perid. In the 2013 three-mnth perid, ttal dispensed dse f quetiapine was 18.07% lwer than baseline. It shws that the dispensed dse f quetiapine has increased frm the 2013 perid t 2014 perid, and then decreased frm the 2014 perid t the 2015 perid. Cmpared t the 2014 baseline, the ttal dispensed dse f risperidne was 27.85% lwer in the 2015 three-mnth perid. In the 2013 three-mnth perid, ttal dispensed dse f risperidne was 3.70% higher than baseline. It suggests that the dispensed dse f risperidne has been cntinuusly decreased frm the 2013 perid t the 2015 perid. In particular, the decrease is mre significant frm the 2014 perid t the 2015 perid than frm the 2013 perid t the 2014 perid. 4. Discussin Current Use f Antipsychtics in Aged Residential Care Facilities: The results f the GP cmpleted BPAC audits indicated that antipsychtics appear t be mre successful in managing symptms f dementia in peple with mderate t severe target behaviurs, than mild behaviurs. Furthermre nn-pharmaclgical strategies were trialled in less than half f 10 P a g e

11 the patients audited, and a differential diagnsis was nt cnsidered in seven patients. If these cnsideratins had been made, it may have resulted in fewer patients being prescribed antipsychtics. The audit als nted mst patients were being prescribed risperidne and quetiapine fr mre than six mnths, with a few cases at higher than recmmended dsages. This suggests an n-ging need t supprt ARC facilities in prescribing first-line antipsychtics at the lwest effective dse fr the shrtest pssible time. Staff Attitudes twards the use f Antipsychtics: Despite participants earlier views regarding the rle and usage f antipsychtics at their respective facilities, changes t knwledge and behaviur manifesting as increased use f best practice guidance and nn-pharmaclgical strategies were reprted fllwing the pilt interventins. Several enablers and barriers t reducing antipsychtic use were highlighted. While the activities f this pilt aligned t taking a case-by-case apprach t reviewing prescribing, educating staff in apprpriate antipsychtic use, and getting ARC management supprt; imprving access t specialist services was utside the scpe f this prject, hwever the attending Psychgeriatrician and Psychgeriatric nurse did change their behaviur in that they practively cntacted and visited the ARC facilities during the pilt, instead f usual practice where they wuld be cntacted by ARC staff t visit the facility. Impact f Pilt n Antipsychtic Prescribing: The analysis cnducted by PHARMAC shwed a small reductin in the number f patients n antipsychtics at bth ARC facilities since the start f this prject. While prmising, the patient numbers invlved in the pilt were small and due t the presence f external factrs such as ARC staff training and management team invlvement at MM-ICC prject meetings it is difficult t say t what extent reductins were attributable t pilt interventins. The reductin in antipsychtic use shwn by the quantitative analysis was nt reflected in the results f the patient audits cnducted by the tw GPs invlved with the pilt. This is because the patient recrds that were audited may nt have necessarily been the same patients seen in the quantitative results. One f the unexpected benefits f the pilt prject has been the develpment f a methd t allw PHARMAC r DHB analysts t measure prescribing activity fr ARC facility patients. This may be useful in expanding the pilt t ther ARC facilities r t ther medicines f interest. 5. Limitatins 1. The nn-experimental design f this study has meant that ther causes fr the pre-pst changes cannt be ruled ut. Bth aged care facilities prvided internal training n antipsychtic use and nn-pharmaclgical strategies during the pilt perid. 11 P a g e

12 2. Participatin in the pilt s training sessins was lwer than anticipated. 3. Findings frm ARC staff interviews relied n self-reprted infrmatin frm a small number f participants and there may be differences between reprted infrmatin and actual practice. 4. We are cnfident in the accuracy f the data abut the medicines prescribed during the pilt, as this infrmatin was taken frm the Pharmhuse database. Hwever, there might still be a difference in what is dispensed t the ARC by the cmmunity pharmacy cmpared t what is then administered t residents e.g. PRN medicines. 5. Due t the small numbers f residents included in the quantitative analysis we cannt state that the changes were statistically significant. 6. Only ne f tw GPs cmpleted bth pre and pst pilt audits. The cllective audit did nt shw any degree f change in patient management r prescribing f antipsychtics. One GP cmpleted bth the pre and pst pilt audits althugh the number f patients audited was small, 12 and 10 respectively. Because few patients were audited it is difficult t draw any cnclusin abut the result. Als, rle f patient audits in future pilts wuld need t be determined by the DHB cnducting the prgramme as audits can be expensive t run. 7. While initial feedback has been psitive, the antipsychtic planning frm used t prmpt the review f patients n antipsychtics had nly been in place fr a shrt perid f time (frm 1 May 2015) befre the pilt s findings had been cnfirmed. 6. Cnclusins and Recmmendatins The results f this pilt study indicate that sme f the prescribing practices fr using antipsychtics in elderly peple are in accrdance with recmmendatins. There is, hwever, rm fr imprvement in certain areas. This pilt prvides a prmising starting pint fr a prgramme f wrk prmting the apprpriate use f antipsychtics in aged residential care settings. Hwever, in rder t validate the pilt s interventins and utcmes this prject needs t be expanded t a larger range f ARC facilities. Based n the findings f this pilt prject it is recmmended that, 1. The Making a Difference in Dementia pilt is expanded t additinal ARC facilities t validate the prpsed interventins and expected benefits. 2. Respnsibility fr cnducting the quantitative analysis is delegated t DHB analyst teams with supprt frm PHARMAC Analyst teams. 3. Nte that the buy-in f ARC facilities staff especially management is essential t any scaled up prgramme f wrk in this area. The benefits f ARC facilities being invlved with any prgramme f wrk which lks t imprve the medicines management and care f 12 P a g e

13 residents need t be sld t ARC staff. The accreditatin prcess fr ARC facilities t perate may be a lever which can be used t encurage participatin in this prgramme f wrk. 4. Nte that the educatin and training f ARC staff abut the use f antipsychtics and nnpharmaclgical interventins has been successful in increasing awareness and knwledge f ARC staff. Any staff educatin r training wuld need t be a regular feature in the ARC facilities timetable due t high staff turnver and t keep staff up t date with any changes in funded medicines and their side effects. 5. Nte that a prject starter pack cnsisting f all the relevant dcumentatin is being develped fr the purpses f intrducing new participants t the initiative. It is anticipated in the future that the prject pack will be hsted n PHARMAC s prgramme website t imprve accessibility t this resurce. 6. Nte the rle f the patient audits cnducted by the ARC pilt GPs in future implementatins f this wrk needs t be evaluated. This is due t the relatively high cst invlved in funding GPs t undertake this activity and lw respnse rate fr the fllw-up audit. It may als be better t cnduct a pst pilt audit after a reasnable amunt f time i.e. at least a year after pilt interventins have been initiated. 7. Nte that it is essential t include everyne wh can drive the prgramme and wh has the mandate t d this. It may mean the Ministry f Health is invlved and a quality use f medicines Key Perfrmance Indicatrs (KPI) apprach is taken with the ARC facilities invlved. Acknwledgements This wrk was supprted by CCDHB s MM-ICC Grup, and PHARMAC. We acknwledge the willing participatin f the management and staff at Malvina Majr Retirement Village, Sprtt Huse Karri, Life Pharmacy Jhnsnville, and Unichem High Street Pharmacy Lwer Hutt. References 1. The Ryal Australian and New Zealand Cllege f Psychiatrists, The Use f Antipsychtics in Residential Aged Care, Best Practice Advcacy Centre (BPAC), Managing patients with dementia: What is the rle f antipsychtics? BPJ, Issue 57, P a g e

14 Appendix One Prject Grup Malvina Majr Retirement Village: Lynne Peirse Clinical Services Manager, Malvina Majr Dr. Shane Dunphy GP, Onslw Medical Centre Dri Chin Pharmacist, Life Pharmacy Jhnsnville Sprtt Huse: Lisa Cke, Dementia Unit Manager, Sprtt Huse Angeline Bryan Clinical Services Manager, Sprtt Huse Dr. Richard Hrnabrk GP, Karri Medical Centre Duncan Sutherland Unichem High Street Pharmacy, Lwer Hutt Medicines Management Integrated Care Cllabrative (ICC) Grup Dr. Peter Mdie Chair, GP Karri Medical Centre Dr. Janet Turnbull Geriatrician, CCDHB Marilyn Tucker Cmpass Health PHO Pharmacist Facilitatr Pam Bremfrd Pharmacist, Kilbirnie Pharmacy Dr. Crawfrd Duncan Psychgeriatrician, CCDHB Lesley Maskery Cmmunity Psychiatric Nurse, CCDHB Linda Bryant Clinical Advisry Pharmacist, Well Health PHO Jeremy Ly Service Develpment Manager, SIDU Michelle Saunders Pharmacist, Wellingtn Hspital Rebecca Rippn Senir Analyst, SIDU Mary-Anne O Rurke PHO & Hspital Pharmacist Bruce Wilsn Prject Manager Palliative Care Managed Clinical Netwrk, SIDU PHARMAC: Karen Grant-Jacbs PHARMAC Thmas Xia Analyst, PHARMAC Hew Nrris Analyst, PHARMAC Kerri Osbrne Implementatin Manager, PHARMAC Bryan Betty PHARMAC, GP Cannns Creek Medical Centre 14 P a g e

15 Appendix Tw BPAC Audit 15 P a g e

16 16 P a g e

17 Appendix Three Antipsychtic Planning Frm 17 P a g e

18 18 P a g e

19 Appendix Fur Timeline f Activities Table 1. Pilt interventins Objectives Date Cmpleted Activities Additinal Cmments July 2014 An utline f the prpsed pilt was presented t the Medicines Management Integrated Care Cllabrative (MM-ICC) by PHARMAC Prject Implementatin Lead. Grup agreed that it wuld be a useful pilt t be invlved with. Aug/Oct 14 Analysts at PHARMAC and the prject team cnsidered the best way f capturing data which culd mnitr any impact n the use f APs during the pilt. The apprach f the pilt was agreed by the grup. The Analyst initially supprting the pilt data capture and interpretatin left PHARMAC and was replaced by anther PHARMAC analyst during this time. Prject Initiatin Initial pilt activities Nv 14 Nv 14 An invitatin letter was sent t Sprtt Huse and Malvina Majr t participate in this study. Invitatin t pilt site GPs and ARC staff t attend PHARMAC Seminar Managing yur patient wh has dementia. Bth ARC management staff agreed t participate. The presentatins frm the seminar were filmed and GPs were able t claim CME and MOPs pints after watching any ne f the presentatins and cmpleting a learning reflectin. Registered Nurses (RNs) are able t add the certificate they receive n cmpletin f their learning reflectin t their prtfli f prfessinal develpment. The tw clinical managers (Sprtt and Malvina Majr) and tw ther staff members attended this seminar. Dec 14 The PHARMAC Prject Manager and PHO Pharmacy Facilitatr met with ARC Managers t discuss in detail the pilt prject and btain preliminary feedback. GP and the Clinical Services Manager frm each site were invited t participate in MM- ICC meetings. Dec 14 Psters and leaflets were develped and distributed t pilt sites t raise awareness amngst patients, their families, and staff. This wrk was dne by a Brand agency hired by PHARMAC t develp this resurce fr the pilt. 19 P a g e

20 Established the views and attitudes f staff that prescribe and manage patients n antipsychtics. Dec 14 Dec 14 Jan 15 Jan/Feb 15 Pre pilt interventins interviews t analyse baseline attitudes f ARC staff twards the use f antipsychtics, cmpleted by Quigley and Watts (Research cmpany). Cmpletin f BPAC Audit Tl abut medicines use in dementia by GP at each pilt site. Sprtt Huse = 16 patients. Malvina Majr = 15 patients. Educatin sessins were delivered t RNs and caregivers at each pilt site. This presentatin fcused n hw t manage the behaviural and psychlgical symptms f dementia with the emphasis being n nnpharmaclgical interventins as a first line interventin and then medicines management f dementia, the side effects, and the need t mnitr. Findings were presented at a regular mnthly meeting f the prject team - May 15 There was sme delay in cmpletin f the pre-pilt interventins audit due t the nline nature f the audit prcess. The tw GPs wh cmpleted the audits were able t claim MOPs pints fr their time and were paid fr each patient audit cmpleted. Nurses and caregivers received certificates f attendance t the educatin sessins. The RNs were able t add their certificate they received t their prtfli f prfessinal develpment. Develp guidelines r tls t assist staff managing patients requiring antipsychtics Jan /Feb 2015 Tls and resurces were repurpsed (frm ther resurces already develped and used fr past prgrammes) These included: The Ryal Australian and New Zealand Cllege f Psychiatrists (RANZCP) best practice prescribing algrithm fr Elders in Residential Care. A BPAC infrmatin bklet which cntained all necessary infrmatin abut medicines management in dementia with an updated medicine table, was prvided t Clinical Managers frm each pilt site. Dcumentatin specifically fr reviewing patients n antipsychtics was raised as an area f need-smething which was highlighted during cmpletin f patient audits by GPs and cmmunity pharmacists. Resurces chsen had mstly already been develped and were repurpsed fr this pilt, eg the RANZCGP algrithm was riginally prduced fr a bklet, The Use f Antipsychtics in Residential Aged Care published by the RANZCGP in cnjunctin with PHARMAC in 2008 and after review by the psychgeriatrician n the prject team still cnsidered t be relevant. Mar 15 BPAC Medicines Table Starting and Maintenance Dses f Antipsychtics in Older Peple updated. The medicines table had riginally been published in the BPJ n. 57 editin (2013) and required updating as the funding fr sme f the medicines had been changed. Mar May 15 Revised PRN medicines signing sheet develped by pharmacy t prmpt staff t dcument reasn fr using administering PRN dse. Duncan Sutherland frm Unichem Pharmacy, Lwer Hutt, wh dispenses medicines t Sprtt Huse cntributed a standard PRN use frm fr the pilt, smething which had already been in use at Sprtt Huse. 20 P a g e

21 May Jun 15 Antipsychtic Use Planning and mnitring frm develped fr use by staff (frm a previus frm which had nt been used fr a past AP prgramme) at three mnthly reviews t help prmpt regular review f antipsychtic effectiveness. The frm which was repurpsed had riginally been prpsed by David Kerr and Marilyn Tucker fr an audit cnducted in The frm was t be started at the time anyne was newly prescribed an antipsychtic. This frm was then t be put in patients ntes which wuld then encurage and flag review and mnitring f antipsychtics being used. Evaluated any changes t prescribing r attitudes twards antipsychtics as a result f interventins Jun Jul 15 Jul 15 Jul 15 Analysis cnducted by PHARMAC analysts t identify any changes in prescribing fr a chrt f rest hme patients between 1 Sep t 30 Nv 2014 and 1 Feb t 30 Apr This was cmpared with the same perid ne year befre the pilt time perid, ie 1 Sep- 30 Nv 2013 and 1 Feb t 30 April Telephne interviews with ARC staff were cnducted t cmplete the pst-pilt qualitative research by Quigley and Watts. Pst-pilt cmpletin f BPAC Audit Tl by ne f the tw GPs. Sprtt Huse = 12 patients. T view pre and pst what srt f impact the pilt activities were having n ARC practice. BPAC were able t reprt back n these findings nce audits were cmpleted. The pstpilt BPAC audit was nt cmpleted by the secnd GP. Aug 15 Delivery f qualitative research utcmes t MMICC By a Quigley and Watts Directr as the researcher wh had cnducted the interviews had left fr an verseas wrk placement. Preliminary findings Aug 15 Presentatin t the ICC Leadership team at CCDHB abut the preliminary findings f the pilt Dr Peter Mdie and the PHARMAC Prject Lead presented the preliminary findings. Aug 15 A cmmunicatin plan was written abut hw the results wuld be disseminated t a wider audience and what the pilt findings and mdel culd mean if scaled up. See recmmendatins. 21 P a g e

22 Appendix Five Prject Benefits Table 2. Outcme/Benefit Achieved Justificatin Using the results frm the quantitative analysis, qualitative research and patient audit data Prescribing f APs use was reviewed, managed and mnitred accrding t the best practice guidelines. Regular Review and titratin f the antipsychtic medicatin f patients wh are taking them are cnducted and are dcumented. Reductin in the frequency f the number antipsychtics f curses f being used t manage symptms f dementia. Yes Yes Yes Increase in uptake f best practice guidance cnfirmed by qualitative analysis with ARC staff. BPAC guidance and updated medicines table attached t antipsychtic use planning and mnitring frm. Algrithm fr best practice use f antipsychtic (RANZCP) was included in patients ntes. Antipsychtic use planning frm has been integrated int each ARC facilities three mnthly review f patients. Anecdtal feedback frm ARC staff is that the use f the frms is increasing and has benefitted residents in that the administratin f PRN use f antipsychtics with residents(see quantitative data) PHARMAC analysts cnfirmed reductins in PRN and/r regular antipsychtic use althugh are nt significant due t the small number f residents. Risperidne went frm 25 t 18 residents, Quetiapine frm 25 t 22 residents. Rest hme staff nted (frm qualitative research) a number f practical barriers t reducing antipsychtic use. Lack f specialised dementia care beds in the cmmunity Delays in assessment by psychgeriatric services Family influence-desire t keep resident in current facility Knwledge f antipsychtic medicatins and their use fr patients with dementia wuld be better understd by staff that takes care f them at the end f the pilt. Psitive changes in attitudes f staff tward the apprpriate use f antipsychtic medicatin t imprve patient behaviur. Tls and resurces intrduced during the pilt t assist staff t mnitr AP use are adpted as standard. Yes Yes Partial Staff reprted an increased awareness f best practice when using antipsychtic including side effects after the pilt and an increase in the use f nn-pharmaclgical interventins fr managing dementia. They als said that they were using the best practice guidance n APs mre and had a greater awareness f AP effects, which in turn made them think twice abut prescribing APs. Prject prmpted staff t think twice befre using antipsychtics. Managers nticed imprvements in staff managing their patients with symptms f dementia. While tls and resurces have been adpted by ARC facilities three mnths is t early t tell whether they have been adpted as standard practice. 22 P a g e

23 Average length f time a patient takes the antipsychtic medicatin is within the clinical recmmendatins limits. Partial Difficult t tell whether this is currently the case. (reductin in PRN althugh nt statistically significant because f small numbers) The antipsychtic planning frm is expected t help supprt decisin making. Average dse f AP medicine if within nrmal limits. N Frm patient audit results: Frm the cllective patient audit results it shws that the majrity f patients taking an AP were being prescribed quetiapine, althugh risperidne is the recmmended first line AP t use in patients wh have dementia and require mre than nn-pharmaclgical interventin t manage mderate t severe behaviural symptms. The average daily dse f quetiapine being prescribed was 53mg with the range frm 12.5mg- 225mg. The three patients taking mre than 100mg/day had been Rx APs by a Psychgeriatrician fr a mental health disrder-eg schizphrenia r biplar disrder. There were three patients were being prescribed mre than ne AP. Of the 37 residents wh had the RX care audited, 18 f them were als taking a sedating medicine as well as an AP, eg. Fluxetine. Mst patients had been taking an AP fr mre than six mnths. Frm cmparative data audit results, ie cmparisn between pre and pst pilt audits, f the audits cmpleted, it des nt indicate there is any significant difference t practice. The numbers being cmpared are very small. Public awareness (patients and families f patients with dementia) f pilt prject benefits. Partial Psters and leaflets were distributed at pilt sites; hwever ARC staff had nt received any feedback frm members f the public. 23 P a g e