Current Topics in Care
Examining Trends in the Administration of ‘‘As Needed’’ Medications to Inpatients With Behavioral and Psychological Symptoms of Dementia
American Journal of Alzheimer’s Disease & Other Dementias® 2015, Vol. 30(3) 247-256 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1533317515585924 aja.sagepub.com
Robert D. Neumann, BSc Pharm1, Peter Faris, PhD2,3, and Richard Klassen, BSc, BSc Pharm1
Abstract Rationale: The use of ‘‘pro re nata’’ (PRN) medication in patients with behavioral and psychological symptoms of dementia (BPSD) is common but may be a source of inappropriate medication administration. Objective: To identify trends in the administration of PRN medications to inpatients with BPSD. Methods: Retrospective chart audits were completed on inpatients with dementia who had PRN medications prescribed for aggression, agitation, or insomnia. Data collected included age, sex, time of day, day of week, medication used, and dementia diagnosis. Additionally, data regarding administration of ranged doses and concurrent use with regularly prescribed medications of the same class were collected. Results: A total of 170 inpatients with dementia were included. Over 50 346 bed days, 4000 PRNs were administered. Individuals were more likely to receive a PRN if they were younger, shortly after shift change, in the evening, or during the weekend. If a ranged dose is provided they are more likely to receive the higher dose. If they are receiving regularly scheduled medication from the same class, there is risk of double dosing. Keywords dementia, PRN medication, behavioral and psychological symptoms of dementia, psychotropic medication
Introduction The burden of dementia-related disease is clear with an exponential rise expected in developed nations over the next 25 years.1 Approximately 60% to 80% of patients with dementia currently display behavioral and psychological symptoms of dementia (BPSD), and through the entire course of the illness 90% may display these behaviors.2 While the intensity and frequency of these behaviors vary between individuals, they can manifest as symptoms of anxiety, agitation, aggression, or insomnia. Psychosocial interventions are the first treatment approach to manage these symptoms, but they are not always effective and restraint may be required during some particularly difficult periods when patients or staff are at risk of harm.3 Chemical restraint has many benefits including convenience and rapid effect, but these benefits can also be the biggest drawbacks as chemical restraint can easily be used for inappropriate purposes such as a means of coercion, out of discipline for an inappropriate behavior, out of retaliation, or for staff convenience. Given the already vulnerable nature of geriatric patients with dementia, use for one of these purposes is of particular concern. While a nondemented individual may have some insight into his or her rights as a patient, an individual with dementia may rely on others to secure his or her rights. Heavy
responsibility is placed on nursing staff who must maintain the patients’ rights as well as administer restraint. Commonly, benzodiazepines and antipsychotics are employed for the purpose of controlling BPSD, although they are both listed in the Beer’s criteria as being potentially inappropriate medications in the elderly patients.4 Elderly patients with dementia have a higher rate of falls,5 and pro re nata (PRN) administration of benzodiazepines or neuroleptics can further contribute to that risk.6 As well, antipsychotics have specific warnings from Health Canada regarding serious risks of therapy associated with increased mortality within this population.7 While the effectiveness of psychotropic medications on some manifestations of BPSD is available, studies
1 Centennial Centre for Mental Health and Brain Injury, Alberta Health Services, Ponoka, Alberta, Canada 2 Alberta Health Services, Calgary, Alberta, Canada 3 Department of Community Health Science, University of Calgary, Calgary, Alberta, Canada
Corresponding Author: Robert D. Neumann, BSc Pharm, Centennial Centre for Mental Health and Brain Injury, Alberta Health Services, Ponoka, Alberta, Box 1000, T4J-1R8, Canada. Email: [email protected]
Downloaded from aja.sagepub.com at Monash University on November 16, 2015
American Journal of Alzheimer’s Disease & Other Dementias® 30(3)
248 evaluating the effectiveness of PRN use of psychotropic medications as chemical restraint in the elderly patients are absent in the literature. Currently no available pharmaceutical treatment is indicated for restraint, but many are used to control behavior and/or restrict the freedom of movement. Certainly there is some rationale behind the use of chemical restraint for BPSD, and a balance must be achieved between the safety of the patient and others as well as the patients’ rights. In an age where evidence-based medicine is the gold standard, we are faced with a paucity of research on the use of PRN chemical restraint in patients with dementia.
Specific Aims The aim of this study was to examine patient population correlations, temporal relationships, and other trends in the administration of PRN medications for BPSD to inpatients with dementia. A further aim was to identify nursing administration habits with particular focus on ranged dosing and potential for double dosing.
Methods Design Setting and Sample The study took place in a 330-bed rural psychiatric facility in Alberta, Canada, where 125 beds (5 units of 25 beds each) are designated for geropsychiatric patients. Of these 125 beds, approximately 80% of them are occupied by patients with dementia. Since the site is an acute care facility, staffing levels were relatively constant throughout the study period. Each unit has a minimum of 3 nurses and 3 nursing aides during the day shift (7:15 AM–3:30 PM), 2 nurses and 4 nursing aides during the evening shift (3:30 PM–11:45 PM), and one nurse and one nursing aide during the night shift (11:45 PM–7:15 AM). Each unit also has a scheduled recreation therapist to work in the day shift from Monday to Friday. Each patient has access to a general practitioner as well as a psychiatrist during the weekdays, and a general practitioner is available for emergent situations after hours and during the weekends. Support staff such as physiotherapists, physiotherapist aides, occupational therapists, social workers, psychologists, psychometrists, dieticians, and pharmacists are intermittently present during the day shift from Monday to Friday. At the beginning of the admission process, a psychiatrist may prescribe psychotropic medications to be administered on a PRN basis as standing orders. The medication with dose (occasionally provided as a range), route, frequency, maximum amount in the 24-hour period, and indication is ordered by the psychiatrist. The order is reviewed occasionally and may be adjusted based on the effect or adverse effects. The decision to administer a PRN is then based on the nurse’s discretion and assessment of the patient’s presentation. Facility procedure for the use of PRNs should be reflected in nursing documentation, with detailed information on description of the behavior, interventions attempted, and the effect of those interventions. Nursing charting practices were not evaluated in this study.
Retrospective chart reviews were conducted on all patients with a diagnosis of dementia from May 1, 2009, until April 30, 2011. Patient data were included in the study if they had a diagnosis of dementia and if they had PRN orders for the preestablished indications (aggression, agitation, anxiety, and insomnia). Patients were excluded from the study if they had a contraindication to all psychotropic PRNs.
Data Collection A PRN was defined as each administration event of a psychotropic PRN medication for the indication of agitation, anxiety, aggression, or insomnia. Chart information was collected retrospectively by a first researcher and a verification check was performed by a second researcher to confirm the accuracy of the PRNs captured for analysis. When a discrepancy was identified, a third researcher verified the discrepancy. The following data were collected from each patient record: age (at start of study period for current inpatients or for patients who were admitted during the study period and their age at time of admission), patient gender, number of bed days, time, day of week of PRN administration, type of PRN administered (antipsychotics, benzodiazepines, antidepressants, mood stabilizers, zopiclone, and others), and the most responsible dementia diagnosis as based on the recent psychiatric assessment. Additionally, if a ranged PRN dose was provided (eg, lorazepam 0.5-1 mg), we recorded what dose (low or high) was administered. Finally, if the patient received a PRN while also receiving a regularly scheduled medication from the same class, we assessed what was the time difference between the PRN administration and the next regularly scheduled dose, rounding to the nearest hour (