Characteristics of the participants
An overview of the different psychotropic medications, defined according to the Australian Medicines Handbook, prescribed to the participants of our study is illustrated in Table 1. The doses of different psychotropic medications prescribed to participants did not exceed the maximum dose recommended in the Australian Medicines Handbook. Medication charts of 31 patients were reviewed. The median age of the participants was 83 years, and 68% were female. Polypharmacy was measured in 87% of the participants, and the median number of mediations use at baseline was 8 (Table 2). Majority of participants (35.5%) do not have formal education followed by secondary schooling (32.3%) and primary schooling (23%). Hypertension, hyperlipidemia, diabetes, eye disease and Alzheimer’s disease were the major comorbidities identified in RwAD (Table 2).
Psychotropic medication uses among the participants
There was a reduction of 22.4% (77.4% vs 55%)) in the use of at least any psychotropic medication 19.6% reduction in antipsychotics (, 39% vs 19.4%) and benzodiazepines (39.0% vs 19.4%) and 6.5% reduction in antidepressants prescriptions (42% vs 35.5%) when comparing residents’ medication charts data covering 3-months pre- and post-intervention , however, was not statistically significant (Table 3). The prescription of anti-dementia medications remained unchanged at 26% from pre- to at post-intervention. For the individual class of antipsychotics, risperidone, olanzapine, and quetiapine were the major medications prescribed. Similarly, mirtazapine and escitalopram were prescribed in the antidepressants group, oxazepam and temazepam in the benzodiazepines group and memantine and donepezil as antidementia medications.
There was a decreasing trend in the concomitant use of antipsychotics and benzodiazepines prescription, antipsychotics and antidepressants, and antipsychotics and antidementia medications (Table 3). Overall, there was no statistically significant difference in reduction patterns. The majority of the residents were prescribed psychotropic and antidementia medications for >6 months duration (Table 4). Up to 43% of the residents were prescribed psychotropic medications, whereas 44.4% were prescribed antidementia medication.
Major themes from in-depth interviews with aged care staff
Three major themes emerged from the qualitative data analysis, reduced/decreased/cessation of medication use, introducing a rest period and the music intervention combined has been an alternative approach for medications use, and less behaviors, and ultimately the less use of medications.
Reduced/decreased/cessation of medication use
Clinical Managers mention that residents have been using less antipsychotics and there is a measure to check it regularly. Carers were unaware of how much medications the residents have been using. Indeed, it is good to have their opinion about potential less use of medications due to less behaviors. Two Residents were taken off of medications like Risperidone. Use of sleeping tablets (benzodiazepines) was also reduced. Residents were offered a drink and Weet-Bix instead of the sleeping tablet. As a result of less use of sleeping tablets, residents exhibited less symptoms of being sleepy and hung over, and there was a reduction of falls.. Participants mentioned that doctors embedded medication weaning as a strategy of using less medications.
Yeah, I would need to look at that, yeah. We don’t use a lot of antipsychotic medication anyway. Um, we have a little bit – a little bit regular for you know, some residents to manage their mental health illnesses. But we don’t use a lot of PRM antipsychotic, and I do – I do measure that regularly from time to time just to measure where we’re at with antipsychotic medication…. [ Staff 1]
I — I’m not a nurse. I do help with medication, so I don’t see all the medications. Um, again, I think some of our extreme cases, we try to use other strategies before the medication. Some people — it — unfortunately, it seems as if every strategy you use, enact, it doesn’t work on everybody. So - - - medication may be the last resort. Um, but it’s those extreme cases that we can’t always cut through from what I’ve seen. Those are the ones that we use medication with, and I don’t know for sure, but I don’t think it’s changed the amount as such. Um, and again, I don’t know, but - Uh, I can’t give you an accurate answer because I’m not here - - - like, I’m not with the nurse all the time - - - I mean I would expect less medication used because of a lower, uh, lower stressors and lower reactive behaviours. But again, I know, through my experience with the people that are more extreme cases, they still get worked up. They still get worked up. They still, um, at times, need medication. Some of them more moderate or lower end of the dementia, I would think that we could probably stick with more of the strategies that aren’t medication based. I mean I — I don’t know for sure but that’s just, from my, uh, my experience, yeah, I would — I would like to think that would be less. But I don’t really know. I can’t give you an exact number. …… [Staff 2]
Um, we've actually reduced, I think, two people are now off Risperidone all together, that we’ve just recently stopped that we were tapering it down and we’ve just, recently they’ve ceased it. We still do have a couple that need it, because they're still in that stage, but we haven’t worked with them quite as intensively just yet…. Yep. Um, there aren’t too many that have sleeping tablets overnight anymore, we used to get people, and they would automatically just give them a sleeping tablet if they were up. Now they give them a drink and Weet-Bix and they don’t need the sleeping tablet, which is really good. Because then you haven’t got people in the morning who are drugged out and sleepy and hung over and falling…... [Staff 3]
Yeah, there’s lots of medication weaning, doctors are reducing the dose of seizing medication. So, that’s really happening, good for these people, yeah, is working on that a lot…. [Staff 4]
Introducing a rest period and the music therapy combined has been an alternative therapy for medications use
Residents receive pain relief and behavioral management medications like Oxazepam. A Clinical Nurse Manager has indicated that she has noticed a marked reduction in the use of medications after the intervention was implemented. Residents showed less behaviors with the opportunity of a resting period and music as a non-pharmacological intervention. Ultimately, because of less behaviors, residents were given less medications like Oxazepam.
…um, obviously we have – we have I guess given less pain relief, given less behavior management medication like Oxazepam and all that. So there has been some because I keep an eye on progress notes while in care. So, I have seen that there was a lot before, but it has decreased. We used to give medications a lot to some people, and now obviously introducing a rest period and the music therapy combined, I think it had an impact on the way they behaved. As I said, Oxazepam we used to give for the behavior management. …. [Staff 5]
Less behaviors, and ultimately the less use of medications
The fewer behaviors of the residents were well reflected by the quiet environment, as noticed by the Lifestyle Manager. There was an anticipation that the use of medications would have been less due to the quiet environment. Changes in behaviors of the PwD can be very confronting and unpredictable, but a carer can notice those change in behaviors of the residents. One participating carer explained that Risperidone and Oxazepam were off due to less behaviors.
I don’t know whether there has been any. I would love to have seen medications have gone down through the floor, because of the quiet, very quiet environment. I would love to have seen that. I don’t know whether there has been…. I don’t know whether there has been any. I would love to have seen medications have gone down through the floor, because of the quiet, very quiet environment. I would love to have seen that. I don’t know whether there has been. Because I’ve come – I’ve just been back and watched, and I’ve been seeing ice-creams being handed out to people. So, I don’t know, but I would love to know whether the medications had dropped during that period. And then it may be worthwhile …... [Staff 6]
Well, medications constantly change. Um, there have been a couple that we’ve been able to take off of things like risperidone and oxazepam which is good. Um, so that’s always a plus when we can do that…because their behaviours aren’t there anymore, they are not needing… it, so, ah, but it’s, yeah, that’s a few of them. Like I said, other than that, their medications change, but, um…. only with that risperidone and oxaz, I’ve seen a reduction in that…but…but nothing….[Staff 7]
Um, well, we do medications, um, I don’t really have a lot of things to say about medications because, um, that’s – as a for now that’s out of my scope. But yeah, ah, at times I have… In general, yeah, I would say it – it – it effects, you know, them and their behaviours as well. Um, even with regards to like falls and stuff because, you know, some medications makes them really drowsy. So, it’s yeah, like some of them I could see like – because they really that sleepier and shaky. So, um, yeah, or some of them, I guess it’s just due to medications as well that doesn’t suit, yeah, you know, them, and they became more agitated. So that’s just……. [Staff 8]
In summary, there was a reduction in the use of psychotropic medication as described by participating staff. In some situations, the dose was lowered and some medications, for example risperidone (antipsychotics) and oxazepam (benzodiazepines) were not given because of less behaviors exhibited by the residents. As the residents were offered a rest period and time to listen to their preferred music, there was less need to use medications.