When caring for residents with BPSD administering staff members had to contend with competing demands while conducting their medication duties. For example, residents coming to the medication trolley, multiple interruptions, residents with difficulties knowing what to do with the medications, residents with difficulties swallowing, people not wanting to take medication, confused residents and residents who were asleep. Staff had to adapt to each resident, for example one resident at Cherry-Plum would only take her tablets while standing up or walking along.
Medication refusals appeared to be infrequent, but did occur. If medication was refused by a resident, staff were observed trying to encourage them to take it, if they declined staff would generally leave them and go back to try again a few minutes later. To get reluctant residents to take medicines administering staff were observed using jam, mousse or sweets to help take the taste of the medications away or distracting the resident with comical conversation while the medications were given. The
observations showed that if these strategies were not successful in getting the person to take the medication other staff member were occasionally asked to sub-administer the medication or the administering staff would continue to try at intervals. If the medication was not taken after many attempts or if it was spat out repeatedly staff
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appeared to give up and either destroy the tablet or sent it back to the pharmacy for safe disposal.
Some medication administration bad practices were noted at the case study CHs. These included not locking the medication trolley up or in place when it was unattended and not waiting with residents who may not have sufficient mental capacity to know what they should do until they had totally finished taking their medications. Over the period of case study observation I found several medications either spat out on tables, plates or the floor, or still in a pot ready to take. On occasion I would alert staff to these tablets, since I was concerned an unintended resident might take them by mistake. Bullace View had a picture of each resident between each MAR sheet to aid correct administration.
Conclusions
These data on medication use in CHs for BPSD show that most administering staff have a good knowledge of the information they need to know to give out medications. These CH staff had to administer medications in frequently busy, hectic environments with multiple interruptions hindering their actions. Many carers had very limited knowledge of residents’ medications, but more rapport with, and intimate knowledge of, CH residents than most senior staff. Sub-administrations were used in one home (Mirabelle Way) to increase residents’ compliance in taking medications. While these occurred in all of the case study CHs to various degrees, in other homes this was apparently for ease or to save time rather than to improve compliance. Covert medication administration was used; however staff professed that the correct risk assessments and procedures had been followed to allow this. Regular doses of some psychotropic medications were omitted on rare occasions if residents were sleepy. Individual staff members disagreed about the appropriateness of such actions and whether it was good practice adapting to the resident’s condition or poor practice by going against the prescription.
The CH staff had an important role in monitoring residents’ BPSD and organising resident reviews. Reviews were usually at the request of CH staff. When they occurred, reviews predominantly focused on re-assessing the resident’s prescriptions. GPs were
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gatekeepers to medications and to specialist help. Access to GPs was a relatively quick process, however unless there was a crisis situation specialist help could take up to six weeks to arrive. This left CH staff and residents experiencing BPSD in an undesirable state with no or limited assistance to help them cope during this time.
Psychotropic medications were perceived to be a required part of care for residents with BPSD at particular stages. Administering staff members were aware of the negative effects of the medications, but also recognised their value in difficult
situations. The right fit between individual medications and residents was viewed as an important factor in the efficacy of psychotropic medications. Trial and error was
required to find a suitable outcome. In all case study sites it appeared that PRN administration decisions were based on previous knowledge of the resident’s usual patterns of behaviour and the right timing. It is likely that CH administering staff who work part time or nights would have less resident specific knowledge to base their PRN decisions on.
The psychotropic medication mapping findings (albeit from a limited sample) indicated that antipsychotic medications were used considerably less than antidepressant
medications. Indeed, antipsychotic medications were the least prescribed psychotropic medication found across the sample. Additionally, the unexpected finding that sodium valproate was prescribed more than antipsychotic medication suggests that alternative ‘off label’ medications are being administered to residents with BPSD in CHs.
The majority of all prescription doses were in the usual recommended range, yet 3 prescriptions exceeded the maximum dose for the particular medication (haloperidol although high dose only through PRN and never given, quetiapine and zopiclone). This finding is concerning; however, due to the limitations of this study in terms of not determining resident diagnoses or reasons for prescriptions the exact need for these high doses cannot be determined and may have been justified. Overall CH staff across all sites had a considered approach to psychotropic medication use for residents with BPSD and felt that there was, and would remain, a need for these medications in certain situations.
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Chapter 8: The Use of Non-pharmacological
Interventions and Strategies
Introduction
Chapter 7 showed that CH staff consider medication to be a useful strategy, if the situation requires it. However, pharmacological interventions are just one part of a range of varied strategies used in CHs to manage BPSD. This chapter examines the non- pharmacological strategies found to be used in the case study CHs. These included formal strategies like NPIs and activities, but also other more subtle strategies, which could be viewed as being part of everyday care practices such as, PCC, the use of routines and flexibility, the placement of residents, staff approaches, monitoring, communication techniques, and distraction. Since the primary focus of this study is the strategies used to manage BPSD, resident behaviours are discussed only in the context of examining the strategies used by CH staff. Before exploring the case study findings, the survey responses from phase one will be revisited for background information.