As a Clinical Studies Officer (CSO) working in Birmingham & Solihull Mental Health Foundation Trust (BSMHFT) I was asked to support the research team led by Dr Ian Maidment at Aston University, in the delivery of the MEDREV study between January 2015 and December 2017. I was responsible for the recruitment of participants to the study across five care homes in the Birmingham area in addition to the collection and scoring of quantitative data. Identification of care homes meeting the inclusion criteria was undertaken with reference to the Care Quality Commission (CQC) website and via the Enabling Research in Care Homes initiative (ENRICH; http://enrich.nihr.ac.uk/).⁽¹⁾ Principally, the MEDREV study⁽²⁾ set out to investigate the feasibility of conducting a full clinical trial of a specialist dementia care pharmacist medication review combined with a health psychology intervention for carers to limit the use of psychotropic prescribing.

Historically, residents with dementia in care homes have been treated with antipsychotics^{(3, 4)}, in order to manage the biological and psychological symptoms of dementia (BPSD). As previously outlined by Banerjee⁽⁴⁾, such behaviours range from agitation, biting and aggression, to wandering and shouting out. These behaviours are known collectively as ‘Behaviours that Challenge.’ The Department of Health (DOH) National Dementia Strategy⁽⁵⁾ estimated that of the 180,000 people who were prescribed antipsychotic medication for these behaviours, as many as 36,000 people derived little benefits from them. Moreover, an additional 1,800 deaths were linked to their use. They argued that behaviour, which can be challenging, can be safely managed in care homes with non-pharmacological approaches; further, senior care home staff should be skilled in appropriate non-pharmacological techniques to help manage this behaviour^{(4, 5)}.

In our study, participants meeting the inclusion criteria (a diagnosis of dementia; medication for behaviour that challenges) or their personal consultee were approached for consent. Trust specialist pharmacist’s reviewed resident’s medication making recommendations to either stop or reduce it in consultation with their general practitioner (GP) and relatives. Respective GPs were also consented.

In the cases where residents did not have mental capacity to participate in the study, quantitative data was collected from proxy informants, who were predominately carers who knew the residents well. We used the Neuropsychiatric Inventory-Nursing Home version as our primary outcome measure, which captured the frequency and severity of BPSD prior to the medication change, and at 8 weeks, and 3 and 6 months after. Secondary outcome measures included quality of life, cognition, health economics, and prescribed medication.

Colleagues in the health psychology arm of the study recruited care home staff who received a three-hour education behaviour change intervention entitled ‘Inside Out’. Those delivering the intervention had health psychology training and experience of working with people with challenging behaviour in a residential setting. GPs also received the modified training. Semi-structured interviews were conducted with care home staff, care home managers, and GPs using framework analysis to explore the acceptability of the person-centred training.

The principles underpinning a person-centred approach⁽⁶⁾ to caring for individuals with behaviour that challenges are based on the theoretical underpinning of Dawn Brooker’s VIP framework⁽⁷⁾ ‘Valuing Personhood’, Individualised Needs and Personal Perspectives. ‘Inside Out’⁽⁸⁾ thinking is based on the notion that people living with dementia exhibit challenging behaviour as an unmet physical, emotional, or psychological need, which is felt internally but is not easily expressed.

The results have yet to be published but will provide researchers and clinicians in the care home community a unique insight into whether the combination of a person-centred intervention and specialist medication review will reduce the use of psychotropic prescribing for behaviours that challenge in a dementia population.

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Sources:

1. NIHR.ENRICH (Enabling Research In Care Homes) [Internet]. 2018 [Cited 2018 May 1]. Available from: https://enrich.nihr.ac.uk/pages/care-home staff

2. Maidment I, Shaw RL, Killick K, et al. Improving the management of behaviour that challenges associated with dementia in care homes: protocol for pharmacy–health psychology intervention feasibility study. BMJ 2016;6:e010279 doi:10.1136/bmjopen-2015-010279  Available from: http://bmjopen.bmj.com/content/6/3/e010279. Accessed May 2018.

3. Ballard C, Lana MM, Theodoulou M, Douglas S, McShane R, Jacoby R, et al. A randomised, blinded, placebo-controlled trial in dementia patients continuing or stopping neuroleptics (The DART-AD Trial). PLoS Med. 2008;5(4):0587–99.

4. Banerjee S. The use of antipsychotic medication for people with dementia: Time for action. Dep Heal [Internet]. 2009;60. Available from: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_108302.pdf

5. World Health Organization. Dementia: a public health prority, Dementia [internet].2012;112. Available from: http://whqlibdoc.who.int/publications/2012/9789241564458_eng.pdf

6. Kitwood, T. Dementia reconsidered: the person comes first. Buckingham: Open University Press, 1997.

7. Brooker, D. What is person-centred care in dementia? Reviews in Clinical Gerontology 2004; 13: 215-222.

8. Shaw, Campbell, Killick, Seare & Maidment. Developing an intervention to promote person-centred care and non-pharmacological management of behaviours that challenge among people living with dementia. Submitted

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MEDREV is led by Dr Ian Maidment, a Senior Lecturer in Clinical Pharmacy at Aston University.

The NIHR Clinical Research Network fund CSO’s to set up and deliver portfolio research across NHS trusts. This blog presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0613-31071). The views expressed are those of the author(s) and not necessarily those of the NHS, NIHR, or Department of Health and Social Care.