Use of major and minor tranquilizers with older patients in an acute care hospital: an exploratory study.

AIM: This paper reports a study to determine how many older patients are prescribed major and/or minor tranquilizers during their hospital stay, and the perceptions of acute care nursing staff towards the use of such medications with older hospitalized patients. BACKGROUND: While considerable research exists on the use of major and minor tranquilizers (chemical restraints) with older people in long-term care, scant research has addressed the use of these drugs with older patients in acute care hospitals. Given the growing numbers of older people with dementia and delirium in hospitals, and the risks these drugs pose to older people, more research on the use of chemical restraints by nurses with older hospital patients is needed. METHODS: Computerized pharmacy records were used to access data on prescriptions of major and minor tranquilizers to older patients during one month on six hospital units (total n = 498), and 140 nursing staff from these units completed the Perceptions of (Chemical) Restraint Use Questionnaire. The data were collected in 2003. RESULTS: A minority of older patients (8.63%) were prescribed a major or minor tranquilizer during the one-month data collection period. The numbers prescribed minor tranquilizers (6.22%, n = 31) were approximately double that of major tranquilizers (3.21%, n = 16). The majority of prescriptions for minor and major tranquilizers were written as pro re nata or 'as needed' (77% and 55.8%, respectively). Nurses' scores on the Perceptions of (Chemical) Restraint Use Questionnaire indicated perceptions consistent with liberal use of chemical restraints, and several of the highly rated reasons for giving such medications could be considered inappropriate. CONCLUSIONS: While these findings suggest that only a small number of older people were prescribed chemical restraint medications in hospital, the risks these medications pose warrants ongoing prudence. More nursing research and education on the use of these medications with older people in hospital settings is needed.

Neuroleptic and benzodiazepine use in long-term care in urban and rural Alberta: characteristics and results of an education intervention to ensure appropriate use.

OBJECTIVES: To examine the use of psychotropic drugs in 24 rural and urban long-term care (LTC) facilities, and compare the effect of an education intervention for LTC staff and family members on the use of psychotropic drugs in intervention versus control facilities. METHODS: Interrupted time series with a non-equivalent no-treatment control group time series. Data on drug use were collected in 24 Western Canadian LTC facilities (10 urban, 14 rural) for three 2-month time periods before and after the intervention. Pharmacy records were used to collect data on drug, class of drug, dose, administration, and start/stop dates. Chart reviews provided demographics, pro re nata (prn) use, and indications for drug use. Subjects comprised 2443 residents living in the 24 LTC facilities during the 1-year study. An average of 796.33 residents (32.7%) received a psychotropic drug. An education intervention on psychotropic drug use in LTC was offered to intervention physicians, nursing staff, pharmacists and family members. RESULTS: Approximately one-third of residents received a psychotropic drug during the study, often for considerable lengths of time. A minority of psychotropic drug prescriptions had a documented reason for their use, and 69.5% of the reasons would be inappropriate under Omnibus Budget Reconciliation Act (OBRA) legislation. Few psychotropic drug prescriptions were discontinued or reduced during the study. More urban LTC residents received neuroleptics and benzodiazepines than their rural counterparts (26.1% vs. 15.7%, and 18.0% vs. 7.6%, respectively). The education intervention did not result in any significant decline in the use of these drugs in intervention facilities. CONCLUSION: The results suggest substantial use of psychotropic drugs in LTC, although rural LTC residents received approximately half the number of psychotropic drugs compared with urban residents. A resource-intensive intervention did not significantly decrease the use of psychotropics. There is a need for better monitoring of psychotropic drugs in LTC, particularly given that voluntary educational efforts alone may be ineffective agents of change.

Pain and agitation in long-term care residents with dementia: use of the Pittsburgh Agitation Scale.

AIM: to explore the relationship between total and sub-scores of the Pittsburgh Agitation Scale (PAS) and five proxy measures of pain in long-term care (LTC) residents. STUDY DESIGN: descriptive correlational design. SAMPLE AND SETTING: 58 residents in three LTC facilities in rural Western Canada with moderate to severe cognitive impairment took part in the study. Six full-time registered nurses working in the facilities and three palliative care nurse consultants provided pain and agitation assessments. MEASUREMENTS: registered nurses used PAS to assess agitation. The five proxy measures of pain were the Discomfort Scale for Dementia of the Alzheimer's Type (DS-DAT), number of pain diagnoses, use of analgesic medications, and pain ratings by both facility nurses and palliative care nurse consultants. RESULTS: there was a moderately strong relationship between total PAS agitation scores and total DS-DAT pain scores (r=0.51, P<0.01). The PAS sub-score "resisting care" was significantly correlated with total DS-DAT scores (r=0.46, P<0.01), and pain ratings by both facility nurses (r=0.48, P<0.01) and palliative care nurse consultants (r=0.51, P<0.01). CONCLUSIONS: for certain residents with dementia, PAS may allow assessment of both agitation and uncommunicated pain. It is possible that the PAS form of agitation "resistance to care" may indicate pain that individual cannot otherwise communicate. One possible response to such resistance would be to trial pain medication and reassess agitation. Nursing staff in LTC facilities may need additional training in pain assessment of residents with dementia.

On a happier note: validation of musical exercise for older persons in long-term care settings.

This paper describes a quasi-experimental study of a musical exercise intervention to improve the physical, cognitive, behavioral status and life satisfaction of older residents in a long-term care facility in the United Kingdom. Twenty long-term care residents from three different units (n=60) were recruited and assigned to one of three groups: a control (C) group (no intervention), an occupational therapy (OT) group (comparison group) and a music exercise group (intervention group). Assessments of physical and cognitive status were made pre-intervention and repeated at the end of the 10-week exercise program and again 10 weeks after the completion of the program. The results show that both OT and exercise participation is associated with improvement in physical and cognitive function. However, the exercise group showed significant improvement in more areas than the OT group. The functional benefits from OT and exercise were not sustainable after these activities ceased and showed significant decline 10 weeks after the end of the programs.