Topic: Antipsychotic and Physical Health in Dementia
Paper Type: Assignment
Word Count: 3450 words
Pages: 14 pages
Referencing Style: Harvard Referencing
Educational Level: Graduate
Antipsychotic and Physical Health in Dementia
[Student's Name]
[Name of Institution]
Antipsychotic and Physical Health in Dementia
This report concerns the use of Antipsychotic in Dementia and its impact on the physical health of patient. Historically, because of its highly sedative, antipsychotics are used to treat these patients. But, in addition to its sedative power, most conventional antipsychotics have adverse effects that carry harmful consequences; it is the case of orthostatic hypotension (Kales, et al., 2011). Between 2 to 4 million people in the UK and United States suffer from Alzheimer's dementia, the authors recall and 70% of them experiencing psychotic symptoms within 7 years after the diagnosis. The development of psychotic symptoms or behavioural disorders, they add, is often cited as a cause of hospitalisations, well, treatment and appropriate interventions could delay this eventuality (Marras, et al., 2012). Dementia is a clinical syndrome that primarily affects people over 60 years, the prevalence increases with age and is characterised by the progressive development of cognitive impairment and, often, by the emergence of neuropsychiatric symptoms that disrupt and hinder family relationships and social activities. Neuropsychiatric symptoms of dementia are presented as psychological and behavioural disorders, often self-limiting and relapsing, including psychotic symptoms (delusions, hallucinations), shaking with or without aggressiveness, anxiety, abnormal emotions and sleep, and others. These symptoms occur in up to 50% of patients with dementia, affecting their quality of life and that of their families and caregivers, and are often the reason for institutionalisation of patients (Kales, et al., 2011). The percentage of patients with dementia treated with antipsychotics is high, but there are significant differences in the prescription of narcoleptics in terms of socio demographic characteristics, severity of dementia and co morbidity of patients. To a lesser extent, using other psychoactive drugs, such as benzodiazepines or antidepressants, but its effectiveness in patients with dementia has not been evaluated (benzodiazepines) or uncertain (antidepressants). We also evaluated the effectiveness of acetyl cholinesterase inhibitor drugs such as rivastigmine, but without success (Marras, et al., 2012) For the treatment of behavioural and psychotic symptoms in patients with Alzheimer's dementia, atypical antipsychotics are potentially more effective and safer than traditional agents according to Sekhri, R. (2010). For these reasons, outlined the specific indications for the use of antipsychotic agents, including the presence of psychotic symptoms and aggressive behaviour specific, as already mentioned. The symptoms for which these agents would not be effective are: vagrancy, poor personal care, lack of cooperation in treatment, and memory impairment. Once symptoms are identified white treatable, the authors note that the appropriate agent should improve psychotic symptoms and behaviour, while delaying possible hospitalization (Sekhri, Evidence Based Practice
Nursing practice in recent decades is struggling to form a body of knowledge capital that could be an independent work of medical practice, which will be achieved, according, with the articulation of general theories, research and evidence-based practice. Evidence-based practice (EBP) attempted to incorporate research clinical decision making for patients (Herrmann,et al., 2004). The gap between books and periodical literature, variability in clinical care for patients with the same disease), the distances between the scientific and clinical practice, and the gap between research and practice (Lopes Monteiro, De Mattos, 2005) facilitated the birth of this Thorough evidence has suggests that the choice of an antipsychotic agent in patients with Alzheimer's dementia should be based on the adverse effect profile. In general, older people have a lower threshold for the appearance of these effects, particularly with regard to sedation, orthostatic hypotension, and extra pyramidal symptoms. Most antipsychotics are associated at least with one of the mentioned side effects. Because in these incidence of these nature in the increased susceptibility of patients with Alzheimer disease conventional antipsychotics would be no more an appropriate choice (Herrmann, et al., 2004). Evidence-based nursing (EBN) is further developed in UK, initially taking the positivist framework of medicine. In recent years there have been various definitions of EBE. Thus its defined as the process by which nurses make clinical decisions using the best available evidence supported the research, clinical experience and patient preferences, in the context of available resources. At the same time (Morales, 2003) defines EBE as the conscientious, explicit and judicious use of information derived from theory and research to decision making on the provision of care to individuals or groups , taking into account their individual needs and The incorporation of the evidence in the daily work of nursing does not eliminate the professional experience gained over years of working with patients and their families, but it comes to giving the necessary scientific support. The implementation of EBE requires nurses encouraged to use their own abilities at different stages of the method, forming working groups to seek new knowledge to be applied in practice. Thus, nurse researchers are better equipped to find, evaluate or create through their own studies and scientific evidence is the clinical nurse more prepared to use the findings of the evidence and assess its implementation (Melnyk, Overholt, 2010). The EBE allows to know how they are applying the nursing care in remote and adapt and / or create protocols to avoid the variability present in the delivery of nursing care, sometimes even within the same institution. It must be remembered that the protocols are a guide and should not be forgotten that personal conditions of each patient to prevent the automation of such care (Melnyk, Overholt, 2010). Locating and Appraising Evidence
To discover evidence regarding the use of Antipsychotic in Dementia, online databases Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus), British Nursing Index (BNI) and the Cochrane Library were used, as these are leading resources for evidence in nursing and midwifery (Steen and Roberts, 2011). These sources allowed me to search worldwide, providing wide provided range of systematic reviews, allowing me to explore wide up-to-date evidence on the topic (Ackley et al., 2008). I searched the databases to locate relevant evidence using key words ‘Antipsychotic', and ‘Dementia' to lead me to appropriate research. I used the Boolean term ‘OR' to explore research which included alternative words I also used the Boolean term ‘AND' to retrieve articles which included all these terms. I used truncation by adding ‘*' after ‘key word' to ensure my search was thorough which found variations of the word maximising the search depth (Barker, 2010). I limited the search to the past 5 years to retrieve up-to-date research evidence (Larrabee, 2009), which excluded research irrelevant to current practice. This also helped in improving the focus of my analysis by reduce ding the research volume. In order to explore a wide variety of worldwide research, area I did not restrict the search to UK which enabled me locating relevant and up-to- date articles on the subject (Moule and Goodman, 2009). Two limitations, despite this benefit, were apparent; some worldwide research results were not written in English and non-UK research is less likely to be applicable to the UK. I ensured it was UK based as I recognise this is seen as more relevant to common practice, when selecting the single research piece to appraise, I refined my search to the English language to overcome the language issue. The evidence located was appraised using the critiquing framework from the Critical Appraisal Skills Programme (CASP, 2010). As I was exploring and narrowing my search results on the use of Antipsychotic in Dementia I found these evidence types were most appropriate to potentially inform practice. I believed CASP would help me determine which research evidence was valid, reliable and general sable. Findings - General Overview
The databases identified a variety of different types of research which suggested that typical antipsychotic drug; haloperidol is that you have more efficacy data. In a systematic review of five randomised clinical trials assessing the efficacy and safety of haloperidol versus placebo in patients with dementia and agitation, there was no significant improvement in agitation, but it was found an improvement in aggression. Adverse effects were more common in patients treated with haloperidol, but not documented differences in the treatment dropout rate. Atypical antipsychotic drugs are those with more data on its efficacy in the treatment of neuropsychiatric symptoms in patients with dementia. A systematic review of clinical trials published until 2004, conducted by the Cochrane Collaboration, evaluated the efficacy and safety of atypical antipsychotics orally in patients with dementia. An evidence reviewed by me has selected randomised trials results indicated a high placebo response that was approximately 40%. Treatment with risperidone (1-2mg daily) was associated with a significant improvement of psychotic symptoms and agitation with aggression, but did not improve without aggressiveness agitation of patients treated. Olanzapine treatment was effective in the treatment of agitation with aggression. There were no sufficient data to assess the effectiveness of the other atypical antipsychotics, nor could it evaluate the effect of atypical antipsychotics on cognitive decline (Schneider, e al., 2005). Also evaluated the evidence on the efficacy and safety of the withdrawal of antipsychotic drugs in patients with dementia. The DARD-AD clinical trial evaluated the efficacy of antipsychotic withdrawal in 128 patients with Alzheimer's disease who had been treated with various antipsychotic drugs (thioridazine, haloperidol, chlorpromazine, and risperidone trifluperacina) during the previous 3 months. Patients were randomised to continue antipsychotic treatment or placebo for 12 months. No statistically significant differences in cognitive function at 6 months compared to baseline (primary endpoint), nor in the frequency of neuropsychiatric symptoms (secondary endpoint), although there was an improvement in these symptoms with continued treatment in the subgroup of patients with more severe symptoms. However, this study had methodological limitations because the number of patients was small, a significant proportion of patients assigned treatment started, and there were a high percentage of losses (Rochon, e al., Analysis of evidence also explore that there is consensus among the recommendations of the various guides on the patterns of use of antipsychotic drugs. We recommend using the lowest possible dose for the shortest period necessary and monitor ongoing and regular clinical response and possible side effects of treatment every 3 months. The guidelines recommend evaluating the possibility of dose reduction or withdrawal of treatment upon stabilisation or remission of symptoms. It is recommended gradual discontinuation of antipsychotic treatment, reducing to 50% of the dose every two weeks after treatment and 2 weeks after administering the minimum dose (Banerjee, 2009). In the analysis of evidence I also noted that conventional antipsychotics are effective agents, but none shows superiority over another. These agents, the authors, would have a limited effect, i.e. the effect compared to placebo, only 18 of 100 patients would benefit from the use of an antipsychotic. Given this limited purpose, you should carefully evaluate the risk / benefit when choosing a drug of this group and consider alternatives such as the use of atypical antipsychotics (Stoppe, et al., 1999). According to some research, there is no significant difference between the phenothiasines and haloperidol. In safety analyses were higher prevalence of adverse effects of antipsychotics group than in the placebo group, and no difference was observed between different types of drugs. The dropout rate was equivalent medication for both the group that antipsychotics were used as for the placebo group. The most common side effects were sedation, movement disorders and orthostatic. Due to the limited effect observed in these drugs, as there is no difference between the different actors, the choice of an antipsychotic should be based on the adverse effect profile. The selected evidence on the impact of health with the usage of Antipsychotic in Dementia I explore that the new study, published in BMJ (British Medical Journal) says that antipsychotics should not be used if there is a clear need. It is thought that only in the UK, around 180,000 people with dementia taking antipsychotic drugs according to a study published in 2009, this has resulted in some 1,800 additional deaths each year. Now new research conducted at Harvard Medical School followed 75,445 people living with dementia in nursing homes and to which they had been prescribed antipsychotic (Fossey, et al., 2006). ACNP (2007) white paper found that those taking some of these drugs were more than twice as likely to die as those receiving risperidone, another antipsychotic used in the study to compare the results. The data suggest that the risk of mortality with these drugs usually increases with higher doses and appears to be higher with haloperidol and quetiapine less high with the researchers say. However, the study does not show with certainty whether the drugs really are causing more death or only an association between the two. Although, the Department of Health of the United Kingdom stated that the use of antipsychotics is resulting in up to 1,800 unnecessary deaths each year. This is simply unacceptable. That's why one of the main priorities of the National Dementia Strategy (the UK) is to reduce by 60% the level of antipsychotics prescribed to people with dementia (Jeste, et al., 2007). Findings - Review of a Single Research Report
Banerjee (2009) in a research study exploring the true scale of antipsychotic showed that use of antipsychotic in dementia may be underestimated. The study suggest that The scale of the challenge to reduce the use of antipsychotic drugs for people with dementia be underestimated, according to researchers at Aston University and the University of East Anglia, working with NHS Kent and Medway. There is a key challenge for public health to reduce prescribing of antipsychotic drugs to people with dementia are associated with probably up to 1,800 deaths a year (Banerjee, 2009). Ian Maidment et al., (2011) suggest that the true scale of antipsychotic use in dementia may be underestimated. Use may be up to 46% higher than official figures suggest. The researchers compared the results of the National Dementia and Antipsychotic prescribing intervention with government research, led by Anne Child, a clinical pharmacist for more experienced NHS Kent and Medway tying of primary care trusts (PCTs). They found that 15.3% of people with dementia received an antipsychotic, compared to the national intervention, which found 10.5%. However, the only 48.9 per cent of GP practices across the country participated in the national intervention compared with 98.3 percent in Medway practices that participated in the study Research evidence alone is insufficient to inform practice, as clinical decision making requires the integration of professional expertise and patient preferences alongside available best research evidence. There are significant barriers to overcome before evidence can inform practice, many of which have been identified by the National Institute for Health and Clinical Excellence (NICE). History shows that when you want to make changes to a particular form of work will always be problems that impede its implementation, both institutional resistances as in people who are involved. It's no different with this new paradigm of EBE, because it is removing everything that had so internalised about their profession (Gonzalez, 2005). Sekhri, R. (2010) in a study identified as the most significant barriers for not using the evidence in order of priority: the nurses enough time to implement new ideas in their work, insufficient time to read research organisations not deliver the necessary structures to implement the evidence, followed by nurses have difficulty understanding the statistics, sense of isolation from his fellow nurses to discuss the findings and the lack of cooperation of physicians, among others. In the same year the study of that instrument Melnyk, et al (2000) finds the following as the most significant barriers: the nurse does not feel sufficient authority and autonomy to change care from research, statistical analysis not understandable, not enough time to implement new ideas, managers do not favour the implementation of the research results and the nurse believes that the results are not generalisable. In UK, Martinez (2003) concludes that the nursing home is not based on the evidence due to the lack of research, the main barriers to the type or-ganisacional lack of orientation and awareness of the importance of research, followed by insulation given by the low reference and reading articles in English, lack of replication, lack of financing, poor access to sources and increasing qualitative research, of little interest in organisations that are guided by paradigms positivists. Research relating to the care, usually more complex, lacks economic aid in its realisation (Martinez, 2005). Boswell and Cannon (2010) also ranks among the main barriers that have limited acceptance even qualitative studies that are being conducted by the discipline of nursing, the proponents of addressing the care from the complexity of the problems of research in health, within the influence of cultural components, behaviours or beliefs, also agrees on the need of time and expertise in information management, the limitation given by the English language, and of administrative barriers institutions in the area of health. Stevens (2009) argues that institutional and organisational barriers have increased the value delivered by the professional culture and the tendency to stagnation of nurses, since for various reasons, among which names the lack of knowledge, insufficient motivation and denial to take Ellis (2010) believes that the lack of motivation in the study, low potential for professional development and lack of recognition become more visible in the lack of updating our discipline, deteriorating knowledge and clinical practice. Knowing the barriers that arise in the pursuit and implementation of the evidence to support our practice, we help you find the strategies to implement the EBE. Strategies that allow us to overcome using persistence and a plan to guide the course of action, because it is not enough to know the best way to provide care, if practitioner fail to implemented in clinical practice and evaluate their results Boswell and Cannon (2010) Implications for Practice
Nurses have to use in daily practice evidence obtained through research is not easy; it's a long way to be done through training and encouragement both nurses interested as future generations. It should not only teach investigate providing tools to research methodology but also to use the results (Gonzalez, 20065). According to Moran (2001) it is essential that nurses have a strong background in quantitative and qualitative research, critical assessment and research reported in the preparation of reports of systematic reviews. It also adds required form and EBE groups interested in having the organisation and management services enable their development through budget and access to library databases. Boswell and Cannon (2010) in their research found and prioritised ten strategies for implementation of EBP, among which the most important are the support of management, time, peer support, personal motivation, access to the recommendations and education and training of In research conducted by Sekhri in the same year, their results showed that increasing the use of evidence by nurses is directly related to the increase of time given by organisations to carry them out. Martinez (2003) identified as the most important instruments for the implementation of BSE: the support of management, adequate organisational culture that creates, promotes and enhances the EBP, advanced training that allows access to the highest levels of management, teaching and research and building research teams to lead evidence-based practice (Sekhri 2010). Sekhri (2010) agree that the positive attitude of managers or organisations facilitate finding and using evidence to improve the effectiveness of nursing care delivered. It is clear that most effectively accomplished in care is directly related to the decrease in the costs of health care. Try this cost-effectiveness of a nursing intervention is required to convince the authorities to allow improving the quality of nursing. Another point of agreement between the authors focus on the training of nurses in research, which should begin at the undergraduate stage, with teaching practices that strengthen reflective thinking, critical and interpretive. Meanwhile some researchers argue that teaching to the method of problem-based learning (PBL) students closer to the model of scientific evidence as a tool in decision making for patient care. During these training nurses should be encouraged and trained to acquire certain skills that will permit completion of the five stages of the EUT. For Lopes et al. (2003) must acquire new skills, such as critical analysis of practice, association of scientific findings to practice, research foci find problems or situations in practice, increase knowledge in research methodology and ability to implement and evaluate changes. These skills are hard to find in one person, so that nurses with training in research skills and must work in conjunction with clinical nurses to increase the chances of successful implementation of evidence. References
Ackley, B.J., Ladwig, G.B., Swan, B.A. and Tucker, S.J. (2008) Evidence-Based Nursing Care Guidelines: Medical-Surgical Interventions. Missouri: Mosby Inc Banerjee, S. (2009). The use of antipsychotic medication for people with dementia: Time for action. Department of Health, 3. Barker, J. (2010) Evidence-Based Practice for Nurses. London: SAGE Publications Ltd. Boswell, C., & Cannon, S. (2010). Introduction to Nursing Research: Incorporating Evidence Based Practice: Incorporating Evidence Based Practice. Jones & Bartlett Learning. Ellis, P. (2010). Evidence-based Practice in Nursing. Learning Matters. Fossey, J., Ballard, C., Juszczak, E., James, I., Alder, N., Jacoby, R., & Howard, R. (2006). Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial. Bmj, 332(7544), 756-761. Gonzalez, C. (2006). Connecting cancer to the asymmetric division of stem cells. Cell, 124(6), Herrmann, N., Mamdani, M., & Lanctôt, K. L. (2004). Atypical antipsychotics and risk of cerebrovascular accidents. American Journal of Psychiatry, 161(6), 1113-1115. Jeste, D. V., Blazer, D., Casey, D., Meeks, T., Salzman, C., Schneider, L., . & Yaffe, K. (2007). ACNP White Paper: update on use of antipsychotic drugs in elderly persons with dementia. Neuropsychopharmacology, 33(5), 957-970. Kales, H. C., Zivin, K., Kim, H. M., Valenstein, M., Chiang, C., Ignacio, R. V., . & Blow, F. C. (2011). Trends in antipsychotic use in dementia 1999-2007. Archives of general psychiatry, 68(2), 190. Maidment, I. D., Fox, C., Boustani, M., & Katona, C. (2011). Medication management—the missing link in dementia interventions. International journal of geriatric psychiatry, 27(5), 439-442. Marras, C., Herrmann, N., Anderson, G. M., Fischer, H. D., Wang, X., & Rochon, P. A. (2012). Atypical Antipsychotic Use and Parkinsonism in Dementia: Effects of Drug, Dose, and Sex. The American journal of geriatric pharmacotherapy, 10(6), 381-389. Melnyk, B. M., & Fineout-Overholt, E. (2010). Evidence-based practice in nursing & healthcare: A guide to best practice. Lippincott Williams & Wilkins. Moule, P. and Goodman, M. (2009) Nursing Research: An Introduction. London: SAGE Publications Ltd. Rochon, P. A., Normand, S. L., Gomes, T., Gill, S. S., Anderson, G. M., Melo, M., . & Gurwitz, J. H. (2008). Antipsychotic therapy and short-term serious events in older adults with dementia. Archives of internal medicine, 168(10), 1090. Schneider, L. S., Dagerman, K. S., & Insel, P. (2005). Risk of death with atypical antipsychotic drug treatment for dementia. JAMA: the journal of the American Medical Association, 294(15), 1934-1943. Sekhri, R. (2010). Dilemma over antipsychotic use in dementia. The British Journal of Psychiatry, 197(6), 501-502. Stevens, K. R. (2009). Essential competencies for evidence-based practice in nursing. Academic Center for Evidence-Based Practice, University of Texas Health Science Center at San Stoppe, G., Brandt, C. A., & Staedt, J. H. (1999). Behavioural problems associated with dementia: the role of newer antipsychotics. Drugs & aging, 14(1), 41-54. Tress, M. L., Martelli, P. L., Frankish, A., Reeves, G. A., Wesselink, J. J., Yeats, C., . & Valencia, A. (2007). The implications of alternative splicing in the ENCODE protein complement. Proceedings of the National Academy of Sciences, 104(13), 5495-5500.

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