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 Introduction
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
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,
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
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,
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
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
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
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
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
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
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
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
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.
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