A Quality Improvement Intervention to Reduce the Use of PRN Psychotropic Medications Among Older Adults in the Long-Term Care Setting

Even with our increasing knowledge about the limited effectiveness and severe side effects of PRN psychotropic medications, the frequency of their use in the geriatric population remains high. Higher drug intake and potentially inappropriate PRN psychotropic medication administration contribute to a higher risk of adverse reactions such as falls and consequent fracture, stroke, or even death as well as increased hospital admission relating to adverse drug effects. Older adults in nursing homes are the most vulnerable individuals for potentially inappropriate PRN psychotropic drug use because either nurses tend to have a lack of knowledge of PRN psychotropic indications and side effects or they overly rely on PRNs without considering alternative nonpharmacological intervention. This project examined the efficacy of psychotropics education training to reduce the rate of PRN psychotropic medication administration among older adults in the long-term care setting. The study used a repeated-measures pre-/post-test design among a sample of 21 geriatric nurses in skilled nursing facilities. The Psychotropic Education and Knowledge Test for Nurses in the Nursing Home (PEAK-NH) test was administered before and after directly after the educational training. Additionally, subjective feedback was obtained to gauge the participants' satisfaction with the training. A pre- and post-intervention EMAR chart review was also conducted to analyze any change in the rate of PRN psychotropic medication administration. Paired sample t-tests revealed a significant improvement in the PEAK-NH test score after the education session (mean percentage from pretest 57.81% to posttest 84%, P=0.000 (P<0.01)), and perceived knowledge level about psychotropic medication. EMAR review results showed, 35% of facility residents for 2 months, with an additional 8.1% PRN psychotropic medication used before the educational intervention was conducted. Whereas, 23.5% of residents used psychoactive medications, with an additional 6.6% of PRN psychotropic medications used for 2 months after the educational intervention was conducted. The retrospective EMAR chart review of the frequency rate of PRN psychotropic medication administration for 2 months before/after educational intervention demonstrated a weak correlation in the Pearson R-value= -0.48, and P=0.796 (P< 0.01). Psychotropic medication education may provide essential knowledge for promoting an understanding of the appropriate psychotropic medication uses for older adults. The lack of a statistical difference in the frequency of PRN psychotropic medication before/after the educational intervention likely indicates possible gaps between perceived knowledge and actual implementation to manage behavioral and psychological symptoms. The retrospective EMAR chart review may suggest that the data are preliminary and that a follow-up, long-term study of the frequency of PRN psychotropic medication for measuring education efficacy and identifying residual barriers may be useful.

A Quality Improvement Intervention to Reduce the Use of PRN Psychotropic Medications Among Older Adults in the Long-Term Care Setting Kimmy Kwong The University of Utah College of Nursing 1 Abstract Problem: Even with our increasing knowledge about the limited effectiveness and severe side effects of PRN psychotropic medications, the frequency of their use in the geriatric population remains high. Higher drug intake and potentially inappropriate PRN psychotropic medication administration contribute to a higher risk of adverse reactions such as falls and consequent fracture, stroke, or even death as well as increased hospital admission relating to adverse drug effects. Older adults in nursing homes are the most vulnerable individuals for potentially inappropriate PRN psychotropic drug use because either nurses tend to have a lack of knowledge of PRN psychotropic indications and side effects or they overly rely on PRNs without considering alternative nonpharmacological intervention. This project examined the efficacy of psychotropics education training to reduce the rate of PRN psychotropic medication administration among older adults in the long-term care setting. Methods: The study used a repeated-measures pre-/post-test design among a sample of 21 geriatric nurses in skilled nursing facilities. The Psychotropic Education and Knowledge Test for Nurses in the Nursing Home (PEAK-NH) test was administered before and after directly after the educational training. Additionally, subjective feedback was obtained to gauge the participants' satisfaction with the training. A pre- and postintervention EMAR chart review was also conducted to analyze any change in the rate of PRN psychotropic medication administration. Results: Paired sample t-tests revealed a significant improvement in the PEAK-NH test 2 score after the education session (mean percentage from pretest 57.81% to posttest 84%, P=0.000 (P<0.01)), and perceived knowledge level about psychotropic medication. EMAR review results showed, 35% of facility residents for 2 months, with an additional 8.1% PRN psychotropic medication used before the educational intervention was conducted. Whereas, 23.5% of residents used psychoactive medications, with an additional 6.6% of PRN psychotropic medications used for 2 months after the educational intervention was conducted. The retrospective EMAR chart review of the frequency rate of PRN psychotropic medication administration for 2 months before/after educational intervention demonstrated a weak correlation in the Pearson R-value= -0.48, and P=0.796 (P< 0.01). Conclusions: Psychotropic medication education may provide essential knowledge for promoting an understanding of the appropriate psychotropic medication uses for older adults. The lack of a statistical difference in the frequency of PRN psychotropic medication before/after the educational intervention likely indicates possible gaps between perceived knowledge and actual implementation to manage behavioral and psychological symptoms. The retrospective EMAR chart review may suggest that the data are preliminary and that a follow-up, long-term study of the frequency of PRN psychotropic medication for measuring education efficacy and identifying residual barriers may be useful. 3 Introduction Problem Description Health care providers commonly prescribe psychotropic medications to older adults to manage behaviors and psychiatric symptoms in various settings, including in the community, assisted living facilities, acute care medical and psychiatric units, and nursing homes (Selbak, Kirkevold, & Engedal, 2006). However, older adults are highly vulnerable to adverse reactions from psychotropic medications, due to age-related changes that impact the pharmacokinetic and pharmacodynamic processes of medications, as well as factors including comorbid medical conditions and polypharmacy (Curkovic, Dodig-Curkovic, Eric, Kralik, & Pivac, 2015). Conn (n.d.) article showed adverse drug reactions and other medication-related problems are closely associated with an increased rate of mortality in older adults. Bilyeu, Gumm, Fitzgerald, Fox, and Selig. (2011) reported more than 100,000 deaths related to the use of inappropriate medications in the geriatric population at the cost of $ 85 billion annually in 2000. Sepassi & Watanabe (2019) conducted the study that a retrospective analysis of geriatric Alzheimer's disease patients who visited the emergency department in 2013 with a 4 psychotropic-related adverse drug event (ADEs) at a national level include Tennessee, Texas, Utah, Vermont, Virginia, and Washington. This study suggested that it is necessary to develop the protocol to reduce future psychotropic-related adverse outcomes for older adults because Alzheimer's patients are more frequently experienced psychotropic-related adverse events than older adults without Alzheimer's (Sepassi & Watanabe, 2019). Geriatric nurses working in nursing homes play a crucial role in decision-making relating to the administration of PRN psychotropic medication (Barr, Wynaden, & Heslop, 2018; Simmons et al., 2018). Although geriatric nurses recognize the potentially inappropriate use of psychoactive medications leads to adverse events such as falls and consequent fractures, stroke, or even death, they also experience multiple barriers to the reduction of PRN psychotropic drug use. These barriers include lack of knowledge and/or lack of staff resources to implement nonpharmacological interventions, aversion of staff, and environmental safety concerns in the nursing home setting (Lindsey, 2009; Simmons et al., 2018). Available Knowledge Psychotropic drug use is high, and treatment is maintained longer than advised in long-term care settings. Some of the most commonly prescribed psychotropic medications in older adults are antidepressants, sedatives, antipsychotics, anxiolytics, hypnotics, and anticholinergic agents (Brooks & Hoblyn, 2007; Conn, n.d.; Helvik, 2017). Among 3,093 nursing home residents surveyed in 2006, 47.2% of older adults received one or more psychotropic medications regularly, and an additional 3.5% of older 5 adults received PRN psychotropic drugs in 51 nursing homes in Sydney, Australia (Snowdon, Day, & Baker, 2006). Notably, the use of antipsychotic medication in older adults with dementia increased from 33.3% in 2000 to 42.0% in 2012 (Norgaard, JensenDahm, Gasse, Hansen, & Walmemar, 2015). Higher drug intake and potentially inappropriate PRN psychotropic medication administration contribute to a higher risk of adverse reactions and hospital admission relating to adverse drug effects (Rehnquist, 2001; Snowdon, Day, & Baker, 2006; Stefanacci, 2017) since older adults are more susceptible to the adverse effects of psychotropic medications (Snowdon, Day, & Baker, 2006; Stefanacci, 2017). An Australian study found that 37% of people receiving PRN psychotropic medications experienced adverse reactions, compared to 3% of people who received regular psychotropic medications (Roughead, Procter, Westaway, Sluggett, & Alderman, 2017), which may have indicated that an increase in side effects was significantly associated with an increased frequency of PRN administration. Brooks and Hoblyn (2007) found that the risk of adverse reactions increases dramatically with increasing age; older adults are 3.5 times more likely to be admitted to the hospital due to adverse drug reactions associated with psychotropic medications when compared with younger individuals. Moreover, Bilyeu et al. (2011) conducted a review of the literature concerning reducing the use of potentially inappropriate medications in older adults and concluded that geriatric nurses work in the nursing home setting play a crucial role in the decisionmaking process relating to the administration of PRN psychotropic medication. However, Lindsey (2009) found that older adults in nursing homes are the most vulnerable 6 individuals for potentially inappropriate PRN psychotropic drug use because either nurses tend to have a lack of knowledge of PRN psychotropic indications and side effects or they overly rely on PRNs without considering alternative nonpharmacological interventions. It is feasible that geriatric nurses need to know more about these medications, be able to respond to adverse effects appropriately, and be able to utilize alternative nonpharmacological interventions effectively to reduce the use of PRN psychotropic medications (Bilyeu et al., 2011). Rationale The theoretical framework used to guide this DNP project is the Health Belief Model (HBM), which was developed by a group of U.S. Public Health Service social psychologists in the 1950s (LaMorta, 2018). The HBM is composed of five major concepts: perceived susceptibility, perceived benefits, perceived barriers, cue to action, and self-efficacy (Glanz, Rimer, & Viswanath, 2008; see Figure 1 in Appendix A). HBM addresses the relationship between a person's beliefs and behaviors (Croyle, 2005). Sharafkhani, Khorsandi, Shamsi, and Ranjbaran (2016), as well as Sadeghi, Hashemi, and Khanjani (2018), conducted randomized control trial studies to identify the effect of the theory-based educational intervention program and the HBM among nurses in terms of the adoption of preventive behaviors. Sharafkhani et al. (2016) demonstrated a decrease in the mean scores of perceived barriers, whereas other subscales, including perceived severity, perceived susceptibility, perceived benefits, and cues to action increased, indicating that this HBM-based educational intervention was successful. Also, the Sadeghi, Hashemi, and Khanjani (2018) study showed similar results in the HBM 7 constructs. The Hashemi and Khanjani (2018) study of implementing blood-borne standard precautions pointed to significant differences in the five HBM major concepts before/after an educational intervention conducted with nurses in emergency centers in Sirjan, Iran. The initial step of the HBM involves conducting a thorough assessment of the two main components that seek to reduce PRN psychotropic drug use: nurse's beliefs and behavioral evaluation (Croyle, 2005). Older adults are highly vulnerable to the adverse effects of psychotropic medications, and therefore will benefit if nurses use fewer PRN psychotropic medications to prevent serious side effects or falls (Lindsey, 2009). The behavioral change evaluation consists of two main concepts: cue to action and selfefficacy (LaMorta, 2018). The cue to action in this project is for nurses to feel more confident in their ability to recognize the side effects of PRN psychotropic drugs and be motivated to use alternative nonpharmacological interventions after receiving an inperson training session. Self-efficacy is the mastery level at which nurses successfully manage behaviors and psychiatric symptoms by utilizing alternative nonpharmacological interventions instead of giving PRN psychotropic medications (Croyle, 2005). Specific Aims The purpose of this project is to reduce the number of PRN psychotropic medication administrations to older adults in a long-term care setting through the development and implementation of an educational intervention. Methods Context 8 Two skilled nursing facilities in Salt Lake County were identified as appropriate sites for this project. Facility A has a 133-bed unit and currently serves 105-122 patients, comprised of Medicare patients requiring acute rehabilitation care after receiving cardiac surgery or orthopedic patients recovering with OT/PT/ST treatment. The facility, as a long-term skilled care setting, offers memory care and mental health service as well as care for other medical conditions. Cascade Company operates this facility, which employs 26 nurses. Facility B, which is privately owned and employs 13 nurses, has an 83-bed facility, and currently serves 80 patients. The diagnoses of Facility B residents are significantly skewed toward mental conditions such as schizophrenia, schizoaffective disorder, bipolar disorder, mood disorder, traumatic brain injury (TBI), and dementia with/without behavioral disturbance. Interestingly, the average stay at Facility B is 5-8 years, whereas the average at Facility A is from 21 days to less than 3 years. Intervention(s) The project comprised four separate phases. Firstly, the PEAK-NH test administered to nurses provided the initial data. The pre-test questionnaire was also used as a data collection tool. The pre-test questionnaire included two sections: (a) the demographic characteristics of the nurses and (b) the psychotropic education and knowledge test for nurses in a nursing home (PEAK- NH) quiz (see Appendix B). Secondly, a retrospective chart review was conducted for 2 consecutive months in the facilities to identify the frequency of PRN psychotropics used during that period. 9 Thirdly, in-person training was developed and implemented. The in-person educational intervention was conducted over a one month period after completion of both a pretest survey and chart review. Education on the psychotropic medication use took approximately 45-50 minutes via a one-to-one in-person education session. This educational presentation included information on five areas of geriatric psychopharmacology, pharmacokinetic and pharmacodynamics of psychotropic drugs in older adults, indications of potential adverse drug reaction related to psychotropic medications, implications of alternative non-pharmacological intervention, and the resident assessment protocol (RAP) when using psychotropic drugs (see Appendix C). Education presentation materials were sent to three experts, include geriatric-psychiatrist, geriatric-psychiatric APRN, and geriatric-pharmacist for review. Additional copies of the "PRN Psychotropic Medication Use Tool" were laminated and made available as reminders in the nurse station, to be used as a "to-go-guideline" for the administration of PRN psychotropic medication in the nurses' practices (see Appendix C). The final step was an evaluation of the effectiveness of the training program and a retrospective chart review for 2 months after the training session to determine if there was a reduction in PRN psychotropic use. Data collection continued as it was part of the evaluation of the in-person educational intervention via the post-test survey, which included two sections: (a) the same PEAK-NH quiz, but with a different order of quiz items and (b) the satisfaction of participants with the educational intervention (see Appendix B). Study of the Intervention(s) 10 To ensure the accuracy and consistency of the data, a validated screening tool, the PEAK-NH questionnaire was used to assess the level of knowledge of using psychotropic medications in geriatric nurses in the long-term care setting (Perehudoff et al., 2016; see Appendix B) and for the portion of the EMAR chart review that required manual data extraction, this was conducted by the same person in before/after educational training was implemented. Measures The effectiveness of the intervention was assessed by comparisons of PEAK-NH test scores, and retrospective medical chart reviews for the frequency of PRN psychotropic use before and after the educational intervention. A self-reported/pretest questionnaire was the baseline data collection tool. The questionnaire included two sections: (a) the demographic characteristics of the nurses and (b) the PEAK-NH test. The PEAK-NH test contains 19 questions concerning dosages and general concepts of geriatric pharmacology (six items) and indications of potential adverse drug reactions related to sedative-hypnotic-anxiolytics (five items) and antipsychotics (eight items). Possible answers are correct (1 point), incorrect (0 points) and do-not-know (0 points). Summary scores range from 0 to 19 points. Next, a retrospective chart review was conducted to obtain data for from September and October in 2019 (2 months) about the frequency of PRN psychotropic medications used. During the pretest survey weeks, Facility B had not used any classes of PRN psychotropic medication in the past 2 months related to "no PRN psychotropic use policy." However, the Facility B management team showed a keen interest in the project 11 after an initial PowerPoint presentation, and the management team decided to make the psychotropics educational training presentation as one of the mandatory in-service programs. At this time, the project was not able to retract from Facility B that has "no PRN psychotropic use policy" following the new rules of Medicaid Long-Term Care Rules in the U.S. (Stefanacci, 2017). After discussed with the management team in Facility B, a decision was made that the project will be conducted the PEAK-NH test, pre- and post-survey in both of facilities, but not EMAR chart review in Facility B. Hence, the baseline data for EMAR chart review about the frequency of PRN psychotropic medications use were collected for only one sample facility. A post-survey questionnaire with three sections was conducted: (a) how helpful the education intervention was at affecting their decision-making relating to the administration of PRN psychotropic medication, (b) how satisfied they were with the training session, and (c) the same PEAK-NH test, but randomly rearranged in a different order. Finally, another retrospective chart review was conducted to obtain the frequency of PRN psychotropic use after the training session from December 2019 to January 2020, for 2 months. EMAR data was printed out as a hard copy of papers include monthly psychotropic drug type, resident's first and last name initial, lists of psychotropic drug names, and frequency of PRN psychotropic drugs by the facility director of nursing and medical recorder initially. After the data were obtained, the same researcher organized and entered them into the statistical package for social sciences (SPSS) for statistical analyses. Analysis 12 Descriptive statistics, including mean (standard deviation) score in the sample ttests, was used to assess demographics and outcomes of PEAK-NH test performance. The statistical analyses were performed using the statistical package for social sciences (SPSS) version 26.0. Between the pre- and post-test surveys, outcomes were compared using the paired sample t-test to evaluate the changes. The confidence interval was set at 95% and a level of significance at 0.05. The EMAR chart review was analyzed for descriptive statistics on the frequency of PRN psychotropic use for 2 months before implementing the educational intervention. A repeat retrospective EMAR review was conducted after 2 months to assess if the rate of PRN psychotropic medication use was changed. This analysis was performed using an independent paired t-test on the percentage of PRN psychotropic administration for 2 months to compare significant differences in the rate of PRN psychotropic use before and after the education training. Ethical Considerations The University of Utah Institutional Review Board (IRB) determined this study to be nonhuman subject research and a quality improvement initiative. Protected health information (PHI) was de-identified. No conflicts of interest were identified in the completion of this project. Results Descriptive Statistics Results Pre-survey Result Twenty-one nurses participated in the study and completed both the pretest and posttest. 13 Table 1 in Appendix A summarizes the demographic data of the participants. Most of the participants were female (N=14; 66.7%), had an RN license (N=13; 61.9%) and an associate degree (N=19; 90.5%). The mean age range from 35 to 44 (N=7; 33.3%) with a standard deviation of 1.153, and with 61.9% of the participants falling between the age range of 35 to 54 years (N=13). Of the nurses who participated in the survey, 42.9% had less than 1 to 10 years of nursing experience (1-5 years N=3, 6-10 years N=6, total N=9), and 47.6% had more than 10 years of nursing experience (total N=10 with two surveys missing data). Many of the survey respondents have been working with older adults for more than 6 years (6-10 years N=10; 47.6%, 11-15 years N=4; 19%, 16 + years N=4; 19%), and only 9.5% of the participants have been working with older adults less than 1 to 5 years. One missing survey was not calculated. The previous mandatory training' category indicated that most of the nurses had received in psychotropic medication (N=17; 81%), and dementia training (N=17; 81%) followed old age depression (N=11; 52.4%) and delirium training (N=7; 33.3%). Post-survey Result Of the participants, 85.7% answered they were " very satisfied " with the education training (N=18; M=3.86, SD=0.36), and 14.3% answered, "satisfied" (N=3). Also, 95.2% of participants responded they were more or very likely to use alternative approaches instead of PRN psychotropic drugs in future practice (more likely N=10; 47.6%, very likely N=10; 47.6%). Table 2 in Appendix A summarizes the post-survey 14 data. A paired sample t-test was conducted for N=21 participants to compare the presurvey and post-survey for differences in the perceived knowledge level about psychotropic drugs before and after the educational intervention. This analysis showed a mean change of 0.52 (M= - 0.52, SD= 0.68; t (20)= -3.532, p= 0.002). A complete list of the correlations is presented in Table 3 in Appendix A. The PEAK-NH Quiz Statistics A paired sample t-test in SPSS was conducted for the entire sample (N=21) to compare the pre-PEAK test before the education intervention and the post-PEAK test after the education intervention for N (sample size), mean score (%), SD (standard deviation), lower and upper CI (95% of CI of difference), df (df = 20), and P-value (α = .05). This analysis yielded significant results, with a mean percentage from 57.81% for the pretest to 84% (M= - 26.19, SD= 13.79); t(20)= -8.70, P< .001) for the posttest. A correlation Pearson R-value was calculated between the pre-PEAK test score and the post-PEAK test score. The Sig. (two-tailed) test resulted in .596, and P= 0.000 (P< 0.01), which indicates that a strong linear correlation is considered between the preand post-PEAK test scores. A complete list of correlations is presented in Table 4 in Appendix A. EMAR Reviews Scheduled psychoactive medications were administered to 35% of Facility A 15 residents, with an additional 8.1% of residents receiving PRN medications for the two months prior to the intervention (September and October 2019). Whereas 23.5% of residents received scheduled psychoactive medications, and 6.6% of residents received PRN psychotropic medications for the two months following the intervention (December 2019 and January 2020). The rate of how many drugs were used per resident receiving psychotropics during the study period was also calculated. 59.5% of residents were received 1 to 2 number of psychotropic medications, 34.5% of residents were received 3 to 4 number of psychotropic medications, and 6% of residents were received 5 to 6 number of psychotropic medication daily basis. Table 5 in Appendix A summarizes the EMAR data for the number of use of psychotropic medications. In terms of scheduled psychotropic medications, antidepressants were most frequently used (N=106; 41.6%), followed by anxiolytics (N=48; 18.8%), sedative/hypnotics (N=58; 22.7 %), antipsychotics (N=19; 7.5%), and other psychoactive (N=24; 9.4%). The most frequently administered PRN psychotropic medication was anxiolytics (N=22; 66.7%), followed by sedative/hypnotics (N=8; 24.2%) and other psychoactive (N=3; 1.2%). This analysis yielded results with a mean of 1.44 (N=32, M=1.44, SD= 0.50), and had a weak correlation in the Pearson R-value with the Pearson correlation = 0.48, and P=0.796 (P< 0.01) for the 2 months before and after education training was given to the nurse participants. Hospice patients received PRN Ativan liquid for comfort 16 measures. Hence, all hospice patients were excluded in the entire EMAR data collection for the frequency of PRN psychotropic use. Figures 2 and 3 in Appendix A show the frequency of use of psychotropics medication and PRN in the EMAR chart review. Discussion Summary The significant improvements in the PEAK-NH test scores and post-survey results suggest participants feel more confident in their ability to recognize the side effects of PRN psychotropic drugs and have improved basic knowledge of psychotropic medication following the intervention. After implementing the education intervention, the post-survey results suggested that (a) 85.7% participants were very satisfied with the education training, (b) the participants' perceived knowledge level was improved (M= -0.52, SD=0.68, CI= -0.83 to -0.21, t= -3.53, df=20, P= 0.002), (c) the participants were more confident about administering psychotropic medication, and (d) 95.2% of them were more or very likely to use alternative approaches instead of PRN psychotropic medications. The EMAR chart review did not indicate a significant mean change of frequency of PRN psychotropic medication use between pre-/post educational training despite the 95.2% of participants who participated in the study responding that they were more or very likely to use alternative approaches instead of PRN psychotropic drugs in future practice. 17 Interpretation In a skilled nursing Facility A, 42% of nurses participated in the project, and in Facility B, 84% participated. In facility B, the management team showed a strong interest in the project after an initial PowerPoint presentation, and the management team decided to make the psychotropics educational training project, one of the mandatory in-service programs. The psychotropic education intervention was given via individual in-person training, a single session using an approximate 40-minute PowerPoint presentation followed by a debriefing session 5-10 minutes after the PowerPoint presentation. Immediately after the educational intervention, a post-survey questionnaire was given to the nurse participant. Twenty-one nurses participated in the project over 3 weeks in November 2019. After discussion with Facility B nurse participants after the educational training, it has appeared that even though Facility B has implemented " no PRN psychotropic drug policy," nurses still can decide to call the house physician for getting "one-time order for PRN psychotropic medication" when it is absolutely indicated such as harm to self or harm to others situation to manage behavioral or psychiatric symptoms. It was interesting to see how Facility B made its own policy to reduce the frequency of PRN psychotropic medication administration. The post-PEAK test results indicated that the test scores improved significantly compared to the pre-PEAK test scores. The mean pre-PEAK test score was 57.81% for the 21 nurses, and the mean post-PEAK score was 84.5%, which may have been a result of administering the post-survey immediately after the educational intervention, and the one-on-one training may have contributed to this results. The individual training was 18 time-consuming and asked to be implemented by following the participant's schedule in Facility B relating the educational training was one of the mandatory services for geriatric nurses; hence some of the cases, in-person training, was performed between 10:00 pm to 12:00 am for night nurses. However, in-person training was appeared to drawing more interest and welcomed because most of the participants expressed that they never had any in-person education presentation before. Moreover, some of the participants felt that it was "participant-centered training" and pointed out the educator's enthusiasm for training. Stones et al. (2019) showed that the rate of psychotropic medication use for residents during 2010-2012 in a long-term care home (LTCH) setting in the province of Ontario, Canada was 74.6% of residents, with one or more daily prescriptions for psychotropic medications, and 8.0% with additional PRN prescriptions. The Stones et al. rate of PRN psychotropic medication use was a similar percentage to that found in this study, whereas the scheduled prescription rate of psychotropics revealed a significantly lower in Facility A. The September and October 2019, initial pre-intervention EMAR chart review showed 35 % of the residents were given at least one psychotropic medication, and 8.1% of the residents were given PRN psychotropic medication by nurses, including Alprazolam, Diphenhydramine, Restoril, Valium, Vistaril, Mirtazapine, Ativan, Trazodone, and Melatonin. In the December 2019 and January 2020, post-intervention EMAR chart review, 19 23.5% of the residents received psychoactive medication with an additional 6.6% receiving PRN psychotropic medication. Limitations This quality improvement project has three limitations. Throughout all phases of this project, the sample size may not have been sufficient to power the statistical tests and find a meaningful effect, and, also, the study used a convenience sample. The results are also limited in that the design did not include a defined control group; hence, the differences in the frequency of PRN psychotropic medication use cannot be tested between a sample group and a control group. The final limitation is that the retrospective EMAR chart review was applied in only one skilled nursing facility because the other facility has " no PRN psychotropic use policy" following the new rules of Medicaid Long-Term Care Rules in the U.S. (Stefanacci, 2017). There is a clear need to collect more EMAR data from different skilled nursing facilities in different locations. The results are encouraging, but they are not generalizable to other settings. Conclusions The retrospective EMAR review suggested the change of frequency of PRN psychotropic medication use between pre- and post-educational training was not significant, despite 95.2% of participants who attended the study responding that they planned to use more or very likely alternative approaches instead of PRN psychotropic drugs in future practice. A cautious interpretation of these results is that nurses can develop "self-efficacy" by utilizing alternative strategies instead of giving PRN 20 psychotropic medications over time in long-term goals, not in a short amount of time. Moreover, there was no immediate change of frequency of PRN psychotropic medication administration due to other variances, and it may indicate a need for additional follow up check-ins to talk about barriers, enablers, and refresh skills training. Consequently, it is strongly recommended that future longitudinal and randomized controlled trials evaluate the relationships this study reports here. The implementation of one-on-one training was useful, but the nature of face to face in-person training intervention makes it hard to sustain; hence individual online module training may more sustainable and also help facilitate the expansion of the training to additional facilities. The study findings support psychotropic medication education training to motivate geriatric nurses to use non-pharmacological approaches to reduce the frequency of PRN psychotropic medication use. Acknowledgments I want to thank Antonette Close and Mija Kim for their constant assistance. I would also like to thank all those who participated in this study. Finally, I would like to thank Dr. Martin Freimer, Dr. Deborah Morgan, and Steven Sessions, Pharm. D, who walked me through the project at each step and gave their expert guidance. 21 References Barr, L., Wynaden, D., & Heslop, K. (2018). Nurses' attitudes toward the use of PRN psychotropic medications in acute and forensic mental health settings. 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Australian Commission on Safety and Quality in Health Care. The University of Soth Australia. https://www.safetyandquality.gov.au/wp-content/uploads/2017/06/MedicationSafety-in-Mental-Health-final-report-2017.pdf Sadeghi, R., Hashemi, M., & Khanjani, N. (2018). The impact of educational intervention based on the health belief model on observing standard precautions among emergency center nurses in Sirjan, Iran. Health Education Research, 33(4), 327-335. doi:https://doi.org/10.1093/her/cyy020 Selbak, G., Kirkevold, Q., & Engedal, K. (2006). The prevalence of psychiatric symptoms and behavioral disturbances the use of psychotropic drugs in Norwegian nursing homes. International Journal of Geriatric Psychiatry, 22(9), 843-849. https://doi.org/10.1002/gps.1749 Sepassi, A., & Watanabe, J. (2019). Emergency Department visits for psychotropic related adverse drug events in older adults with Alzheimer's disease, 2013-2014. Annals of Pharmacotherapy, 53(12). DOI:10.1177/1060028019866927 Sharafkhani, N., Khorsandi, M., Shamsi, M., & Ranjbaran, M. (2016). The effect of an 24 educational intervention program on the adoption of low back pain preventive behaviors in nurses: An application of the Health Belief Model. Global Spine Journal, 6(1), 29-34. doi:https://doi.org/10.1055%2Fs-0035-1555658 Simmons, S., Bonnett, K., Hollingsworth, E., Kim, J., Powers, J., Habermann, R., & Schlundat, D. (2018). Reducing antipsychotic medication use in nursing homes: A qualitative study of nursing staff perceptions. The Gerontologist, 58(4), 239-250. https://doi.org/10.1093/geront/gnx083 Snowdon, J., Day, S., & Baker, W. (2006). Current use of psychotropic medications in nursing homes. International Psychogeriatrics, 18(2), 241-250. https://doi.org/10.1017/S1041610205002449 Stefanacci, R. (2017). New CMS rules on psychotropic medications in SNFs. Annals of Long- Term care, 26(6), 19-20. doi:10.25270/altc.2017.10.00014 Stones, M., Worobetz, S., Randle, J., Marchese, C., Fossum, S., Ostrom, D., & Brink, P. (2019). Psychotropic medication use and mortality in long-term care residents. Life Span and Life Expectancy. DOI: 10.5772/intechopen.85971 25 Appendix A 26 Figure 1. The Health Belief Model (LaMorta, 2018) Figure 2. Types of Psychotropic Drugs 27 Figure 3. Types of PRN Psychotropic Drugs Table 1. Summary of Demographic Data of Participants Characteristics Age Gender Total Frequency Percent Number (N=21) 18-34 35-44 45-54 55-64 65+ Female Male 28 Cumulative 2 7 6 4 2 (%) 9.5 33.3 28.6 19 9.5 Valid Percent (%) 9.5 33.3 28.6 19 9.5 14 7 66.7 33.3 66.7 33.3 66.7 100 Percent(%) 9.5 42.9 71.4 90.5 100 License type RN LPN 13 8 61.9 38.1 61.9 38.1 61.9 100 Education level Associate degree Bachelor degree Graduate degree 19 1 1 90.5 4.8 4.8 90.5 4.8 4.8 90.5 95.2 100 Nursing experience 1-5 years 6-10 years 11-15 years 16+ years Total Missing 3 6 4 6 19 2 14.3 28.6 19 28.6 90.5 9.5 15.8 31.6 21.1 31.6 100 15.8 47.4 68.4 100 Working years in this facility 1-5 years 6-10 years 11-15 years 16+ years Total Missing 11 7 1 1 20 1 52.4 33.3 4.8 4.8 95.2 4.8 55 35 5 5 100 55 90 95 100 Working years for older adults 1-5 years 6-10 years 11-15 years 16 + years Total Missing 2 10 4 4 20 1 9.5 47.6 19 19 95.2 4.8 10 50 20 20 100 10 60 80 100 Received previous training type Psychotropic medication Dementia Delirium Depression Old age pharmacology 17 81 81 81 17 7 11 11 81 33.3 52.4 52.4 81 33.33 52.4 52.4 81 33.3 52.4 52.4 29 Table 2. Summary of Post survey Frequency Percent Valid Cumulative Mean SD(St. Percent Percent Deviation) 14.3 14.3 85.7 100.0 100.0 3.85 0.35857 Satisfaction satisfied very satisfied Total 3 18 21 14.3 85.7 100.0 Knowledge level BEFORE very little 1 4.8 4.8 4.8 below average average above average excellent Total 1 4.8 4.8 9.5 6 11 2 21 28.6 52.4 9.5 100.0 28.6 52.4 9.5 100.0 38.1 90.5 100.0 average 3 14.3 14.3 14.3 above average excellent Total 13 5 21 61.9 23.8 100.0 61.9 23.8 100.0 76.2 100.0 somewhat likely 1 4.8 4.8 4.8 more likely very likely Total 10 10 21 47.6 47.6 100.0 47.6 47.6 100.0 52.4 100.0 knowledge level AFTER Alternative approaches instead of PRN Table 3. Comparison Between Pre-Survey and Post- Survey Results 30 2.57 0.92582 3.09 0.62488 3.43 0.59761 Table 4. Correlation Pearson R-Value Between Pre-PEAK Test Score and Post-PEAK Test 31 Table 5. Summary of EMAR Review Month What type of psychotropic drugs psychotropic drugs How many psychotropic drugs used Frequency 142 Percent 55.7 Valid Percent (%) 55.7 113 44.3 44.3 100.0 106 41.6 41.6 41.6 anxiolytics 48 18.8 18.8 60.4 sedative/hypnotics 58 22.7 22.7 83.1 antipsychotics other psychoactive 19 24 7.5 9.4 7.5 9.4 90.6 100.0 1-2 69 27.1 59.5 59.5 3-4 40 15.7 34.5 94.0 September and October December and January antidepressants 32 Cumulative Percent 55.7 5-6 7 2.7 6.0 100.0 33 12.9 100.0 100.0 22 8.6 66.7 66.7 sedative/hypnotics 8 3.1 24.2 90.9 other psychoactive 3 1.2 9.1 100.0 Additional PRN use What type of PRN anxiolytics Appendix B Pre-PEAK Test Survey 33 Demographic Data & Workplace Characteristics ⦁ Please use the () mark for answering questions. Q1. What is your Age? 18- 34 ( ) 35- 44 ( ) 45- 54 ( ) 55- 64 ( Male ( ) Prefer not to answer ( ) 65 + More ( ) Q2. Gender? Female ( ) ) Q3. What is your current License Type? RN ( ) LPN ( ) Q4. What is your Education Level? Associate's Degree ( ) Bachelor's Degree ( ) Graduate Degree ( ) Q5. How many years of Nursing Experience do you have? ( ) years and ( ) months Q6. How many years have you worked in THIS Facility? ( ) years and ( ) months Q7. How many years of experience do you have to work for Older Adults (including all settings, such as home health care, assisted living facility, nursing homes, acute hospital setting, or outpatient setting)? ( ) years and ( ) months Q8. Have you ever received any of the Training before? (You can choose multiple answers) Psychotropics medication ( Old age depression ( ) ) Dementia ( ) Old age pharmacology ( 34 Delirium ( ) ) The Psychotropic Education and Knowledge Test Survey ⦁ There are three answer choices "True, False, & I do not know" in each question. Please use the () mark for answering questions. Q1. As a result of a change in metabolism and heightened receptor sensitivity, older people often need only a lower dosage of both antipsychotics and sleeping and calming medicines to achieve the same/desired effect. True ( ) False ( ) I do not know ( ) Q2. In the case of anxiety disorders, sleeping and calming medications must be initiated in addition to nonpharmacological therapies to normalize the symptoms. True ( ) False ( ) I do not know ( ) Q3. The recommended daily dose of the antipsychotic risperidone (Risperdal) for older people with severe behavioral disorders in cases of dementia is 0.5 - 2.0 mg. True ( ) False ( ) I do not know ( ) Q4. In cases of sleep disorders, pharmacological interventions must always accompany or take priority over nonpharmacological interventions. True ( ) False ( ) I do not know ( ) Q5. Older people are less sensitive to the side effects of antipsychotics. True ( ) False ( ) I do not know ( ) Q6. Long- term use (൒ 3 months) of antipsychotics increases the risk of cerebrovascular events in older people. True ( ) False ( ) I do not know ( ) Q7. Sleeping pills can be administered over a short period and at a low dose. True ( ) False ( ) I do not know ( ) Q8. Most antipsychotics can cause extrapyramidal symptoms in older people. True ( ) False ( ) I do not know ( ) Q9. Sleeping pills with long half-lives are not indicated in older people. True ( ) False ( ) I do not know ( ) Q10. If undesired effects result in psychotropic medicines, it is best to stop their use immediately. 35 True ( ) False ( ) I do not know ( ) Q 11. Antipsychotics can cause disorientation in older people. True ( ) False ( ) I do not know ( ) Q 12. One of the side effects of the antipsychotic haloperidol (Haldol) is akathisia, resulting in restless patients who continuously walk back and forth. True ( ) False ( ) I do not know ( ) Q13. There is a relationship between long-term use (൒ 3 months) of antipsychotics and falling in older people. True ( ) False ( ) I do not know ( ) Q14. Sleeping and calming medicines may be briefly administered to older people only in cases of severe insomnia and when alternative therapies with proven effectiveness fail. True ( ) False ( ) I do not know ( ) Q15. Sleeping and calming medicines can lead to urine retention in older people. True ( ) False ( ) I do not know ( ) Q16. Antipsychotics should be given priority over behavioral change therapy in older people with behavioral disorders resulting from dementia. True ( ) False ( ) I do not know ( ) Q17. The recommended daily dose of olanzapine (Zyprexa) in older people with severe behavioral disturbances in the scope of dementia is 5- 10 mg. True ( ) False ( ) I do not know ( ) Q18. Older people who use antipsychotics are especially sensitive to orthostatic hypotension at the onset of treatment. True ( ) False ( ) I do not know ( ) Q19. The use of sleeping and calming medicines can lead to both physical and emotional dependence in older people. True ( ⦁ ) False ( ) I do not know ( Excerpted from: https://doi.org/10.1080/13607863.2015.1068738 Post-PEAK Test Survey 36 ) General Post survey Questionnaires ⦁ Please use mark inside the box to answer questions. Q1. How Satisfied are you with the Psychotropics Educational Session? Very Dissatisfied=0 Dissatisfied=1 Moderately Satisfied=2 Very Satisfied=4 Satisfied=3 Q2. Before the Psychotropics Educational Session, what was your Perceived Knowledge Level toward psychotropic drugs? Very Little=0 Below Average= 1 Average=2 Above Average= 3 Excellent=4 Q3. After the Psychotropic Educational Session, what is your Perceived Knowledge Level toward psychotropic drugs? Very Little=0 Below Average= 1 Average=2 Above Average= 3 Excellent=4 Q4. After the Psychotropic Educational Session, How Likely is it that you would Practice Alternative Approaches before administering psychotropic drugs to manage symptoms? Not at all Likely=0 A little Likely=1 Somewhat Likely=2 37 More Likely=3 Very Likely=4 The Psychotropic Education and Knowledge Test ⦁ There are three answer choices "True, False, & I do not know" in each question. Please use the () mark for answering questions. Q1. As a result of a change in metabolism and heightened receptor sensitivity, older people often need only a lower dosage of both antipsychotics and sleeping and calming medicines to achieve the same/desired effect. True ( ) False ( ) I do not know ( ) Q2. Older people are less sensitive to the side effects of antipsychotics. True ( ) False ( ) I do not know ( ) Q3. In the case of anxiety disorders, sleeping and calming medications must be initiated in addition to nonpharmacological therapies to normalize the symptoms. True ( ) False ( ) I do not know ( ) Q4. Sleeping and calming medicines may be briefly administered to older people only in cases of severe insomnia and when alternative therapies with proven effectiveness fail. True ( ) False ( ) I do not know ( ) Q5. In cases of sleep disorders, pharmacological interventions must always accompany or take priority over nonpharmacological interventions. True ( ) False ( ) I do not know ( ) Q6. Sleeping and calming medicines can lead to urine retention in older people. True ( ) False ( ) I do not know ( ) Q7. Sleeping pills with long half-lives are not indicated in older people. True ( ) False ( ) I do not know ( 38 ) Q8. Sleeping pills can be administered over a short period and at a low dose. True ( ) False ( ) I do not know ( ) Q9. The use of sleeping and calming medicines can lead to both physical and emotional dependence in older people. True ( ) False ( ) I do not know ( ) Q10. The recommended daily dose of the antipsychotic risperidone (Risperdal) for older people with severe behavioral disorders in cases of dementia is 0.5 - 2.0 mg. True ( ) False ( ) I do not know ( ) Q11. Long-term use (൒ 3 months) of antipsychotics increases the risk of cerebrovascular events in older people. True ( ) False ( ) I do not know ( ) Q12. Most antipsychotics can cause extrapyramidal symptoms in older people. True ( ) False ( ) I do not know ( ) Q13. If undesired effects result in psychotropic medicines, it is best to stop their use immediately. True ( ) False ( ) I do not know ( ) Q 14. Antipsychotics can cause disorientation in older people. True ( ) False ( ) I do not know ( ) Q 15. One of the side effects of the antipsychotic haloperidol (Haldol) is akathisia, resulting in restless patients who continuously walk back and forth. True ( ) False ( ) I do not know ( 39 ) Q16. There is a relationship between long-term use (൒ 3 months) of antipsychotics and falling in older people. True ( ) False ( ) I do not know ( ) Q17. Antipsychotics should be given priority over behavioral change therapy in older people with behavioral disorders resulting from dementia. True ( ) False ( ) I do not know ( ) Q18. The recommended daily dose of olanzapine (Zyprexa) in older people with severe behavioral disturbances in the scope of dementia is 5- 10 mg. True ( ) False ( ) I do not know ( ) Q19. Older people who use antipsychotics are especially sensitive to orthostatic hypotension at the onset of treatment. True ( ⦁ ) False ( ) I do not know ( ) Excerpted from: Perehudoff, K., Azemai, M., Wauters, M., Van Acker, S., Versluys, K., Steeman, E., & Mirko, P. (November 2016). The psychotropic education and knowledge test for nurses in a nursing home: Striving got PEAK performance. Retrieved from Aging & Mental Health. https://doi.org/10.1080/13607863.2015.1068738 Appendix C Educational Training Hand-Out Material Psychotropic Medication Use for Older Adults 40 Medication Class Drug Name Most Common Side Effects Anxiolytics Benzodiazepine: Drowsy, dry (Calming Xanax, Ativan, mouth, sedation, Medications) Clonazepam, Valium confusion, Others: constipation, Buspar, disinhibition, Hydroxyzine, lack of Gabapentin coordination, blurred vision & Dependence ( Benzodiazepin e) Swelling extremities (Gabapentin) Antidepressant SSRIs: Prozac, Paxil, Stomach upset, s Zoloft, Celexa, diarrhea, Lexapro sleepiness, dizziness, SNRIs: Cymbalta, increased heart Effexor, Pristiq rate, insomnia, suicidal thoughts Atypical: Wellbutrin, (Black Box Mirtazapine(Remero Warning) n) 41 Alternative Interventions Important Things to Remember Music therapy Since & relaxation Benzodiazepine has higher side Calming music, effects, try nonhand massage pharmacologic al approaches Reminiscence FIRST before a therapy: call for PRN storytelling to order reflect on their lives Cognitive exercise: virtual reality training for search, identify, locate visual information Remeron- with multipurpose uses; appetite booster, sleep & depression (lower dose works better for sleep) Art therapy/ social tea time Recreational activities Bupropion can increase seizure risk Antipsychotics Typical: Haldol Atypical: Abilify, Risperdal, Zyprexa, Seroquel, Risperdal Consta shot, Invega Sustenna shot HaldolAkathisia, EPS Atypical - Sedation, dry mouth, tremors, constipation, trouble urinating, orthostatic hypotension, confusion, increased risk of metabolic syndrome Check hearing aids Behavioral and psychological symptoms of dementia Check the (BPSD); can use physical "Risperidone, needsbathroom, wet Zyprexa, Seroquel" in clothes/brief, short- term hungry, too hot or cold, Can increase pain risk of death in dementia Outdoor walks/ physical exercise/dancin g Psychotropic Medication Use for Older Adults Medication Class Drug Name Mood Stabilizers Depakote, Lamictal, Trileptal, Tegretol, Lithium, Nuedexta (Pseudobulbar affect) SedativeHypnotics (Sleeping Medications) Common: Melatonin, Trazodone Controlled: Ambien, Lunesta, Sonata, Restoril Most Common Side Effects Dizziness, drowsiness, nausea/vomiting, constipation, electrolyte imbalance, serious rashes, liver problems (Depakote), kidney problems (Lithium), falls (Nuedexta) Alternative Interventions Psychosocial therapy Important things to Remember Be aware of lithium toxicityextreme sleeping, slurred speech, muscle twitching, eyes going in circles Mostly from controlled sedatives- daytime sleepiness, cognitive impairment, amnesia, hallucinations, lethargy, odd behaviors, Dependence CBT- I (Cognitive behavioral therapy for insomnia) Sleep hygiene Sleep restrictions (no nap in the daytime) Stimulus control Long- halflife sedatives (e.g., Restoril) should be avoided; increased hangover, lethargy, falls, amnesia 42 Free wandering area Natural/enhanced environments Reduced stimulations The Resident Assessment Protocol (RAP) can be triggered by using a psychotropic drug if one or more of the following is present: ⦁ Potential for Drug-Related Hypotension or Gait Disturbance if: Repetitive physical movement, balance problem, hypotension, dizziness, syncope, unsteady gait, fell in past 30 days, hip fracture, swallowing problem ⦁ Potential for Drug-Related Discomfort if Constipation, fecal impaction, lung aspiration ⦁ Potential for Drug-Related Cognitive/Behavioral Impairment if: Mental function varies over the day, delirium, Deterioration (including cognition, communication, mood, behaviors), hallucinations Source: CMS. (2002). Long‐ term care facility resident assessment instrument (RAI); User's Manual, version 2.0. Centers for Medicare & Medicaid Services Owner: Kimmy Kwong, RN, BSN, PMH-DNP-Student Current: November 19, 2019 43 44 45 46 47 48 49 50 51 52 53 54