This research proposal aims to understand the concept of Dementia and the effect of anti-psychotic medicines and the treatment on the same. Find strategies to manage behavioural issues in dementia and reduce the usage of antipsychotic medications.
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Running head:RESEARCH PROPOSAL Research Proposal Name of the Student: Name of the University: ID of the Student: Unit Code:
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1Research Proposal Abstract: The following research proposal aims to understand the concept of Dementia and the effect of anti-psychotic medicines and the treatment on the same. Dementia is a psychological disorder, whereby, the patient loses the capability of retaining information. It is also related to impaired reasoning capability and changes in personality. Therefore, I the following study, the concept of Dementia has been analysed and there upon, the effects of the anti- psychotic medication procedures has also been reviewed. Further, certain strategies have been made that can be effective in order to deal with the problems or issues related to the use of anti- psychotic treatment. Introduction: Background of the Study As opined by (Lin & Lewis, 2015), dementia had emerged as one of the most issues faced by the senior citizens or the people generally over the age of 55 years of age and is characterised by the loss of memory or the inability of the individuals to remember even the most basic details of their lives. Experts are of the viewpoint that one of the most important trends seen within the framework of the treatment or care services which are being offered to the people suffering from dementia is the fact that attempts are being made to reduce the excessive usage of the different kinds of antipsychotic medications because of the negative effects of the same (Dempsey et al., 2014). For example, over the years it had been seen that the antipsychotic medications have proved to be beneficial for the management of the behavioural issues in the patients suffering from dementia however the side effects that the patients had to face because of the same can substantially affect the recovery process as well as the quality of the care which is being offered to the patients under discussion here. Thus, the need for the reduction of the usage of the concerned drugs for the treatment of the people
2Research Proposal suffering from dementia and also for the control of their behavioural issues has arisen for the improvement of the quality of the care which is being offered to the concerned patients and also for the purpose of speeding up of their recovery process. Problem Statement The problem for the usage of the antipsychotic medications for offering effective treatment or care services to the patients suffering from dementia and also for the control of their behavioural issues arises because of the fact that over the years it has not only formed one of the major treatment methods which had been used for offering treatment to the concerned patients but at the same time had offered effective results (Dempsey et al., 2014). However, the side effects or the negative effects that the patients had to face on the score of the usage of the antipsychotic medications reduces the quality of care or treatment services which are being offered to these patients but at the same time adversely affects the process of their recovery as well. It is precisely here that the need for the improvement of the medication which is presently being used for the treatment of the patients suffering from dementia comes into play since it will ensure that the patients do not have to face the side effects of the usage of these drugs which in turn will improve the quality of the treatment or care services that are being offered to them. Pragmatic Decisions The pragmatic decision which the researcher is going to make for the completion of the research is the fact that the researcher would be able to collect adequate primary as well as secondary data to make the study a feasible one. More importantly, another important pragmatic decision which the researcher had made at the beginning of the study is the fact that non- antipsychotic drugs although more expensive in price are likely to widely used by the patients because of the better quality results that they are likely to offer to the patients suffering from dementia (Lindauer & Harvarth, 2014).
3Research Proposal Research Aim The aim of this research is toidentify strategies that can be used to manage behavioural issues in dementia and reduce the usage of antipsychotic medications in the management of behavioural symptoms of dementia Research Questions PopulationDementia patients particularly the ones over the age of 55 years of age InterventionUsage of antipsychotic drugs for themanagement of behavioural issues in dementia ComparisonUsage of antipsychotic drugs and the ones the non- antipsychotic drugs OutcomesReductioninthesideeffectsfacedbythepatientsandtherebythe improvement of the treatment or the care services which are being offered to the patients The researcher will primarily focus on the below given research question for the effective completion of the study- How can the usage of non- antipsychotic drugs with fewer side effects be used for offering improved quality of treatment or care services to the dementia patients particularly the ones over the age of 55 years? Research Objectives Objective 1:Reduction in the side effects faced by the patients suffering from dementia through the usage of antipsychotic drugs SpecificThe specific goal is to reduce the number of side effects faced by the patients on the score of the usage of antipsychotic drugs MeasurableThis can be measured by comparing the results of the patients who are treated with antipsychotic drugs and the ones who are treated with non- antipsychotic drugs AttainableThis is a completely attainable goal provided the right of measures are being adopted by the care givers RelevantThis is a relevant goal since it will help in the improvement of the quality of the care services which are being offered to the dementia patients Timeframe1 year
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4Research Proposal Objective 2:Improvement of the quality of care or treatment services which are being offered to the patients SpecificThe specific goal is to improve the quality of the care or treatment services which are being offered to the patients suffering from dementia MeasurableThis can be measured by the speed of recovery of the patients AttainableThis is a completely attainable goal provided the care givers take the help of the right kind of measures RelevantThis is likely to help in the control of the behavioural issues among the patients suffering from dementia Timeframe1 year Objective 3:Usage of non-antipsychotic drugs for the improvement of care services which are being offered to the patients suffering from dementia SpecificThe specific goal is to promote the usage of non-antipsychotic drugs so as to improve the quality of the care services which are being offered to the patients MeasurableThis can be measured by comparing the results of the patients who are treated with antipsychotic drugs and the ones who are treated with non- antipsychotic drugs AttainableThis is a completely attainable goal provided the right of measures are being adopted by the care givers RelevantThis is a relevant goal since it will help in the improvement of the quality of the care services which are being offered to the dementia patients Timeframe1 year Gap Analysis Recent researches have clearly pointed out that the usage of antipsychotic drugs have various kinds of side effects which adversely affects the quality of the treatment or care services which are being offered to the patients. Thus, there is a need for change of practice of the measures which are being used for offering treatment to the dementia patients and one of the best possible options in this regard is the usage of non-antipsychotic drugs which have fewer side effects on the health of the patients. More importantly, the different kinds of side effects that the patients suffering from dementia inevitably face because of the usage of
5Research Proposal antipsychotic drugs substantially reduces the quality of the treatment services which are being offered to them and this in turn had necessitated the usage of the above-mentioned practice. On the score of these, it can be said that the primary difference between the practice which is being presently and the one which is being proposed is the fact that the usage of the proposed practice is likely to reduce the number of side effects that the patients suffering from dementia had to face and this in turn is also likely to also improve the quality of care or treatment services as well. Therefore, in order to conduct the research, a mixed method approach will be included and the data for the undertaken research will be gathered by following the interview methods and survey procedure. Further, for the analysis of the data both qualitative and quantitated methods will be included. Literature Review: Dementia has become one of the global prevalence among the elderly population around the world now days and it has put a significant burden on the health care system around the globe(Prince et al., 2013). Australia is also out of this scenario, as Australia displays the similar trend around the recent years. According to the Australian government’s health direct advice page, there are more than 400,000 individuals living with dementia in the Australian continent at present(Australia Health direct, 2018). It has also been stated that the around 50 per cent people living in the Australian residential facility for the elderly people are suffering from dementia. Almost one people out every ten people are suffering from dementia who is aged above 65 years(Australia Health direct, 2018). The incidence and prevalence of dementia are more likely increase and it is forecasted by the Australian health care department as such. They have reported that the around 589, 000 people living in Australia will be suffering by dementia by the year 2028 and the number will cross the
6Research Proposal threshold of million individual by the year 2058(Australia Health direct, 2018). From the statistics presented in the above section, it can be stated that the managing of dementia patient is one of the paramount importance for the Australian health care system as it more likely to put tremendous burden on the health care system and social care services for the aged and elderly people. One of most important and vital part of the managing dementia patients is the management of the BPSD or behavioural and psychological disturbance in dementia as most of the people suffering from dementia has experience the behavioural and psychological disturbance in dementia at some of point of their life during the onset of the dementia(Li et al., 2014). It is the most prevalent symptoms reported by the care giver, health care professionals, and nurses in the majority of the health care settings(Kales, Gitlin, & Lyketsos, 2015). One of the first line of treatment for the behavioural and psychological disturbance in dementia among the dementia patients is the administration of antipsychotic drugs for the management of this behavioural issues. However, in most of the cases, these antipsychotic drugs many adverse side effects associated with them. Many academics and researchers investigating in this area have reported the same and there is a significant body of evidence present about the adverse side effects occurring from these drugs(Declercq et al., 2013). Among the many side effects of the use of antipsychotic drugs, one of this are increased chance of stroke,sedation, Parkinsonism, cognitive decline, gait disturbance, pneumonia, and risk of death. People suffering from the dementia have already been compromisedinthetermsofqualityoflifeduethebehaviouralandpsychological disturbance occurs among the dementia patients. This does not only affect the quality of life for the patients, but as well as to the family of the patients as an extension. In addition to the psychological effect perceived by the patient, this also puts financial burden as well to the family of the patient(Guthrie, Clark, & McCowan, 2010). Hence, it can be stated that the not
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7Research Proposal only dementia affects the quality of life among the patients but also affects their family as well. On top of that it also put them under financial burden. All of these only exacerbated by the adverse effect presented by the antipsychotic drugs instead of lessen them. Furthermore, studieshaveshownthatthepsychoticadministeredasafirstlinetreatmentforthe behavioural and psychological disturbance among the dementia patients is not extremely effective. Studies have reported that the antipsychotic drugs like olanzapine, risperidone and aripiprazole have only shown to have moderate amount of beneficial for the treatment of symptoms like behavioural and psychological disturbance in dementia patients(Guthrie et al., 2010). However, it has been reported that the antipsychotic drugquetiapine has not shown similar kind of beneficial effect at all while administered among the dementia patients. In addition to that, all of these drugs have reported to have adverse side effects mentioned above. Thence, it can be deduced that the these antipsychotic drugs have moderate amount of beneficial effect for the treatment ofbehavioural and psychological disturbance in dementia patients but only exacerbated the situation further by exhibiting adverse side effects. These side effects only deteriorate or exacerbate the already compromised quality of life among the patients suffering from the dementia as well as their family(Tampi, Tampi, Balachandran, & Srinivasan,2016).Inadditiontothat,italsoincreasesthefinancialburdenforthe management and treatment of the patient. This well reported among the studies, however, administration of antipsychotic drug is the only viable solution for the management of the behavioural and psychological disturbance among dementia patients. Studies have also reported that the need of balancing of administration of the dosage during the treatment for these manifestation of side effects(Ballard, Corbett, & Howard, 2014). Gap Analysis: From the above discussion, it can be seen that the antipsychotics does have the desired effect while treating behavioural and psychological disturbance in dementia. In
8Research Proposal addition to that it also adds adverse side effects to the suffering individuals which only exaggerate the already deteriorated quality of life among the dementia patients. Researchers and academics investigating in this area have also raised similar concern regarding the administration of the antipsychotic drugs among the dementia patients due the manifestation of adverse side effects among them(NHS Coastal West Sussex Clinical Commissioning Group, 2018). Furthermore, the beneficial advantages are so good for the treatment of behavioural and psychological disturbance, so that the adverse side effects of this can be neglected. Hence, there is an urgent need for the alternative method for the treatment of the dementia patients.One of them can be to understanding the behaviours among the patients suffering from dementia and act according to that for the provision of holistic care to them. These behavioural strategies can be effective for the treatment as it will not have the side effects of the antipsychotic drugs. Another strategy can be to relieve the stress among them by the way of physical exercise(Eggenberger, Heimerl, & Bennett, 2013). Therefore, the goal of this research proposal will be effective treat the patient suffering from dementia with provision behavioural management strategy so that the adverse side effects of the antipsychotic drugs can be avoided. Methodology: Methodology refers to the processes of data collection and gathering information of the chosen topic, in order to deduce the hypothesis and to analyse the results in a systematic manner. The methodology includes the processes of designing the research, collecting the data needed for the analysis and the processes of analysing the data in order to reach a conclusion. For this particular research method a mixed method approach has been included, whereby, both the qualitative and the quantitative research methods will be applied (Taylor, Bogdan & DeVault, 2015). The qualitative research process essentially is primarily a form of
9Research Proposal exploratory research method, whereby, an unknown area of interest or focus is analysed through the modes of interviews and surveys. The interview methods include open ended questions, whereby the interviewer is supposed to incorporate a structured questionnaire and the interviewees are to enlighten upon those questions or areas. The research will further incorporate a quantitative analysis, whereby, the collected data will be analysed with the use of statistical analysis and further proper analysis charts will be presented in order to show the status of the data. Since the research will be including both the qualitative and the quantitative methods, using a mixed method approach therefore, the present research method will be an exploratory research in its orientation. An exploratory research is the one whereby, the researcher wants to find out or rather explore the areas that are unknown, and further present an analysis of the area that have remained unexplored still. Barriers: In order to conduct the study, various asylums and patient car institutions were visited andthedatawereessentiallycollectedformthecaregiversandthedoctorofthe organization. However, while conducting the study, many barriers or hindrances can be faced, these will include, Obtaining Information: One of the major challenge that can be faced in order to deal with the data is the obtaining information from the patients. The patients affected with dementia are essentially seen to be dealing with the problem of forgetfulness and lack the capacity or the ability of retaining any knowledge. Therefore, they are seen to be assisted by the family members or the care givers. They do not even have the knowledge of the medicines that they are provided
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10Research Proposal with, the care givers are the ones who have the proper knowledge of it (Carmody, Traynor & Marchetti, 2015). Moreover, the patients cannot recall the way they feel after having the medicines. Confusion of Information: Another major challenge that can be faced while conducting the research is that the researchers can be faced with confusions regarding the information. As the patients are unabletocommentproperlyonthequestionsduetotheirconditions,therefore,the researchers are to ask the care givers or the family members of the patients. Now, the care givers may entail completely different facts regarding the questions that vary greatly from that of the comments of the patients (De Vleminck et al., 2014). Also as they observe the whole thing from outside, therefore, they may not properly opine on the conditionings of the patients, which further may generate confusion. Ineffective Communication: The patients affected by Dementia, lack the ability to properly communicate upon the questions asked. This can prove to be problematic for the researcher. Also the researchers may lack the tolerance level to provide the patients with proper attention and they may find it difficulttounderstandandfurtherdeducefromtheknowledgethatisgainedupon questioning (De Vleminck et al., 2014). Proposed Strategies: The essential attributes related to Dementia are restlessness, aggression, disruptive behaviours and the lack of retention or a very weak or affected memory. The doctors are usually seen to be prescribing anti-psychotic drugs to help the and treat the patients, but studies have shown that the anti-psychotic drugs are not that effective and further generate much side effects, for example weight gain, pneumonia, tremors, stroke, diabetes and eve
11Research Proposal sudden death (Kales, Gittin & Lyketsos, 2015). Therefore, in order to deal with certain side effects, the following strategies can be maintained and followed. Lowering the Dosage: It is often seen that the anti-psychotics cannot be done without, but at the same time the high dosage of the medicines are advereskly affecting the psychological and behavioural aspects of the patients. Therefore, in such scenarios, lowering the dosage can prove to be helpful. It can be stated that the adverse effects of the dosage are more determined by the dosage of thee medicines and are not really medical urgency (Kales, Gittin & Lyketsos, 2015). Therefore, lowering the dose of the medicines can prove to be effective. However, lowering the dosage is essentially to be asked and modified by the doctor only. Practicing non- pharmacologic Medication: Non- pharmacologic medications procedures can also prove to be effective in certain cases, however, as understood, certain measures are still not invented that can approve to be helpful, yet the diet plan, meditation procedures and continuous attention to the patients by the family members and the care givers can prove to be helpful (Zuidema et al., 2015). Also continuous attention and retelling personal stories or personal achievements of the patients can also prove to be helpful for the patients. Switching to Medications that have different Side Effects: It is often seen that a particular medicine that has side effects of a particular kinds for a particular patient, has another kind of side effect for another patient. Therefore, this particular area can be identified and further can be acted upon. This essentially means that a change in the medications can prove to be helpful (Zuidema et al., 2015). Changing the types of medicine can elicit a different type of side effect to a person, which further can be not as adversely effective for the particular patient.
12Research Proposal Common antipsychotic adverse effects and management strategies Adverse effectsFirst choiceSecond choiceThird choice Others/ Comments DystoniasAnticholiner gic medication Antihistaminic medication Benzodiazep ine Parkinsonism(tremor, rigidity, bradykinesia) Lower doseChangeto antipsychotic with lower risk Concomitant useof anticholiner gic agent AkathisiaLower doseChange antipsychotic Concomitant use of beta‐ blocker Anticholinergic sand benzodiazepine s Tardive dyskinesiaLower doseValbenazineor deutetrabenazine Gingko bilobaor clonazepam SialorrheaConservativ e approaches suchas sugarless gumduring day,towel overpillow at night Anticholinergic drops (ipratropiumor atropine) topically/subling ually SedationDoseat night before sleep Lower doseChangeto less sedating antipsychoti c Stimulants haveunclear benefit Prolactinelevation, sexual side effects Dose reduction Changetoa prolactin‐sparing antipsychotic Add aripiprazole Phosphodiester aseinhibitors forsexual dysfunction Orthostatic hypotension Adjustdose ordosing schedule Behavioral changes including adequate hydration Change antipsychoti c Concomitant medication strategiesare limited QT prolongationChange antipsychoti c Avoidother QT‐prolonging agents Neurolepticmalignant syndrome Discontinue antipsychoti c Supportive measures includingIV hydrationand cooling Dantrolene and bromocripti ne Neutropenia/DiscontinueColony‐
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13Research Proposal agranulocytosisclozapine or other causative agent stimulating factors(e.g., filgastram) Impulsecontrol disorders/behavioral addictions Change antipsychoti c MyocarditisDiscontinue clozapine or other causative agent Weightgain, dyslipidemia Behavioral modificatio n(diet, exercise) Change antipsychotic Metformin Anticholinergic effects (drymouth,blurry vision,tachycardia, constipation) Lower doseChange antipsychotic Treat symptoms, e.g., constipation with osmotic agents, stimulant laxatives; tachycardia withbeta‐ blocker Limitother anticholinergic agents Ethical Consideration: While conducting the research the researchers can be faced with certain ethical issues, which can be, Reliability: As the researchers can be faced with double information, that is, a differed information from the patient and the care givers, therefore, there can be an issue of reliability among the researchers. The issue of reliability can also be generated upon interviewing the doctors. It is seen that the doctors are often faced with impositions form the medical representatives in order to use their medicines, and they get because of the same (Stretch et al., 2013). Therefore, the doctors can
14Research Proposal be seen to be lying about the outcomes or the effects of the medication used. This can also result into the issue of reliability. Target Audience: It can be difficult to choose from the patients, as the basic symptoms of this diseaseareoftenseentobesimilarwithotherformsofdiseases,likeParkinson’s, Alzheimer’s and certain other age related issues. Therefore, the researchers must be adept to understand and recognise form the patients.
15Research Proposal Reference: Australia Health direct, H. (2018, November 5). Dementia statistics. Retrieved June 11, 2019, from https://www.healthdirect.gov.au/dementia-statistics Ballard, C., Corbett, A., & Howard, R. (2014). Prescription of antipsychotics in people with dementia.TheBritishJournalofPsychiatry,205(1),4–5. https://doi.org/10.1192/bjp.bp.113.128710 Carmody, J., Traynor, V., & Marchetti, E. (2015). Barriers to qualitative dementia research: the elephant in the room.Qualitative health research,25(7), 1013-1019. DeVleminck,A.,Pardon,K.,Beernaert,K.,Deschepper,R.,Houttekier,D.,Van Audenhove, C., ... & Vander Stichele, R. (2014). Barriers to advance care planning in cancer,heartfailureanddementiapatients:afocusgroupstudyongeneral practitioners' views and experiences.PloS one,9(1), e84905. Declercq, T., Petrovic, M., Azermai, M., Stichele, R. V., Sutter, A. I. D., Driel, M. L. van, & Christiaens, T. (2013). Withdrawal versus continuation of chronic antipsychotic drugs forbehaviouralandpsychologicalsymptomsinolderpeoplewithdementia. CochraneDatabaseofSystematicReviews,(3). https://doi.org/10.1002/14651858.CD007726.pub2 Dempsey, L., Murphy, K., Cooney, A., Casey, D., O’Shea, E., Devane, D., ... & Hunter, A. (2014). Reminiscence in dementia: a concept analysis.Dementia,13(2), 176-192. Eggenberger, E., Heimerl, K., & Bennett, M. I. (2013). Communication skills training in dementia care: a systematic review of effectiveness, training content, and didactic methods in different care settings.International Psychogeriatrics,25(3), 345–358. https://doi.org/10.1017/S1041610212001664
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16Research Proposal Guthrie, B., Clark, S. A., & McCowan, C. (2010). The burden of psychotropic drug prescribing in people with dementia: a population database study.Age and Ageing, 39(5), 637–642. https://doi.org/10.1093/ageing/afq090 Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia.Bmj,350, h369. Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioralandpsychologicalsymptomsofdementia.BMJ,350,h369. https://doi.org/10.1136/bmj.h369 Li, S. Q., Guthridge, S. L., Aratchige, P. E., Lowe, M. P., Wang, Z., Zhao, Y., & Krause, V. (2014).DementiaprevalenceandincidenceamongtheIndigenousandnon- Indigenous populations of the Lin, S. Y., & Lewis, F. M. (2015). Dementia friendly, dementia capable, and dementia positive: concepts to prepare for the future.The Gerontologist,55(2), 237-244. Lindauer, A., & Harvath, T. A. (2014). Pre‐death grief in the context of dementia caregiving: A concept analysis.Journal of Advanced Nursing,70(10), 2196-2207. NHSCoastalWestSussexClinicalCommissioningGroup.(2018).Areviewof antipsychotics in patients with dementia – SPS - Specialist Pharmacy Service – The firststopforprofessionalmedicinesadvice.RetrievedJune11,2019,from https://www.sps.nhs.uk/repositories/a-review-of-antipsychotics-in-patients-with- dementia-varinder-rai/ NorthernTerritory.MedicalJournalofAustralia,200(8),465–469. https://doi.org/10.5694/mja13.11052
17Research Proposal Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W., & Ferri, C. P. (2013). The global prevalence of dementia: A systematicreview and metaanalysis.Alzheimer’s & Dementia,9(1), 63-75.e2. https://doi.org/10.1016/j.jalz.2012.11.007 Strech, D., Mertz, M., Knuüppel, H., Neitzke, G., & Schmidhuber, M. (2013). The full spectrum of ethical issues in dementia care: systematic qualitative review.The British Journal of Psychiatry,202(6), 400-406. Tampi, R. R., Tampi, D. J., Balachandran, S., & Srinivasan, S. (2016). Antipsychotic use in dementia: a systematic review of benefits and risks from meta-analyses.Therapeutic AdvancesinChronicDisease,7(5),229–245. https://doi.org/10.1177/2040622316658463. Taylor, S. J., Bogdan, R., & DeVault, M. (2015).Introduction to qualitative research methods: A guidebook and resource. John Wiley & Sons. Zuidema,S.U.,Johansson,A.,Selbaek,G.,Murray,M.,Burns,A.,Ballard,C.,& Koopmans, R. T. (2015). A consensus guideline for antipsychotic drug use for dementia in care homes. Bridging the gap between scientific evidence and clinical practice.International psychogeriatrics,27(11), 1849-1859.