Quality and Excellence in Specialist Dementia Care (QESDC): baseline one-off self-assessment tool and reporting arrangements

Outcome 4. Medication, non-pharmacological support and managing stressed and distressed behaviours

People with dementia experience care that is tailored to meet their individual needs and promotes their mental wellbeing. Care for people with dementia meets the Scottish Government Standards of Care for Dementia in Scotland, and guidelines on use of medication for the behavioural and psychological symptoms of people with dementia are available to all staff.

Medication should be used as a last resort in the management of people with dementia who exhibit stressed and distressed behaviours. "Start low, go slow" is the edict used to guide prescribing for people with dementia in NHS Dumfries & Galloway, where the use of discretionary medication is monitored to assess requirements for anti-psychotic medication and carers are involved in reviews.

Boards have review processes in place to ensure medication prescriptions are appropriate to patients' needs. All patient medications in NHS Grampian, for example, are reviewed on admission to hospital. A multidisciplinary review is then carried out on a weekly basis, with progress reports and future plans documented in medical and nursing notes. Weekly multidisciplinary ward rounds are conducted in NHS Highland with a view to reducing polypharmacy for patients. Polypharmacy has also been investigated in four ward areas in NHS Borders, three of which were under the Mental Health for Older Adults service. A complete review was undertaken of each patient's medication regime, with significant changes made to address interactions and multiple prescribing.

Patient medication reviews form an integral part of multidisciplinary meetings and case reviews in NHS Forth Valley, and an audit of six sets of patient notes in a 20-bedded male dementia assessment unit in NHS Lothian revealed that medication had been reviewed weekly by the multidisciplinary team and attempts had been made to reduce the use of anti-psychotic drugs.

NHS Lanarkshire has been instituting psychological and other non-pharmacological approaches in its inpatient sites for several years: these are now established as core elements of care. Community and inpatient staff are trained to assess and respond to distress using methods based on the "Newcastle Model". The training comprises a two-day workshop developed by NHS Education for Scotland that has been delivered (using a "train-the-trainers" approach) to senior clinical staff working at Enhanced/Expertise levels of the Promoting Excellence Framework. The content provides staff with a formal structure from which to coordinate holistic multidisciplinary assessments and develop highly personalised formulation-led care plans.

Stress and distress training has been rolled out extensively across local inpatient, community and nursing home teams in the board area and work is ongoing to establish Stress and Distress Champions from existing nursing staff to support wards. Carers and families are also encouraged to be involved. All this means a non-pharmacological approach is now expected to be the first option.

At present, people with dementia in NHS Forth Valley who are stressed or distressed are assessed and supported with treatment plans agreed by the clinical team in their ward. The availability of specialist support from clinical psychology services is very limited, however, and while several staff trainers for NHS Education for Scotland's "Responding to Stress and Distress in Dementia" course are in place, the roll-out plan for this training is under review. Assessment of distress is the first-line approach adopted in NHS Lothian, with patients referred to Edinburgh Behaviour Support Services if necessary.

Cognitive Stimulation Therapy (CST), a brief treatment for people with mild-to-moderate dementia, has been introduced by some boards, including NHS Ayrshire & Arran. In addition, practically all qualified nursing staff in the elderly mental health service in NHS Ayrshire & Arran have undertaken Promoting Excellence training to Expertise Level. This, the board believes, will enable the achievement of a reduction in the number of incidents involving violence and aggression by implementing ABC charts^[9] as part of a needs-assessment and formulation process. A reduction in the use of "when required" medication is also anticipated.

The board has also introduced a delirium pathway for use in general hospitals and elderly mental health wards, backed by a proactive training programme primarily focused on the acute hospital setting and delivered in conjunction with elderly mental health medical and nursing staff.

Some of the boards have established a range of other non-pharmacological interventions in which people can take part, such as use of outdoor space and dementia-friendly gardens, reminiscence therapy, aromatherapy and music therapy. NHS Lothian in among the boards who use "Memory boxes" as part of a range of meaningful activities for patients.