ESSAY: EVIDENCE BASED RESEARCH AND THE TREATMENT OF DEMENTIAIntroductionFor the purpose of this assignment I have selected the topic of antipsychotic drugs in the treatment of dementia. In the report I will demonstrate my understanding of the components of evidence based research, its place in current nursing care and its application and use in the understanding and treatment of dementia.I was initially drawn to the subject of dementia and antipsychotic drugs as a result of the increased media interest in the subject arising from recent studies on the increased mortality rates associated with such treatment (Schneider et al 2005). I felt the subject choice offered a good opportunity to demonstrate a strategic approach to data collation, the dissemination of the research, the interpretation of any findings, a critical appraisal and to conclude with some personal observations.

Context of Topic, Theory and Critical ObservationsAt the heart of a patients expectations of health care is the belief that nursing and medical care should be based on solid evidence, the existence of which forms a fundamental component of any clinical decision making (Ottenbacher et al 2001). In essence, evidence based practice is the adaptation of epistemology and methodology derived from the natural sciences and applied to fields of clinical medicine, health care and also education (Marks 2002).There are a number of different camps of thought on the importance and definition of evidence based research. For example, Appleby et al (1995) believe that it represents a move away from basing decisions on opinions and past practice, Sackett et al (1996) postulate that evidence is the fundamental component of the health care decision making process, whereas McKibbon and Walker (1994) argue for a more holistic approach with evidence to include the views of the patient. Clearly, with such wide variations of interpretation, there is a potential for the polarisation of evidence based research, the adoption of criteria specific to one single school of thought and consequently a real danger of ignoring some key aspect of research and understanding which could have a significant impact on any clinical decision taken (Hancock and Easen 2004).Nursing practitioners are at the front line of patient care (Mulhall 2002). They represent the single, most constant opportunity to gauge the effectiveness of a particular clinical decision on the patient (Guyatt et al 2000). Their observations, at whatever time frame is relevant to the specific patient in any one nursing shift, represents the greatest opportunity to the clinical profession to check that the outcomes expected from a decision have been successfully realised (Gerrish and Clayton 2004). The source of evidence is clearly of key importance, and the relevance and appropriateness of specific sources is dictated by a defined hierarchy (Ottenbacher et al 2001), at the top of which is the meta-analysis of controlled trials and at the bottom is the views of colleagues and peers. A summary of the hierarchy of evidence, sourced from Evidence Based Nursing Practice (ENBP online) is presented in Table 1 below(1):LevelDescriptionExample

OneStrong evidence from at leastone systematic review of welldesigned randomised controlled trials (RCTS)Meta analyses The Cochrane Collaboration

TwoEvidence from at least one properly designed RCT of appropriate sizeArticles published in peer-reviewed journals

ThreeEvidence from well designed trials without randomization: cohort, time series or matched case controlled studies Articles published in peer-reviewed journals

FourEvidence from well designed non-experimental studies from more than one centre or research groupArticles published in peer-reviewed journals

FiveOpinions from respected authorities, based on clinical evidence, descriptive studies or reports from committeesNICE guidelines. Evidence-based local procedures and care pathways

SixViews of colleagues/peersNursing colleagues or members of the multidisciplinary team

Table 1

In view of the recognised observational benefits arising from the nursing practitioner, it is unfortunate that their personal views and observations are at the lower end of the hierarchy (Welsh et al 2001). Particularly, since there are some areas of nursing care, not least those in the field of mental health (Lines 2001), which are significantly under researched, either due to lack of funding or interest. Consequently, there is a valid challenge to the established hierarchy of evidence based research on the grounds that it is fundamentally wrong to ignore the observations of the nursing practitioners and their exposure to the effects on the patient, positive or not, until more detailed evidential trials are available, or even until the organisers of any research trials have had the opportunity to disseminate their findings and publish the results in a recognised academic journals or have their observations peer reviewed at a conference (Bucknall et al 2001).Evidence based research is often perceived to be primarily a body of empirical knowledge with its basis in proven facts, substantiated by qualitative and quantitative data. This premise is fundamentally nave, and recognition of the weakness in empirical data alone was promoted by Carper (1978) and her identification of the four key types of nursing of empirical, ethical, aesthetic and personal; each of which had their own specific strands of evidence. Empirical and the presence of academic research data is clear and can be perceived as an auditable source of information for influencing the decision making process. In contrast, ethical, aesthetic and personal nursing types, as purported by Carper (1978) and reinforced by Bishop and Scudder (1990), could be unique to the individual nursing practitioner and are influenced by their personal moral code and belief systems, their skill and ability as a practitioner and the interpersonal relationship which exists, or is being developed, between the practitioner and the patient. From a nursing practitioner perspective, empirical evidence based research must be supported by the three other nursing types and any decisions should not only be based on research (Jennings et al 2001). Any conscious choice to focus purely on the qualitative and quantitative research data is unfounded and would undermine the principal objective of the nursing practitioner, that is, to meet the health care needs of the individual (Olade 2004). Fundamental to successful health care is that nursing practitioners do not participate in interventions arising from historic research which has now been proved to be unfounded and a risk to the patient. For example, in mental health care the administration of high dose anti psychotic medication has recently been proved to be detrimental to the long term health outcomes of patients with dementia (Banerjee 2009).In view of this, one could propose that the empirical evidence exists only as a base to inform decisions and to guide best practice; it should not exist to dictate decisions or best practice (Melynk et al 2002). Indeed, it could be argued that the role of the nursing practitioner in evidence based research is to ensure that all nursing and clinical interventions are designed to do more good than harm and, according to Forbes and Griffiths (2002), represent an ongoing lessons learned activity with any intervention being revisited when better evidence and clearer observations come to the fore. Indeed, French (2002), Kitson (2002) and McCormack et al (2002) all emphasise the importance of the nursing practitioner reflecting on the importance of decisions, the outcomes and the value of the initial observational evidence.Although the nursing practitioner operates in a dynamic environment, it is unfortunate that many aspect of nursing are the legacy of historic practice and the hand down of the believed best practice across the generations. As a result of this, there is a growing desire to minimise risk, both to the patient in terms of health and well being, and to the organisation in terms of litigation, and recognition that evidence based practice is fundamental to the continued improvement of nursing (UKCC 1996) . At the heart of any decision relating to the patient is a question (Melnyk et al 2002). For example, what is the problem, why has the problem occurred, what are the potential solutions, what is the best solution for the specific needs of the patient, what are the risks and consequences of any remedial actions? The very need to make a decision and answer any one or more of the above questions, necessitates the consideration of evidential support and existing knowledge; either empirical from previous research studies or personal from the nurse practitioners relationship with the patient. However, before this can be undertaken there is a need to be more specific in terms of what the principal question is, and once this is ascertained, carry out a grading of all ancillary questions and issues which may be relevant, but of lower consequence. To a certain extent, success in this area can be facilitated by the experience of the nursing practitioner who may have experienced a similar case in the past, and as a result, is better able to focus attention on the root problem and then have a sound base for evidence collation.From a personal perspective, I am particularly attracted to the theory offered by Sackett et al (2000) and the concept of P.I.C.O., that is, patient or problem, intervention, comparison and outcome. The notion of the theory is that questions designed to gain specific knowledge about managing the patient and the disorder. A worked example, sourced from Fitzpatrick (2007)(2) is presented in Table 2 below:Worked examples of EBP questionsTopic: Patient education and pain management following surgeryQuestion 1: Does patient education affect the patients understanding of their choices in pain relief following surgery?P = surgical patients offered patient education about pain relief;I = targeted patient education about choices in pain relief;C = no specific education about choices in pain relief;O = knowledge base.Question 2: Does patient education reduce the patients requirement for analgesia post surgery?P = patients scheduled for surgical procedures;I = patient receives targeted patient education about analgesia available post surgery;C = standard information given to the patient;O = comparison between the levels of analgesia required by:a. One group of patients who receive standard preoperative information;b. A second group of patients who receive targeted patient information about analgesia available post surgery.

Table 2The need to find evidence comes from the need to make a decision which, in turn, comes from the answers to the questions (Melnyk et al 2002). Reference has already been made to the hierarchy of evidence which is available to the nursing practitioner to facilitate the successful evidence based practice and is based on the perception that strong empirical evidence, particularly, if it has been subject to rigorous calibration, is far superior to the opinions, thoughts and observations of nursing colleagues or members of any multidisciplinary team (Forbes et al 2002).The choice of evidence in support of any decision or to facilitate the decision making process is of key importance. Although there are many potential sources, it is likely that no single source can fulfil all the nursing practitioners needs or demonstrate effective evidence based research (Mulhall 2002). For most nursing practitioners the principal sources of any evidence are likely to be academic textbooks or guidance and recommendations from more experienced colleagues (Jennings et al 2001). However, both these sources offer two key weaknesses, specifically the textbook sources are highly likely to be out of date and not representative of current empirical assessments and colleagues themselves are likely to be making their judgements on such archived documents. In addition to this, the nature of many academic texts is that they propose theories and provoke thoughts in the reader rather than giving definitive answers to the bespoke problem facing the nursing practitioner. With this in mind, such sources, although a valuable first step towards influencing the decision making process must always be treated with some scepticism (Stevens et al 2001). In view of this, reference to academic journals, literature reviews and the findings and presentations made to conferences offer valuable alternatives (Coomarasamy et al 2001), or rather, support structures for the conventional library sourced material (Marks et al 2000). Not only do these sources represent a more up to date assessment of a topic, they are an invaluable source of empirical data which, if to be successfully included in an academic journal, have been subject to peer calibration and appraisal (Kerse et al 2001). Consequently, the findings reported in such sources offer an insight into the current thinking and an excellent learning opportunity for the nursing practitioner, that is, combining an understanding of and interpretation of the quantitative and qualitative data with the aesthetic and personal knowledge of the practitioner (Dixon-Woods et al 2001).

Practical Application of Theory to DementiaDementia can be defined as a progressive and largely irreversible clinical condition that is characterised by the widespread impairment of mental function. Dementia patients, during the course of their degeneration, will experience some or all of the most common symptoms, including memory loss, language impairment, personality changes, self neglect, psychiatric symptoms and out-of-character behaviour (NICE 2006).In 2009, it was estimated that there were approximately 700,000 people with dementia in the UK, with a forecast increase to 1.4 million within 30 years. The national cost of dementia is currently 17billion per year, with a forecast increase to 50 billion within 30 years (Bannerjee 2009) (3).Numerous adverse effects have been identified in dementia sufferers when treated with antipsychotic drugs, including parkinsonian symptoms, sedation, dizziness, unsteadiness, chest infections, and further cognitive impairment. Furthermore, there is a threefold risk of stroke associated with their use and mortality risk is raised (Lancet 2009).As a result of this, in recent years, there has been increased media interest, arising from published empirical research, for example Schneider et al (2005), on the implications, both to the health of the sufferer and financial cost to the state, on the use of antipsychotic drugs in the treatment of dementia, particularly for Alzheimers patients (The Times, November 2009). In response to this increased concern about the over prescription of antipsychotic drugs and as part of the priority being given to improving care for people with dementia, in 2009 Professor Sube Banerjee, was tasked by the Government to undertake an independent review of the use of anti psychotic drugs (Banerjee 2009).The essential finding of the report was that usage level of antipsychotic drugs were too high in the treatment of dementia sufferers and that the potential benefits were likely to be outweighed by the potential risks. Furthermore, it was acknowledged that the use of drugs presented a significant issue in terms of the quality of care and posed a consequential risk to patient safety and clinical effectiveness.Interest in the subject, particularly the inappropriate prescribing of antipsychotic medication, has not allayed since the 2009. Instead, there has been an ongoing campaign for a substantial reduction in their use, together with the wider adoption of alternative types of support aimed at maximising the quality of life for people with dementia and their carers. As recently as June 2001, the Dementia Action Alliance, with the support of the Social Care Institute for Excellence (SCIE), led a call to action on the use of medication for people with dementia (SCIE 2011)(4).As a nursing practitioner the Bannerjee Report (2009) is an invaluable assessment of the use of antipsychotic drugs in the treatment of dementia. From a personal perspective it represents an insightful desire for information by the Government and the health agencies in order that they can collate a strong body of evidence which would facilitate improved clinical decisions, address public concerns, reduce costs, but, most importantly, lead to improved treatment and life for the sufferer.The report represents a primary example of recommendations and decision making based upon extensive evidence gathering and is a clear example of the application of evidence based practice to the health care problem of dementia. Although it gives strong reference and acknowledgement to the empirical data collation in terms of the statistical analysis arising from the multitude of drug trials which have been carried out on the use of antipsychotics, it also demonstrates that the non meta-physical aspects of the evidence based nursing practice hierarchy (ENBP online) are of importance, for example taking into account the personal perspectives of the dementia carers and their nursing practitioners.The need to reduce the prescription of antipsychotic drugs is clearly a challenge to the clinical team in the treatment of dementia. However, the move offers an excellent opportunity for the nursing practitioner, particularly due to the increased recognition that difficult behaviour in patients suffering from Alzheimers disease and dementia can be managed by using psycho-social interventions and adopting a patient focussed care approach. This places high importance on the individual needs of the patient and requires comprehensive observation of the patient by the nursing practitioner. The objective being, that aggravating or consoling factors affecting the patients behaviour can be spotted earlier and thereby reduce the occurrence of difficult behaviour and avoid the unnecessary use of medication. Indeed, Ballard et al (2004) show that where staff had been trained to provide more patient focussed care with primary consideration of the living environmental, attitudal and care practice factors, there was a reduced need for antipsychotic drugs. It is unfortunate, that due to inadequate staffing levels in care homes and home care services (Cohen-Mansfield et al 2007), together with a lack of appropriate training, in too many circumstances antipsychotics are prescribed unnecessarily early (Douglas et al 2002). In view of this, there is strong justification for the nursing practitioner to take a more holistic approach to the management of dementia sufferers, making full use of all the available evidence, empirical quantitative and qualitative, together with the personal observations which arise outside of any clinical diagnosis but are the fundamental product of the nurse and patient relationship which is established within the care and hospital environment (Fulbrook 2003). The reduction in the reliance on pharmacological measures for the management of the behavioural symptoms of dementia is as much to do with the education of the nursing practitioner. For example, Furniss et al (2000) report that the introduction of clear guidance on the prescription of drugs for residents of nursing homes can lead to a reduction in their use and suggest that between 54% and 88% of antipsychotic drug use in UK residential and nursing homes may be inappropriate(5).Such guidance was provided by the Royal College of Psychiatrists (2005) with their advice that antipsychotic drugs for particular behavioural and psychological symptoms, should only be used when the problem is severe or there is a significant risk to the patient or others and that any prescription should be time constrained. This was reinforced by the need to adequately document the rationale for adopting a pharmacological approach. This guidance represents a clear opportunity for a nursing practitioner to adopt a more holistic, evidence based approach to the management of dementia and Alzheimers and gives relevance to the need for the decision to be based on sound evidence, both specific to the individual patient and empirical in terms of the generic symptoms which may be present (Geannellos 2004). The recommendation that drug treatment is time limited is justified by the findings of Ballard et al (2004) which show supporting evidence that antipsychotics can be withdrawn successfully in people who have been relatively free from symptoms for 3 months(6).In view of this, it is clearly important that non pharmacological interventions are considered as the initial treatment of dementia and Alzheimers. Further justification for the non-drug approach is provided by Sink et al (2005) who argue that despite the extensive use of antipsychotic drug treatments options, there is only modest empirical evidence supporting their use in the management of the behavioural and psychological symptoms of the patient.Objectivity is a fundamental prerequisite of any quantitative research, with researchers seeking to avoid influencing the results and critically examining their methods and conclusions for any possible bias (Flick 2002). Although this is a valid approach, the very nature of dealing with dementia patients is the implied need for a more personal approach, particularly since the main emphasis of quantitative research is on deductive reasoning and such reasoning offers the potential risk of missing key pieces of evidence which will only become apparent outside of clinical observations, for example, an informal, friendly conversation between the nursing practitioner and the patient during bathing and dressing (Kitson 2002).

Conclusion and RecommendationsFrom my research into the theory of evidence based practice, and the consequential observation that there are significant polarities of theories, I feel a pragmatic evidence based approach to research is required. At the heart of this pragmatism is the recognition that nursing practitioners must grant themselves the freedom to use any combination of the research methods, techniques and procedures available with the objective of facilitating the acquisition of the most robust body of evidence to allow informed decisions to be made. In deciding the strength of weighing to be apportioned to each of the research methods, recognition must be given to the fact that each method has its own limitations and that the different approaches may be complementary. In conclusion, with this in mind, I feel strong reliance on the empirical evidence arising from drug trials and the statistical assessment of the impact of antipsychotic drugs to be of fundamental importance. After all, it was the results of these trials which instigated my interest in the subject for the purpose of this paper. However, as a nursing practitioner, and recognising the nursing attributes promoted by Carper (1978), and specifically in terms of the nursing management of dementia sufferers, I believe there is an essential need to bring a more personal focus to the evidence based approach for each patient, recognising that each patient has their own specific needs and problems and the decisions arising from the evidence collated, both empirical and non-empirical, will have to be adapted accordingly (Hancock and Easen 2004).

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