Antipsychotic Deprescription for Older Adults in Long-term Care: The HALT Study

National surveillance using a clinical quality indicator for prolonged antipsychotic use among older Australians with dementia who access aged care services

OBJECTIVES

Dementia guidelines recommend antipsychotics are only used for behavioral and psychological symptoms when non-drug interventions fail, and to regularly review use. Population-level clinical quality indicators (CQIs) for dementia care in permanent residential aged care (PRAC) typically monitor prevalence of antipsychotic use but not prolonged use. This study aimed to develop a CQI for antipsychotic use >90 days and examine trends, associated factors, and variation in CQI incidence; and examine duration of the first episode of use among individuals with dementia accessing home care packages (HCPs) or PRAC.

METHODS

Retrospective cohort study, including older individuals with dementia who accessed HCPs (n = 50,257) or PRAC (n = 250,196). Trends in annual CQI incidence (2011-12 to 2015-16) and associated factors were determined using Poisson regression. Funnel plots examined geographical and facility variation. Time to antipsychotic discontinuation was estimated among new antipsychotic users accessing HCP (n = 2367) and PRAC (n = 15,597) using the cumulative incidence function.

RESULTS

Between 2011-12 and 2015-16, antipsychotic use for >90 days decreased in HCP recipients from 10.7% (95% CI 10.2-11.1) to 10.1% (95% CI 9.6-10.5, adjusted incidence rate ratio (aIRR) 0.97 (95% CI 0.95-0.98)), and in PRAC residents from 24.5% (95% CI 24.2-24.7) to 21.8% (95% CI 21.5-22.0, aIRR 0.97 (95% CI 0.96-0.98)). Prior antipsychotic use (both cohorts) and being male and greater socioeconomic disadvantage (PRAC cohort) were associated with higher CQI incidence. Little geographical/facility variation was observed. Median treatment duration in HCP and PRAC was 334 (interquartile range [IQR] 108-958) and 555 (IQR 197-1239) days, respectively.

CONCLUSIONS

While small decreases in antipsychotic use >90 days were observed between 2011-12 and 2015-16, findings suggest antipsychotic use among aged care recipients with dementia can be further minimized.

Nonpharmacological nursing interventions for behavioural and psychological symptoms of dementia in acute and subacute settings: A systematic review

BACKGROUND

Behavioural and psychological symptoms of dementia are a group of non-cognitive symptoms such as agitation, physical aggression, depression, sexual disinhibition and psychosis. Therapeutic approaches vary because of the multifactorial and complex symptomology. The researchers of this study aimed to systematically review the nonpharmacological interventions for BPSD used by nurses in acute and subacute hospital settings.

DESIGN

The PRISMA guidelines guided this systematic review. The review was registered with PROSPERO (CRD42020184015).

METHOD

The databases Cumulative Index of Nursing and Allied Health Literature (CINAHL) complete, Medline complete, Excerpta Medica (Embase®) and PsycINFO published by the American Psychological Association (APA) were searched for studies published in English to October 2021. Quality appraisal was performed independently by three reviewers using the Critical Appraisal Skills Program tools. Data were synthesized using a narrative approach.

RESULTS

Two studies were identified that focused on interventions used by nurses; findings were positive for the use of nonpharmacological interventions to manage BPSD.

CONCLUSION

Current evidence suggests that nonpharmacological interventions are the best practices to manage BPSD. However, limited, and low-quality evidence suggests that further investigation is required to understand the factors contributing to the lack of use of nonpharmacological interventions by nurses in acute and subacute hospital settings.

Physician Antipsychotic Overprescribing Letters and Cognitive, Behavioral, and Physical Health Outcomes Among People With Dementia: A Secondary Analysis of a Randomized Clinical Trial

Importance

Antipsychotics, such as quetiapine, are frequently prescribed to people with dementia to address behavioral symptoms but can also cause harm in this population.

Objective

To determine whether warning letters to high prescribers of quetiapine can successfully reduce its use among patients with dementia and to investigate the impacts on patients' health outcomes.

Design, Setting, and Participants

This is a secondary analysis of a randomized clinical trial of overprescribing letters that began in April 2015 and included the highest-volume primary care physician (PCP) prescribers of quetiapine in original Medicare. Outcomes of patients with dementia were analyzed in repeated 90-day cross-sections through December 2018. Analyses were conducted from September 2021 to February 2024.

Interventions

PCPs were randomized to a placebo letter or 3 overprescribing warning letters stating that their prescribing of quetiapine was high and under review by Medicare.

Main Outcomes and Measures

The primary outcome of this analysis was patients' total quetiapine use in days per 90-day period (the original trial primary outcome was total quetiapine prescribing by study PCPs). Prespecified secondary outcomes included measures of cognitive function and behavioral symptoms from nursing home assessments, indicators of depression from screening questionnaires in assessments and diagnoses in claims, metabolic diagnoses derived from assessments and claims, indicators of use of the hospital and other health care services, and death. Outcomes were analyzed separately for patients living in nursing homes and in the community.

Results

Of the 5055 study PCPs, 2528 were randomized to the placebo letter, and 2527 were randomized to the 3 warning letters. A total of 84 881 patients with dementia living in nursing homes and 261 288 community-dwelling patients with dementia were attributed to these PCPs. There were 92 874 baseline patients (mean [SD] age, 81.5 [10.5] years; 64 242 female [69.2%]). The intervention reduced quetiapine use among both nursing home patients (adjusted difference, -0.7 days; 95% CI, -1.3 to -0.1 days; P = .02) and community-dwelling patients (adjusted difference, -1.5 days; 95% CI, -1.8 to -1.1 days; P < .001). There were no detected adverse effects on cognitive function (cognitive function scale adjusted difference, 0.01; 95% CI, -0.01 to 0.03; P = .19), behavioral symptoms (agitated or reactive behavior adjusted difference, -0.2%; 95% CI -1.2% to 0.8% percentage points; P = .72), depression, metabolic diagnoses, or more severe outcomes, including hospitalization and death.

Conclusions and Relevance

This study found that overprescribing warning letters to PCPs safely reduced quetiapine prescribing to their patients with dementia. This intervention and others like it may be useful for future efforts to promote guideline-concordant care.

Trial Registration

ClinicalTrials.gov Identifier: NCT05172687.

Prevalence, country-specific prescribing patterns and determinants of benzodiazepine use in community-residing older adults in 7 European countries

BACKGROUND

The use of benzodiazepines (BZDs) in older population is often accompanied by drug-related complications. Inappropriate BZD use significantly alters older adults' clinical and functional status. This study compares the prevalence, prescribing patterns and factors associated with BZD use in community-dwelling older patients in 7 European countries.

METHODS

International, cross-sectional study was conducted in community-dwelling older adults (65 +) in the Czech Republic, Serbia, Estonia, Bulgaria, Croatia, Turkey, and Spain between Feb2019 and Mar2020. Structured and standardized questionnaire based on interRAI assessment scales was applied. Logistic regression was used to evaluate factors associated with BZD use.

RESULTS

Out of 2,865 older patients (mean age 73.2 years ± 6.8, 61.2% women) 14.9% were BZD users. The highest prevalence of BZD use was identified in Croatia (35.5%), Spain (33.5%) and Serbia (31.3%). The most frequently prescribed BZDs were diazepam (27.9% of 426 BZD users), alprazolam (23.7%), bromazepam (22.8%) and lorazepam (16.7%). Independent factors associated with BZD use were female gender (OR 1.58, 95%CI 1.19-2.10), hyperpolypharmacy (OR 1.97, 95%CI 1.22-3.16), anxiety (OR 4.26, 95%CI 2.86-6.38), sleeping problems (OR 4.47, 95%CI 3.38-5.92), depression (OR 1.95, 95%CI 1.29-2.95), repetitive anxious complaints (OR 1.77, 95%CI 1.29-2.42), problems with syncope (OR 1.78, 95%CI 1.03-3.06), and loss of appetite (OR 0.60, 95%CI 0.38-0.94). In comparison to Croatia, residing in other countries was associated with lower odds of BZD use (ORs varied from 0.49 (95%CI 0.32-0.75) in Spain to 0.01 (95%CI 0.00-0.03) in Turkey), excluding Serbia (OR 1.11, 95%CI 0.79-1.56).

CONCLUSIONS

Despite well-known negative effects, BZDs are still frequently prescribed in older outpatient population in European countries. Principles of safer geriatric prescribing and effective deprescribing strategies should be individually applied in older BZD users.

[Safe discontinuation of psychotropic drugs in older people? : New evidence and practical approach]

BACKGROUND

Many older patients are permanently prescribed one or more psychotropic drugs for treatment of symptoms, such as behavioral and psychological symptoms in dementia, depressive symptoms, anxiety, and insomnia. They therefore contribute to the risk of polypharmacy. Recently, deprescribing studies have been published in order to clarify if inadequate medications can be safely discontinued. This mini-review summarizes the study results and derives practical recommendations for routine use.

METHOD

A literature search was carried out in PubMed for clinical studies on deprescribing in association with psychotropic substances.

RESULTS

After removal of duplications, 12 heterogeneous clinical studies were identified and reduction of psychotropic substances could be successfully achieved in 8 studies. In four of these studies psychological, behavioral and functional endpoints were reported. Criteria for successful deprescribing of sedatives were in particular motivation, information and sufficient cooperation of the patients and for antipsychotic drugs in people with dementia, the sustainable establishment of nonpharmaceutical treatment strategies. Deprescribing was not attempted in cases of a history of severe chronic mental illness and in cases of severe behavioral symptoms in dementia. Evidence for antidepressants was not sufficient to extract practical recommendations.

CONCLUSION

Safe deprescribing of antipsychotic drugs in patients with dementia is justified if non-pharmacological treatment options are sustainably implemented, and for sedative drugs in well-informed, highly motivated and cooperative patients.

Ten-Year Trends in Psychotropic Prescribing and Polypharmacy in Australian General Practice Patients with and without Dementia

OBJECTIVE

Little research has evaluated trends in psychotropic prescribing and polypharmacy in primary care patients, especially those with dementia. We sought to examine this in Australia from 2011 to 2020 using the primary care dataset, MedicineInsight.

METHODS

Ten consecutive serial cross-sectional analyses were performed to evaluate the proportion of patients aged 65 years or more, with a recorded diagnosis of dementia, who were prescribed psychotropic medications within the first six months of each year from 2011 to 2020. This proportion was compared with propensity score-matched control patients without dementia.

RESULTS

Before matching, 24,701 patients (59.2% females) with, and 72,105 patients (59.2% females) without, a recorded diagnosis of dementia were included. In 2011, 42% (95% confidence interval [CI] 40.5-43.5%) of patients in the dementia group had at least one recorded prescription of a psychotropic medication, which declined to 34.2% (95% CI 33.3-35.1%; p for trend < 0.001) by 2020. However, it remained unchanged for matched controls (36% [95% CI 34.6-37.5%] in 2011 and 36.7% [95% CI 35.7-37.6%] in 2020). The greatest decline in the dementia groups by medication class was for antipsychotics (from 15.9% [95% CI 14.8-17.0%] to 8.8% [95% CI 8.2-9.4%]; p for trend < 0.001). During this period, the prevalence of psychotropic polypharmacy (use of two or more individual psychotropics) also decreased from 21.7% (95% CI 20.5-22.9%) to 18.1% (95% CI 17.4-18.9%) in the dementia groups, and slightly increased from 15.2% (95% CI 14.1-16.3%) to 16.6% (95% CI 15.9-17.3%) in the matched controls.

CONCLUSIONS

The decline in psychotropic prescribing, particularly antipsychotics, in Australian primary care patients with dementia is encouraging. However, psychotropic polypharmacy still occurred in almost one in five patients with dementia at the end of the study period. Programs focused on encouraging further reductions in the use of multiple psychotropic drugs in patients with dementia are recommended, particularly in rural and remote regions.

State-level nursing home in-service dementia training requirements and inappropriate psychotropic medication use

BACKGROUND

Although non-pharmacological interventions, which are staff intensive, are recommended for behavioral symptoms of dementia, psychotropics are often prescribed in nursing homes (NHs), with insufficient nurse staffing levels and dementia care training. Since 2017, deficiency citations can be assigned for inappropriate psychotropics use (F-758 tag). Some states require in-service dementia training above federal minimums, but it is unknown whether extra dementia training requirements were related to fewer F-758 citations for residents with dementia and whether nurse staffing influenced the relationship between receiving F-758 citations and having additional state-level dementia training requirements.

PURPOSE

To relate F-758 citation occurrence to extra in-service dementia training regulations and to explore how the relationships are affected by nurse staffing levels.

METHOD

Generalized linear mixed models were used to examine F-758 citation occurrence in relation to state-level in-service dementia training regulations. Stratification was also conducted to compare the effects in NHs with low versus high nurse staffing.

FINDINGS

Requiring in-service dementia training with extra hours was inversely related to receiving F-758 tags. That relationship was also noted in NHs with lower registered nurse and certified nurse assistant staffing.

DISCUSSION

In-service dementia training may be helpful in reducing inappropriate psychotropics use, particularly in facilities with lower nurse staffing.

[Déterminants du succès d'une démarche provinciale d'usage optimal des antipsychotiques chez les résidents en soins de longue durée selon les acteurs clés impliqués dans l'implantation]

Le Québec présente le taux de prescriptions d'antipsychotiques le plus élevé chez les personnes âgées de 65 ans et plus au Canada. La démarche « Optimiser les pratiques, les usages, les soins et les services - antipsychotiques » (OPUS-AP) vise à pallier cet enjeu. Étant donné ses premiers résultats prometteurs, notre étude visait à identifier les déterminants de son succès. Elle repose sur un devis d'étude de cas regroupant une analyse documentaire et 21 entrevues auprès d'acteurs clés impliqués dans l'implantation. Les résultats mettent en lumière cinq déterminants centraux : 1) une démarche intégrée, collaborative et probante; 2) des communications et des réseaux au service de la démarche; 3) un climat d'implantation favorable aux changements; 4) un engagement et une implication des parties prenantes; et 5) une stratégie d'application des connaissances intégrée et appuyée. Des défis et recommandations pour assurer la pérennisation et la mise à l'échelle d'OPUS-AP et inspirer des démarches similaires sont identifiés.

[Safe discontinuation of psychotropic drugs in older people? : New evidence and practical approach]

BACKGROUND

Many older patients are permanently prescribed one or more psychotropic drugs for treatment of symptoms, such as behavioral and psychological symptoms in dementia, depressive symptoms, anxiety, and insomnia. They therefore contribute to the risk of polypharmacy. Recently, deprescribing studies have been published in order to clarify if inadequate medications can be safely discontinued. This mini-review summarizes the study results and derives practical recommendations for routine use.

METHOD

A literature search was carried out in PubMed for clinical studies on deprescribing in association with psychotropic substances.

RESULTS

After removal of duplications, 12 heterogeneous clinical studies were identified and reduction of psychotropic substances could be successfully achieved in 8 studies. In four of these studies psychological, behavioral and functional endpoints were reported. Criteria for successful deprescribing of sedatives were in particular motivation, information and sufficient cooperation of the patients and for antipsychotic drugs in people with dementia, the sustainable establishment of nonpharmaceutical treatment strategies. Deprescribing was not attempted in cases of a history of severe chronic mental illness and in cases of severe behavioral symptoms in dementia. Evidence for antidepressants was not sufficient to extract practical recommendations.

CONCLUSION

Safe deprescribing of antipsychotic drugs in patients with dementia is justified if non-pharmacological treatment options are sustainably implemented, and for sedative drugs in well-informed, highly motivated and cooperative patients.

Views of people living with dementia and their families/care partners: helpful and unhelpful responses to behavioral changes

OBJECTIVES

This study investigated the views of people living with dementia and their families/care partners on (i) what they find helpful or unhelpful regarding behavioral changes, i.e. which coping strategies they used for themselves and/or which responses from others, and (ii) what they consider to be appropriate terminology to describe behavioral changes.

DESIGN & SETTING

One-on-one semi-structured interviews were conducted with people living with dementia and families/care partners face to face, online, or over the telephone.

MEASUREMENTS

Data from open-ended questions were analyzed inductively. Common themes were derived from the data using an iterative approach.

RESULTS

Twenty-one people living with dementia and 20 family members/care partners were interviewed. Four main themes were derived for helpful responses, and three main themes for unhelpful responses. Helpful responses included providing clear professional support pathways and supportive environments where people living with dementia can engage in physical, cognitive, social, and spiritual activities. Unhelpful responses included discriminatory treatment from others and use of medicalized terminology. Views toward terminology varied; people with lived experience most favored using "changed behaviors" over other terminology. Areas for improvement included targeting dementia stigma, societal education on dementia, and building confidence in people living with dementia by focusing on living well with dementia.

CONCLUSION

Knowledge of the views of people living with dementia may assist healthcare professionals to provide more appropriate care for people living with dementia.

Bipolar Disorder and Manic-Like Symptoms in Alzheimer's, Vascular and Frontotemporal Dementia: A Systematic Review

BACKGROUND

An increased risk of manic episodes has been reported in patients with neurodegenerative disorders, but the clinical features of bipolar disorder (BD) in different subtypes of dementia have not been thoroughly investigated.

OBJECTIVES

The main aim of this study is to systematically review clinical and therapeutic evidence about manic syndromes in patients with Alzheimer's disease (AD), vascular dementia (VaD), and frontotemporal dementia (FTD). Since manic-mixed episodes have been associated to negative outcomes in patients with dementia and often require medical intervention, we also critically summarized selected studies with relevance for the treatment of mania in patients with cognitive decline.

METHODS

A systematic review of the literature was conducted according to PRISMA guidelines. PubMed, Scopus, and Web of Science databases were searched up to February 2022. Sixty-one articles on patients with AD, VaD, or FTD and BD or (hypo) mania have been included.

RESULTS

Manic symptoms seem to be associated to disease progression in AD, have a greatly variable temporal relationship with cognitive decline in VaD, and frequently coincide with or precede cognitive impairment in FTD. Overall, mood stabilizers, and electroconvulsive therapy may be the most effective treatments, while the benefits of short-term treatment with antipsychotic agents must be balanced with the associated risks. Importantly, low-dose lithium salts may exert neuroprotective activity in patients with AD.

CONCLUSION

Prevalence, course, and characteristics of manic syndromes in patients with dementia may be differentially affected by the nature of the underlying neurodegenerative conditions.

Tailoring a complex intervention to reduce antidepressants in institutionalized older persons with dementia

INTRODUCTION

First-line treatment for behavioral and psychiatric symptoms of dementia is non-pharmacological. Still, psychotropic medication is widely used, despite its limited effect and harmful side-effects. More than half of all nursing home residents with dementia receive antidepressants, even though deprescribing is safe and feasible. Interventions to promote deprescribing of antidepressants in nursing homes are few and complex. To optimize the deprescribing process through an intervention, transparency for the development of the intervention is needed. We aim to describe the steps in the development and tailoring of an intervention targeting GPs, nursing home staff, and relatives to enhance collaboration on reducing the use of antidepressants in institutionalized older persons with dementia in Denmark.

METHOD

A step-wise process guided by the core elements in the Medical Research Council constituted the tailoring process. Five steps were included; 1) a literature search, 2) interviews with stakeholders, 3) drafting the intervention prototype, 4) professionals' assessment of the intervention, and 5) refinement of the intervention. The steps were conducted from June 2020 to June 2022.

RESULTS

Based on the literature search, interviews with stakeholders, and professionals' assessment of the intervention, four main themes were identified; 1) focusing on antidepressants, 2) importance of professional qualifications, 3) collaboration and communication, and 4) patient and relative involvement. They guided intervention development and refinement of the final intervention, which included 1) a case-based training course and 2) a dialog tool including a symptom assessment scale to be used in a structured consultation at the nursing home.

CONCLUSION

This study presents a detailed account of the tailoring process for a complex intervention to optimize deprescribing of antidepressants for older persons with dementia at nursing homes. By presenting a thorough development process, we expect to achieve increased adherence to the intervention which is currently being tested in an ongoing cluster randomized controlled trial. The transparency of the process will also increase the future development of other similar complex interventions.

Stakeholders' views on the use of psychotropic medication in older people: a systematic review

Background

psychotropic medication use has been shown to increase with age and has been associated with increased risk of falls, strokes and mortality. Various guidelines, regulations and tools have been developed to reduce inappropriate prescribing, but this remains high. In order to understand the reasons for this, we aimed to systematically review healthcare professionals’, patients’ and family caregivers’ attitudes towards the use of psychotropic medication in older people.

Methods

a systematic literature search was carried out from inception to September 2020 using PUBMED, EMBASE, PsycINFO and CINAHL and hand-searching of reference lists. Included studies investigated stakeholder views on psychotropic in adults over the age of 65. Findings were thematically synthesised.

Results

overall, there was an acceptance of long-term psychotropic medication for older people both living in the community and in residential care. While healthcare professionals were aware of guidelines for the use of benzodiazepines and psychotropic medicines, they identified barriers to following them on individual, team and organisational levels. Alternative non-pharmacological approaches were not always available or accepted by patients.

Conclusion

psychotropic medicine use in older adults remains a complex issue, which needs to be addressed on a broad level. Attitudes of older people and healthcare professionals encourage long-term use. Meanwhile, various internal and external factors act as barriers to the use of non-drug alternatives in this population. In order to reduce overprescribing of psychotropics, there is a need to increase the acceptability and accessibility of alternative interventions in both care homes and the community.

Geriatric medicine and health care for older people in Australia

Aged care coverage in Australia is universal but fragmented and has been challenged by government policy to deregulate aged care and open it up to market forces. A recent inquiry into aged care (Royal Commission into Aged Care Quality and Safety) documented the outcome of this policy-substandard care at most levels. The provision of services to older Aboriginal and Torres Strait Islander peoples, who have high prevalence of frailty and cognitive impairment, was also identified as inadequate. The effects of yet to be implemented changes in policy and funding in response to this report remain to be seen. Despite this policy backdrop, geriatricians have contributed to a steady growth in medical services and interventions focussed on specific geriatric issues such as dementia, falls, polypharmacy and orthogeriatrics. These are often driven by, or in collaboration with researchers, and aim to generate research data as well as provide patient care. The numbers of academic geriatricians and other aged care health professionals is increasing, and the training of specialist geriatricians now includes a significant research component.

Barriers and enablers to deprescribing in long-term care facilities: a 'best-fit' framework synthesis of the qualitative evidence

INTRODUCTION

older adults are at risk of adverse outcomes due to a high prevalence of polypharmacy and potentially inappropriate medications (PIMs). Deprescribing interventions have been demonstrated to reduce polypharmacy and PIMs. However, deprescribing is not performed routinely in long-term care facilities (LTCFs). This qualitative evidence synthesis aims to identify the factors which limit and enable health care workers' (HCWs) engagement with deprescribing in LTCFs.

METHODS

the 'best-fit' framework approach was used to synthesise evidence by using the Theoretical Domains Framework (TDF) as the a priori framework. Included studies were analysed qualitatively to identify LTCF barriers and enablers of deprescribing and were mapped to the TDF. Constructs within domains were refined to best represent the LTCF context. A conceptual model was created, hypothesising relationships between barriers and enablers.

RESULTS

of 655 records identified, 14 met the inclusion criteria. The 'best-fit' framework included 17 barriers and 16 enablers, which mapped to 11 of the 14 TDF domains. Deprescribing barriers included perceptions of an 'established hierarchy' within LTCFs, negatively affecting communication and insufficient resources which limited HCWs' engagement with deprescribing. Enablers included tailored deprescribing guidelines, interprofessional support and working with a patient focus, allowing the patients' condition to influence decisions.

DISCUSSION

this study identified that education, interprofessional support and collaboration can facilitate deprescribing. To overcome deprescribing barriers, change is required to a patient-centred model and HCWs need to be equipped with necessary resources and adequate reimbursement. The LTCF organisational structure must support deprescribing, with communication between health care systems.

As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study

OBJECTIVES

Psychotropic medications administered on an as-needed basis, often designated as pro re nata (or PRN, hereafter as-needed), can alleviate acute symptoms and facilitate deprescribing, although as-needed use is associated with negative outcomes such as polypharmacy and drug interactions. The aim of this study was to examine the extent to which PRN psychotropic medications are prescribed and administered to assisted living (AL) residents, overall and in relation to resident- and community-level characteristics.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

All AL residents and select staff in 250 AL communities in 7 states.

METHODS

Data regarding prescribing and administration of 5 types of PRN psychotropic medications in the prior 7 days (antipsychotics, mood stabilizers and antiepileptics, antidepressants, anxiolytics/hypnotics, and cognitive enhancers) were abstracted and compared across resident and community characteristics.

RESULTS

Prescribing of PRN psychotropics in AL is low (10.3%). Of prescribed PRN medications, 2.5% of residents were administered a PRN and 8% had PRN that was not administered in the previous 7 days. Anxiolytics were administered PRN more commonly compared with antipsychotics (2.0% vs 0.2%). Of all PRN psychotropic prescriptions (n = 1039), 70.5% had a written indication describing the reason for administration. Among PRN medications administered (n = 242), the proportion with an indication was lower (62.0%). PRN psychotropic medication prescribing was higher among residents with dementia and a psychiatric diagnosis, and in larger AL communities and those with a higher proportion of dementia care beds.

CONCLUSIONS AND IMPLICATIONS

The prescribing and administration of PRN psychotropic medications in AL is relatively rare, although more common among residents with dementia. Emerging psychotropic medication policies should be expanded to address mental health care, anxiolytic/hypnotic use for residents living with dementia, PRN prescribing in chart review, and the use of detailed indications for PRN use, especially when medications are administered by unlicensed care staff.

Trauma-informed care in geriatric inpatient units to improve staff skills and reduce patient distress: a co-designed study protocol

Background

Geriatric hospital wards are highly medicalised environments with limited opportunities for choice and control, and can be distressing for older survivors of psychological trauma. While trauma-informed models of care (TIC) are effectively applied across mental health and other settings, the utility of these models in aged care settings has not been assessed. The objective of this study was to examine whether TIC can reduce responsive behaviour, chemical restraint, and improve staff skills and patient experiences in inpatient geriatric settings.

Methods

Four wards participated in this type I hybrid implementation-effectiveness study across southern Adelaide, Australia, including 79 beds. Using a co-design method, the principles of TIC were transformed into an implementation strategy including staff training, establishment of highly trained ‘champions’ on each ward, screening for trauma-related needs, and amending ward policies and procedures. Primary outcomes will be examined using an interrupted time-series design and are monthly incidence of responsive behaviour incidents and use of chemical restraint. Process evaluation will be used to examine secondary, implementation outcomes including the acceptability, feasibility, and fidelity to the implementation strategy.

Discussion

Trauma-informed care has potential to improve the safety and accessibility of hospital wards for older people who have survived psychologically traumatic events and has an extensive evidence base supporting its effectiveness in other settings. Identifying trauma-related needs and amending care to reduce the risk of re-traumatisation and distress may also reduce the incidence of responsive behaviour change, which has a significant impact on the quality of life of hospital patients and staff and is very costly. The inclusion of a process evaluation will allow us to identify and report changes made on each ward and make recommendations for future implementation efforts.

Clinicians' delirium treatment practice, practice change, and influences: A national online survey

BACKGROUND

Recent studies cast doubt on the net effect of antipsychotics for delirium.

AIM

To investigate the influence of these studies and other factors on clinicians' delirium treatment practice and practice change in palliative care and other specialties using the Theoretical Domains Framework.

DESIGN

Australia-wide online survey of relevant clinicians.

SETTING/PARTICIPANTS

Registered nurses (72%), doctors (16%), nurse practitioners (6%) and pharmacists (5%) who cared for patients with delirium in diverse settings, recruited through health professionals' organisations.

RESULTS

Most of the sample (n = 475): worked in geriatrics/aged (31%) or palliative care (30%); in hospitals (64%); and saw a new patient with delirium at least weekly (61%). More (59%) reported delirium practice change since 2016, mostly by increased non-pharmacological interventions (53%). Fifty-five percent reported current antipsychotic use for delirium, primarily for patient distress (79%) and unsafe behaviour (67%). Common Theoretical Domains Framework categories of influences on respondents' delirium practice were: emotion (54%); knowledge (53%) and physical (43%) and social (21%) opportunities. Palliative care respondents more often reported: awareness of any named key study of antipsychotics for delirium (73% vs 39%, p < 0.001); changed delirium treatment (73% vs 53%, p = 0.017); decreased pharmacological interventions (60% vs 15%, p < 0.001); off-label medication use (86% vs 51%, p < 0.001: antipsychotics 79% vs 44%, p < 0.001; benzodiazepines 61% vs 26%, p < 0.001) and emotion as an influence (82% vs 39%, p < 0.001).

CONCLUSION

Clinicians' use of antipsychotic during delirium remains common and is primarily motivated by distress and safety concerns for the patient and others nearby. Supporting clinicians to achieve evidence-based delirium practice requires further work.

The value of deprescribing in older adults with dementia: a narrative review

Introduction:Mitigating the burden of unnecessary polypharmacy or multiple medication use in people living with dementia has been recognized as a key priority internationally. One approach to reducing inappropriate polypharmacy is through medication withdrawal or deprescribing.Area covered:Non-systematic searches of key databases including PubMed, Embase, and Google Scholar were conducted from inception to 28 February 2021 for articles that assessed the safety and/or efficacy of deprescribing in older adults living with dementia. Personal reference libraries were also utilized. Information on current clinical trials was found in clinicaltrial.gov.Expert Opinion: There is limited direct evidence to inform deprescribing in older adults with dementia specifically. This review identified nineteen studies that have assessed the impact of deprescribing interventions to reduce inappropriate polypharmacy or direct deprescribing of specific medications. However, the current evidence is limited in scope as most studies focused on medication-related outcomes (e.g. discontinuation of high-risk medications) rather than patient-centered outcomes in individuals living with dementia. Furthermore, most studies focused on addressing inappropriate polypharmacy in older adults with dementia living in long-term care facilities, and interventions did not involve the person and their carer. Further evidence on the impact of deprescribing in this population across clinical settings is needed.

CHROME Criteria and Quality of Life: A Pilot Study from Maria Wolff-Albertia

BACKGROUND

Over- and potentially inappropriate prescribing of psychotropic medications is a major public health concern among people with dementia.

OBJECTIVE

Describe the CHemical Restraints avOidance MEthodology (CHROME) criteria and evaluate its effects on psychotropic prescribing and quality of life (QoL).

METHODS

Observational, prospective, two-wave study conducted in two nursing homes. A multicomponent program to eliminate chemical restraints and attain quality prescription of psychotropic medications was implemented. CHROME's diagnostic criteria comprise constellations of behavioral and psychological symptoms of dementia under six primary syndromic diagnoses. Since pharmacologic treatment is aimed at only one syndrome, polypharmacy is avoided. Psychotropic prescription, QoL, neuropsychiatric symptoms (NPS), and other clinical measurements were collected before and one year after the intervention. Results are presented for all residents (n = 171) and for completer subjects (n = 115).

RESULTS

Mean age (SD) of the residents was 87.8 (5.7), 78.9% were women, and 68.5% suffered advanced dementia. Psychotropic prescriptions decreased from 1.9 (1.1) to 0.9 (1.0) (p < 0.0005). Substantive reduction in prescribing frequency was observed for antidepressants (76.9% pre-intervention, 33.8% post-intervention) and for atypical neuroleptics (38.8% pre-intervention, 15.1% post-intervention). There was improvement in patient's response to surroundings (p < 0.0005) and total NPS (p < 0.01), but small worsening occurred in social interaction (p < 0.02, completer subjects). Safety measurements remained stable.

CONCLUSION

CHROME criteria appear to optimize psychotropic prescriptions, avoid chemical restraints, and allow external verification of quality prescriptions. Extensive use seems feasible, related to substantial reduction of prescriptions, and of benefit for people with dementia as de-prescriptions are not associated to increased NPS or QoL loss.

Deprescribing in the Older Patient: A Narrative Review of Challenges and Solutions

Polypharmacy is a major challenge in healthcare for older people, and is associated with increased risks of adverse outcomes, such as delirium, falls, frailty, cognitive impairment and hospitalization. There is significant public and professional interest in the role of deprescribing in reducing medication-related harms in older people. We aim to provide a narrative review of 1) the safety and efficacy of deprescribing interventions, 2) the challenges and solutions of deprescribing research and implementation in clinical practice, and 3) the benefits of using Computerized Clinical Decision Support Systems (CCDSS) and Quality Indicators (QIs) in deprescribing research and practice. Deprescribing is an established management strategy to minimize polypharmacy and potentially inappropriate medications. There is limited clinical evidence for its efficacy on global and geriatric outcomes. Various challenges at patient, healthcare professional and healthcare system levels may impact on the success of deprescribing interventions in research and practice. Management strategies that target all levels of the healthcare system are required to overcome these challenges. Future studies may consider large multicenter prospective designs to establish the effects and sustainability of deprescribing interventions on clinical outcomes.

Clinical impact of antipsychotic and benzodiazepine reduction: findings from a multicomponent psychotropic reduction program within long-term aged care

OBJECTIVES

To explore the relationships between dose changes to antipsychotic and/or benzodiazepine medications and resident outcomes, including variations in neuropsychiatric symptoms, quality of life (QoL), and social withdrawal, within a multicomponent, interdisciplinary antipsychotic and benzodiazepine dose reduction program.

DESIGN

Prospective, observational, longitudinal study.

INTERVENTION

The Reducing Use of Sedatives (RedUSe) project involved 150 Australian Long-Term Care Facilities (LTCFs) incorporating auditing and benchmarking of prescribing, education, and multidisciplinary sedative reviews.

SETTING

A convenience sample of LTCFs (n = 28) involved in RedUSe between January 2015 and March 2016.

PARTICIPANTS

Permanent residents (n = 206) of LTCFs involved in RedUSe taking an antipsychotic and/or benzodiazepine daily. Residents were excluded if they had a severe psychiatric condition where antipsychotic therapy should generally be maintained long-term (e.g., bipolar disorder, schizophrenia) or were considered end-stage palliative.

MEASUREMENTS

Neuropsychiatric symptoms (Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory (CMAI)), QoL (Assessment of Quality of Life-4D), and social withdrawal (Multidimensional Observation Scale for Elderly Subjects-withdrawal subscale) were measured at baseline and 4 months where nursing staff completed psychometric tests as proxy raters.

RESULTS

There was no evidence that psychometric measures were worsened following dose reductions. In fact, dose reduction was associated with small, albeit non-statistically significant, improvements in behavior, particularly less physically non-aggressive behavior with both drug groups (-0.36 points per 10% reduction in antipsychotic dose, -0.17 per 10% reduction in benzodiazepine dose) and verbally agitated behavior with benzodiazepine reduction (-0.16 per 10% dose reduction), as measured with the CMAI. Furthermore, antipsychotic reduction was associated with non-statistically significant improvements in QoL and social withdrawal.

CONCLUSIONS

Antipsychotic and benzodiazepine dose reduction in LTCFs was not associated with deterioration in neuropsychiatric symptoms, QoL, or social withdrawal. Trends toward improved agitation with antipsychotic and benzodiazepine dose reduction require further evaluation in larger, prospective, controlled studies.

Using data linkage for national surveillance of clinical quality indicators for dementia care among Australian aged care users

Care quality has important implications for people with dementia. We examined trends and geographical variation of four clinical quality indicators (CQIs) in Australia. This retrospective cohort study included all people with dementia using Australian government-subsidised aged care in 2008-2016 (n = 373,695). Quality indicator data were derived from linked national aged care, health, and pharmaceutical datasets. Negative binomial regression modelling assessed trends in CQI performance over time (2011-2016) and funnel plots examined geographical variation in performance. The incidence rate of antipsychotic medicine dispensing decreased slightly from 1.17/1000 person-days to 1.07/1000 person-days (adjusted incidence rate ratio (aIRR) = 0.98, 95%CI 0.98-0.99). Cholinesterase inhibitors and memantine dispensing did not change (aIRR = 1.02, 95%CI 1.00-1.04), while exposure to high sedative load increased slightly from 1.39/1000 person-days to 1.44/1000 person-days (aIRR = 1.01, 95%CI 1.00-1.01). Dementia and delirium-related hospitalisations increased slightly from 0.17/1000 person-days to 0.18/1000 person-days (aIRR = 1.02, 95%CI 1.01-1.03). There was marked variation in cholinesterase inhibitor and memantine dispensing by geographical area (0-41%). There has been little change in four indicators of dementia care quality in Australian aged care users over time. Cholinesterase inhibitor and memantine dispensing varied substantially by geographical region. Existing strategies to improve national performance on these indicators appear to be insufficient, despite the significant impact of these indicators on outcomes for people with dementia.

Implementation conditions leading to the scale-up of an innovation involving the optimal use of antipsychotics in long-term care centers: The Optimizing Practices, use, Care and Services-Antipsychotics (OPUS-AP) program

BACKGROUND

Antipsychotics are often used for the first-line management of behavioral and psychological symptoms of dementia despite their limited efficacy and the risk of serious adverse drug events, compounded with disregard for guidelines recommending prioritizing non-pharmacological interventions. Some innovative interventions promote the deprescription of antipsychotics in long term care (LTC) settings.

OBJECTIVE

The objective of this article is to present the conditions leading to the scale-up of an innovative program on the appropriate use of antipsychotics in LTC centers.

METHODS

The Optimizing Practices, Use, Care and Services-Antipsychotics (OPUS-AP) program is a mixed-method project that aims to improve LTC residents' care through increased knowledge and competency among staff, resident-centered approaches, nonpharmacologic interventions, and by deprescribing antipsychotics when appropriate. This article consists of a qualitative study focused on exploring the implementation conditions of the OPUS-AP program. This study was carried out in an integrated health area of Québec. It consisted of 46 semi-structured interviews with staff members and managers involved in the implementation of OPUS-AP. The qualitative data analysis was inspired by a realistic evaluation approach, which shed light on the causal chain between context, mechanisms, and perceived effects.

RESULTS

This study identified certain conditions conducive to scaling up the OPUS-AP program: an integrated, collaborative and evidence-based approach; communications in support of the process; stakeholder engagement at the strategic, tactical and operational levels; an implementation climate conducive to change; and an integrated knowledge translation strategy.

CONCLUSION

Despite evidence of clinical efficacy, deprescribing programs require great deal of scaling up efforts. Hence, this study underscores the need to further examine conditions for scaling up medication usage programs in real life contexts.

Person-centred Australian residential aged care services: how well do actions match the claims?

Recent inquiries into residential aged care services, including the 2018–2019 Australian Royal Commission into Aged Care Quality and Safety, have informed revisions to the 2019 Australian Aged Care Quality Standards. Reforms to the Standards include a greater focus on person-centred services, consumer-directed care and authentic participation in decision-making on service provision by residents and their family members. In respect of person-centred services, the revised Standards reflect the four elements of the ‘Valuing, Individualised Care, Personal Perspective, Social Environment’ (or VIPS) framework for quality aged (social) care services in the United Kingdom. This qualitative study investigated whether the quality of services in a convenience sample of seven Australian aged care homes, which claimed to be person-centred, aligned with the four elements and 24 indicators of the VIPS framework. Data were obtained via semi-structured interviews with a volunteer sample of people associated with these seven aged care homes: 12 residents, 15 family members and 18 staff members in various roles. Data were analysed deductively with a priori reference to the 24 VIPS framework indicators, achieving data saturation for four common themes which indicated more person-centredness and ten common themes indicating less person-centredness. Only two of seven homes adhered to the four elements and 24 indicators of the VIPS framework across most service offerings. The remaining five homes offered some aspects of a person-centred service. The study findings provide insight to the factors which support and hamper the implementation of the VIPS-informed indicators of a person-centred aged care service and, therefore, what is needed to help meet person-centred requirements as outlined in the 2019 Australian Aged Care Quality Standards.

Behavioral and Psychological Symptoms in Dementia (BPSD) and the Use of Antipsychotics

Dementia affects about 47 million people worldwide, number expected to exponentially increase within 30 years. Alzheimer’s disease (AD) is the most common dementia type, accounting on its own for almost 70% of all dementia cases. Behavioral and psychological symptoms (BPSD) frequently occur during the disease progression; to treat agitation, aggressiveness, delusions and hallucinations, the use of antipsychotic drugs should be limited, due to their safety issues. In this literature review regarding the use of antipsychotics for treating BPSD in dementia, the advantages and limitation of antipsychotic drugs have been evaluated. The available medications for the management of behavioral and psychological symptoms are the antipsychotics, classed into typical and atypical, depending on their action on dopamine and serotonin receptors. First generation, or typical, antipsychotics exhibit lack of tolerability and display a broad range of side effects such as sedation, anticholinergic effects and extrapyramidal symptoms. Atypical, or second generation, antipsychotics bind more selectively to dopamine receptors and simultaneously block serotonin receptors, resulting in higher tolerability. High attention should be paid to the management of therapy interruption or switch between antipsychotics, to limit the possible rebound effect. Several switching strategies may be adopted, and clinicians should “tailor” therapies, accounting for patients’ symptoms, comorbidities, polytherapies and frailty.

Prevalence and Associated Factors of Polypharmacy in Nursing Home Residents: A Cross-Sectional Study

In Spain, there has been a progressive increase in aging. Specifically, Leon has been one of the Spanish provinces with the highest aging index. Polypharmacy is highly prevalent among the elderly, with significant consequences for safety. The aim of this study was to assess the consumption of drugs in a nursing home in the province of Leon and establish the relationship between polypharmacy and the most common comorbid diseases. A descriptive, observational, and cross-sectional study design was used. Residents' information and treatments were collected by reviewing on medical charts, completed with clinical information obtained from the physician of the nursing home. The mean age of residents was 86.8 years, and 63.8% were female. Mean medical consumption amounted to 7.02 prescriptions. Polypharmacy was observed in 54.9% of residents, and excessive polypharmacy in 22.1%. The most commonly used medications (ATC classification) were those acting on the cardiovascular system (84.4%) and the nervous system (82.8%). A high-level of drug consumption was observed in the nursing home. Interventions should focus on those residents hospitalized the last year and with recent contact with a general practitioner. There is a need to develop a comprehensive monitoring system to assess the quality of prescriptions for nursing home residents.

Initiation of antipsychotics after moving to residential aged care facilities and mortality: a national cohort study

Background

There is a high burden of antipsychotic use in residential aged care facilities (RACFs) and there is concern regarding potential inappropriate prescribing of antipsychotics in response to mild behavioural symptoms. Antipsychotic use has been associated with a higher risk of mortality in community-dwelling older adults with dementia, but few studies have examined associations upon RACF entry.

Aims

To examine associations between incident antipsychotic use and risk of mortality for people with and without diagnosed dementia in RACFs.

Methods

A retrospective cohort study, employing a new-user design (individuals did not receive an antipsychotic 6 months before enrolment) of 265,820 people who accessed RACFs in Australia between 1/4/2008 and 30/6/2015 was conducted. Cox regression models were used to examine adjusted associations between antipsychotic use in the first 100 days of RACF entry and mortality.

Results

In the 100 days after entering care, 29,455 residents (11.1%) were dispensed an antipsychotic. 180,956 (68.1%) residents died [38,249 (14.4%) were related to cerebrovascular causes] over a median 2.1 years (interquartile range 1.0–3.6) follow-up. Of the residents included, 119,665 (45.0%) had a diagnosis of dementia. Incident antipsychotic use was associated with higher risk of mortality in residents with dementia (adjusted hazard ratio 1.20, 95% confidence interval 1.18–1.22) and without dementia (1.28, 1.24–1.31).

Conclusion

Initiation of antipsychotics after moving to RACFs is associated with a higher risk of mortality. Careful consideration of the potential benefits and harms should be given when starting a new prescription for antipsychotics for people moving to RACFs.

Electronic supplementary material

The online version of this article (10.1007/s40520-020-01518-y) contains supplementary material, which is available to authorized users.

Advocacy for better metabolic monitoring after antipsychotic initiation: based on data from a French health insurance database

Background: Nearly 3% of the population is treated by antipsychotic. The aim of this study was to assess the conformity of monitoring with guidelines to prevent Metabolic Syndrome. Research design and method: The analysis was conducted using SNIIRAM data (2013 to 2017) on a cohort of patients who received at least eight antipsychotic dispensings in the first year. Glucose and lipid testings were recorded according to refunds at initiation [between -3 and 0.5 months], 3 months [between 2 and 4 months], and 12 months [between 11 and 13 months] after, and assuming optimal testing during hospitalization (exclusive of psychiatric unit). Descriptive and comparative analysis, «chi-squared test or Student's t-test», were performed as well as multivariate analysis with logistic regression. Results: 18 760 patients were selected, 14 421 were still alive and monitored at the end of the follow up. In the recommended period, only 2.89% of patients had three complete testings and 50.6% one or two complete testings Non-optimal testing was more likely to occur in children and adults (vs elderly), in patients with less than 3 prescribers, and with universal medical coverage. Conclusion: Monitoring remains dramatically insufficient. New actions involving patients, practitioners, and authorities are warranted.

Nurses', Pharmacists' and Family Physicians' Perceptions of Psychotropic Medication Monitoring in Australian Long-Term Care Facilities: A Qualitative Framework Analysis

BACKGROUND

Current evidence suggests that despite modest benefit in using targeted psychotropic medications in the geriatric population, there is significant iatrogenic morbidity and mortality. Monitoring of the use of psychotropic medications by health care professionals (HCPs) to reduce adverse effects is often suboptimal; however, there have been few theoretically informed studies as to why this is so.

OBJECTIVE

This study aimed to elucidate facilitators and barriers to psychotropic medication monitoring in long-term care facilities (LTCFs) from the viewpoint of nurses, pharmacists and family physicians. Secondly, it intended to identify targets for tailored intervention strategies to improve monitoring practices.

METHODS

A purposive sample of 31 HCPs working in LTCFs in Sydney, New South Wales, Australia was recruited. Three cohorts consisted of twelve registered nurses, ten pharmacists and nine family physicians. Semi-structured interviews were conducted, assessing perceptions of psychotropic medication monitoring in LTCFs, facilitators, barriers and proposed solutions. Interviews were transcribed verbatim and thematically analyzed through an inductive coding approach. Themes were then mapped to Ferlie and Shortell's 'Four Levels of Change' framework for improving quality in healthcare.

RESULTS

Monitoring was revealed as a multi-faceted concept, influenced by factors across individual, group, organization and system levels. Thematic analysis revealed six key themes pertinent to psychotropic monitoring in LTCFs: (1) engagement with monitoring, (2) monitoring capability, (3) opportunity to monitor, (4) roles and responsibilities, (5) communication and collaboration and (6) guidance and regulation. HCPs conceptualized monitoring differently, but consistently felt that monitoring in LTCFs was suboptimal, recognizing a need for guidance and resources to aid collaborative monitoring of psychotropic medications. HCPs internally situated within LTCFs (nurses) viewed psychotropic medication monitoring as a dynamic and ongoing phenomenon, occurring both formally and informally on a day-to-day basis. In contrast, externally situated HCPs (pharmacists and family physicians) typically associated medication monitoring with structured medication reviews and conceptualized monitoring as an intermittent and planned activity.

CONCLUSIONS AND IMPLICATIONS

Psychotropic monitoring is perceived by all HCPs as a shared responsibility; however, the conceptualization of monitoring differs between HCPs. HCPs' beliefs and attitudes require consideration when designing implementation strategies for interventions to ameliorate suboptimal monitoring practices.

A Model Hospice Inpatient Unit Specializing in Patients Living with Advanced Dementia

Objective: This report describes a pilot hospice inpatient unit dedicated to individuals experiencing distressing behaviors from dementia. Background: Patients with dementia who experience distressing symptoms cannot be well managed on typical inpatient units. Hospice of the Valley selected one unit to dedicate to dementia care. Methods: Data were analyzed from 237 patients admitted to the unit between May 2019 and April 2020. Behaviors were identified and rated for severity on admission, discharge, and postdischarge. Rates of inpatient death and associated behaviors were calculated. Results: Fifty percent of patients had their behaviors sufficiently managed to allow discharge. The most common behavior exhibited was agitation; the most common symptom leading to death was pain. Discussion: An inpatient hospice unit dedicated to patients with dementia can be successful. The hospice agency gains admissions that would otherwise be diverted to behavioral care settings. This successful pilot may be a model for other hospices.

GP awareness, practice, knowledge and confidence: evaluation of the first nation-wide dementia-focused continuing medical education program in Australia

Background

Dementia is under-diagnosed in primary care. Timely diagnosis and care management improve outcomes for patients and caregivers. This research evaluated the effectiveness of a nationwide Continuing Medical Education (CME) program to enhance dementia-related awareness, practice, knowledge and confidence of general practitioners (GPs) in Australia.

Methods

Data were collected from self-report surveys by GPs who participated in an accredited CME program face-to-face or online; program evaluations from GPs; and process evaluations from workshop facilitators. CME participants completed surveys at one or more time-points (pre-, post-program, six to 9 months follow-up) between 2015 and 2017. Paired samples t-test was used to determine difference in mean outcome scores (self-reported change in awareness, knowledge, confidence, practice) between time-points. Multivariable regression analyses were used to investigate associations between respondent characteristics and key variables. Qualitative feedback was analysed thematically.

Results

Of 1352 GPs who completed a survey at one or more time-points (pre: 1303; post: 1017; follow-up: 138), mean scores increased between pre-CME and post-program for awareness (M_post-pre = 0.9, p <  0.0005), practice-related items (M_post-pre = 1.3, p <  0.0005), knowledge (M_post-pre = 2.2, p <  0.0005), confidence (M_post-pre = 2.1, p <  0.0005). Significant increases were seen in all four outcomes for GPs who completed these surveys at both pre- and follow-up time-points. Male participants and those who had practised for five or more years showed greater change in knowledge and confidence. Age, years in practice, and education delivery method significantly predicted post-program knowledge and confidence. Most respondents who completed additional program evaluations (> 90%) rated the training as relevant to their practice. These participants, and facilitators who completed process evaluations, suggested adding more content addressing patient capacity and legal issues, locality-specific specialist and support services, case studies and videos to illustrate concepts.

Conclusions

The sustainability of change in key elements relating to health professionals’ dementia awareness, knowledge and confidence indicated that dementia CME programs may contribute to improving capacity to provide timely dementia diagnosis and management in general practice. Low follow-up response rates warrant cautious interpretation of results. Dementia CME should be adopted in other contexts and updated as more research becomes available.

Neuropsychiatric Symptoms as Predictors of Falls in Long-Term Care Residents With Cognitive Impairment

OBJECTIVES

Falls and neuropsychiatric symptoms (NPS) are common among long-term care residents with cognitive impairment. Despite the high prevalence of falls and NPS, little is known about their association. The aim of our study was to explore how NPS, particularly the severity of NPS and specific NPS subgroups, are associated with falls and how psychotropics modify this association.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

In total, 532 long-term care residents aged 65 years or older in Helsinki, Finland.

METHODS

NPS were measured with Neuropsychiatric Inventory (NPI) at baseline. Participants were grouped into 3 groups: no significant NPS (NPI points 0‒3), low NPS burden (NPI 4‒12), and high NPS burden (NPI >12). The number of falls, injuries, fractures, and hospitalizations were collected from medical records over 12 months following baseline assessment.

RESULTS

Altogether, 606 falls occurred during the follow-up year. The falls led to 121 injuries, 42 hospitalizations, and 20 fractures. Falls and injuries increased significantly with NPS burden (P < .001): 330 falls in the high NPS group (n = 184), 188 falls in the low NPS group (n = 181), and 88 falls in the no significant NPS group (n = 167). The risk of falling showed a curvilinear association with NPI total score. Of NPS subgroups, psychosis and hyperactivity were associated with a higher incidence rate ratio of falls, whereas apathy had a protective association even after adjustment for age, sex, and mobility. Affective symptoms were not associated with falls. Psychotropics did not modify the association between NPS burden and falls.

CONCLUSIONS AND IMPLICATIONS

The results of this study show that NPS, especially NPS severity, may predict falls and fall-related negative consequences. Severity of NPS should be taken into account when assessing fall risk in long-term care residents with cognitive impairment.

The Impact of Music and Memory on Resident Level Outcomes in California Nursing Homes

OBJECTIVES

To study the effects of a nonpharmacologic intervention, Music and Memory (M&M), on residents with dementia and/or behavioral problems living in nursing homes (NHs).

DESIGN

This was a prospective, mixed-methods cohort study.

SETTING AND PARTICIPANTS

In total, 4107 residents in 265 California NHs and that reported data at least twice during the 3-year study period were enrolled.

MEASURES

We used a quarterly rolling enrollment process; participants provided data at baseline and quarterly via an online survey that included select resident level data from the Minimum Data Set (psychotropic drug use, cognition, behaviors, mood, pain, and falls), experience with the M&M program, and resident use of music. NHs were eligible if they were Medicare- and Medicaid-certified and had 15 residents with a diagnosis of dementia or cognitive impairment or exhibited significant behavioral symptoms.

RESULTS

M&M was associated with reductions in psychotropic medication use, reduced behaviors, and improved mood. The odds of antipsychotic use declined by about 11%, of antianxiety medications by 17%, and antidepressants by 9% per quarter. Aggressive behaviors, depressive symptoms, pain, and falls also declined significantly over time. The odds of residents exhibiting aggressive behaviors declined by 20% per quarter, depressive symptoms by 16%, reported pain by 17%, and falls by 8%.

CONCLUSIONS AND IMPLICATIONS

This is the largest study of M&M to date. We found clinically and statistically significant reductions in psychotropic medications and improved behaviors in residents using M&M. Although the study showed positive results overall, the lack of a control group was a significant limitation that precluded determining how much more improvement participating residents experienced compared with nonparticipants. Future studies should include a control group so that better conclusions can be drawn regarding the effectiveness of the M&M program.

Prolonged use of antipsychotic medications in long-term aged care in Australia: a snapshot from the HALT project

OBJECTIVES

Use of antipsychotic drugs in long-term aged care (LTC) is prevalent and commonly exceeds the recommended duration, but contributors to this problem are not well understood. The objective of this study is to provide a snapshot of the features of and contributors to prolonged use of antipsychotic medications (>12 weeks) among a sample of LTC residents.

DESIGN

We present retrospective and baseline data collected for the Australian Halting Antipsychotic Use in Long-Term Care (HALT) single-arm longitudinal deprescribing trial.

SETTING

Twenty-four long-term care facilities in Sydney, Australia.

PARTICIPANTS

The HALT study included 146 older people living in 24 Sydney LTC homes who had been prescribed a regular antipsychotic medication for at least 3 months at baseline.

MEASUREMENTS

Detailed file audit was conducted to identify the date and indication recorded at initial prescription, consenting practices, longitudinal course of prescribing, and recommendations for review of antipsychotic medication. Behavioural and psychological symptoms of dementia (BPSD) and functional dependence at baseline were assessed via LTC staff interview. Cognition at baseline was assessed in a participant interview (where possible).

RESULTS

Antipsychotics were prescribed for 2.2 years on average despite recommendations by a doctor or pharmacist for review in 62% of cases. Consent for antipsychotic prescription was accessible for only one case and contraindications for use were common. Longer use of antipsychotics was independently associated with higher dose of the antipsychotic drug and greater apathy, but not with other BPSD.

CONCLUSION

Antipsychotic medications appeared to be prescribed in this sample as a maintenance treatment in the absence of active indicated symptoms and without informed consent. Standard interventions, including recommendations for review, had been insufficient to ensure evidence-based prescribing.

A systematic review of the evidence for the efficacy of opioids for chronic non-cancer pain in community-dwelling older adults

INTRODUCTION

the ageing global population and concomitant increase in the use of opioid analgesia have highlighted the need to evaluate the effectiveness of opioids for chronic pain in older people.

METHODS

a systematic review of the evidence for the efficacy of opioids for chronic non-cancer pain in community-dwelling people aged 65 years or more was conducted using PRISMA guidelines. The databases MEDLINE, EMBASE, Pubmed and PsychINFO were searched. The quality of studies was assessed. Secondary aims were to assess correlates of opioid use and the decision-making processes of prescribers.

RESULTS

seven studies were identified of low to high quality. The majority of older people experienced ongoing pain despite continuing opioid therapy. There were mixed results regarding benefits of opioids in terms of activities of daily living and social engagement. In nursing home residents, opioid use at baseline was associated with severe pain, severe impairment in activities of daily living and a diagnosis of depression. Fear of causing harm to older people was common amongst opioid prescribers, limiting prescription. Facilitators of opioid prescription included educational interventions and access to an evidence base for opioid use.

CONCLUSION

there is limited evidence supporting the use of long-term opioid use in older people for chronic non-cancer pain and a lack of trials in this age group. Age-specific guidelines are required addressing initial assessment, indications, monitoring and de-prescribing.

The dispensing of psychotropic medicines to older people before and after they enter residential aged care

OBJECTIVE

To examine the prevalence of psychotropic medicine dispensing before and after older people enter residential care.

DESIGN

Retrospective national cohort study; analysis of Registry of Senior Australians (ROSA) data.

SETTING, PARTICIPANTS

All concession card-holding residents of government-subsidised residential aged care facilities in Australia who entered residential care for at least three months between 1 April 2008 and 30 June 2015.

MAIN OUTCOME MEASURES

Proportions of residents dispensed antipsychotic, benzodiazepine, or antidepressant medicines during the year preceding and the year after commencing residential care, by quarter.

RESULTS

Of 322 120 included aged care residents, 68 483 received at least one antipsychotic (21.3%; 95% CI, 21.1-21.4%), 98 315 at least one benzodiazepine (30.5%; 95% CI, 30.4-30.7%), and 122 224 residents at least one antidepressant (37.9%; 95% CI, 37.8-38.1%) during their first three months of residential care; 31 326 of those dispensed antipsychotics (45.7%), 38 529 of those dispensed benzodiazepines (39.2%), and 25 259 residents dispensed antidepressants (19.8%) had not received them in the year preceding their entry into care. During the first three months of residential care, the prevalence of antipsychotic (prevalence ratio [PR], 3.37; 95% CI, 3.31-3.43) and antidepressant dispensing (PR, 1.05; 95% CI, 1.04-1.07) were each higher for residents with than for those without dementia; benzodiazepine dispensing was similar for both groups (PR, 1.01; 95% CI, 0.99-1.02).

CONCLUSIONS

Dispensing of psychotropic medicines to older Australians is high before they enter residential care but increases markedly soon after entry into care. Non-pharmacological behavioural management strategies are important for limiting the prescribing of psychotropic medicines for older people in the community or in residential care.

Multidisciplinary perspectives on medication-related decision-making for people with advanced dementia living in long-term care: a critical incident analysis

PURPOSE

This study aimed to explore medication-related decision-making by health professionals from different disciplines and specialties caring for people with advanced dementia living in long-term care facilities, focusing on dilemmas associated with starting, continuing or deprescribing medications commonly regarded as potentially inappropriate.

METHODS

Four focus groups were undertaken, each on a different medication type (antibiotics, lipid-lowering agents, opioids and acetylcholinesterase inhibitors). Transcripts underwent qualitative analysis using line by line inductive coding and then a person-centred framework to highlight themes across medication types.

RESULTS

Sixteen participants participated in focus groups. Regardless of medication type or dilemma, results suggested decision-making for residents with advanced dementia should begin with discussing goals of care and engaging with families, and be viewed as an iterative process involving regular monitoring and adjustment. Decision-making was seen as requiring a dialectical approach involving multiple perspectives, with an emphasis on establishing communication between health professionals, family and the person with dementia to better understand goals/preferences for care.

CONCLUSION

Inter-professional collaboration enables sharing of clinical experience/expertise, differing disciplinary perspectives and knowledge about the resident. Continuing a medication should be considered an active decision that carries as much responsibility as starting or deprescribing.

Antipsychotic Polypharmacy: A Dirty Little Secret or a Fashion?

The term polypharmacy was originally coined to refer to problems related to multiple drug consumption and excessive drug use during the treatment of a disease or disorder. In the treatment of schizophrenia, polypharmacy usually refers to the simultaneous use of 2 or more antipsychotic medications or combined (adjunct) medications such as mood stabilizers, antidepressants, anxiolytics, or hypnotics in addition to single or multiple antipsychotics. Two decades ago, antipsychotic polypharmacy was criticized as being more expensive, having unproven efficacy, and causing more side effects. However, in recent years, antipsychotic polypharmacy has become more or less acceptable in the views of clinical practitioners and academic researchers. Results from recent reviews have suggested that the common practice of antipsychotic polypharmacy lacks double-blind or high-quality evidence of efficacy, except for negative symptom reduction with aripiprazole augmentation. We reviewed some representative studies that enrolled large numbers of patients and compared antipsychotic polypharmacy and monotherapy during the past decade. The results revealed that a certain proportion of select patients can benefit from antipsychotic polypharmacy without further negative consequences. Because most of the current treatment guidelines from different countries and organizations prefer monotherapy and discourage all antipsychotic polypharmacy, guidelines regarding the use of antipsychotic polypharmacy in clinical practice should be revised. On the basis of the findings of 2 large-scale studies from Asia and Europe, we also suggest ideal rates of various maintenance treatments of schizophrenia, which are as follows: antipsychotic polypharmacy, 30%; combined mood stabilizer, 15%; combined antidepressant, 10%; combined anxiolytics, 30%; and combined hypnotic, 10%.

Why deprescribing antipsychotics in older people with dementia in long-term care is not always successful: Insights from the HALT study

INTRODUCTION

Antipsychotic medications are commonly used to manage behavioural and psychological symptoms of dementia despite their side effects and harms. While the Halting Antipsychotic Use in Long-Term care (HALT) deprescribing trial was successful at reducing antipsychotic use, 19% of participants had their antipsychotics represcribed or never reached a dose of zero. The aim of this study was to investigate the reasons for represcription of antipsychotic medication and factors associated with ongoing antipsychotic use, relating to care staff requests and perceived behavioural changes.

MATERIALS AND METHODS

Thirty-nine of 133 HALT participants never ceased their antipsychotic medication or were represcribed a regular or pro re nata (PRN) antipsychotic after initial deprescribing. The views of nursing staff, general practitioner, and family on the circumstances leading up to these outcomes were collected via a questionnaire-based approach. This information was triangulated with observation and detailed file audit (including progress notes, medical notes, medication charts, incident reports, and hospital discharge summaries). A consensus panel reconstructed the represcribing context.

RESULTS

Nurses were the most common drivers of represcribing (63.2%), followed by family members (39.5%), GPs (23.7%), specialists (13.2%), and hospital staff (10.5%). There were multiple drivers for antipsychotic use in 46.2% of participants. Increased agitated and aggressive behaviours were the most commonly reported reasons for represcribing even though these changes were not identified over time on objective measures. Consent and dosage practices remained poor despite education.

DISCUSSION

Nursing staff are the key drivers of deprescribing particularly in response to perceived worsening agitation and aggression among male residents. The train-the-trainer model used in the HALT trial may have been insufficient on its own to improve staff competence and confidence in applying nonpharmacological approaches when responding to behaviour change.

Optimizing Practices, Use, Care and Services-Antipsychotics (OPUS-AP) in Long-term Care Centers in Québec, Canada: A Strategy for Best Practices

OBJECTIVES

Antipsychotic medications are often used for the first-line management of behavioral and psychological symptoms of dementia (BPSD) contrary to guideline recommendations. The Optimizing Practices, Use, Care and Services-Antipsychotics (OPUS-AP) strategy aims to improve the well-being of long-term care (LTC) residents with major neurocognitive disorder (MNCD) by implementing a resident-centered approach, nonpharmacologic interventions, and antipsychotic deprescribing in inappropriate indications.

DESIGN

Prospective, closed cohort supplemented by a developmental evaluation.

SETTING AND PARTICIPANTS

Residents of designated wards in 24 LTC centers in Québec, Canada.

METHODS

Provincial guidelines were disseminated, followed by the implementation of an integrated knowledge translation and mobilization strategy, including training, coaching, clinical tools, evaluation of clinical practices, and a change management strategy. Antipsychotic, benzodiazepine, and antidepressant prescriptions; BPSD; and falls were evaluated every 3 months, for 9 months, from January to October 2018. Semistructured interviews (n = 20) were conducted with LTC teams to evaluate the implementation of OPUS-AP.

RESULTS

Of 1054 residents, 78.3% had an MNCD diagnosis and 51.7% an antipsychotic prescription. The cohort included 464 residents with both MNCD and antipsychotic prescription. Antipsychotic deprescribing (cessation or dose decrease) was attempted in 220 of the 344 residents still admitted at 9 months. Complete cessation was observed in 116 of these residents (52.7%) and dose reduction in 72 (32.7%), for a total of 188 residents (85.5%; 95% confidence interval: 80.1%, 89.8%). A decrease in benzodiazepine prescriptions and improvements in Cohen-Mansfield Agitation Inventory scores were observed among residents who had their antipsychotics deprescribed. Caregivers and clinicians expressed satisfaction as a result of observing an improved quality of life among residents.

CONCLUSIONS AND IMPLICATIONS

Antipsychotic deprescribing was successful in a vast majority of LTC residents with MNCD without worsening of BPSD. Based on this success, phase 2 of OPUS-AP is now under way in 129 LTC centers in Québec.