New Initiative Safely Halts Antipsychotic Use in Dementia Patients

Megan Brooks

July 28, 2016

TORONTO ― Australian researchers have successfully reduced the use of antipsychotics to treat behavioral and psychological symptoms in dementia patients in 23 long-term care facilities in New South Wales.

In the Halting Antipsychotic use in Long Term care (HALT) Project, regular antipsychotic medication was eliminated from the treatment plan in the majority of participating patients.

Successful stopping of antipsychotics was achieved through training of nurses in long-term care facilities in nonpharmacologic and person-centered approaches to managing behavioral and psychological symptoms of dementia (BPSD).

The research was reported here at the Alzheimer's Association International Conference (AAIC) 2016.

Nurse "Champions"

"Deprescribing of antipsychotics in long-term care residents with previous BPSD is feasible without reemergence of BPSD," senior investigator Henry Brodaty, MD, DSc, of the Dementia Collaborative Research Center, University of New South Wales, Sydney, Australia, said in a conference statement.

"Often there can be cultural and logistical barriers to moving away from antipsychotics in aged care settings, but we hope the results of this project will serve as a positive example towards a more person-centered approach globally," he added.

In an oral presentation, Dr Brodaty noted that nurse "champions" at the participating facilities were trained in how to manage neuropsychiatric symptoms using person-centered, nonpharmacologic approaches. In turn, they trained other nurses in how to handle behavioral problems.

A total of 139 patients completed baseline assessments. Of those, four died and two dropped out, leaving 133 for whom deprescribing protocols were initiated. These patients had been receiving continuous antipsychotic medication. Most started taking antipsychotics after admission to the long-term care facility. On average, the patients had been receiving 2.3 psychotropic medications for about 2 years.

Protocols for incremental decreases in antipsychotic dose were established on an individual basis by pharmacists, with agreement from the patient's general practitioner.

To participate, "the nursing home had to agree, the family had to agree, and the GP had to agree," Dr Brodaty said. Deprescribing protocols, he explained, were fairly simple. Essentially, they involved cutting the dose in half every week or 2 weeks. In most cases, it was a one- or two-step process before the patient stopped taking the antipsychotic. Patients were reassessed 3, 6, and 12 months following initial dose reduction.

All 133 patients completed the 3-month follow-up; 118 completed the 6-month follow-up. Data for the 12-month follow-up are still being analyzed.

Of the 125 patients who stopped their antipsychotic, 15 (12%) restarted it in the first 3 months. Of the 118 patients for whom 6-month data were available, 10 (8.5%) restarted antipsychotic therapy; to date, 1 of 68 (1.4%) has restarted medication in the final 6 months, Dr Brodaty reported.

"So 26 out of 125, or about 20%, represcribed. In other words, almost 80% remained deprescribed," he noted.

Importantly, Dr Brodaty said, there was no change in scores on the the Neuropsychiatric Inventory or the Cohen-Mansfield Agitation Inventory after antipsychotics were stopped.

"So 80% could stop their antipsychotics, stay off the antipsychotics, and not have reemergence of the symptoms. There was no evidence of drug substitution, particularly benzodiazepines," he noted.

Interestingly, he said, "when we contacted the GPs and told them we'd like them to be in the study, 22 started deprescribing before we even had the visit with them, so that might be another intervention we might try in the future ― just ring them up." His statement garnered chuckles from audience.

The study had challenges. "It was difficult to recruit, we had 23 out of 50 nursing homes that we approached, and I can't tell you the number of GPs who said no; they thought it was too hard. And sometimes the families said they didn't want to be part of this or rock the boat," Dr Brodaty said.

Positive Solution to a "Huge" Problem

"There is broad consensus that using antipsychotics to treat dementia symptoms should be a last resort. Unfortunately, we still see a systematic use of these drugs in residential care facilities in the United States and around the world. With the right type of care strategies in place, difficult-to-manage behaviors are greatly reduced, and the need for the drugs is significantly decreased, as was seen in this study," said Beth Kallmyer, MSW, vice president of constituent services for the Alzheimer's Association.

"We urge prescribers in the US to assess results of this program and understand how they too can continue to work towards more person-centered, nonpharmacological approaches to manage these symptoms," Kallmyer added.

In an interview with Medscape Medical News, Maria C. Carrillo, PhD, chief science officer of the Alzheimer's Association, said the issue of antipsychotic use in long-term care facilities is "huge."

"Antipsychotic use and black box warnings have been issued, but unfortunately, they are still used widely in nursing home settings, many times because nursing homes are understaffed and overcrowded with patients who have behaviors that are difficult to manage," Dr Carrillo noted.

"Yet what this study showed is that across their clinics, they were able to reduce the amount of usage of antipsychotics, and they did this with nonpharmacologic approaches and appropriately training their staff to deal with neuropsychiatric symptoms in different ways."

Funding for the study was provided by the Australian Government Department of Health. The authors have disclosed no relevant financial relationships.

Alzheimer's Association International Conference (AAIC) 2016. Abstract O2-14-01. Presented July 25, 2016.

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