Advertisement
Original Study| Volume 19, ISSUE 7, P592-600.e7, July 2018

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

      Abstract

      Objectives

      Despite limited efficacy and significant safety concerns, antipsychotic medications are frequently used to treat behavioral and psychological symptoms of dementia (BPSD) in long-term residential care. This study evaluates the sustained reduction of antipsychotic use for BPSD through a deprescribing intervention and education of health care professionals.

      Design

      Repeated-measures, longitudinal, single-arm study.

      Setting

      Long-term residential care of older adults.

      Participants

      Nursing staff from 23 nursing homes recruited 139 residents taking regular antipsychotic medication for ≥3 months, without primary psychotic illness, such as schizophrenia or bipolar disorder, or severe BPSD.

      Intervention

      An antipsychotic deprescribing protocol was established. Education of general practitioners, pharmacists, and residential care nurses focused on nonpharmacological prevention and management of BPSD.

      Measurements

      The primary outcome was antipsychotic use over 12-month follow-up; secondary outcomes were BPSD (Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory, and social withdrawal) and adverse outcomes (falls, hospitalizations, and cognitive decline).

      Results

      The number of older adults on regular antipsychotics over 12 months reduced by 81.7% (95% confidence interval: 72.4-89.0). Withdrawal was not accompanied by drug substitution or a significant increase in pro-re-nata antipsychotic or benzodiazepine administration. There was no change in BPSD or in adverse outcomes.

      Conclusion

      In a selected sample of older adults living in long-term residential care, sustained reduction in regular antipsychotic use is feasible without an increase of BPSD.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Brodaty H.
        • Draper B.
        • Saab D.
        • et al.
        Psychosis, depression and behavioural disturbances in Sydney nursing home residents: prevalence and predictors.
        Int J Geriatr Psychiatry. 2001; 16: 504-512
        • Katz I.R.
        • Jeste D.V.
        • Mintzer J.E.
        • et al.
        Comparison of risperidone and placebo for psychosis and behavioral disturbances associated with dementia: a randomized, double-blind trial. Risperidone Study Group.
        J Clin Psychiatry. 1999; 60: 107-115
        • Ballard C.
        • Corbett A.
        • Chitramohan R.
        • Aarsland D.
        Management of agitation and aggression associated with Alzheimerʼs disease: controversies and possible solutions.
        Curr Opin Psychiatry. 2009; 22: 532-540
        • Schneider L.S.
        • Dagerman K.S.
        • Insel P.
        Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials.
        JAMA. 2005; 294: 1934-1943
        • Schneider L.S.
        • Dagerman K.
        • Insel P.S.
        Efficacy and adverse effects of atypical antipsychotics for dementia: Meta-analysis of randomized, placebo-controlled trials.
        Am J Geriatr Psychiatry. 2006; 14: 191-210
        • Rochon P.A.
        • Normand S.-L.
        • Gomes T.
        • et al.
        Antipsychotic therapy and short-term serious events in older adults with dementia.
        Arch Intern Med. 2008; 168: 1090-1096
        • Vigen C.L.P.
        • Mack W.J.
        • Keefe R.S.E.
        • et al.
        Cognitive effects of atypical antipsychotic medications in patients with Alzheimer’s disease: Outcomes from CATIE-AD.
        Am J Psychiatry. 2011; 168: 831-839
        • Declercq T.
        • Petrovic M.
        • Azermai M.
        • et al.
        Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia.
        in: Declercq T. Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd, Chichester, UK2013: CD007726
        • Gallini A.
        • Andrieu S.
        • Donohue J.M.
        • et al.
        Trends in use of antipsychotics in elderly patients with dementia: Impact of national safety warnings.
        Eur Neuropsychopharmacol. 2014; 24: 95-104
        • Briesacher B.A.
        • Tjia J.
        • Field T.
        • et al.
        Antipsychotic use among nursing home residents.
        JAMA. 2013; 309: 440
        • Stock K.J.
        • Amuah J.E.
        • Lapane K.L.
        • et al.
        Prevalence of, and resident and facility characteristics associated with, antipsychotic use in assisted living vs. long-term care facilities: A cross-sectional analysis from Alberta.
        Canada. Drugs Aging. 2017; 34: 39-53
        • Janus S.I.M.
        • van Manen J.G.
        • IJzerman M.J.
        • Zuidema S.U.
        Psychotropic drug prescriptions in Western European nursing homes.
        Int Psychogeriatr. 2016; 28: 1775-1790
        • Snowdon J.
        • Galanos D.
        • Vaswani D.
        Patterns of psychotropic medication use in nursing homes: Surveys in Sydney, allowing comparisons over time and between countries.
        Int Psychogeriatr. 2011; 23: 1520-1525
        • Ballard C.
        • Hanney M.L.
        • Theodoulou M.
        • et al.
        • DART-AD Investigators
        The Dementia Antipsychotic Withdrawal Trial (DART-AD): Long-term follow-up of a randomised placebo-controlled trial.
        Lancet Neurol. 2009; 8: 151-157
        • Royal Australian and New Zealand College of Psychiatrists
        The Use of Antipsychotics in Residential Aged Care. Clinical Recommendations.
        2011
        • Ballard C.
        • Lana M.M.
        • Theodoulou M.
        • et al.
        A randomised, blinded, placebo-controlled trial in dementia patients continuing or stopping neuroleptics (The DART-AD Trial).
        PLoS Med. 2008; 5: 0587-0599
        • Fossey J.
        • Ballard C.
        • Juszczak E.
        • et al.
        Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: Cluster randomised trial.
        BMJ. 2006; 332: 756-761
        • van Reekum R.
        • Clarke D.
        • Conn D.
        • et al.
        A randomized, placebo-controlled trial of the discontinuation of long-term antipsychotics in dementia.
        Int Psychogeriatr. 2002; 14: 197-210
        • Ruths S.
        • Straand J.
        • Nygaard H.A.
        • et al.
        Effect of antipsychotic withdrawal on behavior and sleep/wake activity in nursing home residents with dementia: A randomized, placebo-controlled, double-blinded study the Bergen District Nursing Home Study.
        J Am Geriatr Soc. 2004; 52: 1737-1743
        • Devanand D.P.
        • Mintzer J.
        • Schultz S.K.
        • et al.
        Relapse risk after discontinuation of risperidone in Alzheimer’s disease.
        N Engl J Med. 2012; 367: 1497-1507
        • Thompson Coon J.
        • Abbott R.
        • Rogers M.
        • et al.
        Interventions to reduce inappropriate prescribing of antipsychotic medications in people with dementia resident in care homes: A systematic review.
        J Am Med Dir Assoc. 2014; 15: 706-718
        • Jessop T.
        • Harrison F.
        • Cations M.
        • et al.
        Halting Antipsychotic Use in Long-Term care (HALT): A single-arm longitudinal study aiming to reduce inappropriate antipsychotic use in long-term care residents with behavioral and psychological symptoms of dementia.
        Int Psychogeriatr. 2017; : 1-13
      1. Australian Department of Health. Dementia and Severe Behaviours Supplement. Canberra, AU: Australian Government; 2013.

        • Jorm A.
        • Mackinnon A.J.
        • Henderson A.S.
        • et al.
        The Psychogeriatric Assessment Scales: A multi-dimensional alternative to categorical diagnoses of dementia and depression in the elderly.
        Psychol Med. 1995; 25: 447-460
        • The Royal Australian & New Zealand College of Pyschiatrists
        Assessment and Management of People with Behavioural and Psychological Symptoms of Dementia (BPSD)—A Handbook for NSW Health Clinicians.
        2013
        • Mandrekar J.N.
        Measures of interrater agreement.
        J Thorac Oncol. 2011; 6: 6-7
        • Wood S.
        • Cummings J.L.
        • Hsu M.A.
        • et al.
        The use of the neuropsychiatric inventory in nursing home residents. Characterization and measurement.
        Am J Geriatr Psychiatry. 2000; 8: 75-83
        • Cohen-Mansfield J.
        • Billig N.
        Agitated behaviors in the elderly. I. A conceptual review.
        J Am Geriatr Soc. 1986; 34: 711-721
        • Pruchno R.A.
        • Kleban M.H.
        • Resch N.L.
        Psychometric assessment of the Multidimensional Observation Scale for Elderly Subjects (MOSES).
        J Gerontol. 1988; 43: P164-P169
        • Storey J.E.
        • Rowland J.T.J.
        • Basic D.
        • et al.
        The Rowland Universal Dementia Assessment Scale (RUDAS): A multicultural cognitive assessment scale.
        Int Psychogeriatr. 2004; 16: 13-31
        • Patterson S.M.
        • Hughes C.M.
        • Crealey G.
        • et al.
        An evaluation of an adapted U.S. model of pharmaceutical care to improve psychoactive prescribing for nursing home residents in Northern Ireland (Fleetwood Northern Ireland Study).
        J Am Geriatr Soc. 2010; 58: 44-53
        • Lawrence V.
        • Fossey J.
        • Ballard C.
        • et al.
        Improving quality of life for people with dementia in care homes: Making psychosocial interventions work.
        Br J Psychiatry. 2012; 201: 344-351
        • Declercq T.
        • Petrovic M.
        • Azermai M.
        • et al.
        Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia.
        Cochrane Database Syst Rev. 2013; 3: 1-80
        • Ballard C.
        • Orrell M.
        • Psych F.R.C.
        • et al.
        Impact of antipsychotic review and nonpharmacological intervention on antipsychotic use, neuropsychiatric symptoms, and mortality in people with dementia living in nursing homes: A factorial cluster-randomized controlled trial by the Well-Being and Health for People With Dementia (WHELD) Program.
        Am J Psychiatry. 2016; 173: 252-262
        • Chenoweth L.
        • King M.T.
        • Jeon Y.H.
        • et al.
        Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: A cluster-randomised trial.
        Lancet Neurol. 2009; 8: 317-325

      Supplemental References

        • Leucht S.
        • Samara M.
        • Heres S.
        • Patel M.X.
        • Woods S.W.
        • Davis J.M.
        Dose equivalents for second-generation antipsychotics: The minimum effective dose method.
        Schizophr Bull. 2014; 40: 314-326
        • Cooper A.J.
        Benzodiazepines: towards more logical use.
        Scott Med J. 1982; 27: 297-304
        • Goodman L.S.
        • Gilman A.
        • Brunton L.L.
        Goodman & Gilman's Manual of Pharmacology and Therapeutics.
        McGraw-Hill Medical, New York2008
        • Ruiz P.
        • Strain E.C.
        • Lowinson J.H.
        Lowinson and Ruiz's Substance Abuse: A Comprehensive Textbook.
        Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia2011