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

Published online by Cambridge University Press:  23 January 2020

Fleur Harrison ,
Monica Cations Open the ORCID record for Monica Cations [Opens in a new window] ,
Tiffany Jessop ,
Liesbeth Aerts ,
Lynn Chenoweth ,
Allan Shell ,
Perminder Sachdev ,
Sarah Hilmer ,
Brian Draper  and
Henry Brodaty
Fleur Harrison
Affiliation:
Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, NSW, Australia Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, UNSW Sydney, NSW, Australia
Monica Cations
Affiliation:
Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, NSW, Australia
Tiffany Jessop
Affiliation:
Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, NSW, Australia
Liesbeth Aerts
Affiliation:
Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, NSW, Australia
Lynn Chenoweth
Affiliation:
Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, NSW, Australia Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, UNSW Sydney, NSW, Australia
Allan Shell
Affiliation:
Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, NSW, Australia
Perminder Sachdev
Affiliation:
Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, UNSW Sydney, NSW, Australia Neuropsychiatric Institute, Prince of Wales Hospital, Randwick, NSW, Australia
Sarah Hilmer
Affiliation:
Kolling Institute, Royal North Shore Hospital, University of Sydney, St. Leonards, NSW, Australia
Brian Draper
Affiliation:
Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, NSW, Australia Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Randwick, NSW, Australia
Henry Brodaty*
Affiliation:
Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, NSW, Australia Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, UNSW Sydney, NSW, Australia Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Randwick, NSW, Australia
*
Correspondence should be addressed to: Henry Brodaty, Dementia Centres for Research Collaboration, AGSM Building, UNSW Sydney, NSW, Australia. Phone: +61 2 9385 0431. Fax: +61 2 9385 2200. Email: h.brodaty@unsw.edu.au.
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Abstract

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.

Keywords

dementialong-term carebehavioural and psychological symptoms of dementianeuropsychiatric symptomsgeriatricspsychotropic medicationsnursing homes

Information

Type
Original Research Article
Information
International Psychogeriatrics , Volume 32 , Issue 3: Issue Theme: Improving Healthcare in Long-Term Care and Nursing Homes , March 2020 , pp. 335 - 345
Copyright
© International Psychogeriatric Association 2020

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References

Ayalon, L., Gum, A. M., Feliciano, L. and Areán, P. A. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Archives of Internal Medicine, 166, 2182–2188. doi: 10.1001/archinte.166.20.2182.CrossRefGoogle ScholarPubMed
Banerjee, S. (2009). The use of antipsychotic medication for people with dementia: time for action. A report for the Minister of State for Care Services. Department of Health, UK. Available at http://psychrights.org/research/digest/nlps/banerjeereportongeriatricneurolepticuse.pdf; last accessed 19 December 2019.Google Scholar
Brodaty, H., et al. (2018). Antipsychotic deprescription for older adults in long-term care: the HALT study. Journal of the American Medical Directors Association, 19, 592–600. e597. doi: 10.1016/j.jamda.2018.05.002.CrossRefGoogle ScholarPubMed
Chenoweth, L., Jessop, T., Harrison, F., Cations, M., Cook, J. and Brodaty, H. (2018). Critical contextual elements in facilitating and achieving success with a person-centred care intervention to support antipsychotic deprescribing for older people in long-term care. BioMed Research International, 2018, 7148515. doi: 10.1155/2018/7148515.CrossRefGoogle ScholarPubMed
Chiu, Y., Bero, L., Hessol, N. A., Lexchin, J. and Harrington, C. (2015). A literature review of clinical outcomes associated with antipsychotic medication use in North American nursing home residents. Health Policy, 119, 802–813. doi: 10.1016/j.healthpol.2015.02.014.CrossRefGoogle ScholarPubMed
Cohen-Mansfield, J., Marx, M. S. and Rosenthal, A. S. (1989). A description of agitation in a nursing home. The Journals of Gerontology, 44, M77–M84. doi: 10.1093/geronj/44.3.m77.CrossRefGoogle ScholarPubMed
Cornegé-Blokland, E., Kleijer, B. C., Hertogh, C. M. and van Marum, R. J. (2012). Reasons to prescribe antipsychotics for the behavioral symptoms of dementia: a survey in Dutch nursing homes among physicians, nurses, and family caregivers. Journal of the American Medical Directors Association, 13, 80. e81–80. e86. doi: 10.1016/j.jamda.2010.10.004.CrossRefGoogle ScholarPubMed
Craig, C., Tannenbaum, C., Ducruet, T. and Moride, Y. (2016). Patterns of antipsychotic use among community-dwelling elderly patients with dementia: impact of regulatory warnings. Medical Safety & Global Health, 5, 100129. doi: 10.4172/2574-0407.1000129.Google Scholar
Cummings, J. L., Mega, M., Gray, K., Rosenberg-Thompson, S., Carusi, D. A. and Gornbein, J. (1994). The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology, 44, 2308–2314. doi: 10.1212/wnl.44.12.2308.CrossRefGoogle ScholarPubMed
Declercq, T., et al. (2013). Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database System Review, 3, CD007726. doi: 10.1002/14651858.CD007726.pub2.Google ScholarPubMed
Dyer, S. M., Harrison, S. L., Laver, K., Whitehead, C. and Crotty, M. (2017). An overview of systematic reviews of pharmacological and non-pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia. International Psychogeriatrics, 30, 295–309. doi: 10.1017/S1041610217002344.CrossRefGoogle ScholarPubMed
Foster, P. D., et al. (2016). Trends in the use and cost of antipsychotics among older adults from 2007 to 2013: a repeated cross-sectional study. CMAJ Open, 4, E292. doi: 10.9778/cmajo.20150095.CrossRefGoogle ScholarPubMed
Gustafsson, M., Karlsson, S. and Lövheim, H. (2013). Inappropriate long-term use of antipsychotic drugs is common among people with dementia living in specialized care units. BMC Pharmacology and Toxicology, 14, 10. doi: 10.1186/2050-6511-14-10.CrossRefGoogle ScholarPubMed
Harrison, S. L., Cations, M., Jessop, T., Hilmer, S., Sawan, M. and Brodaty, H. (2018). Approaches to deprescribing psychotropic medications for changed behaviours in long-term care residents living with dementia. Drugs & Aging, 36, 125–136. doi: 10.1007/s40266-018-0623-6.CrossRefGoogle Scholar
Helmes, E., Csapo, K. G. and Short, J.-A. (1987). Standardization and validation of the multidimensional observation scale for elderly subjects (MOSES). The Journals of Gerontology, 42, 395–405. doi: 10.1093/geronj/42.4.395.CrossRefGoogle Scholar
Helvik, A.-S., Šaltytė Benth, J., Wu, B., Engedal, K. and Selbæk, G. (2017). Persistent use of psychotropic drugs in nursing home residents in Norway. BMC Geriatrics, 17, 52. doi: 10.1186/s12877-017-0440-5.CrossRefGoogle ScholarPubMed
Jacquin-Piques, A., et al. (2016). Psychotropic drug prescription in patients with dementia: nursing home residents versus patients living at home. Journal of Alzheimer’s Disease, 49, 671–680. doi: 10.3233/JAD-150280.CrossRefGoogle ScholarPubMed
Jessop, T., et al. (2017). 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. International Psychogeriatrics, 29, 1391–1403. doi: 10.1017/S1041610217000084.CrossRefGoogle ScholarPubMed
Jorm, A. F., et al. (1995). The psychogeriatric assessment scales: a multi-dimensional alternative to categorical diagnoses of dementia and depression in the elderly. Psychological Medicine, 25, 447–460. doi: 10.1017/s0033291700033377.CrossRefGoogle ScholarPubMed
Kalisch Ellett, L. M., et al. (2019). Reduction in use of risperidone for dementia in Australia following changed guidelines. Pharmacy, 7, 100. doi: 10.3390/pharmacy7030100.CrossRefGoogle ScholarPubMed
Koponen, M., et al. (2017). Risk of mortality associated with antipsychotic monotherapy and polypharmacy among community-dwelling persons with Alzheimer’s disease. Journal of Alzheimer’s Disease, 56, 107–118. doi: 10.3233/JAD-160671.CrossRefGoogle ScholarPubMed
Laver, K., et al. (2016). Clinical practice guidelines for dementia in Australia. The Medical Journal of Australia, 204, 191–193. doi: 10.5694/mja15.01339.CrossRefGoogle ScholarPubMed
Lawton, M. P. and Brody, E. M. (1969). Assessment of older people: self-maintaining and instrumental activities of daily living. The Gerontologist, 9, 179–186.CrossRefGoogle ScholarPubMed
Leucht, S., Samara, M., Heres, S., Patel, M. X., Woods, S. W. and Davis, J. M. (2014). Dose equivalents for second-generation antipsychotics: the minimum effective dose method. Schizophrenia Bulletin, 40, 314–326. doi: 10.1093/schbul/sbu001.CrossRefGoogle ScholarPubMed
Linde, R. M., Dening, T., Matthews, F. E. and Brayne, C. (2014). Grouping of behavioural and psychological symptoms of dementia. International Journal of Geriatric Psychiatry, 29, 562–568. doi: 10.1002/gps.4037.CrossRefGoogle ScholarPubMed
Mahoney, F. I. (1965). Functional evaluation: the Barthel index. Maryland State Medical Journal, 14, 61–65.Google ScholarPubMed
Maust, D. T., Kim, H. M., Chiang, C. and Kales, H. C. (2018). Association of the centers for medicare & medicaid services’ national partnership to improve dementia care with the use of antipsychotics and other psychotropics in long-term care in the United States from 2009 to 2014. JAMA Internal Medicine, 178, 640–647. doi: 10.1001/jamainternmed.2018.0379.CrossRefGoogle ScholarPubMed
Maust, D. T., et al. (2015). Antipsychotics, other psychotropics, and the risk of death in patients with dementia: number needed to harm. JAMA Psychiatry, 72, 438–445. doi: 10.1001/jamapsychiatry.2014.3018.CrossRefGoogle ScholarPubMed
Nielsen, R.-E., Lolk, A., Rodrigo-Domingo, M., Valentin, J.-B. and Andersen, K. (2017). Antipsychotic treatment effects on cardiovascular, cancer, infection, and intentional self-harm as cause of death in patients with Alzheimer’s dementia. European Psychiatry, 42, 14–23. doi: 10.1016/j.eurpsy.2016.11.013.CrossRefGoogle ScholarPubMed
Nielsen, R. E., Lolk, A., Valentin, J. and Andersen, K. (2016). Cumulative dosages of antipsychotic drugs are associated with increased mortality rate in patients with Alzheimer’s dementia. Acta Psychiatrica Scandinavica, 134, 314–320. doi: 10.1111/acps.12614.CrossRefGoogle ScholarPubMed
Nobili, A., et al. (2008). Alzheimer special care units compared with traditional nursing home for dementia care: are there differences at admission and in clinical outcomes? Alzheimer Disease & Associated Disorders, 22, 352–361. doi: 10.1097/WAD.0b013e31818207d0.CrossRefGoogle ScholarPubMed
Nobili, A., et al. (2009). Use and misuse of antipsychotic drugs in patients with dementia in Alzheimer special care units. International Clinical Psychopharmacology, 24, 97–104. doi: 10.1097/yic.0b013e328323aaf0.CrossRefGoogle ScholarPubMed
O’Connor, D. W., Griffith, J. and McSweeney, K. (2010). Changes to psychotropic medications in the six months after admission to nursing homes in Melbourne, Australia. International Psychogeriatrics, 22, 1149–1153. doi: 10.1017/S1041610210000165.CrossRefGoogle ScholarPubMed
Oteri, A., et al. (2016). Prescribing pattern of antipsychotic drugs during the years 1996–2010: a population-based database study in Europe with a focus on torsadogenic drugs. British Journal of Clinical Pharmacology, 82, 487–497. doi: 10.1111/bcp.12955.CrossRefGoogle ScholarPubMed
Pieper, M. J., et al. (2013). Interventions targeting pain or behaviour in dementia: a systematic review. Ageing Research Reviews, 12, 1042–1055. doi: 10.1016/j.arr.2013.05.002.CrossRefGoogle ScholarPubMed
Pruchno, R. A., Kleban, M. H. and Resch, N. L. (1988). Psychometric assessment of the Multidimensional Observation Scale for Elderly Subjects (MOSES). The Journals of Gerontology, 43, P164–169. doi: 10.1093/geronj/43.6.p164.CrossRefGoogle Scholar
Rabinowitz, J., Davidson, M., De Deyn, P. P., Katz, I., Brodaty, H. and Cohen-Mansfield, J. (2005). Factor analysis of the Cohen-Mansfield Agitation Inventory in three large samples of nursing home patients with dementia and behavioral disturbance. The American Journal of Geriatric Psychiatry, 13, 991–998. doi: 10.1176/appi.ajgp.13.11.991.CrossRefGoogle ScholarPubMed
Ralph, S. J. and Espinet, A. J. (2019). Use of antipsychotics and benzodiazepines for dementia: time for action? What will be required before global de-prescribing? Dementia, 18, 2322–2339. doi: 10.1177/1471301217746769.CrossRefGoogle Scholar
Rendina, N., Brodaty, H., Draper, B., Peisah, C. and Brugue, E. (2009). Substitute consent for nursing home residents prescribed psychotropic medication. International Journal of Geriatric Psychiatry, 24, 226–231. doi: 10.1002/gps.2094.CrossRefGoogle ScholarPubMed
Rojas-Fernandez, C., Mikhail, M. and Brown, S. G. (2014). Psychotropic and cognitive-enhancing medication use and its documentation in contemporary long-term care practice. Annals of Pharmacotherapy, 48, 438–446. doi: 10.1177/1060028013520196.CrossRefGoogle ScholarPubMed
Royal Australian and New Zealand College of Psychiatrists (2016). Professional Practice Guideline 10: Antipsychotic Medications as a Treatment of Behavioural and Psychological Symptoms of Dementia. Australia: Royal Australiana and New Zealand College of Psychiatrists, RANZCP.Google Scholar
Royal Commission into Aged Care Quality and Safety (2019). Interim Report: Neglect. Australia: Commonwealth of Australia.Google Scholar
Sawan, M. J., Jeon, Y.-H., Fois, R. J. and Chen, T. F. (2016). A qualitative study exploring visible components of organizational culture: what influences the use of psychotropic medicines in nursing homes? International Psychogeriatric 28, 1725–1735. doi: 10.1017/S1041610216000715.CrossRefGoogle ScholarPubMed
Selbæk, G., Kirkevold, Ø. and Engedal, K. (2008). The course of psychiatric and behavioral symptoms and the use of psychotropic medication in patients with dementia in Norwegian nursing homes—a 12-month follow-up study. The American Journal of Geriatric Psychiatry, 16, 528–536. doi: 10.1097/JGP.0b013e318167ae76.CrossRefGoogle Scholar
Snowdon, J., Galanos, D. and Vaswani, D. (2011). Patterns of psychotropic medication use in nursing homes: surveys in Sydney, allowing comparisons over time and between countries. International Psychogeriatrics, 23, 1520–1525. doi: 10.1017/S1041610211000445.CrossRefGoogle ScholarPubMed
Storey, J. E., Rowland, J.T.J., Conforti, D. A. and Dickson, H. G. (2004). The Rowland Universal Dementia Assessment Scale (RUDAS): a multicultural cognitive assessment scale. International Psychogeriatrics, 16, 13–31. doi: 10.1017/s1041610204000043.CrossRefGoogle ScholarPubMed
Sultana, J., et al. (2016). The effect of safety warnings on antipsychotic drug prescribing in elderly persons with dementia in the United Kingdom and Italy: a population-based study. CNS Drugs, 30, 1097–1109. doi: 10.1007/s40263-016-0366-z.CrossRefGoogle ScholarPubMed
Szczepura, A., et al. (2016). Antipsychotic prescribing in care homes before and after launch of a national dementia strategy: an observational study in English institutions over a 4-year period. BMJ Open, 6, e009882. doi: 10.1136/bmjopen-2015-009882.CrossRefGoogle ScholarPubMed
Taipale, H., Koponen, M., Tanskanen, A., Tolppanen, A.-M., Tiihonen, J. and Hartikainen, S., (2014). High prevalence of psychotropic drug use among persons with and without Alzheimer’s disease in Finnish nationwide cohort. European Neuropsychopharmacology, 24, 1729–1737. doi: 10.1016/j.euroneuro.2014.10.004.CrossRefGoogle ScholarPubMed
Tampi, R. R., Tampi, D. J., Balachandran, S. and Srinivasan, S. (2016). Antipsychotic use in dementia: a systematic review of benefits and risks from meta-analyses. Therapeutic Advances in Chronic Disease, 7, 229–245. doi: 10.1177/2040622316658463.CrossRefGoogle ScholarPubMed
Therapeutic Goods Administration (2015). Risperidone and risk of cerebrovascular adverse events in dementia patients. Medicines Safety Update, 6, 1–2.Google Scholar
van Dalen-Kok, A. H., Pieper, M. J., de Waal, M. W., Lukas, A., Husebo, B. S. and Achterberg, W. P. (2015). Association between pain, neuropsychiatric symptoms, and physical function in dementia: a systematic review and meta-analysis. BMC Geriatrics, 15, 49. doi: 10.1186/s12877-015-0048-6.CrossRefGoogle ScholarPubMed
Vilalta-Franch, J., Calvó-Perxas, L., Garre-Olmo, J., Turró-Garriga, O. and López-Pousa, S. (2013). Apathy syndrome in Alzheimer’s disease epidemiology: prevalence, incidence, persistence, and risk and mortality factors. Journal of Alzheimer’s Disease, 33, 535–543. doi: 10.3233/JAD-2012-120913.CrossRefGoogle ScholarPubMed
Westaway, K., Sluggett, J., Alderman, C., Moffat, A., Procter, N. and Roughead, E. J. D. (2018). The extent of antipsychotic use in Australian residential aged care facilities and interventions shown to be effective in reducing antipsychotic use: a literature review. Dementia. doi: 10.1177/1471301218795792.CrossRefGoogle Scholar
Westbury, J., Gee, P., Ling, T., Kitsos, A., and Peterson, G. J. A. (2019). More action needed: psychotropic prescribing in Australian residential aged care. Australia and New Zealand Journal of Psychiatry, 53, 136–147. doi: 10.1177/0004867418758919.CrossRefGoogle ScholarPubMed
Westbury, J., Tichelaar, L., Peterson, G., Gee, P. and Jackson, S. (2011). A 12-month follow-up study of “RedUSe”: a trial aimed at reducing antipsychotic and benzodiazepine use in nursing homes. International Psychogeriatrics, 23, 1260–1269. doi: 10.1017/S1041610211000421.CrossRefGoogle ScholarPubMed
Wolf, A., Leucht, S. and Pajonk, F.-G. (2016). Do antipsychotics lead to cognitive impairment in dementia? A meta-analysis of randomised placebo-controlled trials. European Archives of Psychiatry and Clinical Neuroscience, 267, 187–198. doi: 10.1007/s00406-016-0723-4.CrossRefGoogle ScholarPubMed
Wood-Mitchell, A., James, I. A., Waterworth, A., Swann, A. and Ballard, C. (2008). Factors influencing the prescribing of medications by old age psychiatrists for behavioural and psychological symptoms of dementia: a qualitative study. Age and Ageing, 37, 547–552. doi: 10.1093/ageing/afn135.CrossRefGoogle ScholarPubMed
Zhang, Y., Letuchy, E. M. and Carnahan, R. M. (2018). Where are antipsychotics prescribed in nursing homes initiated? Journal of the American Geriatrics Society, 66, 1082–1088. doi: 10.1111/jgs.15223.CrossRefGoogle ScholarPubMed
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