Project

Halting antipsychotic use in long term care: the HALT project

Goal: HALT is a single-arm longitudinal intervention study in Sydney, Australia. The aim of HALT is to reduce the use of antipsychotic medication to treat behavioural and psychological symptoms of dementia in residential aged care.

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Project log

Fleur Harrison
added a research item
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.
Monica Cations
added a research item
Antipsychotic and other tranquilising medicines are prescribed to help care staff manages behaviour in one-quarter of older people living in Australian long-term care homes. While these medicines pose significant health risks, particularly for people with dementia, reliance on their use occurs when staff are not educated to respond to resident behaviour using nonpharmacological approaches. The Halting Antipsychotic use in Long-Term care (HALT) single-arm study was undertaken to address this issue with 139 people 60 years and over with behaviours of concern for staff living in 24 care homes. A train-the-trainer approach delivered person-centred care education and support for 22 HALT (nurse) champions and 135 direct care staff, dementia management education for visiting general practitioners (GP) and pharmacists, use of an individualised deprescribing protocol for residents, and awareness-raising for the resident's family. The HALT champions completed open-ended questionnaires and semistructured interviews to identify the contextual elements they considered most critical to facilitating, educating care staff, and achieving success with the study intervention. They reported that person-centred approaches helped care staff to respond proactively to resident behaviours in the absence of antipsychotic medicines; the champions considered that this required strong managerial support, champion empowerment to lead change, reeducation of care staff, and the cooperation of families and GPs.
Allan Shell
added 2 research items
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.
Monica Cations
added a research item
Despite limited evidence for efficacy and safety concerns, antipsychotic medications are commonly prescribed to manage behavioural and psychological symptoms of dementia (BPSD). Guidelines mandating appropriate, short-term use are rarely followed in practice. The aim is to examine conditions under which antipsychotics are prescribed in long term care (LTC) residents to better understand inappropriate practices and opportunities for intervention. Data were from the HALT project, a single-arm longitudinal deprescribing study including 24 facilities across NSW, Australia, with participants aged over 60 years, on regular antipsychotic medication, without primary psychotic illness or severe BPSD. Antipsychotic use including naturalistic dosage history, setting, consent and indication was collected. Of 139 participants, 86.4% were prescribed an atypical antipsychotic, 10.1% a typical, and 3.6% both, among 2.3 concurrent psychotropic medications on average. The current course of antipsychotic was prescribed on average 2.1 years prior, and dose unchanged for 1.2 years. Aggression and agitation were the most common reasons for prescription. Most current courses (57.6%) commenced during residency at an LTC facility. Verbal consent for antipsychotics was recorded in 15.1% of participant files; written consent was located once. Recommendations by health professionals to review antipsychotics were documented in 62.6% of cases. Antipsychotics were commonly prescribed outside guidelines for older adults with dementia. The majority were initiated without informed consent and continued without change for lengthy periods, even when reduction or cessation was recommended. Indications were often unclear or for symptoms with insufficient evidence for benefit. Interventions to improve prescribing practices to meet guidelines are urgently needed.
Monica Cations
added a research item
Background Antipsychotic medications continue to be used in the management of Behavioral and Psychological Symptoms of Dementia (BPSD) despite adverse effects and revised guidelines. The Halting Antipsychotic use in Long Term care (HALT) project aimed to deprescribe these medications and improve non-pharmacological behavior management. Method We recruited residents from 24 long term care facilities who were aged 60+ years, on regular antipsychotic medication, without a primary psychotic illness, and without severe neuropsychiatric symptoms. Consenting participants were assessed one month and one week prior to deprescribing. Training was provided for facility nurses on how to manage neuropsychiatric symptoms and a dose reduction schedule was sent to and approved by GPs before deprescribing commenced. Participants were re-assessed 3, 6 and 12 months later. The primary outcome measure was reduction of regular antipsychotic medication without use of substitute psychotropic medications. The secondary outcome measures were NPI total and domain scores and Cohen-Mansfield Agitation Inventory (CMAI) score. Results Of 157 residents recruited, 133 commenced deprescribing and 125 achieved antipsychotic cessation. Of these, 76% remain off the antipsychotic medication up to 12 months following initial reduction. NPI and CMAI scores remained stable from baseline to 6 month follow-up with a similar trend seen for those who have reached 12 month follow up. Conclusion Deprescribing of antipsychotics in long term care residents with previous BPSD is feasible without re-emergence of BPSD; however, challenges still exist regarding sustainability and culture of prescribing in aged care. The impact of facility and individual factors on outcomes and reasons for recommencement following deprescribing warrant further investigation.
Fleur Harrison
added 5 research items
Objectives: Managing Behavioural and Psychological Symptoms of Dementia (BPSD) is a great challenge, particularly in the residential care setting. Antipsychotic medications are commonly used to treat many of these symptoms however evidence suggests only modest efficacy and an increased risk of stroke, cognitive decline and death. HALT objectives are to 1) educate Residential Aged Care Facility (RACF) staff, GPs and pharmacists in the appropriate use of antipsychotics for BPSD and person-centred approaches to behaviour management. This will provide a foundation to 2) reduce antipsychotic use in residents without use of substitute medications. Methods: Facilities: 20 RACFs have been recruited across greater Sydney and each has nominated at least one ‘HALT Champion’ nurse to facilitate the project. Participants: 200 eligible residents will be recruited. Baseline data will be collected on quality of life, cognition, neuropsychiatric symptoms and adverse events including falls. Deprescribing plans will be established with GPs and follow up data collected 3, 6 and 12 months following cessation of antipsychotics . Education: A train the trainer approach is used to educate Champions in non-pharmacological behaviour management, skills they then pass on to other facility staff to support the deprescribing intervention. GPs of participants will receive education on appropriate use of antipsychotics in the elderly. This has been RACGP accredited as a clinical audit. Results: Recent Australian data suggest around 30% of RACF residents are using antipsychotics regularly and the majority are prescribed inappropriately1. Preliminary HALT data indicates a lower rate (18%) for facilities where data has been collected thus far. Currently, participant recruitment is at 66 with baseline data completed for 62 and 30 have commenced deprescribing. We will present preliminary data on the impact of deprescribing on participants as well as outcomes of education on practice change. Conclusion: HALT takes a multidisciplinary approach, with collaboration between consumers, RACFs, GPs, pharmacists and clinical specialists to achieve reductions in inappropriate antipsychotic use and associated adverse events. Outcomes will be used to inform practice development and culture change models around antipsychotic use and review in RACFs. References: 1. Ballard C, Lana MM, Theodoulou M, Douglas S, McShane R, et al. (2008) A Randomised, Blinded, Placebo-Controlled Trial in Dementia Patients Continuing or Stopping Neuroleptics (The DART-AD Trial). PLoS Med 5(4): e76.
Monica Cations
added a research item
Background Inappropriate use of antipsychotic medications to manage Behavioral and Psychological Symptoms of Dementia (BPSD) continues despite revised guidelines and evidence for the associated risks and side effects. The aim of the Halting Antipsychotic Use in Long-Term care (HALT) project is to identify residents of long-term care (LTC) facilities on antipsychotic medications, and undertake an intervention to deprescribe (or cease) these medicines and improve non-pharmacological behavior management. Methods LTC facilities will be recruited across Sydney, Australia. Resident inclusion criteria will be aged over 60 years, on regular antipsychotic medication, and without a primary psychotic illness or very severe BPSD, as measured using the Neuropsychiatric Inventory (NPI). Data collection will take place one month and one week prior to commencement of deprescribing; and 3, 6 and 12 months later. During the period prior to deprescribing, training will be provided for care staff on how to reduce and manage BPSD using person-centered approaches, and general practitioners of participants will be provided academic detailing. The primary outcome measure will be reduction of regular antipsychotic medication without use of substitute psychotropic medications. Secondary outcome measures will be NPI total and domain scores, Cohen-Mansfield Agitation Inventory scores and adverse events, including falls and hospitalizations. Conclusion While previous studies have described strategies to minimize inappropriate use of antipsychotic medications in people with dementia living in long-term care, sustainability and a culture of prescribing for BPSD in aged care remain challenges. The HALT project aims to evaluate the feasibility of a multi-disciplinary approach for deprescribing antipsychotics in this population.
Monica Cations
added 2 research items
Objectives: Managing Behavioural and Psychological Symptoms of Dementia (BPSD) is a great challenge, particularly in the residential care setting. Antipsychotic medications are commonly used to treat many of these symptoms however evidence suggests only modest efficacy and an increased risk of stroke, cognitive decline and death. HALT objectives are to 1) educate Residential Aged Care Facility (RACF) staff, GPs and pharmacists in the appropriate use of antipsychotics for BPSD and person-centred approaches to behaviour management. This will provide a foundation to 2) reduce antipsychotic use in residents without use of substitute medications. Methods: Facilities: 20 RACFs have been recruited across greater Sydney and each has nominated at least one ‘HALT Champion’ nurse to facilitate the project. Participants: 200 eligible residents will be recruited. Baseline data will be collected on quality of life, cognition, neuropsychiatric symptoms and adverse events including falls. Deprescribing plans will be established with GPs and follow up data collected 3, 6 and 12 months following cessation of antipsychotics . Education: A train the trainer approach is used to educate Champions in non-pharmacological behaviour management, skills they then pass on to other facility staff to support the deprescribing intervention. GPs of participants will receive education on appropriate use of antipsychotics in the elderly. This has been RACGP accredited as a clinical audit. Results: Recent Australian data suggest around 30% of RACF residents are using antipsychotics regularly and the majority are prescribed inappropriately1. Preliminary HALT data indicates a lower rate (18%) for facilities where data has been collected thus far. Currently, participant recruitment is at 66 with baseline data completed for 62 and 30 have commenced deprescribing. We will present preliminary data on the impact of deprescribing on participants as well as outcomes of education on practice change. Conclusion: HALT takes a multidisciplinary approach, with collaboration between consumers, RACFs, GPs, pharmacists and clinical specialists to achieve reductions in inappropriate antipsychotic use and associated adverse events. Outcomes will be used to inform practice development and culture change models around antipsychotic use and review in RACFs. References: 1. Ballard C, Lana MM, Theodoulou M, Douglas S, McShane R, et al. (2008) A Randomised, Blinded, Placebo-Controlled Trial in Dementia Patients Continuing or Stopping Neuroleptics (The DART-AD Trial). PLoS Med 5(4): e76.
Monica Cations
added a project goal
HALT is a single-arm longitudinal intervention study in Sydney, Australia. The aim of HALT is to reduce the use of antipsychotic medication to treat behavioural and psychological symptoms of dementia in residential aged care.