ArticlePDF Available

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

Authors:

Abstract and Figures

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.
Content may be subject to copyright.
International Psychogeriatrics: page 1 of 13 © International Psychogeriatric Association 2017
doi:10.1017/S1041610217000084
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
...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Tiffany Jessop,1Fleur Harrison,1Monica Cations,1Brian Draper,2Lynn Chenoweth,3
Sarah Hilmer,4Juanita Westbury,5Lee-Fay Low,6Megan Heffernan,1
Perminder Sachdev,7Jacqueline Close,8Jenny Blennerhassett,1
Millicent Marinkovich,1Allan Shell1and Henry Brodaty1
1Dementia Collaborative Research Centre, School of Psychiatry UNSW Australia, Sydney, NSW 2052, Australia
2School of Psychiatry UNSW Australia and Clinical Director, Academic Department for Old Age Psychiatry Prince of Wales Hospital, Euroa Centre Prince of
Wales Hospital, Randwick, NSW 2031, Australia
3Centre for Healthy Brain Ageing (CHeBA), UNSW Australia, Sydney, NSW 2052, Australia
4Sydney Medical School, The University of Sydney and Head of Department Clinical Pharmacology and Senior Staff Specialist Aged Care, Royal North
Shore Hospital Level 12, Kolling Building, St Leonards, NSW 2065, Australia
5Wicking Dementia Research and Education Centre, Faculty of Health, University of Tasmania, Pr ivate Bag 143, Hobart, TAS 7001, Australia
6NHMRC Career Development Fellow Faculty of Health Sciences, The University of Sydney, Room M309B M Block 75 East Street, Lidcombe, NSW 2141,
Australia
7Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, UNSW Australia and Director, Neuropsychiatric Institute, The Prince of Wales Hospital,
Randwick, NSW 2031, Australia
8Neuroscience Research Australia, Barker St Randwick, NSW 2031, Australia
ABSTRACT
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.
Key words: antipsychotics, BPSD, aged care, dementia, person-centered care, deprescribing, long-term care
Correspondence should be addressed to: Henry Brodaty, Director, Dementia
Collaborative Research Centre, School of Psychiatry UNSW Australia,
Sydney, NSW 2052, Australia. Phone: +61 2 9385 2585; Fax: +61 2
9385 2200. Email: h.brodaty@unsw.edu.au. Received 22 Mar 2016; revision
requested 19 Jul 2016; revised version received 25 Oct 2016; accepted 15 Jan
2017.
Introduction
Behavioral and psychological symptoms of demen-
tia (BPSD) have a significant impact on quality of
life for both the person with dementia and those
who care for them. As the disease progresses, most
people with dementia will experience at least one
https://doi.org/10.1017/S1041610217000084
Downloaded from https:/www.cambridge.org/core. UNSW Library, on 12 Mar 2017 at 23:02:07, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
2T. Je ssop et al.
type of BPSD (Brodaty et al.,2001). These may
include wandering, verbally disruptive behaviors
(calling out), disinhibition, anxiety, aggression,
agitation, or psychosis.
Antipsychotic medications, developed for the
treatment of acute psychoses in the context of
schizophrenia and bipolar disorder (Kane and
Correll, 2010), are often used to manage BPSD.
Modest benefits with antipsychotic medications
have been demonstrated for agitation, aggression
(Ballard et al.,2009) and hallucinations, and
delusions (Katz et al.,1999). The effects of these
medications on function and quality of life have
received less attention.
Rates of antipsychotic prescribing for people
with dementia, who live in long-term care (LTC)
facilities, remain high: 28% in Australia, 22% in
the USA and just over 20% in the UK (Snowdon
et al.,2011; Briesacher et al.,2013; Maguire
et al.,2013). In 2009, a report into this issue
commissioned by the NHS in England estimated
just one in five people with dementia treated with
antipsychotics were deriving any benefit (Banerjee,
2009). Concern about the use of antipsychotics in
older people, and particularly those with dementia,
is driven mainly by their potential adverse effects
as well as their limited efficacy. Adverse effects
include over-sedation, anticholinergic actions (e.g.
constipation and dry mouth resulting in poor oral
health and delirium), pneumonia, parkinsonism,
falls, hospitalization, accelerated cognitive decline,
and higher rates of stroke and death (Zaudig, 2000;
Ballard et al.,2009).
Two key antipsychotic withdrawal studies in
people with dementia delivered mixed results.
In Ballard et al.’s (2008 and 2009) double-
blind randomized withdrawal trial, the majority of
people who discontinued antipsychotic medication
(placebo) experienced no negative effects on
function, cognition or BPSD; showed improved
cognition and had lower mortality at 6 and 12
months. Cognition assessed using the Standardized
Mini-Mental State Examination (Folstein et al.,
1975) was also better in the placebo group at
follow-up. However, Devanand et al. (2012)re-
ported re-emergence of behavioral symptoms when
antipsychotics were withdrawn, and in Ballard
et al.’s study, a small sub-group with more severe
BPSD had symptom relapse. A possible reason
for the difference between these studies is the
selection of participants randomized. In Devanand
et al.(2012), participants were recruited from a
variety of sources, were outpatients or residents of
LTC facilities and were prescribed an antipsychotic
(risperidone) within the context of agitation or
psychosis in Alzheimer’s disease; only “responders”
were randomized to continuation or placebo. By
contrast, Ballard et al. randomized LTC residents
already taking any antipsychotic for more than 3
months for any type of BPSD to participate in the
randomized withdrawal trial. While Devanand et al.
(2012) provide rigorous outcomes for ideal, appro-
priate use of antipsychotics for BPSD, the dilemma
is that in routine care these drugs are often used
first line for any BPSD and for long periods without
regular review, despite being indicated for severe
agitation/aggression and psychotic symptoms; as in
Ballard et al.’s (2009) study.
Many reasons exist for the potentially excessive
and often inappropriate use of antipsychotic
and other psychotropic medications to manage
BPSD (Cornegé-Blokland et al.,2012; Hilmer and
Gnjidic, 2013), including the perceived (but erro-
neous) lack of evidence for non-pharmacological
alternatives (Cabrera et al.,2015). In this context,
“inappropriate,” refers to prescribing not in line
with current clinical and best practice guidelines;
including indication, dose, and duration. To assist
clinician decision-making in regard to prescribing
antipsychotics, the NSW Health Guidelines (The
Royal Australian & New Zealand College of
Psychiatrists, 2013) recommend employing the “3
T approach” to prescribing: Target behaviors that
potentially respond to antipsychotics; Titrate the
dose carefully starting low and monitoring for side
effects; and Time limit the use of antipsychotics.
Other barriers to good prescribing include, resist-
ance to practice development, negative attitudes
towards people with dementia, pressure from
nurses and other LTC staff on general practitioners
(GPs) to “do something” about BPSD, and a
lack of skills and resources for both GPs and
direct care staff to implement alternatives (Hinton
et al.,2007;Kadaet al.,2009;Ervinet al.,2014).
Further to this, nurses and GPs may be reluctant
to instigate medication review and the potential
for antipsychotic withdrawal of newly admitted
residents because of limited clinical information on
presentation (O’Connor et al.,2010).
Non-pharmacological behavior management is
recommended as a first-line treatment approach for
BPSD (Azermai et al.,2012). The person-centered
approach to dementia care is an effective way of
preventing and reducing BPSD (Fossey et al.,2006;
Edvardsson et al.,2008; Chenoweth et al.,2009;
Brooker et al.,2016). Challenges to implementing
person-centered dementia care focus on critical
buy-in from LTC executives, management, and
staff in terms of time, money investment, and
commitment to culture change (McCormack et al.,
2010; Chenoweth et al.,2014).
Against this background, the Halting Anti-
psychotic use in Long-Term care (HALT) project
aims to “deprescribe” antipsychotic medications
https://doi.org/10.1017/S1041610217000084
Downloaded from https:/www.cambridge.org/core. UNSW Library, on 12 Mar 2017 at 23:02:07, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
Deprescribing antipsychotics in long-term care 3
through a multi-component intervention, including
promotion of person-centered care in participating
LTC facilities. Deprescribing is the “process of
tapering or stopping of drugs aimed at minimizing
polypharmacy and improving outcomes” (Scott
et al.,2015). This implies a more complex protocol
of review, planning, and follow-up than merely
cessation or withdrawal of a drug as described
in the studies mentioned. Given the barriers to
deprescribing antipsychotics and the conflicting
results in the two influential studies mentioned, we
considered that deprescribing would require both
person-centered dementia care education for direct
care staff, as well as GP education on antipsychotic
prescribing and subsequent risks.
The HALT project aims to achieve a reduction
in inappropriate use of antipsychotic medications in
participating LTC facilities without re-emergence
of BPSD and without use of substitute psychotropic
prescribing. Based on Banerjee’s estimate of
benefit, we hypothesize that sustained (12-month)
deprescribing (defined as cessation or a dose
reduction), can be achieved for at least half of
residents living in LTC prescribed antipsychotics
regularly. This will be without an associated rise
in BPSD when care staff use person-centered
dementia care approaches at the same time
that the resident’s GP employs a recommended
deprecribing protocol.
Methods
The HALT project is a single-arm longitudinal
study involving LTC facilities from the greater
Sydney area and their staff and residents, GPs,
and pharmacists. Study approval was obtained
from the lead institution’s Human Research Ethics
Committee (approval number HC13203). The trial
was registered with the Australian New Zealand
Clinical Trials Registry (ANZCTR), number
12614000309684. The protocol includes several
steps as outlined in Figure 1 anddetailedbelow.
Participants
A sample of LTC facilities from across greater
Sydney, Australia, with more than 60 beds will
be approached to participate. We aim to recruit
facilities that are diverse in size, funding source and
geographical location. To be eligible to participate,
LTC facilities require agreement from the Director
of Nursing (DON) or equivalent manager, and
must appoint at least one HALT Champion. The
HALT Champion will be a registered nurse, who
is committed to the requirements of the project,
including training other staff in person-centered
care approaches, identifying potential residents to
participate in the intervention, and monitoring
participants throughout the duration of the project.
A position description for HALT Champions
will be circulated to participating LTC facilities’
DONs who will be responsible for selecting
suitable candidates (see supplementary/appendix,
available as supplementary material attached to the
electronic version of this paper at www.journals.
cambridge.org/jid_IPG).
Champions will be asked to establish a list of all
potential participants within their facility according
to the following eligibility criteria: resident aged
60 years or older; taking an antipsychotic regularly
for >3 months; residing at the LTC facility for
at least one month; and not having a primary
psychotic mental illness (e.g. schizophrenia and
bipolar disorder). Two additional eligibility criteria
will be checked following contact with potential
participants’ family members/designated carer. The
first of these is an agreement from the resident’s GP
to review antipsychotic prescribing and follow the
study deprescribing protocol; this is a requirement
of the Australian Aged Care Act (www.legislation.
gov.au/Details/C2014C00698), which governs all
Australian accredited LTC facility protocols.
Residents will not be eligible to participate if
their GP does not agree that they are suitable for
deprescribing, or does not wish to be involved with
the deprescribing and follow-up. Second, in view of
greater likelihood of recurrence of BPSD in those
with more severe symptoms (Ballard et al.,2009),
residents meeting criteria for extreme severity (see
below) will be excluded.
Participants’ current BPSD will be assessed
using the Neuropsychiatric Inventory–Nursing
Home edition (NPI–NH) (Cummings et al.,
1994). Threshold NPI scores for exclusion due
to severe BPSD will be based on the Australian
Government’s “Dementia Supplement,” which is
an additional payment to LTC facilities based on
residents that exhibit “severe” behaviors (active
during study planning but no longer operational).
Information on the Dementia Supplement can be
found at https://www.dss.gov.au/sites/default/files/
files/about-fahcsia/publication-articles/foi/14_15_
014/doc_011_0.pdf. Accordingly, “severe” BPSD
are characterized by a total NPI score >50,
individual domain scores 12 in >2offiveof
the domains, delusions, hallucinations, agitation/
aggression, anxiety and disinhibition, and an
occupational disruptiveness score 4for>2ofthe
domains above.
Consent
In New South Wales, Australia, the Guardianship
Act provides a hierarchy of people who can give
https://doi.org/10.1017/S1041610217000084
Downloaded from https:/www.cambridge.org/core. UNSW Library, on 12 Mar 2017 at 23:02:07, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
4T. Je ssop et al.
Figure 1. (Colour online) Steps involved in the HALT protocol from appointment of a HALT Champion within each LTC facility, to
identification of potential participants and through to follow-up. Further details provided in the text. Abbreviations: LTC – long-term care;
GP – general practitioner (primary care physician); BPSD – behavioral and psychological symptoms of dementia; PCC – person-centered
care.
proxy consent for a person who, because of disab-
ility, is unable to consent to treatment themselves;
the proxy is called the Person Responsible. Following
the identification of potential participants within
their LTC facility, Champions will be asked to
contact residents’ person responsible and ask for
their assent to allow the study team to contact
them regarding participation, in accordance with
approved ethical procedures. If verbal assent
to contact is given, details of the resident
and person responsible will be passed to the
research team. The study team will contact
assenting persons responsible by telephone unless
otherwise requested. During this first contact, the
team member will introduce the project aims,
respond to questions or concerns from the person
responsible and obtain verbal assent to contact the
potential participant’s GP. If in agreement, a study
Participant Information Statement and Consent
Form will be posted to the person responsible
who will be given at least two weeks to respond,
after which a follow-up phone call will be made.
During this period, the study team will be in touch
with the potential participant’s GP to establish
suitability for deprescribing and agreement. Once
consent has been obtained, the first assessment
will be scheduled. In the event that a potential
participant is deemed by senior LTC staff to
have capacity to consent, then the same process
will be followed with the resident rather than
with the person responsible. See summary of the
participant identification and recruitment process
in Figure 2.
Interventions
The intervention will consist of two components:
training and education of LTC staff and clinicians,
https://doi.org/10.1017/S1041610217000084
Downloaded from https:/www.cambridge.org/core. UNSW Library, on 12 Mar 2017 at 23:02:07, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
Deprescribing antipsychotics in long-term care 5
Figure 2. HALT participant identification and recruitment flow chart, which depicts the procedure involved in identifying potential
participants for deprescribing and the recruitment process passing from HALT Champion to the research team. Abbreviations: PR – person
responsible; GP – general practitioner (primary care physician); NPI – Neuropsychiatric Inventory.
https://doi.org/10.1017/S1041610217000084
Downloaded from https:/www.cambridge.org/core. UNSW Library, on 12 Mar 2017 at 23:02:07, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
6T. Je ssop et al.
Figure 3. Program Logic Model of HALT interventions. The HALT protocol includes a complex process combining an education intervention
with the deprescribing intervention (“activities”). Abbreviations: BPSD – behavioral and psychological symptoms of dementia; GP –
general practitioner (primary care physician).
and deprescribing antipsychotic medications, a
summary of which is presented in Figure 3.
Education will be offered to Champions, GPs of
participants and pharmacists involved in supply
of medicines or clinical services to participating
facilities. All training will occur prior to the
initiation of deprescribing for residents within
each facility; details are provided below. The
deprescribing intervention will commence on a
rolling basis contingent upon receipt of consent
and any facility requirements (i.e. Champions may
wish to limit the number of residents undergoing
deprescribing at one time).
Champion training
To support deprescribing for participating resid-
ents, Champions, and where possible a facility
manager, will attend a 3-day workshop facilitated
by an experienced professor of aged care nursing
(LC) at the commencement of the facility’s
involvement. This workshop will be the first step in
a “train-the-trainer” approach to provide education
to all staff within participating LTC facilities. This
workshop will provide Champions with information
about dementia, BPSD, person-centered, non-
pharmacological approaches to BPSD prevention,
and reduction. In addition, Champions will learn
techniques in up-skilling other staff and opera-
tionalizing practice change, and will be provided
with a manual of resources to support this task.
This includes information on creating 5-minute
“micro-tutorials” that can be used to relay in-
formation on strategic person-centered approaches
for individual residents at staff handover times,
and activities designed to improve documentation
and care planning for residents using a person-
centered approach (Table 1). Following the 3-day
https://doi.org/10.1017/S1041610217000084
Downloaded from https:/www.cambridge.org/core. UNSW Library, on 12 Mar 2017 at 23:02:07, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
Deprescribing antipsychotics in long-term care 7
Table 1. Program for HALT Champion 3-day training workshop. HALT Champions were provided with a
comprehensive training folder containing educational material as well as activities and worksheets to be
completed over the training period
DAY ONE: SUPPORTING PERSONHOOD IN DEMENTIA
Discussion 1 Identifying your learning needs
Activity 1 Personal expectations and experiences of dementia care
Discussion 2 Internalising the care experience
Discussion 3 Experiencing life in the nursing home with dementia
Activity 2 Understanding the changing needs of the person with dementia
Activity 3 Creating a caring culture for people with dementia
Discussion 4 Person-centered care principles
DAY TWO: PRACTISING PERSON CENTRED DEMENTIA CARE
Discussion 1 Reflect on day 1 learning and identify issues arising
Activity 1 Understanding behavior in dementia
Discussion 2 Person-centered communication
Activity 2 Identifying, avoiding and reducing triggers for behavior
Activity 3 Person-centred behavior assessment and care plans
Discussion 3 The team approach to behavior prevention/reduction
Activity 4 Evaluating person-centered approaches to behavior prevention
DAY THREE: BECOMING A FACILITATOR OF PRACTICE CHANGE
Activity 1 Enablers and barriers to culture and practice change
Activity 2 Facilitating culture change in dementia care
Activity 3 Behavior management policy and practice audits
Activity 4 Developing practice improvement memos
Discussion 1 Micro-training techniques in practice change
Activity 5 Role Play – shift handover using micro training and practice memos
Disscussion 2 Practice support requirements
workshop, Champions, along with support from
their manager, are expected to implement these
training strategies so that all staff in participating
areas of the facility are working together on
the person-centered care approaches by the time
resident deprescribing commences. Participating
facilities will be financially compensated for the
time invested by Champions to complete training
and HALT-related duties. It will be an expectation
that upon agreeing to participate in the study, LTC
facility managers support Champions to quarantine
time and provide relief from normal duties for
HALT activities with the understanding that this
time can be claimed. The HALT coordinator will
be in regular contact with Champions, especially
during the deprescribing period. This will be
primarily via email, however, Champions will be
free to contact the coordinator by telephone or
arrange for the coordinator to visit the facility at any
time. Research psychologists will also be available
to discuss participant progress during their visits to
each facility. Should BPSD re-emerge following de-
prescribing, or Champions have any other concerns
about the well-being of participants, the HALT
team will utilize their expertise to provide extra
support to Champions as needed, primarily via
authors HB (psychogeriatrician) and LC (specialist
nurse). Monthly multi-disciplinary team meetings
will be held involving HB, AS (academic GP),
research psychologists and project coordinator, at
which cases will be presented and discussed to de-
termine eligibility, report information provided by
Champions and to determine advice to be given to
Champions.
General practitioner education
A Category 1 Clinical Audit has been established
by the project team and approved by the
Royal Australian College of General Practitioners
(RACGP) under their Quality Improvement and
Continuing Professional Development Program
(activity number 23359). This activity is designed
to promote regular antipsychotic review and
update GPs’ knowledge of current best practice
in this area. To fulfill the conditions of the
audit, participants’ GP’s will be offered academic
detailing by the project GP (AS). This will involve
a 30–60 minute education session accompanied
by reading material on antipsychotic use in
people with dementia provided via the National
Prescribing Service. GPs will be required to
undertake medication reviews for their patients
living in LTC and will participate in a follow-
up educational seminar and evaluation. Australian
GPs are required to undertake a minimum
number of Quality Improvement and Continuing
Professional Development activities every three
years. GPs not wishing to participate in the activity
https://doi.org/10.1017/S1041610217000084
Downloaded from https:/www.cambridge.org/core. UNSW Library, on 12 Mar 2017 at 23:02:07, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
8T. Je ssop et al.
will be offered reimbursement for the time invested
reviewing and making appropriate changes to their
resident participants’ medication.
Pharmacist education
A Continuing Professional Development module
will also be offered to pharmacists, who dispense
medicines for each participating LTC Facility
(Westbury, 2014).
Deprescribing intervention
Current antipsychotic prescription information for
eligible and consented residents will be forwarded
to HALT project pharmacists following the first
data collection point – “Pre-baseline” (see below).
An individualized deprescribing protocol will be
developed for each participant, following a general
rule of reducing the dose by 50% every two weeks
and then ceasing after two weeks on the minimum
dose, in line with current clinical guidelines (Royal
Australian and New Zealand College of Psychiat-
rists, 2011). All deprescribing will be completed
within a maximum period of 12 weeks. If a parti-
cipant is taking more than one antipsychotic, only
one will be withdrawn at a time, leaving risperidone
(if prescribed) to be withdrawn last. Risperidone
is the only antipsychotic approved in Australia
for use for behavioral symptoms, specifically
aggression and psychosis, in persons with dementia.
Individualized deprescribing protocols will be sent
to the participant’s GP for approval prior to the
Baseline assessment (see below), shortly after which
deprescribing will commence. Once deprescribing
starts, Champions will be responsible for close
monitoring of the participant and informing the
research team about any issues or recurrence of
BPSD. If an increase in behavioral disturbances
such as agitation or psychotic symptoms are
experienced following deprescribing, Champions
and staff will be encouraged to follow best practice
guidelines and implement person-centered non-
pharmacological strategies suggested during HALT
training. GPs will be given the option of including
a PRN (as required) order of an appropriate
benzodiazepine as “rescue medication,” according
to current Best Practice Guidelines (Peisah et al.,
2011; The Royal Australian & New Zealand
College of Psychiatrists, 2013), i.e. to be used
in case of an acute behavioral disturbance that
cannot be managed using the non-pharmacological
interventions and/or if there is a risk to the
participant and/or those around them. If BPSD
recur and all person-centered non-pharmacological
interventions fail then the GP will review the res-
ident and antipsychotic therapy may be restarted.
During academic detailing at the commencement
Table 2. Demographic information collected from
HALT participants at the pre-baseline assessment
demographic details collected
from participants
......................................................................................................................................................
Date of birth
Country of birth
Education
Marital status
Children
Previous occupation
Government benefits
of participation, GPs will be informed of current
guidelines for commencing an antipsychotic (Royal
Australian and New Zealand College of Psychiat-
rists, 2011); it is expected that these guidelines will
be followed if recommencement is indicated.
Data collection
The first assessment will be scheduled following
receipt of written consent from the residents’ Per-
son Responsible or from the residents themselves,
if they have capacity. Below is the timeline for data
collection for participants.
T1 Pre-baseline (approximately 1 month prior to
baseline; all assessments and data collection
plus demographic information, NPI to confirm
eligibility)
T 0 Baseline (deprescribing to commence within 7–10
days following)
T+3 Post 3 months from baseline
T+6 Follow-up 6 months from baseline
T+12 Follow-up 12 months from baseline
At each time point, data will be collected from
LTC facility records, staff interview and resident
interview if capable. Additional items relating to
demographics and medical history, including vision
and hearing status plus LTC facility admission
details will be collected from resident files during
the first visit (Table 2).
Re-prescribing
Based on previous studies, the risk of relapse of
behavioral symptoms is acknowledged (Devanand
et al.,2012) and there may be participants
for whom antipsychotic medication will be re-
prescribed following reduction or cessation. In the
instance, where re-prescribing is deemed appro-
priate, LTC staff will follow usual practices and
contact the participant’s GP or medical specialist
for review. If re-prescribing an antipsychotic is
indicated, it will be recommended that the initial
https://doi.org/10.1017/S1041610217000084
Downloaded from https:/www.cambridge.org/core. UNSW Library, on 12 Mar 2017 at 23:02:07, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
Deprescribing antipsychotics in long-term care 9
Table 3. Data collection list organized by collection method (record audit, resident assessment, staff
interview, and person responsible self-complete). Medication data and information on adverse events such as
hospitalizations will be collected at each time-point. For the pre-baseline assessment, this will take in the
previous 12 months; for subsequent assessments data will be collected for the intervening period. Validated
assessment tools will be used to collect data on neuropsychiatric symptoms, agitation, function, cognition,
impulsivity, engagement, and quality of life across all time-points. Abbreviations: RACF – residential aged care
facility; RA – research assistant
data source method
.........................................................................................................................................................................................................................................................................................................................
Antipsychotic medication RACF records Record audit
Non-antipsychotic medication RACF records Record audit
RACF hospitalisations, events RACF records Record audit
Self-rated health Participant RA Interview
Satisfaction with care Participant RA Interview
Quality of life (QOL-AD) Logsdon et al.(1999) Participant RA interview
aPsychogeriatric Assessment Scales – Cognitive impairment
subscale (PAS) Jorm et al. (1995)
Participant RA interview
aRowland Universal Dementia Assessment Scale (RUDAS) Storey
et al. (2004)
Participant RA interview
Neuropsychiatric Inventory (NPI-NH) RACF Staff RA interview
Cohen-Mansfield Agitation Inventory (CMAI) Cohen-Mansfield
et al. (1989)
RACF Staff RA interview
Impulsivity measure Whitney et al.(2012) RACF Staff RA interview
Function (ADLs) Lawton and Brody (1969) RACF Staff Self-complete
Multi-dimensional observation scale for Elderly Subjects (MOSES)
– withdrawn behavior subscale Pruchno et al.(1988)
RACF Staff Self-complete
Satisfaction with RACF InformantbSelf-complete
Quality of life Logsdon et al.(1999) InformantbSelf-complete
Notes: aParticipants only complete one of PAS or RUDAS. RUDAS is an alternative for people with English as a second language.
bPR informant to provide these data if consented to participation for themselves in addition to resident.
dose be low and titrated slowly, consistent with
guidelines (Royal Australian and New Zealand
College of Psychiatrists, 2011). Following this,
GPs, HALT Champions/LTC staff, and persons
responsible will be asked to complete a short
questionnaire about the events leading up to
the medication re-instatement with the aim of
understanding the factors that may predict re-
prescribing.
Assessment Tools
Trained research psychologists will undertake
assessments with staff and residents using a variety
of validated tools to collect data on resident
quality of life, agitation, engagement, activities of
daily living, and current BPSD (Table 3) (Lawton
and Brody, 1969; Pruchno et al.,1988; Cohen-
Mansfield et al.,1989; Jorm et al.,1995; Logsdon
et al.,1999; Storey et al.,2004; Whitney et al.,
2012). Inter-rater reliability analysis will be carried
out. Resident file audits will be undertaken at each
time point to collect data on documented incidents
of aggression, falls, hospitalizations, and medical
diagnoses. Current medication data on drug name,
dose, and frequency for all prescription medicines
will be collected at each time point and for the
12 months preceding the trial from residents’
medication charts. Non-prescription medication
data will also be collected but will exclude
creams, eye drops, mouth washes, and vitamin
supplements.
Facility-wide psychotropic prescribing
Facility-wide psychotropic medication usage will
be collected for each participating LTC facility 12
months prior to commencement of involvement, at
commencement and 6 and 12 months following.
This will include name of drug, dose, and
frequency for antianxiety drugs, antidepressants,
anticonvulsants, antiemetics, sedative agents, and
medication for movement disorders (ATC codes
N05 and N06A). Quality Use of Medicines (QUM)
pharmacists for each facility will be invited to
supply this information via a Psychotropic Drug
Use Evaluation report. This is not a compulsory
activity for QUM pharmacists servicing LTC
facilities in Australia and is dependent on the
request of the facility; however, this activity is
often included in the annual contracted services.
The report provides information on drug class,
https://doi.org/10.1017/S1041610217000084
Downloaded from https:/www.cambridge.org/core. UNSW Library, on 12 Mar 2017 at 23:02:07, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
10 T. Je ssop et al.
type, and dose for each resident at a given
point in time though formats vary between
pharmacists. Medication usage from each facility
will be compared with national averages as well
as between HALT facilities. LTC facility-specific
information, such as size, staffing ratios, GP policy,
organizational structure, and geographic location
will also be collected.
Data analysis
Sample size
Approximately 1,600 aged care residents will be
screened from 12–18 LTC facilities. We predict up
to 30% (n =480) of residents will be prescribed
long-term antipsychotics, and thus eligible to par-
ticipate, based on previously published local data
(Snowdon et al.,2011). We anticipate deprescribing
for 175 residents on long-term antipsychotics,
based on a recruitment rate of 40%. Allowing for
25% withdrawals over 12 months (based on similar
sample and study duration in literature) (Barca
et al.,2010; Ballard et al.,2016), this sample size
(approx. n =131 after accounting for attrition)
provides 82% power to demonstrate a reduction of
at least 25% in antipsychotic use (proportion test;
effect size =0.25, α=0.05). To detect an effect size
of 0.50, this sample size will result in >95% power.
Statistical methods
SPSS version 22 will be used for data analysis.
Statistical significance will be set at 0.05 for
the primary outcome. Demographic factors and
clinical characteristics of all participants will
be summarized as counts and percentages for
categorical variables and as means ±SD or median
and IQR for normally or non-normally distributed
continuous variables, respectively. Non-normally
distributed outcome measures will be transformed.
Missing covariate data will be imputed using the
multiple imputation procedure in SPSS. Variables
that will be included in the multiple imputation are
socio-demographics, medical history, and other po-
tential covariates in the analyses. Other pre-baseline
covariates will be included in multiple imputation.
Depending on the actual percentage of missing
values, we will perform four to ten imputations.
Outcome measures
The primary outcome measure will be reduction
of regular antipsychotic medication without use
of substitute psychotropic medications. The doses
of different antipsychotic medications administered
to each participant at all time-points, will be
converted into olanzapine-equivalent doses (Leucht
et al.,2014) allowing for standardized measure of
the primary outcome across all participants. Time
on or off antipsychotics post intervention will be
monitored and this outcome will be dichotomized,
either based on deprescribing (complete cessation)
of antipsychotic medication, or a dose reduction.
The intervention will be considered successful,
if antipsychotic use can be reduced for at least
50% of participants and sustained for 12 months.
Secondary outcome measures will be NPI total and
domain scores (Cummings, 1997) and CMAI total
score (Cohen-Mansfield et al.,1989)aswellas
adverse events, including falls and hospitalizations.
Secondary outcome measures will be analyzed
over time using multi-level linear models, which
take correlations between repeated measures into
account. Data gathered from the period prior
to baseline will allow us to compare changes
pre and post-deprescribing for all participants.
Covariates for each model will be identified
through univariate testing of their association with
dependent variables. In this model, differences
across participants and across care facilities will
be handled as random effects, and time will be
handled as a fixed variable. We hypothesize that
antipsychotic reduction will not be accompanied
with a significant rise in BPSD.
Discussion
Prescription of antipsychotics for people exper-
iencing BPSD is a significant concern due to
the growing evidence for adverse events such as
increased risk of stroke and death (Brodaty et al.,
2003; Ballard and Waite, 2006). Interventions to
reduce the inappropriate use of antipsychotics for
BPSD are challenging for LTC facilities because
of the resources needed: LTC staff time plus the
cost of training in non-pharmacological behavior
management, as well as the need for culture
change to facilitate implementation of training.
While government guidelines and quality standards
are promoting a shift to person-centered care
approaches for the person with dementia in LTC,
as well as in acute care settings (National Institute
for Health and Care Excellence, 2006; Australian
Commission on Safety and Quality in Health Care,
2011; Australian Government, 2015), the current
systems require a number of structural changes to
accommodate this approach.
We anticipate barriers to staff’s ability to adopt
person-centered non-pharmacological approaches
to preventing and reducing BPSD, as has occurred
in similar studies, where low-level commitment and
engagement from LTC executive and management
have disabled direct care staff’s attempts to
https://doi.org/10.1017/S1041610217000084
Downloaded from https:/www.cambridge.org/core. UNSW Library, on 12 Mar 2017 at 23:02:07, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
Deprescribing antipsychotics in long-term care 11
individualize resident care and collectively work
on strategies to prevent or reduce the psychosocial
triggers for BPSD. Without the strong support
of managers and reallocation of resources, the
Champions will be unable to spend the required
amount of time on the project due to competing
priorities. Another potential issue will be the
ambivalence, concern, or refusal by GPs and
families/carers to allow the resident’s medications
to be deprescribed (Stein-Parbury et al.,2012;
Chenoweth et al.,2015). In taking a holistic, multi-
disciplinary approach to deprescribing, HALT
will attempt to address some of these barriers
and improve communication between LTC
management and staff, clinicians, and families,
not only relating to BPSD and antipsychotic use,
but also more generally to improve the care and
well-being of residents living in LTC facilities.
Limitations of the study include the single-
arm longitudinal design rather than a randomized
controlled trial, meaning higher risk of bias and
making findings difficult to generalize. Taking
into account the idiosyncratic nature of dementia,
however, our repeated measures approach may
have more “real world” applicability and be more
sensitive to the effect of deprescribing on individual
residents. There is also potential for any positive
effects of deprescribing to be masked by the natural
decline in resident cognition, health and/or function
over the 12-month follow-up period. A number
of requirements within the protocol rely heavily
on Champion time investment, commitment,
and an unbiased approach to identification of
potential participants. Being bound by ethical
responsibilities, recruitment at arms-length is
necessary and thus the importance of following the
established eligibility criteria will be reiterated to
Champions by the research team. The potential
for Champions and GPs to be subjective when
nominating residents for participation will be
taken into account in the analysis. Should the
results using the recruitment protocol demonstrate
feasibility and safety of deprescribing antipsychotics
in the context of BPSD, it will be useful to look
at applying the model more generally to remove
any potential bias created by the GP and LTC
facility staff involvement in participant selection.
Finally, the quality of the data on BPSD relies
on staff reporting of presence, frequency, and
severity of symptoms that can be subjective. While a
direct observational methodology would reduce this
uncertainty, the intense resources required would
not be feasible for this study.
Being mindful of the organizational and design
limitations imposed on the HALT project, the
planned protocol will, however, be a more
nuanced approach as regards reducing reliance
on antipsychotic medications to address BPSD
in people living in LTC facilities. Specifically,
the HALT project will promote better use
of non-pharmacological management strategies
through the adoption of person-centered non-
pharmacological approaches to preventing and
reducing BPSD, avoidance of antipsychotics where
possible, best psychotropic prescription practices
and more informed and more skillful GPs and
direct care staff. Should the study outcomes be
achieved and limitations successfully addressed, it
is anticipated that with the support of the Australian
government and the aged care sector, a model
of deprescribing antipsychotics in residents with
BPSD will be developed for widespread roll out.
Conflicts of interest
H. Brodaty: Over the last three years, Professor
Brodaty’s department has received grants for drug
trials from Lilly, Servier and Tau Therapeutics.
Professor Brodaty is on the advisory board for
Nutricia and is a member of clinical advisory
committees for the Montefiore Homes and the
Cranbrook Care, which operate residential care
homes.
J. Westbury: Dr Westbury was supported by an
NHMRC fellowship during the duration of this
project and receives support from the Australian
Government Department of Health as part of the
Dementia and Aged Care Service Fund for the
Expansion of the Reducing Use of Sedatives project
(RedUSe).
Description of authors’ roles
T. Jessop wrote the manuscript, contributed to
design, coordinated study implementation. F. Har-
rison contributed to design, collected data, edited
manuscript. M. Cations contributed to design,
collected data, edited manuscript. B. Draper
contributed to design, edited manuscript. L.
Chenoweth contributed to design, developed and
provided the Champion training program, edited
manuscript. S. Hilmer contributed to design, ed-
ited manuscript. J. Westbury contributed to design,
edited manuscript. L.F. Low contributed to design,
edited manuscript. M. Heffernan contributed to
design and writing of the study method, edited
manuscript. P Sachdev contributed to design,
edited manuscript. J. Close contributed to design,
edited manuscript. J. Blennerhassett contributed
to design and establishing deprescribing process,
edited manuscript. M. Marinkovich contributed to
design and establishing deprescribing process, ed-
ited manuscript. A. Shell developed and provided
https://doi.org/10.1017/S1041610217000084
Downloaded from https:/www.cambridge.org/core. UNSW Library, on 12 Mar 2017 at 23:02:07, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
12 T. Je ssop et al.
the GP training program, edited manuscript. H.
Brodaty designed the study, obtained the grant,
oversaw the conduct of the study, and assisted with
writing and editing the manuscript.
Acknowledgments
This project is funded by the Australian Depart-
ment of Health under the Aged Care Service
Improvement and Healthy Ageing Grant Fund.
The project is supported by the Dementia
Collaborative Research Centre – Assessment and
Better Care, UNSW. Dr Liesbeth Aerts and the
UNSW Statistical Consulting Unit advised on the
statistical analyses.
Supplementary material
To view supplementary material for this
article, please visit https://doi.org/10.1017/
S1041610217000084
References
Australian Commission on Safety and Quality in Health
Care, A. (2011). Patientcentred Care: Improving Quality and
Safety Through Partnerships With Patients and Consumers.
Sydney: ACSQHC,
AustralianGovernment,D.o.S.S.(2015). National
FrameWork for Action on Dementia 2015–2019. Canberra,
Australia: Australian Government, Department of Social
Services.
Azermai, M., Petrovic, M., Elseviers, M. M., Bourgeois,
J., Van Bortel, L. M. and Vander Stichele, R. H.
(2012). Systematic appraisal of dementia guidelines for the
management of behavioural and psychological symptoms.
Ageing Research Reviews, 11, 78–86.
Ballard, C. et al. (2008). A randomised, blinded,
placebo-controlled trial in dementia patients continuing or
stopping neuroleptics (the DART-AD trial). PLoS
Medicine/Public Library of Science,5,e76.
Ballard, C. et al. (2009). The dementia antipsychotic withd-
rawal trial (DART-AD): long-term follow-up of a random-
ised placebo-controlled trial. Lancet Neurology, 8, 151–157.
Ballard, C. et al. (2016). 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.
American Journal of Psychiatr y, 173, 252–262.
Ballard, C. and Waite, J. (2006). The effectiveness of
atypical antipsychotics for the treatment of aggression and
psychosis in Alzheimer’s disease. Cochrane Database
Systematic Review, CD003476.
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. In Department of
Health (Ed.). http://webarchive.nationalarchives.gov.uk/
20130107105354/http://www.dh.gov.uk/prod_consum_dh/
groups/dh_digitalassets/documents/digitalasset/dh_108302.
pdf
Barca, M. L., Engedal, K., Laks, J. and Selbaek, G.
(2010). A 12 months follow-up study of depression among
nursing-home patients in Norway. Journal of Affective
Disorders, 120, 141–148.
Briesacher, B. A., Tjia, J., Field, T., Peterson, D. and
Gurwitz, J. H. (2013). Antipsychotic use among nursing
home residents. Journal of the American Medical Association,
309, 440–442.
Brodaty, H. et al. (2001). Psychosis, depression and
behavioural disturbances in Sydney nursing home
residents: prevalence and predictors. International Journal of
Geriatric Psychiatr y, 16, 504–512.
Brodaty, H. et al. (2003). A randomised placebo controlled
trial of risperidone for the treatment of agitation and
psychosis of dementia. Journal of Clinical Psychiatry, 64,
134–143.
Brooker, D. J. et al. (2016). FITS into practice: translating
research into practice in reducing the use of anti-psychotic
medication for people with dementia living in care homes.
Aging and Mental Health, 20, 709–718.
Cabrera, E. et al. (2015). Non-pharmacological
interventions as a best practice strategy in people with
dementia living in nursing homes. A systematic review.
European Geriatric Medicine, 6, 134–150.
Chenoweth, L. et al. (2014). PerCEN: a cluster randomized
controlled trial of person-centered residential care and
environment for people with dementia. International
Psychogeriatrics, 26, 1147–1160.
Chenoweth, L. et al. (2015). PerCEN trial participant
perspectives on the implementation and outcomes of
person-centered dementia care and environments.
Inter national Psychogeriatrics, 27, 2045–2057.
Chenoweth, L. et al. (2009). 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 Neurology, 8, 317–325.
Cohen-Mansfield, J., Marx, M. S. and Rosenthal, A. S.
(1989). A description of agitation in a nursing home.
Journal of Gerontology, 44, M77–84.
Cornegé-Blokland, E., Kleijer, B. C., Hertogh,
C. M. P. 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.
Cummings, J. L. (1997). The neuropsychiatric inventory:
assessing psychopathology in dementia patients. Neurology,
48, S10–16.
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.
Devanand, D. P. et al. (2012). Relapse risk after
discontinuation of risperidone in Alzheimer’s disease. New
England Journal of Medicine, 367, 1497–1507.
https://doi.org/10.1017/S1041610217000084
Downloaded from https:/www.cambridge.org/core. UNSW Library, on 12 Mar 2017 at 23:02:07, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
Deprescribing antipsychotics in long-term care 13
Edvardsson, D., Winblad, B. and Sandman, P. O. (2008).
Person-centred care of people with severe Alzheimer’s
disease: current status and ways forward. Lancet Neurology,
7, 362–367.
Ervin, K., Cross, M. and Koschel, A. (2014). Barriers to
managing behavioural and psychological symptoms of
dementia: staff perceptions. Collegian, 21, 201–207.
Folstein, M. F., Folstein, S. E. and McHugh, P. R. (1975).
“Mini-mental state”. A practical method for grading the
cognitive state of patients for the clinician. Journal of
Psychiatric Research, 12, 189–198.
Fossey, J. et al. (2006). Effect of enhanced psychosocial care
on antipsychotic use in nursing home residents with severe
dementia: cluster randomised trial. British Medical Journal,
332, 756–761.
Hilmer, S. N. and Gnjidic, D. (2013). Rethinking
psychotropics in nursing homes. Medical Journal of
Australia, 198, 77.
Hinton, L., Franz, C., Reddy, G., Flores, Y., Kravitz, R.
and Barker, J. (2007). Practice constraints, behavioral
problems, and dementia care: primary care physicians’
perspectives. Journal of General Internal Medicine, 22,
1487–1492.
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.
Kada, S., Nygaard, H. A., Mukesh, B. N. and Geitung,
J. T. (2009). Staff attitudes towards institutionalised
dementia residents. Journal of Clinical Nursing, 18,
2383–2392.
Kane, J. M. and Correll, C. U. (2010). Past and present
progress in the pharmacologic treatment of schizophrenia.
The Journal of Clinical Psychiatry, 71, 1115–1124.
Katz, I. R., Jeste, D. V., Mintzer, J. E., Clyde, C.,
Napolitano, J. and Brecher, M. (1999). Comparison of
risperidone and placebo for psychosis and behavioral
disturbances associated with dementia: a randomized,
double-blind trial. Risperidone study group. Journal of
Clinical Psychiatry, 60, 107–115.
Lawton,M.P.andBrody,E.M.(1969). Assessment of
older people: self-maintaining and instrumental activities of
daily living. The Gerontologist, 9, 179–186.
Leucht, S., Samara, M., Heres, S., Patel, M. X., Woods,
S.W.andDavis,J.M.(2014). Dose equivalents for
second-generation antipsychotics: the minimum
effective dose method. Schizophrenia Bulletin, 40,
314–326.
Logsdon, R. G., Gibbons, L. E., McCurry, S. M. and
Te r i , L . (1999). Quality of life in Alzheimer’s disease:
patient and caregiver reports. Journal of Mental Health and
Aging, 5, 21–32.
Maguire, A., Hughes, C., Cardwell, C. and O’Reilly, D.
(2013). Psychotropic medications and the transition into
care: a national data linkage study. Journal of the American
Geriatrics Society, 61, 215–221.
McCormack, B. et al. (2010). Developing person-centred
practice: nursing outcomes arising from changes to
the care environment in residential settings for older
people. International Journal of Older People Nursing,5,
93–107.
National Institute for Health and Care Excellence.
(2006). Dementia: supporting people with dementia and
their carers in health and social care. Clinical guideline.
https://www.nice.org.uk/guidance/cg42
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.
Peisah, C., Chan, D. K., McKay, R., Kurrle, S. E. and
Reutens, S. G. (2011). Practical guidelines for the acute
emergency sedation of the severely agitated older patient.
Internal Medicine Journal, 41, 651–657.
Pruchno, R. A., Kleban, M. H. and Resch, N. L. (1988).
Psychometric assessment of the Multidimensional
Observation Scale for Elderly Subjects (MOSES). Journal
of Gerontology, 43, P164–169.
Royal Australian and New Zealand College of
Psychiatrists, R. (2011). The use of antipsychotics in
residential aged care. Clinical Recommendations developed
by the RANZCP Faculty of Psychiatry of Old Age (New
Zealand).
Scott, I. A. et al. (2015). Reducing inappropriate polypha-
rmacy: the process of deprescribing. Journal of the American
Medical Association Internal Medicine, 175, 827–
834.
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. Inter national Psychogeriatrics, 23, 1520–
1525.
Stein-Parbury, J., Chenoweth, L., Jeon, Y. H., Brodaty,
H.,Haas,M.andNorman,R.(2012). Implementing
person-centered care in residential dementia care. Clinical
Gerontologist, 35, 404–424.
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.
The Royal Australian & New Zealand College of
Psychiatrists. (2013). Assessment and Management of
People with Behavioural and Psychological Symptoms of
Dementia (BPSD). A handbook for NSW Health Clinicians.
North Sydney, NSW: NSW Ministry of Health.
https://www.ranzcp.org/Files/Publications/
A-Handbook- for-NSW-Health-Clinicians-BPSD_June13_
W.aspx
We st b u r y, J . (2014). Quality use of Psychotropic Medications in
RACFs. Canberra, Australia: Pharmaceutical Society of
Australia Ltd.
Whitney, J., Close, J. C., Lord, S. R. and Jackson, S. H.
(2012). Identification of high risk fallers among older
people living in residential care facilities: a simple screen
based on easily collectable measures. Archives of Gerontology
and Geriatrics, 55, 690–695.
Zaudig, M. (2000). A risk-benefit assessment of risperidone
for the treatment of behavioural and psychological
symptoms in dementia. Drug Safety, 23, 183–195.
https://doi.org/10.1017/S1041610217000084
Downloaded from https:/www.cambridge.org/core. UNSW Library, on 12 Mar 2017 at 23:02:07, subject to the Cambridge Core terms of use, available at https:/www.cambridge.org/core/terms.
... : lignes directrices nationales) (Langford et al., 2019;Tannenbaum et al., 2017). Ces deux groupes d'initiatives se butent à de nombreux défis liés à l'utilisation et à la pérennisation des interventions de déprescription de médicaments chez les aînés (Dharmarajan et al., 2019;Jessop et al., 2017;Langford et al., 2019). Plusieurs recherches ont identifié les facteurs qui freinent l'implantation de la déprescription, dont les structures organisationnelles rigides (Palagyi et al., 2016), la culture de soins centrée sur la tâche (Palagyi et al., 2016), le manque ou le roulement des ressources humaines (Bjerre et al., 2018;Chenoweth et al., 2018;Palagyi et al., 2016;Turner et al., 2016), le manque de formation des équipes de soins sur les effets secondaires, la gestion et la documentation des médicaments (Palagyi et al., 2016), la croyance que l'usage d'antipsychotiques peut alléger le fardeau des soignants (Bjerre et al., 2018), la peur de contribuer à la détérioration de l'état (Turner et al., 2016) ou du comportement du patient (Bjerre et al., 2018;Chenoweth et al., 2018), les différences de perception entre les professionnels, les patients ou leurs proches (ex. ...
... Plusieurs recherches ont identifié les facteurs qui freinent l'implantation de la déprescription, dont les structures organisationnelles rigides (Palagyi et al., 2016), la culture de soins centrée sur la tâche (Palagyi et al., 2016), le manque ou le roulement des ressources humaines (Bjerre et al., 2018;Chenoweth et al., 2018;Palagyi et al., 2016;Turner et al., 2016), le manque de formation des équipes de soins sur les effets secondaires, la gestion et la documentation des médicaments (Palagyi et al., 2016), la croyance que l'usage d'antipsychotiques peut alléger le fardeau des soignants (Bjerre et al., 2018), la peur de contribuer à la détérioration de l'état (Turner et al., 2016) ou du comportement du patient (Bjerre et al., 2018;Chenoweth et al., 2018), les différences de perception entre les professionnels, les patients ou leurs proches (ex. : à l'égard du bien-fondé de la démarche et du rôle de chacun) Jessop et al., 2017;Palagyi et al., 2016;Turner et al., 2016), la volonté d'éviter les conflits (Palagyi et al., 2016;Turner et al., 2016) et le manque de suivi (Palagyi et al., 2016). D'autres recherches ont également identifié les facteurs qui facilitent l'implantation de la déprescription, dont la volonté administrative, le leadership et le soutien politique et logistique des gestionnaires et de la direction Chenoweth et al., 2018;Jessop et al., 2017), la vision interdisciplinaire du changement (Abrahamson, Nazir, & Pressler, 2017;Turner et al., 2016), la combinaison de la déprescription avec une approche centrée sur le patient et ses besoins Jessop et al., 2017), l'implication et la collaboration de toutes les parties prenantes dans les décisions et les changements apportés auprès du patient (Abrahamson et al., 2017;Brodaty et al., 2018;Chenoweth et al., 2018;Palagyi et al., 2016;Turner et al., 2016), l'accessibilité à de l'information, à des preuves empiriques et à des protocoles définis (Abrahamson et al., 2017;Bjerre et al., 2018;Brodaty et al., 2018;Chenoweth et al., 2018;Farrell et al., 2018;Jessop et al., 2017;Palagyi et al., 2016;Turner et al., 2016), la formation du personnel Chenoweth et al., 2018;Farrell et al., 2018), la présence de champions au sein des équipes de soins , la mobilisation des médecins généralistes en synergie avec les autres membres de l'équipe (ex. ...
... : à l'égard du bien-fondé de la démarche et du rôle de chacun) Jessop et al., 2017;Palagyi et al., 2016;Turner et al., 2016), la volonté d'éviter les conflits (Palagyi et al., 2016;Turner et al., 2016) et le manque de suivi (Palagyi et al., 2016). D'autres recherches ont également identifié les facteurs qui facilitent l'implantation de la déprescription, dont la volonté administrative, le leadership et le soutien politique et logistique des gestionnaires et de la direction Chenoweth et al., 2018;Jessop et al., 2017), la vision interdisciplinaire du changement (Abrahamson, Nazir, & Pressler, 2017;Turner et al., 2016), la combinaison de la déprescription avec une approche centrée sur le patient et ses besoins Jessop et al., 2017), l'implication et la collaboration de toutes les parties prenantes dans les décisions et les changements apportés auprès du patient (Abrahamson et al., 2017;Brodaty et al., 2018;Chenoweth et al., 2018;Palagyi et al., 2016;Turner et al., 2016), l'accessibilité à de l'information, à des preuves empiriques et à des protocoles définis (Abrahamson et al., 2017;Bjerre et al., 2018;Brodaty et al., 2018;Chenoweth et al., 2018;Farrell et al., 2018;Jessop et al., 2017;Palagyi et al., 2016;Turner et al., 2016), la formation du personnel Chenoweth et al., 2018;Farrell et al., 2018), la présence de champions au sein des équipes de soins , la mobilisation des médecins généralistes en synergie avec les autres membres de l'équipe (ex. : infirmier-ère, pharmacien-ne) Palagyi et al., 2016;Turner et al., 2016), la communication de l'information concernant le patient (ex. ...
Article
Résumé 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.
... 10 Differences in perception between professionals, residents, and families can also hinder the successful implementation of these programs. 6,8,9,11 These perceptions are often the result of a lack of information about the real value of the medications. 9 Professionals may, therefore, demonstrate resistance to the innovation due to a lack of information and training 6,8,9,11 ; pressure from other professionals 7,11,12 ; a lack of resources or flexible organizational structures 9 ; a hierarchical structure in which appropriate medication usage is not a priority 6,8,9 ; a fear of contributing to a deterioration in the patient's condition 8 or behavior 6,7 if nothing is done; a desire to avoid conflicts with colleagues 8,9 ; or fear of being the subject of complaints. ...
... 6,8,9,11 These perceptions are often the result of a lack of information about the real value of the medications. 9 Professionals may, therefore, demonstrate resistance to the innovation due to a lack of information and training 6,8,9,11 ; pressure from other professionals 7,11,12 ; a lack of resources or flexible organizational structures 9 ; a hierarchical structure in which appropriate medication usage is not a priority 6,8,9 ; a fear of contributing to a deterioration in the patient's condition 8 or behavior 6,7 if nothing is done; a desire to avoid conflicts with colleagues 8,9 ; or fear of being the subject of complaints. 9 3. Capacity of professionals Brodaty et al. point out the importance of training professionals on non-pharmacological interventions. ...
... 8 The involvement of all stakeholders in the change and its governance, has been identified as a key determinant. 2,6,8,[11][12][13] The emergence of a culture of interprofessional collaboration 8,15 and the administrative willingness of managers and policy makers to bring it about 6,11,13 is also a major factor in facilitating the implementation of these innovations. Therefore, organizational support for interprofessional communication appears to be a key element of success. ...
Article
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.
... médecin, pharmacien, équipe multidisciplinaire) et parfois des étudiants en médecine (Thiruvinvamalai et al., 2019). Selon plusieurs études, la pérennité des interventions cliniques de déprescription se bute à de nombreux enjeux dont la forte culture de prescription dans les cas de SCPD, le manque de formations destinées aux équipes de soins de longue durée et le faible engagement des directions et des gestionnaires pour promouvoir la culture du changement (Thiruvinvamalai et al., 2019;Jessop et al., 2017) ou encore à la faiblesse de l'utilisation des approches non pharmacologiques (Cossette et al., 2019). ...
... D'autres démarches nationales étaient en cours en même temps aux États-Unis (National Partnership to Improve Dementia Care in Nursing Homes), en Angleterre (National Dementia Strategy) et en Australie (Halting Antipsychotic Use in Long-Term care). À l'exception de la démarche anglaise qui ne présentait pas de résultats significatifs (Szczepura et al., 2016), ces dernières semblaient également prometteuses (Gurwitz, Bonner et Berwick, 2017;Jessop et al., 2017). ...
... Non-pharmacological management within a person-centred approach is considered an effective, first-line treatment for behaviours (Jessop et al., 2017). Other pressing care priorities can however be compromised, while a cause is identified through detailed assessment and management (New South Wales Nursing & Midwifery Association, 2016). ...
... To reduce any soporific effect, some study participants suggested lowering medication dosages. Of note, regular use of medications to reduce agitation further compromised assessment, as side effects often removed the resident's voice and limited use of alternate methods in favour of medications (Gallagher & Herrmann, 2015;Jessop et al., 2017;Rapaport et al., 2018). ...
Article
Background Agitation in older people is commonly associated with cognitive decline, complex medical diagnoses and polypharmacy. Impaired communication and comprehension within a dementia trajectory adds complexity to assessment and management. Despite high prevalence, agitated behaviours remain challenging to manage in residential aged care settings. Aim To explore staff perceptions of agitation in residents of aged care facilities, including the influence of dementia, when selecting management strategies to reduce agitated behaviour. Design Qualitative descriptive. Methods Semi‐structured interviews with 11 aged care staff were conducted at two aged care sites. Transcripts were examined using content analysis to identify common issues and categories. The study complied with COREQ guidelines (see. Appendix S1). Results Participants reported managing resident agitation at least once per shift; most frequently manifesting as wandering, restlessness or aggression. Management strategies included distraction, providing space, knowing the resident, identifying causative factors, spending individual time and if necessary medication administration. Agitation management was more challenging for residents with dementia due to impaired communication or comprehension of instruction. Conclusions While participants strived to deliver individualized person‐centred care, this was difficult given time and resource constraints. Contemporary management of agitation therefore remains variable in everyday practice, with resident preference used when causative factors were known. Conversely, for residents with impaired communication and/or comprehension, distraction and chemical restraint were commonly used. Nuanced education for assessment and management is recommended to better address this unmet need for some residents. Relevance to clinical practice For optimal care, appropriate allocation of time and resources is necessary to identify causative and contextual factors for individual residents. Recommendations are for additional staff training in communication and attitude, and collaborating with frontline staff to develop a practical guide for management of agitation in aged care. These simple initiatives may help to improve consistency of care delivery and resident outcomes.
... One of catalysts for this was the Australian Royal Commission's enquiry into Aged Care Quality and Safety which emphasized high prevalence of psychotropic use for behavioural and psychological symptoms of dementia in their interim report [45]. This also may be explained by the multiple public health campaigns and interventions aimed at reducing the use of antipsychotics and benzodiazepines in RACFs such as the Reducing the Use of Sedatives (RedUSe) project and the Halting Antipsychotic use in Long Term care (HALT) study as well as the introduction of the NPS Medicinewise dementia education program in Australia [44,46,47]. ...
Article
Full-text available
Prescribing potentially inappropriate medications (PIMs), including antipsychotics and benzodiazepines, has been used as an indicator of the quality use of medicines in residential aged care facilities (RACFs). PIMs are associated with an increased risk of falls and hospitalisations in the elderly. The purpose of this study is to assess the extent of prescribing of PIMs in RACFs at baseline in the Pharmacists in residential aged care facilities (PiRACF) study and examine the association of resident and system factors with the number of PIMs. A cross-sectional analysis of 1368 participants from 15 Australian RACFs was performed to detect PIMs using the American Geriatrics Society 2019 Beers® criteria. Most residents (68.1%) were taking at least one regular PIM; 16.9% were taking regular antipsychotics and 11.1% were taking regular benzodiazepines. Long-term proton pump inhibitors were the most frequent class of PIMs. History of falls and higher Charlson Comorbidity Index were associated with an increased number of prescribed PIMs, while dementia diagnosis and older age (85 years or more) were associated with decreased number of PIMs (p-value <0.05). Residents in facilities with lower nurse-to-resident ratios were more likely to have an increased number of PIMs (p value = 0.001). This study indicates that potentially inappropriate prescribing is common in RACFs and interventions to target residents at highest risk are needed.
... Except for pimavanserin for hallucinations and delusions in Parkinson's disease (PD), antipsychotic drugs are not FDA approved for the treatment of the BPSD [41••]. Unfortunately, these medications are widely prescribed for the BPSD [42][43][44], prompting proposals for limiting their use [45,46]. Data from 146 randomized trials of 44,873 patients does show modest efficacy in treating BPSD with the antipsychotics risperidone, aripiprazole, haloperidol, and quetiapine compared to placebo [29,47]; however, the potential adverse effects of these drugs limit their overall usefulness to severe disruptive behaviors and psychosis [48]. ...
Article
Full-text available
Purpose of Review Alzheimer’s disease and related dementias are the source of significant distress, impairment, and caregiver burden in aging populations. A prominent reason for this impact is the Behavioral and Psychological Symptoms of Dementia (BPSD). Common BPSD include disruptive behaviors, such as agitation, aggression, severe anxiety, delusions, depression, apathy, and sleep disturbances. Specific dementias, such as behavioral variant frontotemporal dementia and dementia with Lewy bodies, are associated with socioemotional disturbances and visual hallucinations, respectively. The aim of this review is to present current treatment options for the major BPSD. Recent Findings The management of the BPSD requires familiarity with non-pharmacological interventions and skill in the use of pharmacological agents in patients with dementias. This review outlines five important areas of non-pharmacological intervention. It then discusses the use of serotonergic medications, before considering antipsychotic drugs for disruptive behaviors and other BPSD. What is known about psychoactive drug use in cognitively normal populations does not necessarily apply to those with dementia, and the current treatment of patients with dementia emphasizes the need to consider their increased susceptibility to side effects from antipsychotic drugs. Summary Effective dementia care requires knowing both non-pharmacological and pharmacological interventions for the BPSD, which are present in nearly all patients with dementia at some time in their course. This review presents relatively easily applicable non-pharmacological techniques followed by discussions of the medication options for the major BPSD. In particular, clinicians need to understand current treatment strategies, particularly with regards to psychoactive medications, in this vulnerable population.
... They can only do so if they are informed. Previous studies, particularly regarding quality use of psychotropics, have focused on the aged care and clinical workforce [18][19][20][21]. Shelton et al. [22] refer to the "Dementia Care Triad" as the partnership between the person with dementia, family carers, and healthcare team, each being an essential component. ...
Article
Full-text available
The aged care system in Australia is in crisis and people living with dementia are especially vulnerable to breaches of human rights to autonomy, dignity, respect, and equitable access to the highest quality of health care including meeting needs on account of disability. To be powerful advocates for themselves and others, people with dementia and the wider community with vested interests in quality aged care must be informed about their rights and what should be expected from the system. Prior to the Australian Royal Commission into Aged Care Quality and Safety, the Empowered Project was established to empower and raise awareness amongst people with dementia and their families about changed behaviours, chemical restraint, consent, end of life care, and security of tenure. A primary care-embedded health media campaign and national seminar tour were undertaken to meet the project aims of awareness-raising and empowerment, based on 10 Essential Facts about changed behaviours and rights for people with dementia, established as part of the project. Knowledge translation was assessed to examine the need and potential benefit of such seminars. We demonstrated that this brief educational engagement improved community knowledge of these issues and provided attendees with the information and confidence to question the nature and quality of care provision. With the completion of the Royal Commission and corresponding recommendations with government, we believe the community is ready to be an active player in reframing Australia’s aged care system with a human rights approach.
Article
Full-text available
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.
Article
Frequent use of psychotropic medicines in people with dementia is a significant concern globally, doing this without informed consent is a violation of human rights, ethics and law. Capacity Australia piloted an intervention to address several hypothetical barriers to obtaining consent for psychotropic use in aged care and has developed a suite of resources to improve rights and health literacy for clinicians, patients and community alike.
Article
Objective The purpose of this study was to test the effectiveness of the Function and Behavior Focused Care for the Cognitively Impaired (FBFC-CI) intervention on function, physical activity, and behavioral symptoms among nursing home residents with dementia, and to explore the adoption of the intervention at the facility level. Design This study was a clustered, randomized controlled trial with a repeated measures design that was implemented in 12 nursing homes randomized to either treatment (FBFC-CI) or educational control (Function and Behavior Focused Care Education [FBFC-ED]). Setting and Participants Twelve nursing homes (6 treatment and 6 control) and 336 residents (173 treatment and 163 control) with moderate to severe cognitive impairment. Measures Outcomes included functional ability (Barthel Index), physical activity (actigraphy and survey), behavioral symptoms (Resistiveness to Care Scale, Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia), and psychotropic medication use. Results The participants were 82.6 (SD = 10.1) years of age, mostly female, and were moderate to severely cognitively impaired (Mini-Mental State Exam of 7.8, SD = 5.1). There was a significantly greater increase in time spent in total activity (P = .004), moderate activity (P = .012), light activity (P = .002), and a decrease in resistiveness to care (P = .004) in the treatment versus control group at 4 months. There was no change in mood, agitation, and the use of psychotropic medications. There was some evidence of adoption of the intervention at treatment sites. Conclusions and Implications This study provides some support for the use of the FBFC-CI Intervention to increase time spent in physical activity and decrease resistive behaviors during care commonly noted among nursing home residents with moderate to severe cognitive impairment.
Article
Full-text available
Background: Well-being and various forms of agitation in people with dementia can be improved in a person-centered long-term care setting. Data obtained during the Person-Centered Dementia Care and Environment (PerCEN) randomized controlled trial shed light on the factors that influenced the adoption and outcomes of person-centered interventions in long-term care from the perspective of study participants. Methods: Data were obtained from PerCEN participants: individual semi-structured interviews with care managers (29), nurses and care staff (70); telephone surveys with family members (73); staff reports of care approaches; and 131 field note entries recorded by the person-centered care and environment facilitators. Data were interpreted inductively using content analysis, code building, theme development, and synthesis of findings. Results: All data sources confirmed that, when adopted, the person-centered model increased the number and variety of opportunities for resident interaction, improved flexibility in care regimens, enhanced staff's attention to resident needs, reduced resident agitation, and improved their well-being. Barriers and enablers for the person-centered model related to leadership, manager, staff and family appreciation of the model, staff's capacity, effective communication and team work among direct care staff, care service flexibility, and staff education on how to focus care on the person's well-being. Conclusions: Successful knowledge translation of the person-centered model starts with managerial leadership and support; it is sustained when staff are educated and assisted to apply the model, and, along with families, come to appreciate the benefits of flexible care services and teamwork in achieving resident well-being. The Australian New Zealand Clinical Trials Registry number is ACTRN 12608000095369.
Article
Full-text available
Objectives This paper reports on the acceptability and effectiveness of the FITS into Practice Programme which was scaled up from an intervention that had proven significant results from an earlier cluster randomised controlled trial. Method An in depth ten-day education course in person-centred care was delivered over a three-month period and followed by 6 supervision sessions. Participants were care-home staff designated as Dementia Care Coaches (DCCs) responsible for implementing interventions in their home. The course and supervision was provided by educators called Dementia Practice Development Coaches (DPDCs). Effectiveness data included monitoring antipsychotic prescriptions, goal attainment, knowledge, attitude and implementation questionnaires. Qualitative data elucidated issues of implementation. Results Of the 100 DCCs recruited, 66 DCCs completed the programme. Pre-post questionnaires demonstrated increased knowledge and confidence and improved attitudes to dementia. 20.1% of residents were prescribed antipsychotics at baseline which reduced to 13.9% (30.5% reduction) with additional dose reductions being reported alongside improved personalised goal attainment. Crucial for FITS into Practice to succeed was the allocation and protection of time for the DCC to attend training and supervision and to carry out implementation tasks in addition to their existing job role. Evaluation data showed that this was a substantial barrier to implementation in a number of homes. Discussion and conclusions The FITS intervention can be delivered at scale and is a robust way of bringing about positive change. The evaluation informed revisions to the person specification for DCCs and DPDCs and factors to enable successful implementation.
Article
Objective: This study evaluated the impact of antipsychotic review, social interaction, and exercise, in conjunction with person-centered care, on antipsychotic use, agitation, and depression in people with dementia living in nursing homes. Method: A cluster-randomized factorial controlled trial with two replications was conducted in people with dementia in 16 U.K. nursing homes. All homes received training in person-centered care. Eight homes were randomly assigned to antipsychotic review, to a social interaction intervention, and to an exercise intervention for 9 months, with most homes assigned to more than one intervention. The primary outcome measures were antipsychotic use, agitation, and depression. Secondary outcome measures were overall neuropsychiatric symptoms and mortality. Results: Antipsychotic review significantly reduced antipsychotic use by 50% (odds ratio 0.17, 95% confidence interval [CI] 0.05 to 0.60). Antipsychotic review plus the social interaction intervention significantly reduced mortality (odds ratio 0.26, 95% CI 0.13 to 0.51) compared with the group receiving neither. The group receiving antipsychotic review but not the social intervention showed significantly worse outcome in neuropsychiatric symptoms compared with the group receiving neither (score difference +7.37, 95% CI 1.53 to 13.22). This detrimental impact was mitigated by concurrent delivery of the social intervention (-0.44, CI -4.39 to 3.52). The exercise intervention significantly improved neuropsychiatric symptoms (-3.59, 95% CI -7.08 to -0.09) but not depression (-1.21, CI -4.35 to -1.93). None of the interventions had a significant impact specifically on agitation. Conclusions: While reductions in antipsychotic use can be achieved by using a "real world" intervention, this may not be of benefit to people with dementia in the current climate of more judicious prescribing unless nonpharmacological interventions such as social interaction or exercise are provided in parallel.
Article
Inappropriate polypharmacy, especially in older people, imposes a substantial burden of adverse drug events, ill health, disability, hospitalization, and even death. The single most important predictor of inappropriate prescribing and risk of adverse drug events in older patients is the number of prescribed drugs. Deprescribing is the process of tapering or stopping drugs, aimed at minimizing polypharmacy and improving patient outcomes. Evidence of efficacy for deprescribing is emerging from randomized trials and observational studies. A deprescribing protocol is proposed comprising 5 steps: (1) ascertain all drugs the patient is currently taking and the reasons for each one; (2) consider overall risk of drug-induced harm in individual patients in determining the required intensity of deprescribing intervention; (3) assess each drug in regard to its current or future benefit potential compared with current or future harm or burden potential; (4) prioritize drugs for discontinuation that have the lowest benefit-harm ratio and lowest likelihood of adverse withdrawal reactions or disease rebound syndromes; and (5) implement a discontinuation regimen and monitor patients closely for improvement in outcomes or onset of adverse effects. Whereas patient and prescriber barriers to deprescribing exist, resources and strategies are available that facilitate deliberate yet judicious deprescribing and deserve wider application.
Article
Background Residential aged care facilities are increasingly using pharmacological methods of managing BPSD such as antipsychotics, despite little evidence of effectiveness and high rates of adverse effects. Nonpharmacological approaches to management of behavioural and psychological symptoms of dementia (BPSD) have not been widely implemented in residential aged care, despite reported effectiveness of these strategies. Residential aged care staff opinions on the effectiveness of non-pharmacological approaches to dementia care and any limitations to their use are not well documented. Methodology This is the qualitative arm of a broader research project. A 43-point questionnaire was distributed to 6 rural aged care facilities to explore nurses’ perceptions of the limitations of five commonly employed non pharmacological and pharmacological interventions in managing BPSD. Findings Staff reported that some non-pharmacological methods of managing BPSD were not the role of nursing staff. This suggests that other interventions such as increased staffing levels would not be effective in facilitating non pharmacological approaches to managing BPSD.
Article
Background Two-thirds of nursing home residents suffer from dementia and there is a need for effective and efficient interventions with meaningful outcomes for these individuals. This study aims to identify current best practices in non-pharmacological interventions in nursing homes. Methods A systematic literature review was conducted, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration guideline. Studies and Randomized Controlled Trials (RCT) evaluating non-pharmacological interventions focused on improving the Quality of Care (QoC) and/or Quality of Life (QoL) of people with dementia (PwD) living in nursing homes were included. For individual study evaluation, the Cochrane Collaboration risk of bias assessment tool was used. Results A total of 31 articles were included and five main categories emerged: psychosocial and educational, physical activity, sensorial therapies, staff-focused interventions and complex interventions. Psychosocial interventions were the most exhaustively studied and evaluated interventions. Few studies related to physical therapy were identified and they did not provide enough evidence of their effectiveness. Therapeutic touch was revealed to have positive effects on residents with dementia. Conclusion Psychosocial interventions have been shown to have the potential to improve the QoL and QoC of people with dementia in nursing homes. Before implementation of the intervention, it is recommended that activities are adjusted according to residents’ characteristics and external factors controlled to achieve effectiveness and to structure a well-designed intervention. However, there is not enough evidence to support the effectiveness of non-pharmacological interventions in general. Further well-designed research is needed on non-pharmacological interventions in nursing facilities.
Article
Background: There is good evidence of the positive effects of person-centered care (PCC) on agitation in dementia. We hypothesized that a person-centered environment (PCE) would achieve similar outcomes by focusing on positive environmental stimuli, and that there would be enhanced outcomes by combining PCC and PCE. Methods: 38 Australian residential aged care homes with scope for improvement in both PCC and PCE were stratified, then randomized to one of four intervention groups: (1) PCC; (2) PCE; (3) PCC +PCE; (4) no intervention. People with dementia, over 60 years of age and consented were eligible. Co-outcomes assessed pre and four months post-intervention and at 8 months follow-up were resident agitation, emotional responses in care, quality of life and depression, and care interaction quality. Results: From 38 homes randomized, 601 people with dementia were recruited. At follow-up the mean change for quality of life and agitation was significantly different for PCE (p = 0.02, p = 0.05, respectively) and PCC (p = 0.0003, p = 0.002 respectively), compared with the non-intervention group (p = 0.48, p = 0.93 respectively). Quality of life improved non-significantly for PCC+PCE (p = 0.08), but not for agitation (p = 0.37). Improvements in care interaction quality (p = 0.006) and in emotional responses to care (p = 0.01) in PCC+PCE were not observed in the other groups. Depression scores did not change in any of the groups. Intervention compliance for PCC was 59%, for PCE 54% and for PCC+PCE 66%. Conclusion: The hypothesis that PCC+PCE would improve quality of life and agitation even further was not supported, even though there were improvements in the quality of care interactions and resident emotional responses to care for some of this group. The Australian New Zealand Clinical Trials Registry Number is ACTRN 12608000095369.
Article
Background: Clinicians need to know the right antipsychotic dose for optimized treatment, and the concept of dose equivalence is important for many clinical and scientific purposes. Methods: We refined a method presented in 2003, which was based on the minimum effective doses found in fixed-dose studies. We operationalized the selection process, updated the original findings, and expanded them by systematically searching more recent literature and by including 13 second-generation antipsychotics. To qualify for the minimum effective dose, a dose had to be significantly more efficacious than placebo in the primary outcome of at least one randomized, double-blind, fixed-dose trial. In a sensitivity analysis, 2 positive trials were required. The minimum effective doses identified were subsequently used to derive olanzapine, risperidone, haloperidol, and chlorpromazine equivalents. Results: We reviewed 73 included studies. The minimum effective daily doses/olanzapine equivalents based on our primary approach were: aripiprazole 10 mg/1.33, asenapine 10 mg/1.33, clozapine 300 mg/40, haloperidol 4 mg/0.53, iloperidone 8 mg/1.07, lurasidone 40 mg/5.33, olanzapine 7.5 mg/1, paliperidone 3 mg/0.4, quetiapine 150 mg/20, risperidone 2 mg/0.27, sertindole 12 mg/1.60, and ziprasidone 40 mg/5.33. For amisulpride and zotepine, reliable estimates could not be derived. Conclusions: This method for determining antipsychotic dose equivalence entails an operationalized and evidence-based approach that can be applied to the various antipsychotic drugs. As a limitation, the results are not applicable to specific populations such as first-episode or refractory patients. We recommend that alternative methods also be updated in order to minimize further differences between the methods and risk of subsequent bias.