Interventions to Reduce Inappropriate Prescribing of Antipsychotic Medications in People With Dementia Resident in Care Homes: A Systematic Review (original) (raw)

Developing a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia

HRB Open Research

Background: Antipsychotics are commonly prescribed to people living with dementia in nursing home settings, despite strong guideline recommendations against their use except in limited circumstances. We aimed to transparently describe the development process for a complex intervention targeting appropriate requesting and prescribing of antipsychotics to nursing home residents with dementia in Ireland, by nurses and general practitioners (GPs) respectively. Methods: We report the development process for the ‘Rationalising Antipsychotic Prescribing in Dementia’ (RAPID) complex intervention, in accordance with the ‘Guidance for reporting intervention development studies in health research’ (GUIDED) checklist. The UK Medical Research Council framework for developing and evaluating complex interventions guided our overall approach, incorporating evidence and theory into the intervention development process. To unpack the intervention development process in greater detail, we followed th...

Antipsychotic prescribing in care homes before and after launch of a national dementia strategy: an observational study in English institutions over a 4-year period

BMJ open, 2016

To assess associations between the launch of the National Dementia Strategy (NDS) and antipsychotic prescribing in long-term residential care (LTC) in England. Retrospective analysis of prescribing patterns in 616 LTC institutions (31 619 residents) following launch of the NDS, using information from electronic medicines management system. Antipsychotic prescribing point prevalence (PP) for all residents in a cross section of LTC settings over a 4-year period following NDS launch. Secondary outcomes included dosages, length of treatment and use of recommended second-generation antipsychotics (SGAs) versus first-generation antipsychotics (FGAs). Associations between facility-level PP values and institutional characteristics, resident demographics were explored. Variations across geographical areas examined. Prescription net ingredient costs calculated. No statistically significant difference was observed in overall prescribing rates over the 4-year period (Kolmogorov-Smirnov (KS) tes...

Exploring Antipsychotic Prescribing Behaviors for Nursing Home Residents With Dementia: A Qualitative Study

Journal of the American Medical Directors Association

dementia antipsychotics qualitative nursing home behavioral and psychological symptoms of dementia (BPSD) a b s t r a c t Objectives: Caution is advised when prescribing antipsychotics to people with dementia. This study explored the determinants of appropriate, evidence-based antipsychotic prescribing behaviors for nursing home residents with dementia, with a view to informing future quality improvement efforts and behavior change interventions. Design: Semistructured qualitative interviews based on the Theoretical Domains Framework (TDF). Setting and Participants: A purposive sample of 27 participants from 4 nursing homes, involved in the care of nursing home residents with dementia (8 nurses, 5 general practitioners, 5 healthcare assistants, 3 family members, 2 pharmacists, 2 consultant geriatricians, and 2 consultant psychiatrists of old age) in a Southern region of Ireland. Measures: Using framework analysis, the predominant TDF domains and determinants influencing these behaviors were identified, and explanatory themes developed. Results: Nine predominant TDF domains were identified as influencing appropriate antipsychotic prescribing behaviors. Participants' effort to achieve "a fine balance" between the risks and benefits of antipsychotics was identified as the cross-cutting theme that underpinned many of the behavioral determinants. On one hand, neither healthcare workers nor family members wanted to see residents oversedated and without a quality of life. Conversely, the reality of needing to protect staff, family members, and residents from potentially dangerous behavioral symptoms, in a resource-poor environment, was emphasized. The implementation of best-practice guidelines was illustrated through 3 explanatory themes ("human suffering"; "the interface between resident and nursing home"; and "power and knowledge: complex stakeholder dynamics"), which conceptualize how different nursing homes strike this "fine balance." Conclusions: Implementing evidence-based antipsychotic prescribing practices for nursing home residents with dementia remains a significant challenge. Greater policy and institutional support is required to help stakeholders strike that "fine balance" and ultimately make better prescribing decisions. This study has generated a deeper understanding of this complex issue and will inform the development of an evidence-based intervention.

Fifteen year comparison of antipsychotic use in people with dementia within hospital and nursing home settings: sequential cross-sectional study

International Journal of Geriatric Psychiatry, 2010

The use of antipsychotics to treat people with behavioural and psychological symptoms associated with dementia is controversial, especially in long-stay settings. We assessed the relationship between behaviour, function and antipsychotic use in people with dementia in a long-stay psychiatric unit and designated elderly mentally ill (EMI) nursing homes over a 15-year period. Method: Sequential cross-sectional studies assessing twelve behaviours and seven measures of function for each patient. Antipsychotic and antidepressant use was obtained from current prescription records. Results: Regular antipsychotic use in hospital fell between 1990 and 1998. In 1998 use in nursing homes was significantly greater than in hospital, and increased between 1998 and 2005. Noisiness/verbal aggression (NVA) was the only behaviour more commonly associated with regular antipsychotic use over that timescale. Those with low levels of core symptoms (p ¼ 0.021) and high dependency patients (p ¼ 0.001) were more likely to be receiving regular antipsychotics in nursing homes than in hospital. Depression was not treated well even when identified. Conclusion: Compared to a long-stay hospital setting, antipsychotic drug use for people with dementia in nursing homes has risen and become less systematic. This cannot be explained by increasing core behaviour symptoms or differences in physical dependency.

Improvements in the prescribing of antipsychotics in dementia and psychogeriatric units in New Zealand

International Journal of Clinical Pharmacy, 2016

Impacts on Practice • Interventions (educational, managerial, environmental, recreational and resident-specific) can decrease antipsychotic prescribing in residential care. • Pharmacists should alert managers to high use of antipsychotics, encourage them to implement interventions aimed at appropriate use, educate staff on the risks and benefits of antipsychotic treatment, and conduct/participate in medication reviews. • Future studies should identify the most effective interventions to decrease antipsychotic prescribing in residential care, and encourage their implementation in order to improve patient care.

Can the PROPER intervention reduce psychotropic drug prescription in nursing home residents with dementia? Results of a cluster-randomized controlled trial

International Psychogeriatrics

Objectives: To evaluate the effect of the PROPER intervention in nursing home residents with dementia on the prevalence of psychotropic drug use and neuropsychiatric symptoms. Design: A cluster-randomized controlled design with two parallel groups (intervention versus usual care) and assessments at 0, 6, 12, and 18 months. Setting: Thirty-one dementia special care units within 13 long-term care organizations in the Netherlands. Participants: Three hundred eighty nursing home residents with dementia Intervention: The PROPER intervention consisted of a structured and repeated multidisciplinary medication review, supported by education and continuous evaluation. Measurements: Prescriptions of antipsychotics, antidepressants, anxiolytics, and hypnotics, and occurrence of neuropsychiatric symptoms. Results: The prescription of any type of psychotropic drugs increased in the intervention group, and decreased in the control group, with an estimated difference of 3.9 percentage points per 6...

Variation in use of antipsychotic medications in nursing homes in the United States: A systematic review

BMC geriatrics, 2017

The use of antipsychotic medications (APMs) in nursing home residents in the U.S. is an increasingly prominent issue and has been associated with increased risk of hospitalization, cardiovascular events, hip fractures, and mortality, among other adverse health events. The Food and Drug Administration has placed a black box warning on these drugs, specifying that they are not meant for residents with dementia, and has asked providers to review their treatment plans. The purpose of this systematic PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses)-based review was to summarize original research studies on facility level characteristics contributing to the use of antipsychotics in nursing homes across the United States, in order to investigate the variation of use. We searched Ovid Medline, Embase, Cochrane Library, Web of Science, CINAHL, PsycInfo, and Sociological Abstracts. Articles were selected according to the following criteria: (1) Population of interes...

Psychotropic Medication Burden and Factors Associated with Antipsychotic Use: An Analysis of a Population-Based Sample of Community-Dwelling Older Persons with Dementia

Journal of the American Geriatrics Society, 2011

OBJECTIVES: To estimate the proportion of communitydwelling older adults with dementia being prescribed a psychotropic and to identify patient and caregiver factors associated with antipsychotic use. METHODS: Retrospective cohort study of the Aging, Demographics, and Memory Study (ADAMS) from 2002 to 2004 designed to assess dementia severity and service use of community-dwelling older adults. The frequency of psychotropic medication (antipsychotics, antidepressants, anticonvulsants, and benzodiazepines) use was tabulated and weighted to the U.S. population according to dementia diagnosis. Logistic regression analysis identified factors associated with antipsychotic use. RESULTS: The 307 ADAMS participants had the following dementia diagnoses: Alzheimer's disease (69.3%), vascular dementia (17.7%), and other dementia (12.4%). The proportion of participants prescribed a psychotropic medication broken down according to therapeutic class was 19.1% antipsychotics, 29.1% antidepressants, 9.8% benzodiazepines, and 8.8% anticonvulsants. Older adults with dementia were significantly more likely to receive an antipsychotic if they had moderate (odds ratio (OR) = 7.4, P = .002) or severe (OR = 5.80, P = .002) dementia than if they had mild dementia or were diagnosed with Alzheimer's disease (OR = 6.7, P = .04) compared to vascular dementia. Older adults with dementia who lived with a caregiver were significantly less likely to taking an antipsychotic (OR = 0.19, P = .001) than those who lived alone. Also, persons with dementia were significantly less likely to be prescribed an antipsychotic if their caregiver was clinically depressed (OR = 0.03, P = .005) than if their caregiver was not depressed. CONCLUSION: Psychotropic medication use is common in community-dwelling older adults with dementia. Caregivers appear to have a substantial effect on whether an antipsychotic is prescribed, which adds additional complexity to conversations discussing the risk:benefit ratio of this medication class.

Variability between nursing homes in prevalence of antipsychotic use in patients with dementia

International Psychogeriatrics, 2013

ABSTRACTBackground:Antipsychotic drugs (APD) are widely prescribed for people with dementia residing in long term care facilities (LTCFs). Concern has been expressed that such prescribing is largely inappropriate. The objective of this study is to examine if differences in facility-level prevalence of APD use in a sample of LTCFs for patients with dementia can be explained by patient and facility-related characteristics.Methods:A point prevalence study was conducted using data from the VU University Resident Assessment Instrument (VURAI) database from nursing homes and residential care facilities in the Netherlands. Patients were selected who had a diagnosis of dementia. LTCF and patient characteristics were extracted from the VURAI; facility-level resident satisfaction surveys were provided by the National Institute for Public Health.Results:In total, 20 LTCFs providing care for 1,090 patients with dementia were investigated. Overall, 31% of patients used an APD. In facilities with...

Halting Antipsychotic Use in Long-Term care (HALT): a single-arm longitudinal study aiming to reduce inappropriate antipsychotic use in long-term care residents with behavioral and psychological symptoms of dementia

International psychogeriatrics, 2017

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. 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 man...