Approaches to Deprescribing Psychotropic Medications for Changed Behaviours in Long-Term Care Residents Living with Dementia

Harrison, Stephanie L; Cations, Monica; Jessop, Tiffany; Hilmer, Sarah N.; Sawan, Mouna; Brodaty, Henry

doi:10.1007/s40266-018-0623-6

Cited by 47 publications

(46 citation statements)

References 107 publications

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“…The finding that nursing staff were the most common drivers of represcribing, or abandoned deprescribing, is consistent with several studies demonstrating that physicians feel pressure to prescribe sedating medications when requested by long‐term aged care staff . Nursing staff, especially those who are inexperienced or time‐poor, may find it difficult to implement nonpharmacological approaches to manage BPSD and are subsequently vulnerable to overreliance on psychotropic medications . Organisational factors such as inadequate staffing, managerial expectations, and teamwork between staff and visiting health professionals can contribute to a “prescribing culture” within a facility .…”

Section: Discussionsupporting

confidence: 79%

“…The aim of this paper is to explore the circumstances of these cases and to better understand the context of and putative reasons for nondeprescribing or represcribing. This information will be useful to identify risk factors for failed deprescribing efforts and provide guidance to a process that is a noted clinical challenge . We collected feedback about the represcribing or abandoned deprescribing and review practices from the relevant stakeholders in the HALT study, comprising study‐trained staff, treating general practitioners (GPs), and participants' proxy caregivers.…”

Section: Introductionmentioning

confidence: 99%

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Why deprescribing antipsychotics in older people with dementia in long‐term care is not always successful: Insights from the HALT study

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Cations

Harrison

et al. 2019

Int J Geriat Psychiatry

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Introduction Antipsychotic medications are commonly used to manage behavioural and psychological symptoms of dementia despite their side effects and harms. While the Halting Antipsychotic Use in Long‐Term care (HALT) deprescribing trial was successful at reducing antipsychotic use, 19% of participants had their antipsychotics represcribed or never reached a dose of zero. The aim of this study was to investigate the reasons for represcription of antipsychotic medication and factors associated with ongoing antipsychotic use, relating to care staff requests and perceived behavioural changes. Materials and methods Thirty‐nine of 133 HALT participants never ceased their antipsychotic medication or were represcribed a regular or pro re nata (PRN) antipsychotic after initial deprescribing. The views of nursing staff, general practitioner, and family on the circumstances leading up to these outcomes were collected via a questionnaire‐based approach. This information was triangulated with observation and detailed file audit (including progress notes, medical notes, medication charts, incident reports, and hospital discharge summaries). A consensus panel reconstructed the represcribing context. Results Nurses were the most common drivers of represcribing (63.2%), followed by family members (39.5%), GPs (23.7%), specialists (13.2%), and hospital staff (10.5%). There were multiple drivers for antipsychotic use in 46.2% of participants. Increased agitated and aggressive behaviours were the most commonly reported reasons for represcribing even though these changes were not identified over time on objective measures. Consent and dosage practices remained poor despite education. Discussion Nursing staff are the key drivers of deprescribing particularly in response to perceived worsening agitation and aggression among male residents. The train‐the‐trainer model used in the HALT trial may have been insufficient on its own to improve staff competence and confidence in applying nonpharmacological approaches when responding to behaviour change.

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Section: Discussionsupporting

confidence: 79%

Section: Introductionmentioning

confidence: 99%

Why deprescribing antipsychotics in older people with dementia in long‐term care is not always successful: Insights from the HALT study

Aerts

Cations

Harrison

et al. 2019

Int J Geriat Psychiatry

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“…Deficits in orientation, memory, and communication introduced by dementia and other neurological conditions likely further complicate these issues, though empirical evidence on this topic is lacking. Changed behaviours that occur in response to unmet needs are common in dementia care settings and are highly disruptive and distressing for the person, their families, other residents, and aged care staff . The extent to which psychological trauma contributes to this is unknown.…”

Section: Aged Carementioning

confidence: 99%

“…Awareness of a person's history and unique triggers allows aged care staff to implement preventative measures and recognise early warning signs of distress, potentially reducing aggressive, agitated, or other challenging behaviour. Aged care staff consistently report low skill and confidence in managing these symptoms, and this contributes to burnout and an overreliance on chemical restraint . Sedating medications, particularly antipsychotics, are commonly used to manage challenging behaviour in aged care settings .…”

Section: Trauma‐informed Aged Carementioning

confidence: 99%

“…Aged care staff consistently report low skill and confidence in managing these symptoms, and this contributes to burnout and an overreliance on chemical restraint . Sedating medications, particularly antipsychotics, are commonly used to manage challenging behaviour in aged care settings . The efficacy of these medications is low, and they are associated with serious side effects including increased mortality .…”

Section: Trauma‐informed Aged Carementioning

confidence: 99%

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The case for trauma‐informed aged care

Cations

Laver

Walker

et al. 2020

Int J Geriat Psychiatry

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Deprescribing Education vs Usual Care for Patients With Cognitive Impairment and Primary Care Clinicians

et al. 2022

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Key Points Question Can increasing awareness about deprescribing prior to primary care visits reduce the use of potentially inappropriate long-term medications for individuals with cognitive impairment? Findings In this pragmatic cluster randomized clinical trial of deprescribing education for 3012 older adults with cognitive impairment taking 5 or more medications and their primary care clinicians, patients from intervention clinics and control clinics were taking a similar mean number of medications (6.4 vs 6.5) at 6 months, and similar proportions of patients were taking 1 or more potentially inappropriate medications after 6 months. Meaning Educating patients and clinicians about deprescribing in primary care did not have an effect on the number of long-term medications or percentage of potentially inappropriate medications for older adults taking 5 or more long-term medications; findings suggest such interventions should target older adults taking relatively more medications.

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Approaches to Deprescribing Psychotropic Medications for Changed Behaviours in Long-Term Care Residents Living with Dementia

Cited by 47 publications

References 107 publications

Why deprescribing antipsychotics in older people with dementia in long‐term care is not always successful: Insights from the HALT study

Why deprescribing antipsychotics in older people with dementia in long‐term care is not always successful: Insights from the HALT study

The case for trauma‐informed aged care

Deprescribing Education vs Usual Care for Patients With Cognitive Impairment and Primary Care Clinicians

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