Critical Contextual Elements in Facilitating and Achieving Success with a Person-Centred Care Intervention to Support Antipsychotic Deprescribing for Older People in Long-Term Care

Abstract

Antipsychotic and other tranquilising medicines are prescribed to help care staff manages behaviour in one-quarter of older people living in Australian long-term care homes. While these medicines pose significant health risks, particularly for people with dementia, reliance on their use occurs when staff are not educated to respond to resident behaviour using nonpharmacological approaches. The Halting Antipsychotic use in Long-Term care (HALT) single-arm study was undertaken to address this issue with 139 people 60 years and over with behaviours of concern for staff living in 24 care homes. A train-the-trainer approach delivered person-centred care education and support for 22 HALT (nurse) champions and 135 direct care staff, dementia management education for visiting general practitioners (GP) and pharmacists, use of an individualised deprescribing protocol for residents, and awareness-raising for the resident's family. The HALT champions completed open-ended questionnaires and semistructured interviews to identify the contextual elements they considered most critical to facilitating, educating care staff, and achieving success with the study intervention. They reported that person-centred approaches helped care staff to respond proactively to resident behaviours in the absence of antipsychotic medicines; the champions considered that this required strong managerial support, champion empowerment to lead change, reeducation of care staff, and the cooperation of families and GPs.

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

“…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 .…”

“…While nursing staff reported that nonpharmacological approaches were insufficiently effective in managing BPSD, HALT nurse champions often felt that the antipsychotic was not needed despite another nurse driving its represcription. As previously reported, nurse champions reported reluctance to deprescribe among their colleagues as a key challenge in the implementation of HALT. Our “train‐the‐trainer” model of implementation may have sometimes been insufficient, and more ongoing support and reinforcement may be required.…”

“…Our “train‐the‐trainer” model of implementation may have sometimes been insufficient, and more ongoing support and reinforcement may be required. Critical contextual elements in facilitating and achieving success with a nonpharmacological, person‐centred care intervention were reported previously . More optimistically, there was good communication between the nurses and the GPs in relation to change in BPSD and (attempts at) nonpharmacological management.…”

“…This is a noted facilitating factor for appropriate prescribing in long‐term care and may have been a positive by‐product of the HALT intervention even where withdrawal was not achieved. In addition, staff could identify positive changes upon antipsychotic withdrawal such as increased alertness and improved interaction …”

“…Fifth, we could only assess whether nonpharmacological approaches to manage BPSD had been implemented by asking nursing staff, GPs, and PRs. Further information on the appropriateness and effectiveness of these implementations is lacking and could potentially explain their failure leading to the reinstatement of regular antipsychotic medication …”