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

Jessop, Tiffany; Harrison, Fleur; Cations, Monica; Draper, Brian; Chenoweth, Lynn; Hilmer, Sarah N.; Westbury, JL; Low, Lee‐Fay; Heffernan, Megan; Sachdev, Perminder S.; Close, Jacqueline C.T.; Blennerhassett, Jenny; Marinkovich, Millicent; Shell, Allan; Brodaty, Henry

doi:10.1017/s1041610217000084

Cited by 23 publications

(37 citation statements)

References 43 publications

(52 reference statements)

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“…All but two participants were documented or judged to have dementia. Exclusion criteria were presence of a primary psychotic illness, a terminal illness, or very severe BPSD (NPI‐NH score ≥ 50; individual domain score of 12, and occupational disruptiveness score ≥ 3 for at least two of the following domains: delusions, hallucinations, agitation/aggression, anxiety, and disinhibition) …”

Section: Methodsmentioning

confidence: 99%

“…The HALT intervention included (a) antipsychotic withdrawal following an individualised, step‐wise deprescribing protocol and (b) training and education of health care staff . GPs and pharmacists were offered academic detailing (one‐on‐one peer education) and a continuing professional development module, respectively.…”

Section: Methodsmentioning

confidence: 99%

“…Antipsychotic medication can be deprescribed without re‐emergence of BPSD for most people with dementia . In the Halting Antipsychotics in Long‐Term care (HALT) withdrawal trial, regular antipsychotic medication was successfully deprescribed for 81.7% of participants at 12 months following intervention . Deprescription of antipsychotics did not lead to re‐emergence of BPSD or to increased agitation, as assessed with the Neuropsychiatric Inventory (NPI) and Cohen‐Mansfield Agitation Inventory (CMAI) …”

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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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: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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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Harrison

et al. 2019

Int J Geriat Psychiatry

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“…However, the long-term use remains frequent in care homes and psychiatric wards. 1,2 Expert consensus suggests that the use of antipsychotics can be appropriate in those with dangerous agitation or psychosis and can minimise the risk of violence and reduce patient distress. However, there is growing research that the benefits are at best small and that antipsychotics are associated with an increased risk of cardiovascular deaths, cerebrovascular events, venous thromboembolism, falls, sedation, hyperprolactinemia and sudden death in elderly people with dementia.…”

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confidence: 99%

“…However, there is growing research that the benefits are at best small and that antipsychotics are associated with an increased risk of cardiovascular deaths, cerebrovascular events, venous thromboembolism, falls, sedation, hyperprolactinemia and sudden death in elderly people with dementia. 2,3 Antipsychotics are also associated with an increased risk of metabolic side-effects such as weight gain, hyperlipidaemia and diabetes; anticholinergic effects such as confusion, and extrapyramidal side effects such as tardive dyskinesia. 4,5 There has been extensive research into the use of antipsychotics in dementia, including their safety profiles, however, studies have mainly focussed on the association between antipsychotics and a few adverse outcomes such as cerebrovascular events and mortality.…”

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Association between antipsychotics and adverse outcomes in dementia

Bangash¹,

Stubbs²,

Khan³

et al. 2017

Prog Neurol Psychiatry

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Prolonged use of antipsychotics continues to be a controversial subject area, especially in the older adult population due to age‐related changes in pharmacokinetic and pharmacodynamics parameters. Best practice guidelines recommends that they should be used at their lowest dosage for no longer than 6–12 weeks. Here, the authors discuss the prevalence of antipsychotic use to treat the behavioural and psychological symptoms of dementia in the older adult population and the dilemma it poses.

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Pro re nata prescribing and administration for neuropsychiatric symptoms and pain in long-term care residents with dementia and memory problems: a cross-sectional study

et al. 2019

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Background Prescribing, dispensing and administering pro re nata (PRN; as needed or necessary, as determined by an individual) medicines to people with intermittent or short-term conditions is a potential area for medication errors and inappropriate prescribing and administration. In people with dementia, regular PRN medicines use can demonstrate good practice when appropriate or poor in situations where their use is not recommended. However, the frequency of PRN prescription and administration within long-term care settings (care homes) for people with dementia is largely unknown. A limited number of studies worldwide suggest variation between countries. Objective To describe the prescription and administration rates of PRN medicines for people with dementia in UK care homes. Setting Fifty UK care homes. Method Medication details were collected from review of residents' medicines records within the care home for the previous month. Main outcome measure Prescription and administration of PRN medicines for the treatment of behaviours associated with neuropsychiatric symptoms and pain. Results The most commonly prescribed PRN medicines were analgesics (35.3%), although lower levels of PRN prescription were observed compared to recent studies. The percentage of residents receiving PRN administrations varied, with 20% for antipsychotics, 50% for benzodiazepines, 59% for analgesics, and 85.7% for nonbenzodiazepine hypnotics being administered. Conclusion Further research is needed to understand the decision making in PRN prescription and administration within long-term care. The prescribing of potentially inappropriate medicines remains a problem in long-term care settings and pharmacists have a key role in reducing inappropriate polypharmacy by undertaking medication reviews that consider both regular and PRN medicines.

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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

Cited by 23 publications

References 43 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

Association between antipsychotics and adverse outcomes in dementia

Pro re nata prescribing and administration for neuropsychiatric symptoms and pain in long-term care residents with dementia and memory problems: a cross-sectional study

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