Prolonged use of antipsychotic medications in long-term aged care in Australia: a snapshot from the HALT project

Abstract

Objectives:Use of antipsychotic drugs in long-term aged care (LTC) is prevalent and commonly exceeds the recommended duration, but contributors to this problem are not well understood. The objective of this study is to provide a snapshot of the features of and contributors to prolonged use of antipsychotic medications (>12 weeks) among a sample of LTC residents.Design:We present retrospective and baseline data collected for the Australian Halting Antipsychotic Use in Long-Term Care (HALT) single-arm longitudinal deprescribing trial.Setting:Twenty-four long-term care facilities in Sydney, Australia.Participants:The HALT study included 146 older people living in 24 Sydney LTC homes who had been prescribed a regular antipsychotic medication for at least 3 months at baseline.Measurements:Detailed file audit was conducted to identify the date and indication recorded at initial prescription, consenting practices, longitudinal course of prescribing, and recommendations for review of antipsychotic medication. Behavioural and psychological symptoms of dementia (BPSD) and functional dependence at baseline were assessed via LTC staff interview. Cognition at baseline was assessed in a participant interview (where possible).Results:Antipsychotics were prescribed for 2.2 years on average despite recommendations by a doctor or pharmacist for review in 62% of cases. Consent for antipsychotic prescription was accessible for only one case and contraindications for use were common. Longer use of antipsychotics was independently associated with higher dose of the antipsychotic drug and greater apathy, but not with other BPSD.Conclusion:Antipsychotic medications appeared to be prescribed in this sample as a maintenance treatment in the absence of active indicated symptoms and without informed consent. Standard interventions, including recommendations for review, had been insufficient to ensure evidence-based prescribing.

We need to do better: most people with dementia living in aged care facilities use antipsychotics for too long, for off-label indications and without documented consent

“…The HALT study aimed to reduce inappropriate long-term use of antipsychotics by providing education and training in appropriate and nonpharmacological management of BPSD, followed by implementation of an intervention to promote deprescribing of antipsychotics (Brodaty, 2018). The analysis of baseline data from the HALT study presented in this issue of the journal used data collected before the deprescribing intervention commenced (Harrison et al, 2020). Harrison and colleagues found that the 146 study participants had been using antipsychotics for an average of 2.2 years at baseline, which was equivalent to use for more than 80% of the time the participants had been living in aged care.…”

“…The indication for antipsychotic initiation was documented for 90% of participants, and for three quarters of these people, the indication for initiation matched the approved indications for use in dementia. Current BPSD symptoms (experienced in the past month) were documented for 87% of participants and were most commonly aggression (81% of participants with BPSD) or irritability (72%) (Harrison et al, 2020). Sixty-two percent of participants had recommendations documented in their aged care notes by an appropriately qualified health professional to review the need for continued use of the antipsychotic (Harrison et al, 2020).…”

“…Current BPSD symptoms (experienced in the past month) were documented for 87% of participants and were most commonly aggression (81% of participants with BPSD) or irritability (72%) (Harrison et al, 2020). Sixty-two percent of participants had recommendations documented in their aged care notes by an appropriately qualified health professional to review the need for continued use of the antipsychotic (Harrison et al, 2020). Regression analysis showed that apathy was significantly associated with longer duration of use of antipsychotic, and longer duration of use was significantly associated with using larger doses of antipsychotics (Harrison et al, 2020).…”

“…The new study by Harrison and colleagues reports several important findings which continue to raise a red flag on inappropriate use of antipsychotics in aged care. They found that the average duration of antipsychotic use was at least 2.2 years (but potentially longer, because duration of use was incorrectly recorded for 73% of participants), with the majority of people initiating the antipsychotic after their admission to the aged care facility (Harrison et al, 2020). The average length of stay for people in residential aged care in Australia is two and a half years, with over 80% of people who leave aged care doing so because they die (Australian Institute of Health and Welfare, 2018).…”

“…It is also troubling to note that in the study by Harrison and colleagues (2020), two-thirds of residents had documented recommendations from healthcare professionals to review or cease their antipsychotics, but these recommendations were not implemented. Only two-thirds of participants were initiated on antipsychotic for an approved indication, and although they continued to use antipsychotic, more than half were not currently experiencing any severe BPSD (Harrison et al, 2020). As Harrison and colleagues alluded to, current regulations and prescribing guidelines are inadequate to reduce inappropriate antipsychotic use in aged care.…”